HospitalInspections.org

Based on record review, interview, and policy review, the provider failed to:
*Ensure a nursing assessment for one of ten sampled patient's (8) response to pain medication was documented prior to discharge.
*Ensure a referral was made to the wound care nurse for one of seven sampled patients (8) with skin breakdown.
*Assess and document the skin breakdown for one of one sampled patient (8) prior to discharge.
*Complete an initial nursing assessment of the patient's skin breakdown for one of three sampled patients (2) admitted with known skin breakdown.
*Ensure the nursing staff implemented facility protocol for completing the home medication reconciliation process for one of ten sampled patients (7).
Findings include:

1. Review of patient 8's medical record revealed:
*A 12/23/13 admission date for right total shoulder arthropathy surgery. There was no documentation of any skin breakdown.
*A 12/26/13 discharge to home (no time documented). There was no nursing documentation of pain or skin integrity at the time of discharge.

Review of patient 8's 12/26/13 nursing assessment notes and medication administration record revealed:
*12:51 a.m. Two ulcers right buttocks. General appearance of areas red and moist. Tegaderm (clear see-through dressing) applied. Would obtain wound consultation.
*12:21 p.m. Percocet was documented as administered for right shoulder pain for a pain score of 8/10. There was no documentation of any reassessment of her pain after the administration of the Percocet or that a referral had been made for a wound consultation regarding the two ulcers to the right buttock.

Phone interview on 2/7/14 at 10:30 a.m. with patient 8's daughter regarding her pain and ulcers on her right buttock revealed:
*She had tried to tell the nursing staff on 12/23/13 after her surgery she had some sore areas on the back of her right leg. She thought the areas might have been from her Foley catheter tubing (tube inserted into the bladder to drain urine). She did not think they had done anything about the areas.
*There was no documentation in the medical record of any areas on her right leg on 12/23/13.
*They were given no discharge instructions on 12/26/13 on how to care for the two buttock areas. She took the patient to her own doctor on 12/27/13, and a treatment had been prescribed.
*She had not been informed of the patient's pain on 12/26/13 and that Percocet had been administered at 12:21 p.m. She had felt the patient had not had adequate pain control after her right shoulder surgery.
*The patient had been discharged from the hospital at about 1:30 p.m. on 12/26/13.

Review of patient 8's 12/26/13, 10:26 a.m. nursing discharge assessment revealed:
*No mention of the two ulcer areas on her right buttock or any treatment for them.
*"Controlling pain is an important part of your surgery. Take your pain medications or treatments as prescribed. Call your doctor if these are not working, your pain gets worse, or you have onset of new pain."
*Percocet and Tramadol (pain medication) were prescribed as needed for pain (two of the same pain medications she had received in the hospital).

Interview on 2/7/14 at 11:15 a.m. with wound care certified registered nurse (RN) A regarding patient 8's above ulcers revealed:
*She had not evaluated the areas on 12/26/13 as she had not been on duty. The patient had been discharged from the hospital on 12/26/13.
*No preventative skin measures had been put in place on 12/23/13 when she had been admitted due to her low risk of skin breakdown indicated by her Braden score of 21 (Braden scale of 21 to 23 was low risk on a 21 out of 24 skin assessment).
*She was not aware of the daughter's comment the areas had been present on 12/23/13 after surgery.

Interview on 2/7/14 at 9:00 a.m. with nurse manager B regarding patient 8's pain revealed:
*There was no documentation in the medical record what time she had been discharged from the hospital.
*The Percocet that had been administered at 12:21 p.m. should have been reassessed and documented regarding its effectiveness on her pain.

Review of the provider's June 2002 Pain Management policy revealed:
*"Identify discharge pain needs, arrange for services to meet them, and facilitate appropriate referrals."
*"Document pain plan, pain assessments, interventions, and effectiveness of pain measures in the EMR (electronic medical record)."



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2. Interview and review on 2/7/14 at 2:00 p.m. with nurse manager B regarding patient 2's EMR and wound assessment/skin assessment records revealed:
*She had been admitted on 1/30/14 at 5:03 p.m. from the hospital's emergency room (ER) to the medical/surgical floor.
*There was no documentation of a coccyx (buttock) pressure ulcer/wound description found in the ER record.
*The initial wound assessment/skin assessment documentation had been completed by the nurse on 1/30/14 at 8:00 p.m. for a pressure ulcer to her coccyx.
*She had a DuoDerm dressing in place, the dressing had not been removed at the time of the skin assessment, and there was no initial description of the pressure ulcer appearance.
*On 1/30/14 at 8:00 p.m. the nurse should have removed the DuoDerm dressing and documented the appearance of the pressure ulcer.
*The wound assessment/skin assessment documentation completed by the nurse on 1/31/14 at 8:15 a.m. indicated the DuoDerm dressing was intact, the pressure ulcer was not observed, and there was no description of the pressure ulcer appearance.
*There was no initial description of the pressure ulcer on 1/30/14 the nurse should have removed the DuoDerm dressing and documented a description of the patient's pressure ulcer.
*The nurses might have thought it was the wound care certified RN's responsibility to document the wound description.
*The wound assessment/skin assessment documentation completed by the nurse on 1/31/14 at 8:30 p.m. had a wound description, and the nurse had applied Calmoseptine cream to the pressure ulcer.
*The Braden Scale skin assessment risk score was 12 which indicated she was at a high risk for skin breakdown.

