HospitalInspections.org

Based on observation and interview, the hospital failed to ensure the safety of patients by failing to provide an environment in patient rooms which minimized safety risks for patients admitted to the hospital. Findings:
The following observations were made during the initial tour with S2DON on 06/13/16 at 10:10 a.m. in all patient rooms:
Beds which were made of open metal framework with springs and contained hand crank handles attached at the foot of the beds.
Interior bathroom doors contained three separate hinges which allowed space between the hinges (ligature risk); interior bathroom door handles were downward-facing paddle type door handles (ligature risk); bathroom door handles were secured with regular screws (no safety screws); bathroom door plates were secured with regular screws.
The bathrooms had gooseneck faucets on the sinks, and the toilets had exposed plumbing on top.
The holders for patient alarms were attached to the walls with regular screws.
Attached to the windows from the outside were metal open-weave-design grates instead of screens (ligature risk).
In an interview on 06/13/16 at 10:25 a.m., S2DON confirmed the above-referenced observations, and she agreed there were safety and ligature risks in patient rooms.
In an interview on 06/14/16 at 3:00 p.m., S1Director confirmed all of the patient rooms were set up identically with the same type of beds, metal grates on the windows, bathroom doors, sink faucets, and exposed plumbing pipes on the toilets. S1Director indicated the hospital had been made aware of the issue regarding the beds, and the corporate office was looking into how the company was going to address the issue. S1Director agreed the above-referenced observations were safety and ligature risks.

Based on record review and interview, the hospital failed to ensure the QAPI program failed to measure, analyze and track quality indicators for all processes of care, hospital service and operations. This deficient practice is evidenced by failing to include indicators in the QAPI program for various aspects of wound care.

Findings:

Review of a hospital provided list of patients with wounds revealed there had been 17 patients requiring wound care since January 2016.

Review of the medical records for Patients #1, #2, #3, #4, and #5 revealed they were all assessed to have wounds while in the hospital. Further review revealed no documented measurements of the wounds or detailed descriptions of the wounds in the medical records.

Review of the QAPI data for the hospital revealed no indicators for wound care, documentation of wound care, assessment of wounds, or the number of hospital acquired wounds.

In an interview on 06/14/16 at 10:34 a.m. with S1Director, she said they had not previously identified any problems with wound care at the hospital and the QAPI program was not tracking any indicators for wounds. S1Director also said she did not track how many of the patients' wounds were acquired at the hospital. After reviewing wound care documentation for Patients #1, #2, #3, #4 and #5, S1Director verified the nurses were assessing wounds incorrectly and failing to document wounds as per the hospital's policy.

In an interview on 06/14/16 at 2:30 p.m. with S11LPN, she said she was over the QAPI program at the hospital. S11LPN verified there were no indicators for wounds or wound care in the QAPI program, and the hospital did not track patients' hospital acquired wounds or wounds that increased in severity while receiving care in the hospital.

