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Based on documentation review and interview, the facility staff failed to ensure the Plan of Care for one (1) of two (2) patients (Patient #5) incorporated the physicians' orders, were kept current, and developed to meet the patients' needs.

Patient #5 could not swallow but discharge medications were all by mouth.

The findings include:

Review of the medical records for Patient #5 revealed:
A 93 year old who was seen in the Emergency Department (ED) on 12/3/2020 and 12/12/2020 for a urinary tract infection and was administered Rocephin. Patient #5 was admitted on 12/22/2020 with the diagnoses of Acute GI Bleed, Severe anemia and NSTEMI (non-ST elevated myocardial infarction (Heart attack)), systolic CHF (Congestive Heart Failure) and an Acute UTI (urinary tract infection). Patient #5 was discharged on 12/23/2020 Patient #5 was then readmitted on 12/24/2020 for severe sepsis, CHF exacerbation and AKI (Acute Kidney Injury) and discharged on 12/25/2020 at 4:43 P.M.

Consults and physician orders:
12/22/2020:
5:33 P.M. - Patient arrives in ED.
Diet: NPO on admit.

8:25 P.M. Vancomycin 1,000 mg (milligrams) in 0.95 sodium chloride 250 mL (milliliters), 125 mL per hour; given at 9:00 P.M.
12/23/2020:
Vancomycin 1,000 mg (milligrams) in 0.95 sodium chloride 250 mL (milliliters), 125 mL per hour; given at 9:00 P.M. and completed at 11:19 P.M. (Nursing documentation on 12/23/2020 at 8:16 P.M. indicated Patient #5 was discharged at this time.)

One of the I&O (Intake and Output) nursing flowsheets documented for 12/22/2020 at 7:00 A.M. through 12/23/2020 at 6:59 A.M. a total intake (blood) of 236.3 mL.
12/23/2020 at 7:00 A.M. through 12/24/2020 at 6:59 A.M. indicated the total intake by blood (311.3 mL) and IV fluids (601.70 mL). The total output from 12/22/2020 at 7:00 A.M. to 12/24/2020 at 6:59 A.M. was 500 mL.
A second nursing flowsheet documented from 12/23/2020 at 7:00 A.M. through 12/25/2020 at 6:59 A.M. that the total intake (IV fluids) was 560 mL and there was no output documented.
There was no documentation in nursing progress notes or flowsheets of any attempts to provided food or any other nutrients for Patient #6.

Readmit on 12/24/2020:
Diagnoses: Dementia, COPD, Failure to thrive in adult, Debility.
Diet: NPO on readmit.
11:30 P.M.
Physician ordered a Swallow Test; Test completed on 12/25/20220 at 10:40 A.M. Speech Language Pathology Bedside Swallow Evaluation and Treatment:
Plan of care: Recommendations: Diet NPO (Nothing by mouth), Meds: non-oral, Aspiration Precautions, Oral Care TID (three (3) times a day), ice chips sparingly following thorough oral care.

On 12/25/2020 at 4:43 P.M. the nurse documented, "I have reviewed discharge instructions with the Patient. The patient and caregiver verbalized understanding.
Discharge Medications, Start taking the following medications:
Tylenol: 325 mg take 2 tabs by mouth every 6 hours as needed for pain or fever,
Phenergan: 12.5 mg 1 tab by mouth every 6 hours as needed for nausea,
Potassium Chloride: 1 tab by mouth daily,
Roxanol (morphine concentrated solution: 100 mg/5 mL (20 mg/mL) 0.5 mL by mouth every two (2) hours as needed for pain or shortness of breath...
Ativan: 1 mg tablet 1 tablet by mouth every six (6) hours as needed for anxiety."

Patient #5 was admitted/treated at this facility on 12/3/2020, 12/12/2020 and 12/22/2020 for an acute UTI. Patient #5 was readmitted on 12/24/2020 with a UTI as well. The list of discharge medications in the medical record did not contain documentation that Patient #5 was discharged with an antibiotic. The physician's discharge summary on 12/24/2020 documented, "Continue current IV abx (antibiotic therapy) pending cx (culture) results."

On April 14, 2021, the above information was shared with Staff Members #2 and 3, they offered no response.

