HospitalInspections.org

Based on record review and interview the hospital failed to ensure a patient received care in a safe setting as evidenced by a patient assessed as a high suicidal risk and a danger to self was allowed to have an electronic cigarette in the Emergency Department.
Findings:

Review of the hospital's policy titled Suicide Risk Assessment and Prevention revealed in part, "High Risk Patients: Patient did attempt suicide. Patient is in imminent danger of implementing suicide plan immediately or or in near future. Patient's behavior involved verbalizing clear intent for self harm, concrete and viable plan, delusions of self-mutilation, command hallucinations, unable to commit to safety, poor impulse control, no insights into existing problems, and has had past attempts at lethal methods. The following interventions can be selected or modified as suicide precautions for patients determined to have a high suicide risk:

Continuous direct observation by staff with documentation every hour.
Must be accompanied by staff for any necessary off-unit activities.
Remove from the environment anything the patient may use to inflict injury to self (razor, belt, shoe strings, sharp objects, trash bags).
Personal items removed and secured to include purse, wallet and cell phone.
Limited access to the roof; easily opened locks on bathroom/shower doors; functioning security cameras and secured hazardous chemicals and medications.
Remove all needles and sharps from the patient's room.
Room will be search daily for potentially harmful items..."

Review of the Emergency Department (ED) Record for Patient #7 revealed the patient was a 26 year old male seen in the ED on 5/19/14 and was transferred from the ED on 5/23/14 to a psychiatric hospital. The patient's chief complaint was listed as the patient was depressed and had suicidal Ideations and took 13 tablets of Klonopin (2 milligrams each) and slit his left wrist.

Review of the Physician Notes in the ED dated and timed 5/19/14 at 2120 revealed the patient's chief complaint was Suicidal Thoughts, Suicide Attempt and Depression. Prior to being brought to the ED the physician documented the patient slit his left wrist with cardboard. The clinician assessed his suicide risk as high risk.

Review of his Physician Emergency Certificate dated 5/19/14 and timed 2120 revealed he was currently suicidal and was dangerous to self.

Review of the Suicide Risk Intervention form revealed he was assessed as a Suicide High Risk Patient and the following interventions were instituted at 5/19/14 at 2000:
Continuous direct observation by staff with documentation every hour.
Must be accompanied by staff for any necessary off-unit activities.
Remove from the environment anything the patient may use to inflict injury to self (razor, belt, shoe strings, sharp objects, trash bags).
Personal items removed and secured to include purse, wallet and cell phone.
Limited access to the roof; easily opened locks on bathroom/shower doors; functioning security cameras and secured hazardous chemicals and medications.
Remove all needles and sharps from the patient's room.
Room will be search daily for potentially harmful items.

Review of the Narrative Nursing Notes and Interventions dated and timed 5/19/14 at 2230 revealed, "Mother brought food and electronic cigarette into Pt (patient) informed pt that electronic cigarettes are not allowed in the ER (Emergency Room). Asked Mother to take it home. Patient questioned why they are not allowed and demands to see the rule in writing. Informed pt again that he is not allow to smoke electronic or any other cigarettes in the ER. Mother at bedside. 2245- Pt smoking electronic cigarette in room. Staff went into room to remove cigarette. I asked mother to leave three times before she finally left and she called me a B*tch and C*nt while walking out."

An interview was conducted with S14Director of ED(Emergency Department) on 6/5/14 at 11:15 a.m. He reported the patient's electronic cigarette should have never been allowed to be left in the room. The electronic cigarette should have been removed from the room when it was first discovered on 5/19/14 at 2230.

Based on record reviews and interviews, the hospital failed to ensure its ongoing quality assessment and performance improvement (QAPI) program measured, analyzed, and tracked quality indicators that assess processes of care and hospital services and operations. The hospital failed to identify opportunities for improvement in patient care processes on the Medicine Unit related to patient assessments and reassessments, PEG (percutaneous esophageal gastrostomy) tube assessments and care, pressure ulcer and wound assessments, and assessments by the RN (registered nurse) to determine that patients met the criteria established by the Louisiana State Board of Nursing's (LSBN) practice act for delegation of patient care by the RN to a LPN (licensed practical nurse).
Findings:

Review of the hospital policy titled "Facility Performance Improvement Plan", revised March 2010 and reviewed March 2014, revealed that the primary goal of the plan was to continually and systematically plan, design, measure, assess, and improve performance of critical focus areas, improve healthcare outcomes, and reduce and prevent medical/health care errors. Further review revealed that collaborative and specific indicators of both processes and outcomes of care are designed, measured, and assessed by all appropriate departments/services and disciplines of the facility in an effort to improve patient safety and organizational performance.

Review of the "Medical Quality Indicators" for 2014 revealed no documented evidence that any quality indicators were developed for the Medicine Unit related to patient assessments and reassessments, PEG tube assessments and care, pressure ulcer and wound assessments, and assessments by the RN to determine that patients met the criteria established by the LSBN's practice act for delegation of patient care by the RN to an LPN.