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Based on record review and interview, the hospital failed to ensure that each patient's care was assessed and evaluated by a RN as evidenced by:
(1) failing to ensure that wound care was accurately assessed and documented for 5 (#1-#5) of 5 sampled patients in a total sample of 5; and
(2) failing to follow/implement physician orders for 2 (#1,#3) of 5 sampled patients in a total sample of 5; and
(3) failing to notify the physician of abnormal assessment findings for 1 (#4) of 5 sampled patients in a total sample of 5.
Findings:
(1) Failing to ensure that wound care was accurately assessed and documented
A review of the policy and procedure entitled Skin and Wound Care, Policy Number, NSG-39, presented as current by S1Director, revealed in part: ". . . A weekly skin assessment and risk evaluation is performed by the nurse on geriatric patients; Prevention Protocol Procedure: 1. Patients are identified as at risk for wound development based on the Braden scale, nursing judgment or by orders; 2. Implements prevention protocol on at risk patients; 3. Completes the prevention assessment form on all patients that are identified at risk; 4. Implements the wound care protocol; 5. Notes the close observation sheet with the at risk protocol; 6. Communicates the at risk status to all staff to implement the prevention protocol . . . Nurse: will assess the patient's skin for alteration in integrity and risk for breakdown on admission; will implement Prevention Protocol if Braden score is < 18 and will reassess weekly and PRN, refer to Prevention Protocol; will implement appropriate Wound Care Protocol when applicable or as ordered by physician for specific wound management regimen, refer to Wound Care Protocol; Will notify physician to order nutritional consult if patient admitted with a wound; will document initial wound findings in the admit nursing assessment and indicate on the figure/drawing of the person on the nursing assessment form; a picture of the wound will be taken on admit and findings of the assessment of the wound to provide a baseline; pictures will be retaken as a comparison of progress or worsening at a minimal every 2 days; Nursing will utilize the wound assessment guidelines to describe and document the wound in a consistent and accurate manner. The description many include as relevant the location, type, where acquired, stage, length; wound description will be documented in the progress notes when wound care is performed. Wound length, width, and depth will be measured in centimeters weekly.
Patient #1
Review of the medical record for Patient #1 revealed she was a 59 year-old female admitted to the hospital on 05/20/16 at 1:30 p.m. Admission diagnosis was Bipolar Disorder, Current Episode Depressed. Other diagnoses included a history of breast cancer with bilateral mastectomy in 2002, and a wound to the right mastectomy site. Further review revealed the initial nursing assessment done by the RN on 05/20/16 revealed no documented evidence the wound was assessed and documented with a description of the wound which included wound measurements, description of the wound bed, surrounding tissue, color, odor, drainage, etc. The initial nursing assessment revealed under the section, "Wounds, number of:" a zero. A review of the "Wound Assessment" documentation forms dated 05/20/16, 05/26/16, 05/31/16, 06/03/16, 06/06/16, 06/09/16 and 06/12/16 revealed there was no documented evidence the wound had been measured to include the width, length, and depth. Review of the "Skin and Braden Reassessment Documentation" sheets dated 05/21/16, 5/28/16, 06/04/16, and 06/11/16 revealed no documented evidence the wound had been measured to include the width, length, and depth.
In an interview on 06/16/16 at 10:20 a.m., S2DON reviewed the entire medical record and confirmed there were no wound measurements documented on the initial assessment in the medical record, and no subsequent wound measurements documented in the medical record. S2DON agreed the wound should have been assessed and documented to include all components of accurate and complete wound assessments.
Patient #2
Review of the medical record for Patient #2 revealed he was admitted from home on 01/18/16 at with diagnosis which included Dementia with Lewy bodies.

Review of documents in Patient #2's medical record titled Skin and Braden Reassessment Documentation revealed the following assessments:
01/23/16- Skin intact- some redness to sacrum.
01/25/16- redness to sacrum; no wounds
01/30/16- 2 stage 2 wounds to bilateral buttocks. Consult put in for medical MD to assess
02/7/16- Multiple stage II pressure ulcers to buttocks x 7.

Review of Patient #2's multi-disciplinary notes revealed no mention or description of the wounds on the buttocks until 02/11/16 (day of the discharge).

Review of Patient #2's medical record revealed no physician's progress notes about his wounds until the day of discharge, no detailed descriptions of the wounds by the nursing staff, and no measurements of the wounds by the nursing staff.

In an interview on 06/14/16 at 10:34 a.m. with S1Director, she verified the only physician's progress note for Patient #2 concerning his wounds was documented on the day of discharge (02/11/16). She also verified dimensions of the wounds were not assessed and there were no detailed wound descriptions documented.

