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Safe nursing services was not provided to 1 of 4 sampled patients with hypothermia, causing the patient to sustain blisters and burns to the patient's back, arms and breast from for the use of warm packs to treat hypothermia. This practice was not in the hospital's policy for the treatment of hypothermia. (#1).

Findings:

Based on observation, interview, record review and a review of facility documentation, the facility failed to ensure that nursing staff developed a plan of care to address physician orders for the use of warm packs as entered into the medical record which contradicted facility protocols on how to address patient hypothermia and meet the patient needs, and document such actions and the response to such actions, while avoiding multiple burns on the body for 1 of 4 sampled patients (#1).

Based on observation, interview, record review and a review of facility documentation, the facility failed to ensure that nursing staff developed a plan of care to address physician orders for the use of warm packs as entered into the medical record which contradicted facility protocols on how to address patient hypothermia and meet the patient needs, and document such actions and the response to such actions, while avoiding multiple burns on the body for 1 of 4 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. The patient was admitted to the facility on 6/29/19. The History & Physical of 6/30/19 read that the patient had "a PMHX (past medical history) significant for morbid obesity, hypertension, alcoholic cirrhosis, diabetes, mood disorder, CVA (cerebrovascular accident) with residual left-sided weakness...." The patient was nonverbal and followed simple commands appropriately.

Nurse's notes for 9/14/19 at midnight revealed that the patient had a temperature of 94.2 degrees Fahrenheit. This is suggestive of the patient having hypothermia. Verbal physician orders of 9/14/19 at 6:12 AM by physician A, as entered by registered nurse (RN) C, House Supervisor read, "Apply warm packs to patient until patient's temp normalizes." Later text revealed statements from various staff members which indicated that an order, documented in the medical record as being from the physician in response to a report of hypothermia and the actual performance of warm pack placement, took place closer to 2 AM on 9/14/19.

There was no evidence of any nursing documentation by the patient's assigned 7 PM - 7 AM nurse, RN F, or any other nurse, which indicated the performance of warm pack placement. RN F did not document the occurrence of any subsequent burns.

A nurse's note of 9/14/19 at 8 AM by RN G read, "Received pt (patient) in bed, as per nurse pt got burn, upon assessment pt noted to have burn to right upper arm, right breast, left upper arm, left breast and right abd. Dressing done." This was the first nursing entry in the medical record which indicated that the patient had experienced recent, multiple burns. A nurse's note by RN H on 9/14/19 at 8:30 AM read, "Night shift advised me of wounds on patient's arms, breasts and groin area. I advised ARNP (Advanced Registered Nurse Practitioner) and received orders for Silvadene."

Advanced Registered Nurse Practitioner (ARNP) I acknowledged the presence of blisters in his note of 9/14/19 at 9:30 AM. A nurse's note of 9/14/19 at 120 PM by RN H read, "Right arm reddened and blistered with partially open blister and a large dark center area. Right breast open blister, red with dark edges. Left breast partially opened blister, fluid filled blister, dark areas. Left upper arm red with dark blister, partially fluid filled. Left lower arm reddened with fluid filled blisters. Right lower abdomen fluid filled blister. Right thigh reddened. Head and neck red, blistered open and fluid filled with dark areas. Silvadene applied as per order this am. Wound Care RN will see patient today."

Wound Care nurse notes of 9/14/19 at 5:29 PM recorded burn wounds on the following sites with respective dimensions: (1) arm left 8 CM (centimeters) X (by) 13 CM; (2) arm left 15 CM X 6 CM; (3) Left 15 CM X 39 CM; (4) arm right 15 CM X 25 CM; (5) right 15 CM X 26 CM; (6) quadrant, abdomen right lower 12 CM X 18 CM; (7) leg right, anterior 115 CM X 10 CM; (8) and neck posterior 12 CM X 21 CM.

A physician's note on 9/23/19 read, "Numerous deteriorating wounds, fat necrosis changes." A physician's note of 9/24/19 read, "Examined wounds today with RN, agree with transfer to (local acute care hospital) for burn unit." The patient was discharged from the facility on 9/25/19.

The Discharge Summary of 10/01/19 read, "Pt also developed multiple burn wounds during her stay. She received wound care while she was hospitalized however the burn wounds progressively worsened. It was determined that pt. would require further treatment at (local acute care hospital) burn unit so she is being transferred there for further care of her wounds."