Policy titled: Interdisciplinary Plan of Care - Patient Care Plan with an effective date of 7/7/2020 documents the following:
"Scope: Acute Care and Inpatients...
For admitted patients:
The Interdisciplinary Plan of Care (IPOC)/Patient Care Plan identifies the major patient problems, (past and present), needs or issues identified on or during admission, then determines appropriate interventions and target date for expected outcomes for each identified problem...
a) Initiated by the RN (Registered Nurse) within 24 hours of patient admission...
b) Updated by any subsequent caregiver(s) who identifies any additional new problem(s).
c) Developed with input from the patient and family.
d) Reviewed by the nurse caregiver each shift. Updates are documented at least once a day.
e) Updated during patient care conferences and as needed..."

Based on documentation and interview, the facility staff failed to ensure they documented pain assessment and reassessment, per the facility policy, of one (1) patient, Patient #6, prior to and after administration of medication prescribed for pain.

The findings include:

Patient #6's medical record was reviewed and the following was noted:

On 12/20/2020 at 4:24 A.M. Patient # 6 had no complaints of pain documented. At 4:53 A.M. Patient #6 received morphine 0.5 mg IV. At 7:16 A.M. nursing documentation states "Pain Intensity is 10 out of 10", but Patient #6 did not receive any pain medication at this time.

Post surgery on 12/24/2020, intensity was either blank or zero until 12/27/2020. On 12/27/2020 at 11:32 P.M. Patient #6 received morphine 0.5 mg IV. There was no documentation evaluating Patient #6's pain.

There were no documented pain medications administered prior to physical therapy (PT).

On 12/25/2020 at 11:01 A.M. prior to treatment with PT, Patient #6 described their pain as a 6 out of 10. Post treatment, Patient #6 described their pain as 7 out of 10. The Physical Therapist documented they reported this information to the nurse. There was no documentation as to an evaluation or intervention by the nurse.

A request was made to interview the nursing staff involved in Patient #6's care. One nurse out of four (4) was interviewed. Staff Member #9 was interviewed on 4/15/21 at 8:05 A.M. Present during the interview was another nurse (Staff Member #9's supervisor, Staff Member #18). Staff Member #9 stated, "Yes, I remember taking care of the Patient (#6) but I don't remember any issues. I probably updated the family but had no direct contact with them."

Policy titled: Pain Management with a revision date of 05/2019 was provided and contained in part the following documentation:...
I. Assessment / Reassessment
A. Pain is to assessed upon admission, with each patient hand-off, and per unit assessment and reassessment standards using a scale to meet the patient's individual needs including age, condition and ability to understand (see Attachment A).
B. If pain is present, patients are to be assessed for their individual pain goal on admission and at minimum daily.
C. Pain assessment includes intensity, location and description of pain.
D. Upon admission, the assessment of pain prior t admission also includes pain relieving interventions, pain aggravating factors, and effect of pain on daily living...
F. Reassessment of the patient's pain will be performed as appropriate per the Assessment and Reassessment Policy. Reassessment will also be performed within one hour after administration of a medication given to relieve pain to determine the effectiveness of the medication...

Based on document review and interview, the facility staff failed to ensure one (1) Patient, Patient #5, was discharged with proper treatment (given oral medications and could not swallow) for a UTI (Urinary Tract Infection), and that a second patient, Patient #6, potentially had a HAI (Hospital Acquired Infection) related to a Foley and external catheters.

The findings include:

Patient #5's medical record review revealed:
A 93 year old who was seen in the Emergency Department (ED) on 12/3/20 and 12/12/2020 for a urinary tract infection and was administered Rocephin.
Patient #5 was admitted on 12/22/2020 with the diagnoses of Acute GI Bleed, Severe anemia and NSTEMI (non-ST elevated myocardial infarction (Heart attack)), systolic CHF (Congestive Heart Failure) and an Acute UTI (urinary tract infection). Patient #5 was discharged on 12/23/2020 Patient #5 was then readmitted on 12/24/2020 for severe sepsis, CHF exacerbation and AKI (Acute Kidney Injury). Patient #5 was discharged on 12/25/2020 at 4:43 P.M.