Patient #3
A review of the medical record for Patient #3 revealed she was a 77-year-old female admitted to the hospital on 03/08/16 at 8:30 p.m. Admitting diagnoses was Major Depressive Disorder, Single Episode, Unspecified. The patient also had a diagnosis of Stage II pressure ulcers. Further review revealed on the initial nursing assessment revealed the 3 pressure ulcers to the left buttock were all documented as "0.5 cm diameter," but there was no documentation of the length, depth, wound bed, surrounding tissue, color, odor, and drainage.
In an interview on 06/14/16 at 12:40 p.m., S2DON reviewed Patient #3's entire medical record and confirmed there was no documented evidence in the medical record the 3 pressure ulcers had been assessed and documented for length, depth, wound bed, surrounding tissue, color, odor, and drainage, and it should have been assessed and documented to include all components of accurate and complete wound assessments.
Patient #4
A review of the medical record for Patient #4 revealed he was a 78 year-old male admitted to the hospital on 05/25/16 at 10:15 a.m. Admitting diagnosis was Major Depressive Disorder, Single Episode, Unspecified. Further review of the initial nursing assessment dated 05/25/16 revealed Patient #4 had an unstageable ulcer to the right heel with a description documented as "5 x 5 cm." Review of the Hospital Wound Assessment" form dated 05/31/16 revealed there was no documented evidence of the assessment of the wound measurements, wound bed, or odor. Review of the Hospital Wound Assessment" form dated 06/03/16 revealed a picture of a heel with the location of the wound described as "left buttock."
In an interview on 06/14/16 at 1:54 p.m., S1Director and S2DON reviewed Patient #4's entire medical record and confirmed there was no documented evidence the above-referenced wound had been correctly assessed and documented, the descriptions of the wounds were incomplete and inaccurate, and S1Director and S2DON agreed the wound should have been assessed and documented to include all components of accurate and complete wound assessments.
Review of Patient #4's "Skin and Braden Reassessment Documentation dated 05/28/16 revealed" Red, Stage 1 to left buttock," and there was no picture of the left buttock in the medical record. Review of the "Skin and Braden Reassessment Documentation" sheet dated 06/04/16 revealed "Stage I" documented to left buttock. Further review of the medical record revealed there was no documented evidence the red area of the left buttock had been assessed for blanching, dimensions, and a description of the surrounding tissue.
In an interview on 06/14/16 at 1:54 p.m., S1Director and S2DON reviewed the entire medical record and confirmed there was no documented evidence the red area to Patient #4's left buttock had been correctly assessed and documented, and S1Director and S2DON agreed the area should have been correctly assessed and documented to include all components of accurate and complete wound assessments.
Patient #5
A review of the medical record for Patient #5 revealed she was a 93-year-old female admitted to the hospital on 04/19/16. Admit diagnoses included Major Depression, Recurrent, Severe, Without Psychotic Features, and Dementia Early Stages. Further review of the medical record revealed the initial nursing assessment dated 04/19/16 documented "red, no breaks" with a line drawn to the patient's sacral area.
Review of Patient #5's "Skin and Braden Reassessment Documentation" sheets revealed the following documentation: 04/23/16, "Stage II, right buttock"; 04/30/16, "Stage II, right buttock"; 05/07/16, "redness to bilateral buttocks, Stage II right buttock"; 05/14/16, "redness to bilateral buttocks, Stage II right upper thigh and right buttock."
Review of Patient #5's "Hospital Wound Assessment" forms revealed: 1) 04/28/16 "Stage II, right buttocks" (no dimensions documented); 05/07/16 "Pressure wound, buttocks" (no documentation regarding redness to bilateral buttocks, stage of ulcers, and wound dimensions). Further review of the medical record revealed there was no documented evidence the above-referenced reddened areas had been assessed for blanching, dimensions, and a description of the surrounding tissue.
In an interview on 06/14/16 at 3:00 p.m., S1Director reviewed the entire medical record and confirmed there was no documented evidence Patient #5's wounds had been correctly assessed and documented, and S1Director agreed the areas should have been correctly assessed and documented to include all components of accurate and complete wound assessments.