A review of facility policy "Hypo/Hyperthermia Units read, "Use of warming blanket is indicated for patients with core temperature <36 degrees centigrade or 96.8 degrees Fahrenheit." The patient had a axillary temperature of 94.2 degrees Fahrenheit. There was no mention in the policy of any authorization for the use of warm packs of any type.

On 1/28/20 at 9:40 AM, the Director of Quality confirmed the preceding information in the medical record. As to any policy concerning the questioning of unreasonable commands, the Employee Handbook read, "Employees who find themselves in a situation where a question exists as to whether certain conduct might violate legal or regulatory requirements or the Company's Compliance Program should refrain from taking any questionable action or promptly consult with their Manager/Supervisor. Employees also may raise questions directly with the Compliance Officer, any other member of the Compliance and Audit Committee...or the Legal Department....Select Medical also expects employees to know enough to ask questions before engaging in any questionable conduct. When in doubt, the right course is to refrain from taking any action or raise questions with the above-mentioned senior personnel before taking any action." Thus, the use of warm packs for patient #1 was in violation of facility policy concerning hypothermia and the failure of nurses to object to an order, as it appeared in the medical record, while they had a right to do so per policy was itself a failure to follow the hospital policy.

A statement by physician A on 9/30/19 read, "I was covering the Night Physician call at Select Specialty Hospital North Campus on Friday September 13th.... During the night, I was notified by the Night Nurse Supervisor around 1 AM about the patient... had low body temperatures than her baseline. I gave orders to... start on hypothermia treatment as per the Hospital protocol...." Thus, per this statement, the physician stated that she ordered hypothermia treatment per an established protocol. It does not indicate that she specifically ordered warm packs in any form.

A statement by RN B on 9/15/19 read, "I would hereby like to express what happened on Friday, September 13, 2019 with the assigned patient to the nurse [RN F]. Patient...did not have regulated temperature.... At that time the (House) Supervisor [RN C] along with [RN D] took ice packs and filled them with hot water to help regulate the patient's temperature, around 2:00 AM they were placed beside the patient. Around 3:00 AM [Certified Nursing Assistant (CNA) E] and [RN F] noticed that the patient's bed was wet and the water bags that were placed were leaking and/or open caused by the hot water. When they were removed from the patient, they observed burn wounds on the patient. Immediately [RN C] Supervisor was called. When [RN D] was in the room, she immediately called me to head out to the patient's room. At that time the supervisor showed us the burn wounds that the patient had in the right arm...."

An addendum to the immediately preceding statement, also by RN B (date unknown) read, "the patient in 21B [#1] is in...hypothermia....When I observed [RN C] House Supervisor next to [RN D] heading to the nourishment room with some ice packs, I went to the room couples of minutes after I saw them preparing the ice packs with hot water from the coffee machine. At that moment I asked both [RN C] HS (House Supervisor) and [RN D] what they going to do with the bags. They both told me that they were going to place the bags on the patient to help her to regulate temperature. Immediately they gave me 3 bags...(fill with hot water) and told me to place them on the patient while they both finished filling the remaining bags. At 2 AM I put a towel on the back of the patient's neck and placed the bag given to me by [RN C] HS and [RN D]. Then on the right side I put a sheet under the arm and put another bag and finally put one more on the right leg. I want to emphasize that I was following instructions from two superiors of mine.... Then, [RN D] places the bags on the left arm, left leg and chest area. Around 3:00 AM [CNA E] and [RN F] noticed that the patient's bed was wet and the water bags that were placed were leaking and/or opened by the hot water. When they had removed them from the patient, they observed burn wounds on the patient. Immediately [RN C] Supervisor was called....At that time the supervisor showed us the burn wounds that the patient had in the right arm and left the room...."

A statement by RN F on 9/16/19 read, "I had the patient (patient #1) for the night shift of 9/13/19....Around 2:00 AM [RN D] told me that (patient #1) was septic and they were going to get a terminal blanket for her...Later on [RN C] House Supervisor), [RN D] and [RN B] came in to the room with warm water bags to place on her...[RN D] and [RN B] placed the bags on (patient #1). Around 3:00 AM [CNA E] and myself went in to the room and notice the blankets were wet from the bags, and decided to take the bags off; at this point is when [CNA E] and I noticed the skin burns.