Review of the provider's November 2013 Skin Integrity: Maintenance, Protection/Prevention, and Treatment policy revealed:
*"1. Assess skin integrity with special attention to bony prominences upon admission and every shift."
*"2. Complete the Skin Integrity Risk Assessment (Braden Scale) on admission and every shift thereafter."
*"3. If open areas/wounds noted perform wound and peri-wound assessment."

3. Review and interview with RN J on 2/6/14 at 3:00 p.m. regarding the EMR and the Patient Orders Summary for patient 7's medications ordered by the physician revealed:
*He had been triaged in the ER on 12/5/13 at 3:04 a.m., discharged from the ER at 5:42 a.m., and admitted as an inpatient to the medical unit.
*The medication reconciliation form had not been used by the physician to order medications. That form was an option for physicians to use when ordering medications.
*There were no medication orders on the Patient Orders Summary dated 12/5/13 for heart medications, blood pressure medications, or organ antirejection medication.
*The patient's heart medications, blood pressure medications, and organ antirejection medication were ordered on 12/6/13 at 6:01 a.m.
* The patient did not receive his heart medications, blood pressure medications, and organ anti-rejection medication on 12/5/13.
*She did not know why the patient had not received those medications on 12/5/13.
*There was no documented summary or medication hold orders for those medications found in the EMR.
*The Home Medication List had been completed on 12/5/13 between 9:30 a.m. and 10:00 a.m. by the medication reconciliation nurse. The completion of that list had been indicated on the hospital computer status board. It was available for viewing by the nursing staff and physicians.
*It was the responsibility of the floor nurse assigned to a patient to ensure interventions listed on the computer status board were completed or addressed.

Review of patient 7's Home Medication List revealed it had been completed on 12/5/13 by RN K and last edited between 9:51 a.m. and 9:53 a.m. The Home Medication List documented the medications the patient was taking prior to admission, administration time, current dosage, and the date and time of the last dose.

Interview on 2/7/14 at 8:22 a.m. with RN K revealed:
*She was responsible for reconciliation of home medications for all inpatients in the hospital.
*Medication reconciliation included talking with the patients, family, physicians, and other sources to compile an accurate list of the medications taken by patients.
*The physician reviewed the Home Medication List when ordering medications during the patient's hospital stay.
*The floor nurse responsible for patient 7 had called her twice on 12/5/13 inquiring when she would complete the Home Medication List.
*She had completed the Home Medication List between 9:30 a.m. and 10:00 a.m., and completion of that list was indicated on the hospital status board.
*The hospital status board had an intervention that would have been marked completed by the nurse when the physician had addressed home medications.
*She did not know why the staff nurse responsible for patient 7's care on 12/5/13 had not addressed ordering the patient's home medications with the physician.
*Each floor nurse had a responsibility to review the computer status board to determine what care/treatments/tasks were required or needed completion for patients each day.
*Once the nurse responsible for the patient's care had addressed home medications with the patient's physician that intervention on the status board would be documented as completed.
*The nurses and physicians had assess to the computer status board.
*The provider's April 2013 Home Medication Reconciliation Order Form policy was outdated because:
-The Home Medication List was not used as an order sheet.
-The admission reconciliation process had changed October 18, 2013. The medication reconciliation form was no longer an option for physicians to order admission medications.

Interview on 2/7/14 at 10:30 a.m. with the medical director, vice-president of patient services, and nurse manager B regarding patient 7 revealed:
*The medical director indicated it was an acceptable practice for the admitting physician to withhold medications for up to 24 hours while assessing the patient's condition.
*The physician caring for the patient on 12/5/13 might have received an update/report on the patient's status and medication orders from the physician going off-duty. Those updates/reports were not documented.
*The Home Medication List was reviewed by physicians when ordering medications.

Review of the April 2013 Home Medication Reconciliation Order Form policy revealed:
*All patients admitted would have an accurate and complete list of the medication they were taking at home in their EMR.
*The home medications would be reconciled against the admission orders, and any discrepancies should have been explained or clarified within 24 hours of admission.