(2) Failing to follow/implement physician orders
Patient #1
Review of the medical record for Patient #1 revealed she was a 59 year-old female admitted to the hospital on 05/20/16 at 1:30 p.m. Admission diagnosis was Bipolar Disorder, Current Episode Depressed. Other diagnoses included a history of breast cancer and hypertension. Review of the physician's orders revealed an order written on 06/11/16 at 12:20 p.m. to monitor vital signs every four hours. Review of the vital signs on the graphic sheets revealed no documented evidence Patient #1's vital signs had been assessed and documented every 4 hours. There were no times documented under the columns for the night, day, and evening shifts, and there were blank spaces where vital signs were to be documented on 06/11/16, 06/12/16, and 06/13/16.
In an interview on 06/14/16 at 10:40 a.m., S2DON reviewed Patient #1's medical record and indicated she could not determine if the patient's vital signs had been assessed every 4 hours because there were no times documented in the medical record entries as to when the vital signs were assessed, and there were blank spaces in the columns where the vital signs should have been documented. S2DON confirmed there was no order to discontinue the vital signs every four hours, and the vital signs were not assessed as ordered by the physician.
Patient #3
A review of the medical record for Patient #3 revealed she was a 77-year-old female admitted to the hospital on 03/08/16 at 8:30 p.m. Admitting diagnoses was Major Depressive Disorder, Single Episode, Unspecified. The patient also had a diagnosis of a Stage II pressure ulcer. Further review revealed a physician's order dated 03/09/16 at 7:30 a.m. for "Duoderm as directed every day until wound healed." Review of the medical record revealed there was no documented evidence in the medical record the physician's order for Duoderm had been implemented.
In an interview on 06/14/16 at 12:40 p.m., S2DON reviewed Patient #3's entire medical record and confirmed there was no documented evidence in the medical record the physician's order had been implemented and the Duoderm had been applied to Patient #3, and she agreed it should have been applied and documented.
(3) Failing to notify the physician of abnormal assessment findings
Patient #4
A review of the medical record for Patient #4 revealed he was a 78 year-old male admitted to the hospital on 05/25/16 at 10:15 a.m. The admitting diagnosis was Major Depressive Disorder, Single Episode, Unspecified. Further review of the initial nursing assessment dated 05/25/16 revealed Patient #4 had an unstageable ulcer to the right heel with a description documented as "5 x 5 cm." Review of the medical record revealed there was no documented evidence Patient #4's physician had been notified on the patient's admission Patient #4 had an unstageable ulcer to the right heel.
Review of Patient #4's "Skin and Braden Reassessment Documentation dated 05/28/16 revealed "Red, Stage 1 to left buttock," and there was no picture of the left buttock in the medical record. Review of the "Skin and Braden Reassessment Documentation" sheet dated 06/04/16 revealed "Stage I" documented to left buttock. Further review of the medical record revealed there was no documented evidence the red area of the left buttock had been assessed for blanching, dimensions, and a description of the surrounding tissue, and there was no documented evidence Patient 4's physician had been notified of the Stage I to the left buttock.
In an interview on 06/14/16 at 1:54 p.m., S1Director and S2DON reviewed Patient #4's entire medical record and confirmed there was no documented evidence Patient #4's physician had been notified on admission of the patient's unstageable ulcer to the right heel, and the red area to Patient #4's left buttock identified on 05/28/16. S1Director and S2DON confirmed Patient #4's wounds had not been correctly assessed and documented, and also confirmed Patent #4's physician had not been notified of the patient's ulcer to the right heel and the Stage I ulcer to the left buttock. S1Director and S2DON agreed the areas should have been correctly assessed and documented to include all components of accurate and complete wound assessments, and the patient's physician should have been notified of the abnormal findings upon the nursing assessments.