An undated statement by RN D read, "During the early morning hours of September 14, 2019, at approximately between 01:00 - 01:45 AM, ice pack bags were filled with hot water to assist in normalizing the temp of the patient in 8621B....Warm compresses were filled and given to [RN B].... After filling packs...between 03:30 AM and 04:00 AM, [RN C] (House Supervisor) was called to room 8621. [RN C] went to patient's room and returned shortly to ask me to come to 8621. When I walked into the room [RN C] was holding patient's right arm up, at which time I saw that the patient's arm looked to have a large blister, and a blister was also noted to on left side of patient's left breast....On 9/14/19, I assisted house sup. [RN C], with filling ice packs with hot water and handing them to nurse [RN B] in the nutrition room.... While in room 8607, [RN C] was paged to go to 8621. She shortly returned and asked me to come to 8621. Upon entering the room, [RN C] was holding patient's right arm, I saw a large blister under patient's right arm and on patient's left breast."

A statement by CNA E on 9/13/19 read, "Approx 4:30 AM I went back into (patient #1) rm (room)...I removed her linen and water bags. As I removed the water bags, I noticed blisters under (patient #1) arms and on her breast. ... She was soiled and wet from the water bags, as we turned her I then noticed the blisters on back of her neck."

A statement of 9/14/19 by RN C, House Supervisor, read, "On 9/14/2029 at 1:30 AM, the patient in room 8621B(patient #1) developed a hypothermic temp of 94 f (Fahrenheit) ax (axillary) bilaterally.... On-call [physician A] notified....Order received to apply warm packs on pt until pt's temp normalized ....[RN D] and myself began filling multiple ice pack bags with warm water and provided instructions to [RN B] by both of us... [RN B] verbalized acknowledgment of instructions and gathered up the warm packs... and took items to pt's room to apply to pt per MD (physician) orders.... At 03:45 AM, the assigned [CNA E], and primary RN began...cleaning pt since she was now stable, at which I was called to the pt's room & shown that her bilat upper inner arm/breast areas had developed large blistered areas from warm packs that they removed....At that time all the warm packs that remained on the pt were removed...." An addendum to the immediately preceding statement, also by RN C, House Supervisor, on 9/27/19 read, "At 01:30 AM I called the on-call room from the nurse's station and notified [physician A] that 8621B had triggered a sepsis alert...[physician A] gave me orders to...apply warm packs to patient until patient temp normalized. All MD orders were entered by me.... At 03:45 AM when I was alerted to the room due to staff discovering the new blisters, and after I ordered the staff to take all the warm packs off the patient...I called [physician A] from the nurse's station to the on-call room and notified her of the development of multiple medium and large blistered areas from the warm packs..."

An examination of the bag type that was used as warm packs was performed on 1/28/20 at approximately 10:15 AM. It was labeled by the manufacturer (CardinalHealth) as "Ice Bags". There was nothing on the brief informational sheet which came with it to indicate that any hot water could be used with it. A closed, flat Ice Bag had the dimensions of approximately 11 inches by 5 ½ inches. This bag was not appropriate or approved for use with hot water, in addition to not being authorized for use with hot water by facility policy.

An examination of the coffee maker which provided the water for the ice bags ("warm packs") was performed on 1/27/19 in the presence of the Administrator and the Director of Quality. The temperature of water produced by the coffee maker was 167 degrees Fahrenheit.

In summary of the findings from interview, observations, record review, written statements and facility documentation, the patient had developed hypothermia in the early morning hours of 9/14/19. The House Supervisor stated that the physician had ordered the use of warm packs; she entered this as a verbal order. The physician stated that she had ordered the following of the hypothermia protocol, instead. The use of warm packs in any form was not an approved practice of the facility in cases of hypothermia or any other condition. The ice bags were not designed by the manufacturer to hold hot liquid. Nurses at all levels had the responsibility to challenge the order, command or practice to use warm packs, and not follow the hypothermia policy. There was no evidence of such an objection having been made. As a result, warm packs were applied to the patient and they caused numerous burn wounds on her body. The temperature of the water used had a reasonable prospect of being close to 167 degrees Fahrenheit. Other than the documentation of the physician order, there were no entries in the medical record by the nurse on the 7:00 PM - 7:00 AM shift which addressed the orders for warm packs, their effects on the patient or the circumstances surrounding their removal.

During an interview of the Director of Quality on 1/28/20 at approximately 1:45 PM, she confirmed the above findings.