HospitalInspections.org

Based on document review and interview the facility failed to insure nursing staff accurately assessed the needs and provide nursing interventions for 1 of 1 patents reviewed.

On 2/23/2012 at 9:30 am in the conference room the patient ' s medical record was reviewed. The medical record revealed the following physician documentation:
Patient (pt) #1 was an 83 year old female who was admitted on 2/25/2012 following a motor vehicle collision (MVC) for stabilization of her injuries.
Pt #1 diagnosis upon admission to the specialty hospital included the following;
-Acute respiratory failure
-Chronic respiratory failure
-Dysphasia
-Protein Energy Malnutrition (albumin 2.3 normal 3.5 or greater)
-Debilitation
-Multiple Fractures (Fx)
-Chest wall contusions
-Abdominal wall contusions
-On 2/25/2012 the pt was evaluated in the emergency department by Emergency -Department (ED) physician.
-ED physician notified the trauma the on call trauma surgeon.
-ED physician noted the pt might require resuscitation and even ventilatory support over night.
-The trauma surgeon took the pt to surgery on 2/25/2012.
-The attending physician documented the pt returned from surgery 2/25/2012intubated.
-The pt was still intubated when she returned to surgery on 2/26/2012
-The attending documented pt #1 failed multiple attempts to extubate.
-The pt received two (2) units packed red blood cells on the 2/27/2012
-Documentation recorded the pt developed thick secretions over the next two (2) days from her airway.
-Documentation records the pt underwent a bronchoscopy and bronchoaveolar lavage on 2/28/2012
-Physician recorded the pt underwent a tracheostomy on 3/5/2012
-Documentation records the pt underwent a swallowing evaluation 3/9/2012
-The pt underwent percutaneous endoscopic gastrostomy (PEG) placement on 3/11/2012.
-Documentation records attempts to downs size her tracheostomy resulted in difficulty ventilating
-Nursing documentation recorded the pt developed a reddened area with drainage to the back of her head on 3/11/2012 wound care orders were noted 3/12/2012
-The patient tracheostomy was down sized on 3/17/2012
-The pt was seen for consult by an otolaryngologist on 3/22/2012 and diagnosed with subglottic edema
Pt was transferred to the specialty hospital on 3/24/2012


Review of the pt ' s nursing assessment revealed:
-The pt mobility was recorded as very limited when in fact she was in a drug induced coma secondary to mechanical ventilation 2/25/2012
-The nursing assessments documented the pt ' s nutritional status as adequate when the pt ' s was admitted with a PEM 2/25/2012
-The pt later required a peg tube 3/11/2012
-There was no documentation the nursing staff recognized the risk to skin break down or the difficulty healing the patient faced with PEM, immobility, multiple fx and multiple underlying etiologies.
-There was no documentation a special low air loss bed or any other off loading intervention was in use for this immobile patient until after the wound had occurred on the pt ' s head.

The nursing staff failed to accurately assess the needs and provide intervention for this debilitated pt even though physician documentation was available.