HospitalInspections.org

Based on interview and record review the facility failed to ensure that the nursing assessment, intervention and care plan is documented and kept current in 4 of 10 sampled patients (SP # 1, SP#6, SP#7 and SP#9).

Findings include:

(1) Clinical record review of SP#1 conducted on 12/30/2013 showed documentation on 10/25/2013 that the Integumentary Assessment was WDL (Within Defined Limits). The Nursing Note documentation on 10/30/213 at 17:09 showed that the patient ' s skin is intact with the exception of the mid-abdominal surgical incision. The Wound Care Note on 10/31/2013 at 15:14 pm showed that the patient has no evidence of pressure ulcer. Nurses to monitor the skin integrity every shift. . There is no description of the skin assessment of the sacral area on 11/4/2013, 11/5/2013 and 11/6/2013.

The Director of Oncology/1N stated on 12/30/2013 at 1:14 p.m. that when the patient was transferred to our floor, the nurse did not document that there was a scab, a hardened area on the sacrum. The next day, a student nurse showed it to the patient ' s nurse but that nurse did not do anything and did not document. A different nurse saw that the scab fell off. The patient was already on an air mattress and a wound care consult was called and it was an unstageable ulcer. The nurses were counseled and they went with the Wound Care Nurse for a full day to be educated on the proper assessment and documentation of pressure ulcers.

Further record review of SP#1 ' s chart revealed that photographs of the sacral ulcer were taken but there was no photograph taken prior to the patient ' s discharge. This finding was confirmed from the Director of Clinical Information on 12/30/2013 at 4:15 p.m..

Review of the policy on Skin Integrity Assessment & Protocol for Impaired Skin revealed that if the Registered Nurse/Licensed Practical Nurse identifies patient has skin integrity issue, notify Wound Care Nurse for proper assessment, staging and recommended treatment. A skin reassessment will be performed no less than every 12 hours and documented in the electronic medical record. It is also stated that photographs of the wound will be taken upon discharge.

(2). Clinical record review of SP#6 conducted on 12/30/2013 shows that the patient was admitted to the facility on 12/29/2013 for leg infection. Review of the Physician Orders revealed a Nursing Communication Order which stated to turn patient q 2 hours (every 2 hours). Review of the patient's medical records did not reveal any documentation that the patient was turned.
Observation of SP#6 on 12/30/2013 at 12:50 pm revealed that the patient was alert in bed with family at the bedside. Both of the patient's legs were observed to be wrapped with bandages from the ankles to the knees.
In an interview with SP#6 on 12/30/2013 at 12:50 pm, the patient stated that I am not able to turn on my own. Nobody has been in to see me they come in and out and ask me questions, nobody came to help me use the bathroom, I use my wheelchair to get myself to the bathroom.
In an interview with Registered Nurse (RN) #1 on 12/30/2013 at 12:55 pm, the RN stated, I have been in to see her (SP#6). I assisted her with the bedpan this morning.

(3). Clinical record review of SP#9 conducted on 12/30/2013 showed that the patient was admitted to the facility on 12/26/2013 with diagnosis of slip and fall, rule out lumbar fracture. Review of Physician Orders on 12/28/2013 stated to turn the patient (every)q2hr. Review of Activity of Daily Living documentation from 12/28/2013 to 12/30/013 revealed the only documentation that the patient was turned was on 12/28/2013 at 8:31am. On 12/29/2013, the patient's activity status is documented as complete limited and needing total assistance.

In an interview with the Dir. of Med-Surg/Oncology on 12/30/2103 at 11:40am, the Dir. stated that turning should be charted every two hours if it was ordered even if the patient can turn on their own, it should still be documented. The findings that there were no documentation for both SP#6 and #9 on turning the patients as ordered by the physician was confirmed with the Director of Med.Surg/Oncology.
(4). Clinical record review of SP#7 conducted on 12/30/2013 showed that the patient was admitted to the facility on 12/27/2013 with a diagnosis of DKA (Diabetic Ketoacidosis). According to the ED Nurse Notes, the patient has an open wound to the left upper extremity, drg (dressing) applied to affected area. The Wound Care Notes on 12/27/2013 at 16:47 stated, that the Pt (patient) was seen for left arm wound present on admission. The wound measures L (length) 45cm (forty-five centimeters) x W (width) 3.5 (three point five) cm x D (depth) 0.5 (zero point five)cm. The wound bed is necrotic and yellow. It is recommended that a multidisciplinary approach to wound healing be adapted. Review of SP#7's Interdisciplinary Care Plan that was started on 12/29/2013 revealed that the section on Skin Integrity was not initiated or updated to reflect care of the patient's wounds.
In an interview with the Director of Medical-Surgical/Oncology (Dir.) on 12/30/2103 at 12:22 pm, the Dir. stated that the care plans should be updated every shift. The nurses update the care plans by dating and initialing the plan beside the patients' problems that have been identified. The findings were confirmed that there was failure to ensure that the nursing care plans are maintained accurate and current.