Consults and physician orders:
12/22/2020:
5:33 P.M.
Patient arrives in ED.
Diet: NPO on admit
8:25 P.M. Vancomycin 1,000 mg (milligrams) in 0.95 sodium chloride 250 mL (milliliters), 125 mL per hour; given at 9:00 P.M.

12/23/2020:
Vancomycin 1,000 mg (milligrams) in 0.95 sodium chloride 250 mL (milliliters), 125 mL per hour; given at 9:00 P.M. and completed at 11:19 P.M. (Nursing documentation on 12/23/2020 at 8:16 P.M. indicated Patient #5 was discharged at this time.)
On one nursing flowsheet, where I&O (Intake and Output) is recorded, documented for 12/22/2020 at 7:00 A.M. through 12/23/2020 at 6:59 A.M. the total intake was 236.3 mL (blood).
12/23/2020 at 7:00 A.M. through 12/24/2020 at 6:59 A.M. indicated the total intake by blood (311.3 mL) and IV fluids (601.70 mL). The total output from 12/22/2020 at 7:00 A.M. to 12/24/2020 at 6:59 A.M. was 500 mL.
A second nursing flowsheet documented from 12/23/2020 at 7:00 A.M. through 12/25/2020 at 6:59 A.M. the total intake (IV fluids) was 560 mL. There was no output documented.

There was no documentation in nursing progress notes or flowsheets of attempts to provid food or other nutrients for Patient #6.

Readmit: 12/24/2020:
Diagnoses: Dementia, COPD, Failure to thrive in adult, Debility.
Diet: NPO on readmit
11:30 P.M.
Physician ordered a Swallow Test; Test completed on 12/25/20220 at 10:40 A.M. Speech Language Pathology Bedside Swallow Evaluation and Treatment:
Plan of care: Recommendations: Diet NPO (Nothing by mouth), Meds: non-oral, Aspiration Precautions, Oral Care TID (three (3) times a day), ice chips sparingly following thorough oral care.

On 12/25/2020 at 4:43 P.M. the nurse documented, "I have reviewed discharge instructions with the Patient. The patient and caregiver verbalized understanding."
Discharge Medications, Start taking the following medications:
Tylenol: 325 mg take 2 tabs by mouth every 6 hours as needed for pain or fever.
Phenergan: 12.5 mg 1 tab by mouth every 6 hours as needed for nausea.
Potassium Chloride: 1 tab by mouth daily.
Roxanol (morphine concentrated solution: 100 mg/5 mL (20 mg/mL) 0.5 mL by mouth every two (2) hours as needed for pain or shortness of breath...
Ativan: 1 mg tablet 1 tablet by mouth every six (6) hours as needed for anxiety.

Patient #5 was admitted/treated at this facility on 12/3/2020, 12/12/2020 and 12/22/2020 for an acute UTI. Patient #5 was readmitted on 12/24/2020 with a UTI as well. The list of discharge medications in the medical record did not contain documentation that Patient #5 was discharged with an antibiotic. The physician's discharge summary on 12/24/2020 documented, "Continue current IV abx (antibiotic therapy) pending cx (culture) results."


Patient #6's medical record was reviewed and revealed:
12/22/2020
Foley Catheter placed In Emergency Department; Urinalysis with Reflex to Microscopic at 8:00 A.M. noted the following:
Color = yellow
Appearance = clear
Specific gravity 1.011 Normal Range = 1.005-1.030
pH = 6.5 Normal Range = 5.0-8.0
Bacteria = 2+
White Blood Cells = 20 to 25
Protein, glucose, ketones, bilirubin, blood, nitrites and Leukocyte Esterase = Negative

MedScape
Updated: Dec 15, 2015
Author: Edgar V Lerma, MD, FACP, FASN
Documents the following:
Normal values are as follows:
" Color - Yellow (light/pale to dark/deep amber)
" Clarity/turbidity - Clear or cloudy
" pH - 4.5-8
" Specific gravity - 1.005-1.025
" Glucose - less than or equal to 130 mg/d
" Ketones - None
" Nitrites - Negative
" Leukocyte esterase - Negative
" Bilirubin - Negative
" Blood - less than or equal to 3 RBCs
" Protein - less than or equal to 150 mg/d
" RBCs - less than or equal to 2 RBCs/hpf
" WBCs - less than or equal to 2-5 WBCs/hpf
" Squamous epithelial cells - less than or equal to 15-20 squamous epithelial cells/hpf
" Casts - 0-5 hyaline casts/lpf
" Crystals - Occasionally
" Bacteria - None
" Yeast - None


