HospitalInspections.org

Based on review of hospital polices, review of medical records, interview with staff, the nursing staff failed to assess pain for 1 out of 2 patients (#3) and reassess pain response after pain medication administration for 2 out of 6 patients. (#3 and #5).

The findings include:

Review of the Pain Management policy, with a revision date of 04/2015, revealed "...3. Ongoing pain assessments will be completed and documented each shift. The following criteria will be assessed and documented. a. Presence of pain b. Intensity of the pain, using a 0 to 10 pain scale (0 = no pain, 1-3=mild pain, 4-6 = moderate pain, 7-10 = severe pain) or other scale appropriate for the patient. c. Location of the pain...5. Thirty to sixty minutes after pain relieving interventions the patient's pain will be reassessed to evaluate effectiveness using one of the pain scales or objective findings....It is preferred that the nurse will use the same scale for assessment and reassessment whenever possible."

1. Closed medical record review on 01/18/2017 of Patient #3 revealed the Patient was admitted on 01/04/2017 for COPD exacerbation (Worsening of lung condition causing inability to exchange oxygen and carbon dioxide properly) after inability to receive dialysis treatment. Review of nurses notes dated 01/04/2017 revealed no available nurses pain assessments for night shift of 7P and day shift, 7A for 01/08/2017.
Interview on 01/18/2017 at 1425 with AS #1 (Director of Quality) revealed documentation is expected for shift assessments.
2. Closed medical record review on 01/18/2017 of Patient #3 revealed the Patient was admitted on 01/04/2017 for COPD exacerbation after inability to receive dialysis treatment. Review of the MAR (medication administration record) dated 01/07/2017 revealed documentation of administration of Percocet tablets on 01/07/2017 at 1022. There was no available documentation of nurses reassessment until 1748, 7 hours and 26 minutes later.
Interview on 01/18/2017 at 1425 with AS #1 revealed pain assessments and reassessments are expected to follow policy.
Closed medical record review of Patient #5 revealed the Patient was admitted on 01/16/2017 from home after a fall caused a hip fracture. Review of MAR dated 01/17/2017 at 1233 revealed documentation of administration of Percocet tablets at 1233, with a nurse reassessment at 2039, 8 hrs and 6 minutes later. Further review revealed documentation of administration of Percocet at 0924 on 01/18/2017 with reassessment at 1457, 5 hrs and 33 minutes later.
Interview on 01/18/2017 at 1425 with AS #1 revealed pain assessments and reassessments are expected to follow policy.
NC00123940

Based on policy and procedure review, observation during tour and staff interviews, the hospital's nursing staff failed to maintain the facility in a manner to prevent cross contamination by failing to clean and disinfect glucometers (meters to test patients' blood glucose) for 2 of 4 glucometers observed.

The findings include:

Review of hospital policy and procedure "Whole Blood Glucose Screening..." reviewed on 06/22/2016 revealed, "...3. Clean/disinfect after every patient test."

Observation during tour, on 01/18/2017 at 0950, of the 3rd floor Medical Surgical Unit revealed 2 of 4 glucometers were not cleaned and disinfected. Observation revealed dry blood on ready for use glucometers.

Interview with NM (Nurse Manager) #1 on 01/18/2017 at 0950, revealed NM #1 observed dry blood on two [2] ready for use glucometers. Further interview revealed "the expectation of staff is to clean equipment between each patient per policy." Interview revealed the policy was not followed.

NC00123195

Based on reviews of hospital policy and procedure reviews, reviews of medical record, interviews with physician and staff, the facility staff failed to provide adequate post hospital care assessment for 1 out of 5 patients (#3).
The findings include:
Review of policy, titled "Discharge Planning Services", with revision date of 10/16, revealed "...IV. PROCEDURE: The Case Manager or Social Worker will assist the admitting physician, nursing staff, patient and family in making appropriate and timely discharge plans at the request of patient by MD referrals, by patient and caregiver assessments, or by patient request...."
Closed medical record of Patient #3 revealed a 72 year old female presented to the ER on 12/23/2016 after a fall at home. Further review revealed patient #3 was admitted for treatment and discharged on 12/27/2016 to home. The medical history is significant for oxygen dependent COPD (Chronic Obstructive Pulmonary Disease-lung condition causing difficulty in breathing), Diabetes (inability to regulate blood glucose), and ESRD (End Stage Renal Disease--chronic kidney condition causing the inability of the kidneys to filter wastes) requiring 3 times weekly hemodialysis (End Stage Renal Disease-condition of the kidneys preventing adequate filtration requiring mechanical filtering of the blood at a clinic). Further review revealed patient lived alone and had no regular caregiver and requires cane/walker for ambulation prior to fall. The patient's sister is listed as POA (Power of Attorney-person designated by court papers to assist patient in making decisions). Further review revealed no current POA papers were available in medical record at discharge. Review of nurses notes dated 12/23/2016 at 2351 revealed total assist bath, on 12/24/2016 at 2252 max (maximum) assist bath, on 12/25/2016 at 1738 minimal assist bath, on 12/26/2016 at 0529 total assist bath and at 2235 moderate assist for complete bath.
Review of case manager's evaluation notes dated 12/24/2016 at 1419 revealed the patient was not independent with ADL's upon admission. Further review revealed no available nurses or CM (Case Manager) notes on the day of discharge with documentation of self care.
Interview on 01/18/2017 at 1030 with the assigned case manager revealed we evaluate all patients and go by PT (Physical Therapy) notes and suggestions. Further interview revealed no attempts were made to reach patient's sister (POA) to arrange care.
Interview on 01/18/2017 at 1130 with the assigned PT revealed pain was a problem for the patient. Further interview revealed the fracture was described as a broken chip off of the head of the trochanter (upper portion of the femur--leg bone) and did not require surgery. Further interview revealed initial evaluation of the patient showed the patient "needed significant help--recommended SNF for patient....Took 3 steps x 2 (twice)..limited by pain." Further interview revealed a family member was present and appeared to be attentive. Further interview revealed no documentation of conversations with family member that was present.
Interview with attending physician revealed patient has been under Nephrology service for 2 years and receives dialysis three times weekly. Further interview revealed the patient's left hip injury was unusual. Further interview revealed the discussion with radiologist to understand treatment. "Walking was the treatment for this type of injury. After 48 hrs (hours) of rest, the patient should walk." Further interview revealed patient's home health nurse arrived and the patient could not stand. Further interview revealed hemodialysis nurse from the clinic visited patient at her home and arranged 24 hour care for patient over the weekend because the patient's sister was not available 24 hours a day." Further interview revealed (patient #3) did miss dialysis treatment on the following week. (Patient #3) was readmitted to the hospital on 01/04/2017 for fluid overload and was discharged on 01/09/2017 to a local nursing home for further care.
Interview on 01/18/2017 at 1300 with an external assigned DSS worker (Department of Social Services) revealed when home health nurse arrived to patient's home 2 days after discharged from hospital patient was found in severe pain and unable to stand. Further interview revealed patient was unable to transfer to wheelchair to load into the dialysis van on Monday, January 3, 2017 and was not able to receive dialysis. Further interview revealed Patient #3 was admitted for fluid overload on 01/04/2017.
Interview on 01/18/2017 at 1030 with director of case management revealed no conversations were conducted with patient's sister (POA) to coordinate care for patient after discharge. Further interview revealed no attempts were made to speak with sister regarding post hospital care. Further interview revealed staff should have called or notified director of situation and notified family to coordinate care.
NC00123940