Review of 4 (#1, #3, #4, #5) current patients' records and 4 (#2, #6, #7, #8) closed patients' records from a total sample of 8 patients revealed the following findings (opportunities for improvement) that had not been identified by the QAPI program:

1) There was no documented evidence that the hospital had a policy and procedure for assessing wounds and/or pressure ulcers. There were 2 (#4, #5) of 2 (#4, #5) current patient's record and 2 of 2 (#2, #6) closed patients' records reviewed for pressure ulcer or wound assessments that had no documented evidence of an assessment that included a measurement of the wound or pressure ulcer.

2) There was no documented evidence that an RN assessed each patient at least every 24 hours as required by LSBN's Declaratory Statement for 1 (#3) of 4 current patients' records (#1, #3, #4, #5) and 2 of 2 (#2, #6) closed patients' records reviewed for RN assessments every 24 hours.

3) There was no documented evidence that an RN assessed each patient with a change in their medical condition to determine that the patient met the criteria to be delegated to the LPN as required by LSBN's Declaratory Statement for 2 (#1, #5) of 2 current patients with a change in condition whose care was delegated to the LPN from a review of 4 current patients' records (#1, #3, #4, #5) records for delegation of patient care to the LPN.

4) There was no documented evidence that an RN performed each patient's initial admit assessment as evidenced by Patient #5's initial admit assessment being performed by an LPN for 1 (#5) of 4 (#1, #3, #4, #5) current patients' records reviewed for initial admit assessments by the RN;

5) There was no documented evidence that an RN assessed a newly established PEG tube and ensured the physician was notified of a patient's refusal of tube feedings for 1 (#3) of 1 current patient's record and 1 (#2) of 1 closed medical record reviewed for PEG tube care.

6) The nursing staff failed to follow physician orders for notification of a patient's abnormal vital signs according to established parameters ordered by the physician for 1 (#1) of 1 current patient's record reviewed with physician orders for treatment of hypertension.

7) The RN failed to ensure patients who were PEC'd (Physician Emergency Certificate) in the Emergency Department (ED) due to being suicidal and a high risk for suicide were observed one-to-one in direct continuous observation by a staff member or security guard according to hospital policy for 1 (#8) of 2 closed patients' records reviewed for observation of PEC'd patients in the ED.

8). The RN failed to ensure patients who were PEC'd in the ED due to being suicidal and high risk for suicide were cared for in a safe setting as evidence by failing to remove potentially harmful objects from their person for 1 (#7) of 2 closed patients' records reviewed for observation of PEC'd patients in the ED.

In an interview on 06/05/14 at 10:50 a.m., S6Unit Manager of the Medicine Unit confirmed that the established quality indicators for her unit did not include anything that would have helped to identify the above listed problems identified during the survey.

Based on record review and interview, the hospital failed to ensure a quality indicator for discharge information that was identified as an opportunity for improvement in 2014 on the Medicine Unit had interventions revised when the monthly rates were below the goal for January, February, and March 2014.
Findings:

Review of the "Performance Improvement 2014 Increasing HCAHPS (Hospital Consumer Assessment of Health Care Providers) Scores on Medical Unit for Discharge Information" revealed that the plan was to increase patient perception of the quality of discharge information provided by the medical unit staff. Further review revealed that the action was to provide ongoing education to the nursing staff in order to foster compliance with the performance improvement plan, and the goal was 90% (percent) or greater.

Review of the "Medical Quality Indicators 2014" for the Medicine Unit revealed the customer service indicator related to discharge information had a goal of 85% rather than 90% as stated in the plan. Further review revealed the score for January 2014 was 79.4%, February 83.3%, and March 73.7%.

Review of the education material presented by S6Unit Manager of the Medicine Unit revealed that education was not presented to the nursing staff until 05/01/14.

In an interview on 06/05/14 at 11:40 a.m., S6Unit Manager of the Medicine Unit confirmed that education of the staff did not occur when the indicator scores were consistently noted to be below the goal set.

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:

1) Failing to develop and implement a policy/procedure for assessing patients' wounds/pressure ulcer, which resulted in the inability to determine if a wound/pressure ulcer was healing or progressively becoming worse for 2 (#4, #5) of 2 (#4, #5) current patient's record and 1(#2) of 2 (#2, #6) closed patients' records reviewed for wound assessments from a total sample of 8 patients; (See Findings in A0395)

2) Failing to ensure a RN assessed the patients according to the Louisiana State Board of Nursing's (LSBN) Declaratory Statement as evidenced by:

a). Failing to ensure a RN assessed a patient at least every 24 hours for 1 (#3) of 4 current patients' records (#1, #3, #4, #5) and 1 (#2) of 2 (#2, #6) closed patients' records reviewed for RN assessments from a total sample of 8 patients;

b) Failing to ensure a RN assessed a patient with a change in condition to determine the patient met the criteria to be delegated to the LPN (licensed practical nurse) for 2 (#1, #5) of 2 current patients with a change in condition whose care was delegated to the LPN from a review of 4 current patients' records (#1, #3, #4, #5) records for delegation of patient care to the LPN from a total sample of 8 patients;

c.) Failing to ensure the RN performed the initial admit assessment for 1 (#5) of 4 (#1, #3, #4, #5) current patients' records reviewed for initial admit assessments from a total sample of 8 patients; (See Findings in A0395)

Based on record reviews and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by:

1) Failing to develop and implement a policy/procedure for assessing patients' wounds and/or pressure ulcers, which resulted in the inability to determine if a wound was healing or progressively becoming worse for 2 (#4, #5) of 2 (#4, #5) current patient's record and 1 (#2) of 2 (#2, #6) closed patients' records reviewed for wound assessments from a total sample of 8 patients;

