HospitalInspections.org

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Based on record review and interview the facility failed to ensure evidence the right to formulate Advanced Directives was offered for 2 patients (#s 1, 3), out of 10 sampled patients. This failed practice had the potential to deny the patients the right to choose and make end of life medical care decisions. Findings:

Patient #1

Record review on 8/8-10/18 revealed Patient #1 was admitted to the facility on 1/11/18 with diagnoses that included kyphoscoliosis (curvature of the spine) and radiculopathy (injury to a nerve or root) of the lumbar/sacral region of the spine.

Review of the "Conditions of Admission and Consent for Outpatient Care" form signed by the Patient on 1/11/18 revealed the Patient did not acknowledge the information about Advance Directives under number 16 of the form. The form stated " ...I have furnished information regarding Advance Directives (such as durable power of attorney for healthcare and living wills ...Please initial or place a mark next to one of the following applicable statements: ...". There were 3 boxes:

1. "I executed an Advance Directive and have been requested to supply a copy to the hospital".
2. "I have not executed an Advance Directive, wish to execute one and have received information on how to execute an Advance Directive".
3. "I have not executed an Advance Directive and do not wish to execute one at this time".

The Patient had not marked any of the applicable statements.

Patient #3

Record review on 8/8-10/18 revealed Patient #3 was admitted to the facility on 7/19/18 with diagnosis that include Legionella Pneumonia and Acute Respiratory Distress.

Review of the "Conditions of Admission and Consent for Outpatient Care" form signed by the Patient on 7/19/18 revealed the Patient did not acknowledge the Advance Directives information under number 16 of the form. The form stated " ...I have furnished information regarding Advance Directives (such as durable power of attorney for healthcare and living wills ...Please initial or place a mark next to one of the following applicable statements: ...". There were 3 boxes:

1. "I executed an Advance Directive and have been requested to supply a copy to the hospital".
2. "I have not executed an Advance Directive, wish to execute one and have received information on how to execute an Advance Directive".
3. "I have not executed an Advance Directive and do not wish to execute one at this time".

The Patient had not marked any of the applicable statements.

During an interview on 8/10/18 at 10:15 am with the Director of Patient Access when asked if one of the boxes on the aforementioned form should be filled out by the patient, the reply was yes.

Review on 8/10/18 of the facility's policy and procedure "Patient Rights & Responsibilities" dated July 2018, revealed "We adopt and affirm as policy the following rights of patients/clients who receive services from our facilities:...Decision Making and Notification...To formulate advance directives..."
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Based on record review and interview the facility failed to ensure the plan of care identified skin integrity concerns for 2 patients (#s 1 and 3) out of 10 sampled patients. The failure to ensure the care plan identified skin integrity concerns placed the patients at risk for skin integrity issues not being identified and treated. Findings:

Patient #1

Record review on 8/8-10/18 revealed Patient #1 was admitted to the facility on 1/11/18 with diagnoses that included kyphoscoliosis (curvature of the spine) and radiculopathy (injury to a nerve or root) of the lumbar/sacral region of the spine. Further review revealed the Patient was transferred to a rehabilitation facility on 1/18/18.

Review of the medical records nursing notes from the admitting facility dated 1/18/18, revealed "...Multiple wounds present ...Also present was suspected DTIs [deep tissue injuries] on bilateral [both] heels and the lateral aspect of the left midfoot..."

Review of the nursing "Plan of Care" from 1/12-18/2018 revealed no problems with skin integrity (integumentary system) was identified on the nursing plan of care.

Review of the Integumentary (skin) flow sheets for the period 1/12-18/18, revealed no documentation of any skin issues on the bilateral heels. The flow sheets did identify skin alterations of abrasions on face, chest and lower abdomen.

Review of the "Discharge Summaries" from the physician dated 1/18/18 at 7:52 am, revealed no documentation of pressure injuries.

