HospitalInspections.org

Based on document review and interview, the facility failed to ensure the provision of care in accordance with facility policy and procedure for 9 of 9 (1-9) patient medical records reviewed.

Findings:

1. Policy #PTOP-COP_40, TENS (transcutaneous electrical nerve stimulation), revised/reapproved 11/15, indicated therapy staff is to inspect the treatment area prior to application of the TENS unit and record the information on patient's chart.

2. Policy #PTOP-COP_21, Moist Heat Packs, revised/reapproved 11/15, indicated therapy staff is to inspect the treatment area prior to application of moist heat packs and record the information on patient's chart.

3. Review of Physical Therapist Physical Therapy Job Description indicated principal duties and responsibilities included documenting assessments and interventions accurately and timely.

4. Review of patient medical records indicated patients 1-9 received treatment of heat with interferential stim (meaning moist heat packs with TENS unit application) and the Physical Therapy Outpatient Daily Notes lacked assessment of patient's skin in the treatment area prior to application of the moist heat packs and the TENS unit. The dates of service were:
A. 5/20/16, 5/24/16, 5/26/16, 6/1/16 and 6/3/16 for patient 1.
B. 5/19/16, 5/20/16, 5/25/16 and 6/8/16 for patient 2.
C. 5/23/16, 5/24/16, 6/2/16, 6/6/16, 6/15/16, 6/17/16, 6/20/16, 6/24/16 and 7/1/16 for patient 3.
D. 5/23/16 for patient 4.
E. 5/24/16 for patient 5.
F. 6/22/16, 6/24/16, 6/28/16, 6/30/16, 7/8/16, 7/11/16, 7/15/16 and 7/18/16 for patient 6.
G. 6/8/16, 6/10/16, 6/13/16, 6/16/16, 6/20/16, 6/22/16, 6/24/16, 6/27/16, 6/29/16 and 6/30/16 for patient 7.
H. 4/8/16, 4/11/16, 4/13/16, 4/26/16, 4/28/16, 4/29/16, 5/2/16, 5/3/16, and 5/5/16 for patient 8.
I. 7/12/16 and 7/13/16 for patient 9.

5. Staff 2 (Staff Physical Therapist) was interviewed on 7/25/16 at approximately 1149 hours and confirmed prior to application of moist heat packs or TENS unit treatment, the patient's skin should be assessed to make sure there are no open areas, wounds, or swelling. If there is no issue with skin integrity, staff may proceed with the treatment. In the Physical Therapy Outpatient Daily Notes, the words "heat with interferential stim" mean moist heat packs with TENS unit application.

6. Staff 4 (Manager of Therapy Services) was interviewed on 7/25/16 at approximately 1206 hours and confirmed policy states staff are to assess area of patient where moist heat pack and/or TENS unit treatment will be applied and they are to document this in the patient's electronic medical record. This was not documented as required by facility policy and procedure for the above-mentioned patients.