2) Failing to ensure an RN assessed patients in accordance with the requirements for nursing practice set forth by the Louisiana State Board of Nursing (LSBN) as evidenced by:

a) Failing to ensure an RN assessed each patient at least every 24 hours for 1 (#3) of 4 current patients' records (#1, #3, #4, #5) and 1 (#2) of 2 (#2, #6) closed patients' records reviewed for RN assessments from a total sample of 8 patients;

b) Failing to ensure an RN assessed each patient with a change in condition to determine that the patient met the criteria to be delegated to the LPN (licensed practical nurse) for 2 (#1, #5) of 2 current patients with a change in condition whose care was delegated to the LPN from a review of 4 current patients' records (#1, #3, #4, #5) records for delegation of patient care to the LPN from a total sample of 8 patients;

c) Failing to ensure the RN performed the initial admit assessment for 1 (#5) of 4 (#1, #3, #4, #5) current patients' records reviewed for initial admit assessments from a total sample of 8 patients;

d) Failing to ensure the RN assessed a newly established PEG (percutaneous esophageal gastrostomy) tube and ensured the physician was notified of a patient's refusal of tube feedings for 1 (#3) of 1 current patient's record and 1 (#2) of 1 closed medical record reviewed for PEG tube care from a total sample of 8 patients;

3) Failing to ensure the nurses implemented physician's orders for notification of a patient's abnormal vital signs according to established parameters ordered by the physician for 1 (#1) of 1 current patient's record reviewed with physician orders for treatment of hypertension from a total sample of 8 patients;

4) Failing to ensure the RN supervised the direct one-to-one (1:1) observation of each patient who had a PEC (Physician Emergency Certificate) due to being suicidal and a high risk for suicide in the ED according to hospital policy as evidenced by having no assigned staff member or contracted security guard providing 1:1 direct observation in the ED of a patient who was PEC'd as suicidal and assessed as a high risk for suicide for 1 (#8) of 2 closed patients' records reviewed for observation of PEC'd patients in the ED from a total sample of 8 patients.

Findings:


1) Failing to develop and implement a policy and procedure for assessing patient wounds and/or pressure ulcers, which resulted in the inability to determine if a wound/pressure ulcer was healing or progressively becoming worse;

Review of the hospital policy titled "Pressure Ulcer Prevention," revised October 2012 and presented by S8RN when the policy for pressure ulcer and wound assessments was requested, revealed that documentation should include the Braden Score and skin assessment on admission and each shift, the condition of the skin including pressure areas and other areas of breakdown, the treatment of these areas, positioning, and pressure redistribution surfaces and devices. There was no documented evidence that the policy explained the measurements to be taken and the staging of the pressure ulcer.

Review of the policy titled "Nursing Procedures," revised December 2007 and presented by S6Unit Manager Medicine when another request was made for the hospital's policy for pressure ulcer and wound assessments, revealed that the "Nursing Procedures, Third edition Springhouse" book will be used to describe nursing procedures. Further review revealed that specific policies have been developed for procedures which are not found in this book or if the hospital's policy is different than that in the book. Review of the literature presented from this book by S6Unit Manager Medicine revealed information on pressure dressing application, pressure ulcer care, staging pressure ulcers, Braden scale, patient teaching, complications, and documentation. There was no documented evidence that the literature addressed the measurement of a pressure ulcer and the requirements of the patient assessment by the nurse.

Patient #2
Review of Patient's #2 medical record revealed she was a 42 year old female, brought to the Emergency Department on 5/3/14. Her chief complaint per her family was, she was " multi-handicap " and had lost greater than 60 pounds in the last 6 months. The patient has been nonverbal since childhood. Her diagnoses included Severe Dehydration, Hyperosmolality, Hypernatremia, Acute Kidney Failure, Urinary Tract Infection, Anorexia, Dysphasia, Hypopotassemia, Elevated LFT (Liver Functions Test) and Abnormal Glucose. Her initial lab work was as follows: Na (Sodium) 168 (Normal lab value 135-145mmol/L (millimeters per liter) ), Glucose- 445 milligrams/deciliter (70-105 mg/dl), BUN (Bilirubin Urea Nitrogen) 72.71 mg/dl (normal values 7.0 to18.7 ), AST 108 Units/liter (normal value 5- 34) ALT 112 U/L (normal value 0-55U/L), WBC (White Blood Cell Count) 13.2 K/ul (thousandths per per microliter) normal value 4.1 - 10.6 K/ul.

Review of the Electronic Medical Record (EMR) with S1VP of Quality (Vice President of Quality) on 6/4/14 at 1:30 p.m. revealed the following:

On 5/3/14 at 0200, Patient #2's initial assessment was began. Her integument assessment was started at 0730 on 5/3/14, and amended on 5/4/14 at 11:12. Patient #2's initial skin assessment for the hospitalization stated, "sore with scab to right buttocks- multiple bruises (misspelling- bruises) in different stages of healing noted to bil (bilateral) legs and right scapula." The patient was assessed as being at risk for pressure ulcers. Her Braden Score was listed as less than or equal to a 16 and the following interventions were implemented and addressed on her plan of care:

Reposition every 2 hours
Maintain hydration per at risk guideline
HOB (head of bed) elevated no more than 30 degrees, Use lift sheet to move patient.
Low airloss mattress. Consult dietician and Case management. Obtain baseline prealbumin level.
On 5/3/14 at 20:00 and amended on 5/4/14 at 02:34 an assessment was documented on her skin condition as, "Intact. Bruising noted to abdomen and B/L (bilateral left) LE (lower extremities)." Her Braden Score was assessed as a 15 and the same interventions were implemented as previously.