During an interview on 8/10/18 at 9:00 am, Charge Nurse (CN) #2 stated the nurses should do a head to toe skin assessment 1 time per shift and upon discharge. The CN stated the skin assessments included the heels. The CN further stated any skin risks or wounds should be on the plan of care. The CN confirmed there were no skin issues on the nursing plan of care in the electronic medical record (EMR).

Patient #3

Record review on 8/8-10/18 revealed Resident #3 was admitted to the facility on 7/19/18 with diagnosis that include Legionella Pneumonia and Acute Respiratory Distress.

Review of the medical record nursing notes dated 8/3/18 at 3:00 pm, revealed "Left ear unstageable pressure injury...area measures 1.5x1cm... area purple and yellow..."

Review of the nursing "Plan of Care" dated 7/20/18 to 8/8/18 revealed no problems with skin integrity was identified on the nursing plan of care.

Review of the "ICU/Pulmonary Attending Progress Note" from the physician dated 8/6/18 at 2:42 pm, revealed no documentation of pressure injuries.

Review of the "Discharge Summaries" from the physician dated 8/8/18 at 3:12 pm, revealed no documentation of pressure injuries.

During an interview on 8/10/18 at 8:15 am with RN #2, when asked if the patient's pressure injury should have been added to the care plan, the response was "ideally, yes".

Review on 8/10/18 of the "Standards of Care for Orthopedic Unit" dated May 2016, revealed "...The RN will update and prioritize the care plan every shift and prn [as needed] with a change in the patient's status...Wound assessment and documentation every shift and prn as needed..."

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Based on observation, record review and interview, the facility failed to ensure 2 topical steroid medications included the application for use. Specifically, the facility failed to include the location where to apply the topical medications for 1 patient (#9) out of 2 patients observed during a medication pass. Findings:

Record review on 8/9-10/18 revealed Patient #9 was admitted to the facility on 7/31/18 with diagnoses that included Parkinson's disease and back pain.

Observation during a medication pass on 8/9/18 at 8:30 am, revealed RN #1 omitted 2 topical steroid medications, hydrocortisone 1% ointment and triamcinolone 0.1% cream due to Patient #9's refusal. The RN did not ask the Patient where the medications were to be applied.

Record Review on 8/9/18 of the medication orders revealed the following medications:

Hydrocortisone 1% ointment, Frequency: Daily
Triamcinolone 0.1% cream, Frequency: 2 times daily.

The start for both topical medications was 7/31/18. There was no information regarding where to apply the topical medications.

Further review of the medication administration record (MAR) revealed the Patient received hydrocortisone cream on 2 out of 9 days, on 8/6/18 and 8/7/18. The triamcinolone cream, was given 6 out of 18 times on 7/31/18 at 9:51 pm; 8/2/18 at 8:45 am; 8/6/18 at 8:42 am; 8/7/18 at 9:57 am; 8/7/18 at 8:00 pm; and 8/8/18 at 8:17 am. The missed topical medications were documented as "Missed Patient/family refused.

Additionally, the MAR for the triamcinolone cream on 8/8/18 at 8:26 pm, revealed the RN wrote "Ordered for itch on R [right] leg, pt [patient] denies itchiness".

Review of the physicians progress note dated 8/9/18 at 1:36 pm, revealed "...has chronic erythema [redness] in her armpits, and below breasts, and I clarified with RN regarding hydrocortisone cream, and triamcinolone use..."

During an interview on 8/9/18 at 2:25 pm, Charge Nurse (CN) #1 confirmed the order was missing the information on where to apply the medication. The CN stated the RN or provider could put in the information.

During an interview on 8/10/18 at 10:25 am, the Pharmacy Director (PD) stated the order/MAR should have indicated the location the topical medications should be applied. The PD stated the Pharmacy should double check the orders.

Review of the facility's policy and procedure dated November, 2012 and the policy and procedure under revision dated August 2018, revealed "...Incomplete/Illegible Orders: Orders that are incomplete, illegible or unclear are to be clarified with the prescriber. No order will be processed until it is clear and complete.

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