Based on record review and interview, the hospital failed to ensure a registered nurse assigned nursing care to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. This deficient practice is evidenced by the hospital not providing training and evaluating competencies for nurses providing wound care to patients.

Findings:

Review of an employee roster revealed there were currently 12 RN's and 10 LPN's employed at the hospital.

Review of the hospital's personnel records for the 4 full time RNs (S3RN, S4RN, S5RN, S6RN) and 4 full time LPN's (S7LPN, S8LPN, S9LPN, S10LPN) revealed no documented hospital provided training or competencies for wound care.

In an interview on 06/14/16 at 12:45 p.m. with S1Director, she verified the nurses performed wound care on the patients. S1Director said the hospital did not provide any hospital training, orientation, or competencies for wound care.

In an interview on 06/14/16 at 12:52 p.m.with S3RN, she said she had been working at the hospital a little over two years. S3RN said since she has been at the hospital she has had no training on wound care.

In an interview on 06/14/16 at 1:21 p.m. with S7LPN, she said she had been at the hospital for 5 years. S7LPN said she had not received any formalized hospital training on wound care. S7LPN verified she did perform wound care at the hospital.

Based on record review and interview, the hospital failed to ensure verbal order authentications had been dated and timed for 4 (#2, #3, #4, #5) of 5 (#1, #2, #3, #4, #5) sampled patients.

Findings:

Patient #2
Review of the medical record for Patient #2 revealed verbal orders dated 01/20/16 at 8:30 p.m., 01/27/16 at 5:15 p.m. and 02/11/16 at 6:30 p.m. that had been authenticated, but the authentications had not been dated or timed.

Patient #3
Review of the medical record for Patient #3 revealed a verbal order dated 03/08/16 at 8:30 p.m. that had been authenticated, but the authentication had not been dated or timed.

Patient #4
Review of the medical record for Patient #4 revealed a discharge medication order dated 06/09/16 at 1:30 p.m. that had been authenticated, but the authentication had not been dated or timed.

Patient #5
Review of the medical record for Patient #5 revealed verbal orders dated 04/22/16 at 5:00 p.m. and 04/23/16 at 4:00 p.m. that had been authenticated, but the authentications had not been dated or timed.

In an interview on 06/16/16 at 1:45 p.m. with S1Director, she verified the physician's should have been timing and dating their authentications.

Based on record review and interview, the hospital failed to ensure the patient's discharge summaries were complete to include all medical problems for 2 (#2, #5) of 5 (#1, #2, #3, #4, #5) patients sampled.

Findings:

Patient #2
Review of the medical record for Patient #2 revealed he was admitted from home on 01/18/16 at with diagnosis which included Dementia with Lewy bodies.

Review of Patient #2's medical History and Physical dated 01/19/16 revealed no documentation of skin breakdown. Patient #2's skin was listed as "no rash" and turgor normal.

Review of documents in Patient #2's medical record titled Skin and Braden Reassessment Documentation revealed the following assessments:
01/23/16- Skin intact- some redness to sacrum.
01/25/16- redness to sacrum; no wounds
01/30/16- 2 stage 2 wounds to bilateral buttocks. Consult put in for medical MD to assess
02/7/16- Multiple stage II pressure ulcers to buttocks x 7.
No other assessments.

Review of Patient #2's progress note dated 02/11/16 (day of discharge) revealed in part:
Patient admitted without wounds. Buttocks multiple abscesses. Needs surgical debridement and IV antibiotics.

Review of Patient #2's discharge summary revealed the hospital course listed that on 02/11/16 Patient #2 was discharged to a long term acute care hospital for a higher level of care for medical issues. Further review revealed no documentation of what the medical issues were and no documentation of the sacral wounds that had been acquired at the hospital.

Patient #5

A review of the medical record for Patient #5 revealed she was a 93-year-old female admitted to the hospital on 04/19/16. Admit diagnoses included Major Depression, Recurrent, Severe, Without Psychotic Features, and Dementia Early Stages. Further review of the medical record revealed the initial nursing assessment dated 04/19/16 documented "red, no breaks" with a line drawn to the patient's sacral area. Patient #5 was discharged on 5/17/16.
Review of documents in Patient #5's medical record titled Skin and Braden Reassessment Documentation revealed the following documentation: 04/23/16, "Stage II, right buttock"; 04/30/16, "Stage II, right buttock"; 05/07/16, "redness to bilateral buttocks, Stage II right buttock"; 05/14/16, "redness to bilateral buttocks, Stage II right upper thigh and right buttock."
Review of Patient #5's discharge summary revealed no documentation of the Stage II pressure ulcers that had been acquired at the hospital.
In an interview on 06/16/16 at 1:45 p.m. with S1Director, she verified the discharge summaries for the patients should include all of the patient's medical history including wounds and pressure sores.