On 5/4/14 at 05:30, her skin condition was documented as bruising noted to abdomen and B/L LE. Patient #2's Braden Score was a total of 15 and the same interventions were implemented. On 5/4/14 under the section labeled Wound Assessment: Pressure Ulcer/Location: Integument assessed, not applicable. On 5/4/14 at 7:30 the patient's skin condition was noted as sore noted to right buttocks-multiply bruises note to bil (bilateral) legs. The patient's Braden Score was a 15 with the same implementations in place. Wound Assessment/Pressure Ulcer/Location stated integument assessed, not applicable.

On 5/4/14 at 20:00, Patient #2's integument was assessed and the skin was listed as bruising and the Braden Score continued to be a 15 with the same interventions implemented. Her Wound Assessment: Pressure Ulcer/Location was documented as integument assessed and not applicable.

On 5/5/14 at 08:00, her integument was assessed as intact and her Braden Score was assessed as a 15 with the same interventions implemented. Her Wound assessment: Pressure Ulcer Location stated, "See Unisex Body Documentation." Review of the Unisex Body Documentation revealed a sketch of a body with an "A" on the middle of the body sketch's sacrum. Site A was listed as the location of the sacrum, date first observed: 5/5/14, Stage 2, duoderm applied. The definition of Stage II was listed at the bottom of the page and stated, "Stage II: Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or a shallow crater."

On 5/5/14 at 20:00, an assessment of her integument was listed as her skin condition intact, her Braden Score was listed as an 18 and a risk for pressure ulcers were no longer assessed as a problem and documented as not addressed on the care plan due to her Braden Score being greater than a 16. A pressure ulcer dressing/duoderm was documented to her sacrum as dry and intact. A wound assessment /wound intervention was documented as turned and repos (repositioned) as needed per PT (Patient) and family.

On 5/6/14 at 07:15, an integument assessment was documented as skin condition intact and a Braden Score of 18 was listed and her risk for Pressure Ulcers were addressed as a problem in the care plan. The Pressure ulcer dressing was documented as dressing clean, dry, and intact. Wound assessment/pressure ulcer location was documented as see Unisex Body Documentation. The body sketch indicated a sacral, pressure ulcer, Stage II, duoderm. The date first observed was listed as 5/6/14.

On 5/6/14 at 20:00, Patient #2's integument assessment was listed as intact and her Braden Score was a 17 and pressure ulcers were no longer listed in the care plan as a problem because the Braden Score was greater than 16. Her wound assessment: Pressure Ulcer/Location was documented as integument assessed, not applicable.

On 5/7/14 at 7:10, an assessment was made of Patient #2's integument, which documented the skin was intact. Patient #2's Braden Score was listed as a 20 and pressure ulcers were listed as a problem on the care plan. Her wound assessment stated to see Unisex Body Documentation. Review of the Unisex Body Documentation revealed the patient had a wound on her sacral and the wound was first observed on 5/7/14.

On 5/7/14 at 20:00, an assessment was completed on Patient #2's integument. The patient's skin condition was listed as intact and the Braden Score was list as a 17. Pressure ulcer was not listed as a problem because the patient's Braden Score was greater than a 16. Incision/Dressing was documented as location of her sacral area, dry and intact dressing. A wound assessment was listed as Stage II-loss of dermis.

On 5/8/14 at 08:00, an integument assessment was completed and Patient #2's integument was listed as intact and her Braden Score was an 18. Wound assessment was documented as Wound Interventions: Special mattress/bed.

On 5/8/14 at 19:30, an assessment of the patient's integument was performed, the patient's skin was listed intact. Her Braden score was documented as a 17 and since the score was greater than a 16, her integument was not considered a problem on her care plan. Patient #2's wound assessment was listed as Stage II-loss of dermis.

On 5/9/14 at 08:11, an assessment of the patient's skin was listed as intact with Stage 2 noted to sacrum. Her Braden Score was a 14 and was skin integument was addressed as a problem on the patient's care plan. Wound assessment was documented as Stage II-loss of dermis, see Unisex Body Documentation. Review of the Unisex body Documentation revealed a pressure ulcer on the patient's sacrum and the duoderm was intact. Another wound assessment was performed at 16:00 and the documentation stated, " No change from previous assessment. "

On 5/9/14 at 19:30, the patient's skin condition was listed as intact and the Braden Score was documented as an 18 and integument was not listed as a problem due to the Braden score being greater than a 16. Wound assessment was listed as Pressure ulcer/location: Stage II-loss of dermis, coccyx size ___ (a blank space) cm (centimeter) depth ____ (blank space) cm.

On 5/10/14 at 08:00, the patient's integument was listed as intact and the Braden Score was listed as 23 and not listed as a problem on the patient's plan of care.