12:53 P.M.
I&O (Intake and Output) Q8H (Every eight (8) hours); physician to be called if output less than 120 mL per four (4) hours. I&O not consistently documented every eight (8) hours. from 7:00 A.M. on this date to 6:59 A.M. (twenty-four (24) hours) Intake 3,339.60 mL and Output 600 mL.

2:15 P.M.
Physician orders:
I&O Q8H; Call if urine output less than 0.5 mL/kg/hr (per kilogram per hour) which was discontinued on discharge on 12/31/2020 at 9:06 P.M.

12/23/2020:
4:09 A.M.
7:00 A.M. to 6:59 A.M. on 12/24/2020
I&O: Intake 2,157.6 mL, Output 450 mL
10:00 P.M. nursing documents Patient #6 was on a Continuous Lateral Rotation Therapy bed.
Patient Preparation:
Ensure the patient and family understand pre-procedural teachings. There was no evidence this teaching was provided to Patient #6 or the family.

12/24/2020:
7:00 A.M. to 6:59 A.M. on 12/25/2020
I&O: Intake 3,048.5 mL, Output 1,748.5 mL

12/25/2020:
7:00 A.M. to 6:59 A.M. on 12/26/2020
I&O: Intake 1,627.2 mL, Output 200 mL

12/26/2020:
7:00 A.M. to 6:59 A.M. on 12/27/2020
I&O: Intake 310 mL, Output 850 mL

12/27/2020:
8:38 A.M.
Staff Member #21 documents, "Renal: Hx (history) CKD (chronic kidney disease). Creatinine improving. DC (discontinue) IV fluids and monitor urine output/creatinine."
7:00 A.M. to 6:59 A.M. on 12/28/2020
I&O: Intake 625 mL, Output 705 mL

1:44 P.M.
Physician orders:
Foley catheter discontinued. There was no nursing documentation related to patient's ability to void following the removal of the indwelling Foley catheter.

12/28/2020:
10:50 A.M.
Physician orders:
Foley catheter discontinued (No documentation could be found where the Foley catheter was replaced since the physician order for removal at 1:44 P.M. on 12/27/2020).
7:00 A.M. to 6:59 A.M. on 12/29/2020
I&O: Intake none documented, Output 920 mL
No repeat urinalysis was performed.

12/29/2020:
7:00 A.M. to 6:59 A.M. on 12/30/2020
I&O: Intake 165.8 mL, Output 1,200 mL

12/30/2020:
8:30 P.M. Linen and Purewick (external female urinary catheter) changed.
This was the only documentation found in the medical record related to changing linen and the use of a Purewick.

Staff Members #3 and #20 were interviewed on 4/13/21 and 4/19/21 respectively. Staff Member #3 stated, "External catheters are replaced every twelve (12) hours or when they become soiled. Patient #6 did not leave with a UTI."
Staff Member #20 stated, "Wound Care could probably provide a better answer to the potential for a UTI and skin breakdown when using an external female catheter like Purewick. I would expect to see documentation by the nurses if the skin was breaking down."

The medical records were obtained from the Rehab Hospital where Patient #6 was transferred to and the records revealed the following:
Upon admission to the Rehab Facility on 12/31/2020, Patient #6's skin was assessed by the admitting Registered Nurse (RN). Patient #6 was noted the have a Deep Tissue Pressure Injury to the sacrum (DTPI) and Moisture Associated Skin Damage (MASD) to the groin, with hematoma and bruising of the peri-area. The Nurse Practitioner (NP) saw Patient #6 on 1/1/21 at 1:06 P.M. to complete the admission history and physical. The NP agreed with the skin assessment performed by the RN on 12/31/2020. The Admitting Physician saw Patient #6 at 2:10 P.M. on 1/1/21 and agreed with the NP's assessment.