Based on interview and record review the facility failed to ensure that the nursing assessment, intervention and care plan is documented and kept current in 4 of 10 sampled patients (SP # 1, SP#6, SP#7 and SP#9).

Findings include:

(1) Clinical record review of SP#1 conducted on 12/30/2013 showed documentation on 10/25/2013 that the Integumentary Assessment was WDL (Within Defined Limits). The Nursing Note documentation on 10/30/213 at 17:09 showed that the patient ' s skin is intact with the exception of the mid-abdominal surgical incision. The Wound Care Note on 10/31/2013 at 15:14 pm showed that the patient has no evidence of pressure ulcer. Nurses to monitor the skin integrity every shift. . There is no description of the skin assessment of the sacral area on 11/4/2013, 11/5/2013 and 11/6/2013.

The Director of Oncology/1N stated on 12/30/2013 at 1:14 p.m. that when the patient was transferred to our floor, the nurse did not document that there was a scab, a hardened area on the sacrum. The next day, a student nurse showed it to the patient ' s nurse but that nurse did not do anything and did not document. A different nurse saw that the scab fell off. The patient was already on an air mattress and a wound care consult was called and it was an unstageable ulcer. The nurses were counseled and they went with the Wound Care Nurse for a full day to be educated on the proper assessment and documentation of pressure ulcers.

Further record review of SP#1 ' s chart revealed that photographs of the sacral ulcer were taken but there was no photograph taken prior to the patient ' s discharge. This finding was confirmed from the Director of Clinical Information on 12/30/2013 at 4:15 p.m..

Review of the policy on Skin Integrity Assessment & Protocol for Impaired Skin revealed that if the Registered Nurse/Licensed Practical Nurse identifies patient has skin integrity issue, notify Wound Care Nurse for proper assessment, staging and recommended treatment. A skin reassessment will be performed no less than every 12 hours and documented in the electronic medical record. It is also stated that photographs of the wound will be taken upon discharge.

(2). Clinical record review of SP#6 conducted on 12/30/2013 shows that the patient was admitted to the facility on 12/29/2013 for leg infection. Review of the Physician Orders revealed a Nursing Communication Order which stated to turn patient q 2 hours (every 2 hours). Review of the patient's medical records did not reveal any documentation that the patient was turned.
Observation of SP#6 on 12/30/2013 at 12:50 pm revealed that the patient was alert in bed with family at the bedside. Both of the patient's legs were observed to be wrapped with bandages from the ankles to the knees.
In an interview with SP#6 on 12/30/2013 at 12:50 pm, the patient stated that I am not able to turn on my own. Nobody has been in to see me they come in and out and ask me questions, nobody came to help me use the bathroom, I use my wheelchair to get myself to the bathroom.
In an interview with Registered Nurse (RN) #1 on 12/30/2013 at 12:55 pm, the RN stated, I have been in to see her (SP#6). I assisted her with the bedpan this morning.

(3). Clinical record review of SP#9 conducted on 12/30/2013 showed that the patient was admitted to the facility on 12/26/2013 with diagnosis of slip and fall, rule out lumbar fracture. Review of Physician Orders on 12/28/2013 stated to turn the patient (every)q2hr. Review of Activity of Daily Living documentation from 12/28/2013 to 12/30/013 revealed the only documentation that the patient was turned was on 12/28/2013 at 8:31am. On 12/29/2013, the patient's activity status is documented as complete limited and needing total assistance.

In an interview with the Dir. of Med-Surg/Oncology on 12/30/2103 at 11:40am, the Dir. stated that turning should be charted every two hours if it was ordered even if the patient can turn on their own, it should still be documented. The findings that there were no documentation for both SP#6 and #9 on turning the patients as ordered by the physician was confirmed with the Director of Med.Surg/Oncology.
(4). Clinical record review of SP#7 conducted on 12/30/2013 showed that the patient was admitted to the facility on 12/27/2013 with a diagnosis of DKA (Diabetic Ketoacidosis). According to the ED Nurse Notes, the patient has an open wound to the left upper extremity, drg (dressing) applied to affected area. The Wound Care Notes on 12/27/2013 at 16:47 stated, that the Pt (patient) was seen for left arm wound present on admission. The wound measures L (length) 45cm (forty-five centimeters) x W (width) 3.5 (three point five) cm x D (depth) 0.5 (zero point five)cm. The wound bed is necrotic and yellow. It is recommended that a multidisciplinary approach to wound healing be adapted. Review of SP#7's Interdisciplinary Care Plan that was started on 12/29/2013 revealed that the section on Skin Integrity was not initiated or updated to reflect care of the patient's wounds.
In an interview with the Director of Medical-Surgical/Oncology (Dir.) on 12/30/2103 at 12:22 pm, the Dir. stated that the care plans should be updated every shift. The nurses update the care plans by dating and initialing the plan beside the patients' problems that have been identified. The findings were confirmed that there was failure to ensure that the nursing care plans are maintained accurate and current.