Review of the EMR revealed on 5/10/14 at 20:00, the patient's skin was intact, patient's Braden Score was listed as a 17 and since the score was above a 16, patient's skin was not listed as a problem on the patient's plan of care. The patient's wound assessment was documented as see Unisex Body Documentation, Stage II-loss of dermis to sacral area. Review of the Unisex Body Documentation revealed the location of the wound was on the patient's sacrum.

Review of the patient's skin assessment on 5/11/14 at 08:00, revealed her skin was intact and her Braden Score was an 17 and wounds were not listed on her plan of care due to score being greater than 16. Pressure ulcer documentation was listed as see Unisex Body Documentation and Stage II- loss of dermis. Review of the Unisex Body Documentation revealed the wound was on the patient's sacrum.

Review of the patient's skin assessment on 5/11/14 at 20:00, revealed her skin was intact and her Braden Score was an 18 and wounds were not listed on her plan of care due to score being greater than 16

Review of the patient's skin assessment on 5/12/14 at 07:30, revealed her skin was intact and her Braden Score was an 18 and wounds were not listed on her plan of care due to score being greater than 16. Wound assessment: Pressure ulcer location was documented as Stage I-red but intact, noted to sacrum. See Unisex Body Documentation. Review of the Unisex body Documentation revealed location on sacrum and first observed on 5/12/14.

Review of the patient's skin assessment on 5/12/14 at 20:00, revealed her skin was intact and her Braden Score was a 14 and wounds were listed on her plan of care due to score being less than 16. Wound assessment: Pressure Ulcer Location was listed as see Unisex Body Documentation and wound intervention was listed as applied a pillow. Review of the Unisex Body Documentation revealed the location of the wound was the sacrum and duoderm was on the wound.

Review of the patient's skin assessment on 5/13/14 at 08:00, revealed her skin was intact and her Braden Score was a 14 and wounds were listed on her plan of care due to score being less than 16. Wound assessment/Pressure ulcer location was documented as see Unisex Body Documentation. Review of the Unisex Body Documentation revealed a wound location documented on the body sketch as at the sacrum and then a large " X " drawn, crossing out the body sketch.

The last documentation before the patient was transferred to Hospital "A" revealed on 5/13/14 at 12:40, "report given to S ....at Hospital A, transfer form signed, copy give to A ....Ambulance, pat (patient) stable and transferred via stretcher by A ..... to Hospital A."

An interview was conducted with S1VP of Quality on 6/4/14 at 1:55 p.m. She confirmed there was no documentation of measurements of the pressure ulcer, which is an incomplete assessment of pressure ulcers/wounds. She also confirmed that according to the documentation, the patient received a Stage II pressure ulcer on her sacrum during her hospital stay. S1VP confirmed there was no evidence the physician was made aware of the pressure ulcer.

Review of the Initial Assessment from Hospital A dated 5/13/14 and timed 14:30 revealed the following initial skin assessment assessed on transfer from Iberia General Hospital and Medical Center:

Callous, unstageable , L (left) heel, color- black, measurements- .6 cm X .5 cm.
Abrasion, Sacrum, color-pink, measurements- 1 cm X .7 cm
Pressure, Sacrum, color- red, measurements- 6 x 5 cm

Review of the Wound Detail Report from Hospital A dated 5/15/14 revealed:

Pressure ulcer, status- closed, sacrum, healing Stage II, Erythema, Size 0.00 X 0.00 X unknown.
L heel, status- active, date identified 5/13/14, Unstageable, ulceration, .70 X .70 X unknown.
Area .49 cm2. Eschar noted.

Patient #4
Review of Patient #4's medical record revealed, he was a 60 year old male, admitted on 06/03/14 with diagnoses of Acute Asthma Exacerbation, Fall, Morbid Obesity, and Left Knee/Foot Pain. Review of his "Initial Physical Assessment" revealed his integumenary assessment indicated that he did not have a pressure ulcer.

Review of Patient #4's "Patient Progress Notes" dated 06/04/14 at 7:30 a.m., by 9RN revealed he had a new skin breakdown. Further review revealed S9RN documented that Patient #4 had a Stage II "small opening to right skin fold" and a Stage II "small opening to midline buttocks". There was no documented evidence of the measurement of either pressure ulcer, whether there was drainage present, and the condition of the surrounding skin.

In an interview on 06/04/14 at 11:15 a.m., S9RN indicated Patient #4 had a Stage II pressure ulcer to his right skin fold and a Stage II pressure ulcer to the midline of his buttocks. She further indicated that she did not measure either pressure ulcer and wasn't "sure if I'm supposed to measure it."

Patient #5
Review of Patient #5's medical record revealed, he was a 73 year old male, admitted on 05/30/14 and discharged on 06/03/14 with diagnoses of Staph Aureus secondary to an Infected Right Arm Graft, End Stage Renal Disease, Coronary Artery Disease, Gout, and Hyperlipidemia.

Review of Patient #5's "Initial Physical Assessment" performed by S16LPN on 05/30/14 at 9:31 p.m., revealed Patient #5 had "redness noted to infected left forearm dialysis shunt. Open sore above left arm shunt covered with bandage." There was no documented evidence of the measurement of the wound, whether there was drainage and odor noted, and the condition of the surrounding skin.

