HospitalInspections.org

Based on document review and interview the facility failed to insure the daily hygiene needs of 1 of 1 patients was met.

On 9/6/2012 a written complaint was received to the investigating authority that patient #2 was found with feces between her legs with prescription ointment applied over the feces. Family reported this information was told to the shift nurse who stated she had seen it and reported it to the house supervisor. The staff nurse, having knowledge of the feces with the medicated ointment over it, did not provide hygiene services for the patient after she reported it to the house supervisor.

On 9/12/2012 a thorough review of the patient's Electronic Medical Record (EMR) revealed:
- Patient #2's respiratory status was maintained via ventilator.
- Patient #2 was maintained with sedation while on the ventilator and unable to make her needs known.
- no documentation personal hygiene, such as a bath, was provided.
-The Braden scale found in the EMR recorded the patient was bed bound, incontinent of bowel and had a Foley catheter.
-The EMR also revealed the patient was unable to turn herself and unable to meet her daily hygiene needs.
-The EMR also recorded the patient had no skin break down upon admission other than a surgical incision and drainage of a facial abscess, however, patient #2 developed a stage II pressure ulcer on her right buttock, which required debridement.

On 9/12/2912 at 11:00 am, an interview with RN #3 confirmed no daily hygiene was recorded and the Braden scale reflect a dependent patient that was a high risk for skin break down. RN #3 confirmed the patient did in fact develop a stage II pressure ulcer on her Right buttock. RN #3 confirmed she was not aware of a policy for documentation of daily hygiene needs of the patient

On 9/13/2012 at 10:00 AM, an interview with RN #2 also confirmed the patient was discharge from the acute hospital to a long term acute hospital with a stage II pressure wound that was not present upon admission

Based on document review and interview the facility failed to insure the Registered Nurse assessed and evaluated the needs of 1 of 1 patients identified.

On 9/12/2012, the Electronic Medical Records (EMR) of patient #2 was reviewed and the following was documented in the EMR:

-Pt #2 was admitted on 8/4/2012 and the initial nursing assessment records the patient weighed 187 kilograms (kg) (1 kg = 2.2 pounds (lbs)), 187 kg x 2.2 lbs = 411.4 lbs, and had no skin break down other than the surgical wound to the right jaw.
-The family members complain the patient had a foul odor during the first week after admission.
-The first record of patient #2 skin break down is recorded in the EMR 8 days after admission, on 8/12/2012.
-On 8/12/2012 the EMR for patient #2 records 3 areas of skin integrity compromise.
-Left (Lt) breast skin fold 14 centimeters (cm) x 5 cm open and draining
-Right (Rt) breast skin fold 14 cm x 3 cm open and draining
-Right buttocks 16 CM x 14 cm open draining hematoma
- The EMR records nurses applied "skin barrier" (a heavy cream based ointment) to the skin folds of the patient's breast.
-On 8/17/2012 the EMR recorded the following:
-Lt and Rt breast improved with use of Nystatin powder.

The patient's Rt buttock continues to deteriorate without successful pressure reduction and on 8/19/2012 the patient's Rt buttock is debrided at the bedside by Physical Therapy (PT). The EMR recorded the resulting wound measures "11.5 cm in length".

On 8/21/12 patient #2 is transferred to a long term acute care facility and the EMR revealed the wound measures 12 cm x 8 cm with continued pressure necrosis visible on the photo.

On 9/5/2012 at 10:00 AM in the conference room RN #3 confirmed there was no documentation in the EMR that the nurses recorded any nursing intervention for pressure reduction and off loading other than a bariatric bed that offered some pressure relief.

Further discussion with RN#3 confirmed there was no recorded assessment, evaluation or interventions provided patient #2 for frequent episodes of fecal incontinence. There was no recorded skin care for daily hygiene. The nursing staff did not document the physician was notified of the patient's fecal incontinence, that was no longer formed, but had become liquid.

Based on record review and interview the facility failed to develop and keep current the nursing care plan for 1 of 1 patients identified.

On 9/5/2012, the electronic medical record (EMR) for patient #2 was reviewed. The EMR revealed the care plan was identified by topical reference only. There were no interventions located in the EMR for the following:

-Alteration in skin integrity established 8/4/2012 post op surgery for Incision and Drainage of abscess on right jaw line. Nothing was identified for the decubitus of right buttocks identified in the nurse's note on 8/12/2012 or beneath bilateral breast identified on 8/10/2012 in the nurses note. No nursing intervention or care plan updates were located in the EMR for patient #2.

On 9/5/2012 at 10:00 AM in the conference room, RN #3 confirmed there were no interventions or updates for patient #2 care plan.

On 9/5/2012 at 1:00 PM RN #2 confirmed there were no nursing interventions recorded or updates recorded on patient #2 care plan.

Based on document review and interview the facility failed to insure a discharge summary was available on 1 of 1 patient medical record reviewed.


On 9/12/2012, the Electronic Medical Record (EMR) for Patient #2 was reviewed and no discharge summary was located in the EMR.

On 9/12/2012 at 10:00 AM in the conference room RN #3 confirmed no Discharge summary was to be found in the EMR.

Based on record review and interview the facility failed to insure a history and physical (H&P) was completed prior to surgery in 1 of 1 patient medical record reviewed.


On 9/5/2012, the Electronic Medical Record (EMR) was reviewed for patient #2. No H&P was located within the EMR for patient #2 who was seen in the Emergency Department (ED) on 8/4/2012 for painfull right mandibular facial area and subsequently taken to surgery for extraction of tooth #30 and Incision and Drainage of the underlying abscess.

On 9/5/2012 at 10:00 AM, RN #3 confirmed no H&P was located for patient #2 within the EMR.