US National Library of Medicine
National Institutes of Health

J Wound Ostomy Continence Nurse. 2018 Mar; 45(2): 187-189. Published online 2018 Feb 1.
Urinary Management With an External Female Collection Device
Terrie Beeson and Carmen Davis

"...Until recently, alternative management of urinary incontinence with an external urinary collection device has only been successful with males.6,9 A multitude of designs with a variety of materials have been created through the years for females, but none have flourished.6,9 Therefore, the problem is managing female urinary incontinence and leakage after removal of an indwelling catheter. Discontinuing the catheter prevents a CAUTI but may lead to incontinence-associated dermatitis (IAD). Urinary incontinence predisposes the epidermal layer of skin to damage by raising the pH, causing potential adverse outcomes such as pain, itching, burning, infection, or pressure injuries.10-14..."

Based on documentation and interview, the facility staff failed to ensure the Discharge Planning of Care of one (1) of two (2) patients, Patient #5, was kept current and developed to meet the patients' needs at the time of discharge. Patient #5 could not swallow but discharge medications were all by mouth.

The findings include:

Review of Patient #5's medical record revealed:
A 93 year old who was seen in the Emergency Department (ED) on 12/3 and 12/2020 for a urinary tract infection and was administered Rocephin. Patient #5 was admitted on 12/22/2020 with the diagnoses of Acute GI Bleed, Severe anemia and NSTEMI (non-ST elevated myocardial infarction (Heart attack)), systolic CHF (Congestive Heart Failure) and an Acute UTI (urinary tract infection). Patient #5 was discharged on 12/23/2020 Patient #5 was then readmitted on 12/24/2020 for severe sepsis, CHF exacerbation and AKI (Acute Kidney Injury) and discharged on 12/25/2020 at 4:43 P.M.

Consults and physician orders:
12/22/2020:
5:33 P.M.
Patient arrives in ED.
Diet: NPO on admit.

8:25 P.M. Vancomycin 1,000 mg (milligrams) in 0.95 sodium chloride 250 mL (milliliters), 125 mL per hour; given at 9:00 P.M.
12/23/2020:
Vancomycin 1,000 mg (milligrams) in 0.95 sodium chloride 250 mL (milliliters), 125 mL per hour; given at 9:00 P.M. and completed at 11:19 P.M. (Nursing documentation on 12/23/2020 at 8:16 P.M. indicate Patient #5 was discharged at this time.)
Patient was diagnosed with a stroke two (2) weeks prior (12/12/2020) to this admission on 12/22/2020.

Readmit: 12/24/2020:
Diagnoses: Dementia, COPD, Failure to thrive in adult, Debility.
Diet: NPO on readmit.
11:30 P.M.
Physician ordered a Swallow Test; Test completed on 12/25/20220 at 10:40 A.M. Speech Language Pathology Bedside Swallow Evaluation and Treatment:
Plan of care: Recommendations: Diet NPO (Nothing by mouth), Meds: non-oral, Aspiration Precautions, Oral Care TID (three (3) times a day), ice chips sparingly following thorough oral care. There was no assessment on prior admissions.

On 12/25/2020 at 4:43 P.M. the nurse documented, "I have reviewed discharge instructions with the Patient. The patient and caregiver verbalized understanding."
Discharge Medications, Start taking the following medications:
Tylenol: 325 mg take 2 tabs by mouth every 6 hours as needed for pain or fever.
Phenergan: 12.5 mg 1 tab by mouth every 6 hours as needed for nausea.
Potassium Chloride: 1 tab by mouth daily.
Roxanol (morphine concentrated solution: 100 mg/5 mL (20 mg/mL) 0.5 mL by mouth every two (2) hours as needed for pain or shortness of breath...
Ativan: 1 mg tablet 1 tablet by mouth every six (6) hours as needed for anxiety.

Patient #5 was admitted/treated at this facility on 12/3/2020, 12/12/2020 and 12/22/2020 for an acute UTI. Patient #5 was readmitted on 12/24/2020 with a UTI as well. The list of discharge medications in the medical record did not contain documentation that Patient #5 was discharged with an antibiotic. The physician's discharge summary on 12/24/2020 documents, "Continue current IV abx (antibiotic therapy) pending cx (culture) results."

On April 14, 2021, the above information was shared with Staff Members #2 and #3.