In an interview on 06/04/14 at 2:55 p.m., S1Vice-President of Quality confirmed that the hospital did not have a policy and procedure for assessment of pressure ulcers and wounds. She also confirmed that Patient #5's wound assessment did not include measurements, whether there was odor or drainage, and the condition of the surrounding skin.

2. Failing to ensure an RN assessed patients in accordance with the requirements for nursing practice set forth by the Louisiana State Board of Nursing (LSBN) as evidenced by:


a) Failing to ensure a RN assessed each patient at least every 24 hours
Review of the LSBN's "Declaratory Statement On The Role And Scope Of Practice Of Registered Nurses Delegating Intravenous Therapy Interventions" revealed that "in accordance with the Louisiana State Board of Nursing's (Board) rules and regulations
regarding nursing practice, LAC 46:XLVII.3701-3703, specifically the delegation of
nursing interventions and managing and supervising the practice of nursing, the Board
believes that registered nurses (RNs) RNs may delegate select nursing interventions provided the patient is assessed by an RN every 24 hours."
Patient #2
Review of Patient #2's medical record revealed the following nurses provided care and assessed the patient during her hospital stay from 5/3/14 to 5/13/14.

On her admission to the hospital S18LPN performed the initial assessment and S27RN cosigned the assessment on 5/3/14 at 02:00. The shifts (other than the initial assessment) that the LPNs provided care revealed no co-signature by an RN and no evidence a RN assessed the patient or was involved in the patient's care.

The following RNs and LPN provider care to Patient #2 on the following dates and shifts:
On 5/3/14 at 07:30 S29LPN
On 5/3/14 at 20:00 S21LPN
On 5/4/14 at 07:30 S29LPN
On 5/4/14 at 20:00 S28RN
On 5/5/14 at 07:30 S22LPN
On 5/5/14 at 20:00 S23LPN
On 5/6/14 at 07:30 S17LPN
On 5/6/14 at 20:00 S19LPN
On 5/7/14 at 07:30 S17LPN
On 5/7/14 at 20:00S19LPN
On 5/8/14 at 07:30 S30LPN
On 5/8/14 at 20:00 S19LPN
On 5/9/14 at 07:30 S31RN
On 5/9/14 at 20:00 S19LPN
On 5/10/14 at 07:30 S24LPN
On 5/10/14 at 20:00 S18LPN
On 5/11/14 at 08:00 S25LPN
On 5/11/14 at 20:00 S18LPN
On 5/12/14 at 07:30 S20LPN
On 5/12/14 at 20:00 S21LPN
On 5/13/14 at 07:00S32RN

With review of the patient's medical record a RN provided care and assessment for 3 shifts out of 21 shifts and a LPN provided care for the patient 18 shifts out of 21shifts. A RN cosigned one assessment performed by a LPN, which was the initial assessment of the patient on admission to the hospital.

There were numerous nursing shifts where LPNs reported off to LPNs without evidence of a RN assessing to confirm the patient's condition was stable enough for a LPN to continue to assume care of the patient.

Patient #3
Review of Patient #3's medical record revealed he was a 68 year old male admitted on 05/28/14 with diagnoses of status post Laryngectomy, Bilateral Neck Dissection, Possible Voice Prosthesis Placement, Possible Blood Transfusion.

Review of Patient #3's medical record revealed S33LPN was assigned Patient #3's care on 05/30/14 at 8:00 p.m. Further review Patient #3 was transferred to the care of S20LPN on 05/31/14 at 7:30 a.m. with no documented evidence that an RN had assessed Patient #3 to determine if he met the criteria to have his care delegated by the RN to an LPN. Further review revealed Patient #3's care was transferred from S20LPN on 06/01/14 at 4:35 p.m. to S34LPN and then to S33LPN at 7:30 p.m.with no documented evidence that an RN had assessed Patient #3 to determine if he met the criteria to have his care delegated by the RN to an LPN. There was no documented evidence that Patient #3 was assessed by an RN every 24 hours as required by the LSBN Declaratory Statement.

In an interview on 06/04/14 at 2:55 p.m., S1Vice-President of Quality indicated the hospital's policy only required that the patient's admission assessment be done by an RN, and all other patient assessments can be done by the LPN. She confirmed that the hospital did not require an RN to assess each patient at least every 24 hours. S1Vice-President of Quality indicated that she was not familiar with LSBN's declaratory statement regarding the RN delegating a patient's care to the LPN.

c) Failing to ensure an RN assessed each patient with a change in condition to determine that the patient met the criteria to be delegated to the LPN
Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed, in part, "3703. Definition of Terms Applying to Nursing Practice ... Delegating Nursing Interventions - ... The registered nurse retains the accountability for the total nursing care of the individual. ... The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. a. Any situation where tasks are delegated should meet the following criteria: i. the person has been adequately trained for the task; ii. the person has demonstrated that the task has been learned; iii. the person can perform the task safely in the given nursing situation; iv. the patient's status is safe for the person to carry out the task; v. appropriate supervision is available during the task implementation; vi. the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all. b. The registered nurse may delegate to licensed practical nurses the major part of the nursing care needed by individuals in stable nursing situations, i.e. (that is), when the following three conditions prevail at the same time in a given situation: i. nursing care ordered and directed by R.N./M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; and ii. change in the patient's clinical conditions is predictable; and iii. medical and nursing orders are not subject to continuous change or complex modification."

Review of the hospital policy titled "Assessments of Patients", revised February 2014 and presented as the current policy by S1Vice-President of Quality, revealed that each patient is reassessed at regularly specified times as related to approved Standards of Care and the patient's course of treatment to determine the patient's response to treatment, when a significant change occurs in the patient's condition, or at a minimum every shift. Review of the policy revealed no documented evidence that the patient's assessment when there's a significant change in his/her condition had to be performed by an RN as required by the LSBN's practice act.
Review of Patient #1's medical record revealed he was a 56year old male admitted on 05/30/14 with diagnoses of CVA (Cerebrovascular Accident), Neurologic Deficit, Hypertensive Emergency Dysarthria, Right-sided weakness, and Acute Renal Failure. Review of his admission physician orders revealed an order to notify the physician for a heart rate less than 50 or greater than 120, a systolic blood pressure less than 100 or greater than 160, and a respiratory rate less than 12 or greater than 24.

Review of Patient #1's "Medication Reconciliation Report" revealed physician orders on 05/30/14 at 2:22 p.m. to administer Vasotec 1.25 mg (milligrams) IVP (intravenous push)every 6 hours as needed for a systolic blood pressure greater than 220 or a diastolic blood pressure greater than 110. Further review revealed a physician's order on 05/30/14 at 8:11 p.m. to administer Lopressor 5 mg IVP every 4 hours as needed for a systolic blood pressure greater than 190 or a diastolic blood pressure greater than 100.

Review of Patient #1's "Med/Surg (Medical/Surgical) Assessment Flowchart" revealed the following dates and times that Patient #1 had systolic blood pressure outside the acceptable physician-ordered parameters with no documented evidence that the physician was notified according to physician orders:
05/30/14 - 5:10 p.m. (205/110); 5:30 p.m. (154/118); 6:00 p.m. (212/100) - Vasotec administered at 6:18 p.m.; 6:30 p.m. (186/115);
05/31/14 - 12:00 a.m. (172/75); 4:00 a.m. (198/97) - Lopressor should have been administered as ordered and was not given; 4:00 p.m. (179/84); 9:48 p.m. (234/112) - Vasotec was administered; 10:48 p.m. (166/71);
06/01/14 - 12:00 a.m. (169/73); 4:00 a.m. (171/83); 7:30 a.m. (209/120) - Lopressor administered at 8:38 a.m. (1 hour and 8 minutes after elevated blood pressure was assessed); 12:00 p.m. (185/107); 3:18 p.m. (217/106) - Lopressor should have been administered as ordered and was not given; 8:00 p.m. (203/76) - Lopressor should have been administered; Lopressor was given at 5:59 p.m. with no documented evidence of a blood pressure assessment at 5:59 p.m.;
06/02/14 - 12:00 a.m. (156/102); 3:10 a.m. (224/114) - Vasotec was administered; 4:55 a.m. 154/111; 7:30 a.m. (244/125) - Vasotec was administered; 10:30 a.m. (180/110); 6:00 p.m. (179/89);
06/03/14 - 3:30 a.m. (199/96) - Lopressor as administered; 9:00 a.m. (174/109) - Lopressor should have been administered and was not given; 12:00 p.m. (187/80); 4:00 p.m. (170/92); 7:30 p.m. (190/74); 11:30 p.m. (202/104) - Lopressor was administered;
06/04/14 - 2:50 a.m. (199/91); 6:10 a.m. (171/93).

Review of documentation presented by S6Unit Manager of Medicine as the physician notification of elevated blood pressures for Patient #1 revealed the following 4 times:
05/30/14 at 8:00 p.m. by S18LPN - physician order received to proceed with standing order of Lopressor; there was no documented evidence that an RN assessed Patient #1's blood pressure prior to calling the physician;
06/02/14 at 9:30 a.m. by S17LPN - S17LPN notified the nurse practitioner of elevated blood pressure (blood pressure at 8:55 a.m. was 210/97) and received orders to repeat the blood pressure in 15 minutes; there was no documented evidence that an RN assessed Patient #1's blood pressure prior to calling the nurse practitioner and that the blood pressure was reassessed by an RN in 15 minutes;
06/02/14 at 12:00 p.m. by S17LPN - S17LPN notified the nurse practitioner of the elevated blood pressure (217/127), and orders were received to administer Apresoline 10 mg IVP now and 10 mg IVP every 6 hours as needed; there was no documented evidence of an assessment by an RN, ordered blood pressure parameters for administering Apresoline every 6 hours as needed, and there was no clarification order that addressed this;
06/04/14 at 7:15 a.m. by S17LPN - nurse practitioner was notified of elevated blood pressure and no new orders were received; there was no documented evidence that an assessment of Patient #1's blood pressure was performed by an RN.

In an interview on 06/04/14 at 11:00 a.m., S6Unit Manager of Medicine confirmed there were only 4 documented reports of physician notification of elevated blood pressure for Patient #1. She confirmed there was no documented evidence in the medical record of an RN assessment of Patient #1 to determine that he met the criteria for delegating his care to the LPN by the RN.

Patient #5
Review of Patient #5's medical record revealed he was a 73 year old male admitted on 05/30/14 and discharged on 06/03/14 with diagnoses of Staph Aureus secondary to an Infected Right Arm Graft, End Stage Renal Disease, Coronary Artery Disease, Gout, and Hyperlipidemia.

Review of Patient #5's medical record revealed he returned from a surgical procedure to remove his left arm graft on 06/02/14 at 2:15 p.m. and was assessed by S17LPN upon his arrival to his room on the medical unit. There was no documented evidence that an RN assessed Patient #5 after having had a surgical procedure until 7:30 p.m. the same day (5 hours and 15 minutes later) when S17LPN reported to the oncoming nurse who was an RN.

In an interview on 06/04/14 at 2:55 p.m., S1Vice-President of Quality indicated the hospital's policy only required that the patient's admission assessment be done by an RN, and all other patient assessments can be done by the LPN. S1Vice-President of Quality indicated that she was not familiar with LSBN's declaratory statement regarding the RN delegating a patient's care to the LPN.

d) Failing to ensure the RN performed each patient's initial admit assessment:
Review of the hospital policy titled "Assessments of Patients", revised February 2014 and presented as the current policy by S1Vice-President of Quality, revealed that an RN assesses the patient's physical and psychosocial needs for nursing care in all settings in which nursing care is provided within 24 hours of admission. Data collection may be delegated to the LPN but must be reviewed and co-signed by an RN. Further review revealed that the RN analyzes information obtained in the patient assessment and determines and prioritizes the patient's nursing care needs.

Review of Patient #5's medical record revealed he was a 73 year old male admitted on 05/30/14 and discharged on 06/03/14 with diagnoses of Staph Aureus secondary to an Infected Right Arm Graft, End Stage Renal Disease, Coronary Artery Disease, Gout, and Hyperlipidemia.

Review of Patient #5's "Initial Physical Assessment" performed by S15LPN on 05/30/14 at 9:31 p.m. revealed no documented evidence that an RN had performed Patient #5's initial admission assessment as required by hospital policy.

In an interview on 06/04/14 at 2:55 p.m., S1Vice-President of Quality confirmed that Patient #5's initial admission assessment was conducted by S15LPN and not by an RN as required by the hospital's policy.

e) Failing to ensure the RN assessed a newly established PEG (percutaneous esophageal gastrostomy) tube and ensured the physician was notified of a patient's refusal of tube feedings:
Review of the hospital policy titled "Nursing Procedures", revised December 2007 and presented S6Unit Manager Medicine when a request was made for the hospital's policy for PEG (percutaneous esophageal gastrostomy) tube care and assessment, revealed that the "Nursing Procedures, Third edition Springhouse" book will be used to describe nursing procedures. Further review revealed that specific policies have been developed for procedures which are not found in this book or if the hospital's policy is different than that in the book. Review of the literature presented by S6Unit Manager Medicine revealed the literature was from "Lippincot's Nursing Procedures, Sixth Edition" and related to feeding tube insertion (inserted nasally or orally) and removal and did not address the care of, feedings, flushing, and checking residual fluid from a PEG tube. No literatu

Based on record reviews and interviews, the hospital failed to ensure that the RN (registered nurse) assigned the nursing care of each patient to nurses who had been oriented, trained, and evaluated for competency as evidenced by having no documented evidence of training and competency evaluations for performing patient assessments, providing care for a PEG (percutaneous esophageal gastrostomy) tube, performing pressure ulcer and wound assessments, and determining when a patient met criteria to be delegated from an RN's care to that of an LPN (licensed practical nurse) for 2 (S9, S32) of 2 (S9, S32) RNs' personnel files reviewed for competency from a total of 23 employed RNs on the Medicine Unit. The RN failed to ensure the LPNs had been oriented, trained, and determined to be competent for providing PEG tube care for 2(S16 and S18) of 2 (S16 and S18) LPNs' personnel files reviewed for competency from a total of 17 employed LPNs on the Medicine Unit.
Findings:

Review of the "Orientation Skills Checklist" used to document competency of the nursing staff revealed no documented evidence that care of a PEG tube, performing an initial nursing assessment and a reassessment of a patient with a change in condition, performing pressure ulcer and wound assessments, and the criteria used to determine if a patient's care was able to be delegated by the RN to the LPN was included in the hospital's nursing orientation, training, and competency evaluations.

Review of the personnel files of S9RN and S32RN revealed no documented evidence that they had been oriented, trained, and evaluated for competency in caring for a PEG tube, performing an initial nursing assessment and a reassessment of a patient with a change in condition, performing pressure ulcer and wound assessments, and the criteria used to determine if a patient's care was able to be delegated by the RN to the LPN.

Review of S16LPN's personnel file revealed no documented evidence that he had been oriented, trained, and evaluated for competency in caring for a PEG tube.

Review of the personnel file for S18LPN revealed no documented evidence that she had been orientate, trained and evaluated for competency in caring for a PEG tube.

In an interview on 06/05/14 at 12:00 p.m., S6Unit Manager of the Medicine Unit confirmed that the competency evaluations of the RNs did not address care of the PEG tube, performing an initial nursing assessment and a reassessment of a patient with a change in condition, performing pressure ulcer and wound assessments, and the criteria used to determine if a patient's care was able to be delegated by the RN to the LPN. She also confirmed that LPN's competency evaluation did not address caring for a PEG tube.


26351