HospitalInspections.org

Based on review of medical records, review of policy and procedures and interview it was determined the facility failed to:

1. Provide medical care and treatment

2. Provide screening to identify the needs of 2 of 2 discharged patients with medical issues.

This had the potential to affect all patients served by this Senior Care Unit (Unit) a distinct part of this facility and did affect Patient Identifer (PI) # 1 and # 2.

Findings Include:

Nutritional Assessment and Meals: CTZ_SCU 0071

Purpose: To ensure patient's nutritional needs are evaluated and included in their plan of care if indicated.

Policy: When clinically indicated, a nutritional assessment will be provided and documented in the medical record.

Procedure:

1. A baseline nutritional screening will be included in the psychiatric nursing assessment.
2. When necessary, and as deemed by physician orders or nursing assessment, the hospital's dietician will conduct a detailed nutritional or dietetic assessment of the patient.
9. Meals/nutritional intake are supervised and monitored by program staff and recorded on the daily patient flow sheet.

Meal Supervision: CTZ_SCU 0070

Purpose: To maintain a safe, therapeutic environment during meal times and to see that the patient's nutritional needs are met.

Policy: Nursing staff will monitor patients during meal times on the Senior Care Unit.

Procedure:

1. The charge nurse will assign a nursing staff member to monitor patients at each meal on day and evening shift.

4. The staff member monitoring the patients at mealtime will note the amount or percentage of food consumed by each patient.

Patient Findings:


1. PI # 1 was admitted to the medical floor October 10, 2012 and discharged to the PPS (Prospective Payment System) excluded Geriatric psychiatric unit of the hospital on 10/17/12 with an Axis I diagnosis of Depressive disorder, not otherwise specified and rule out Dementia. Axis III diagnosis included Severe Mitral Regurgitation, Diastolic Heart Failure, History of Hypertension, Chronic Atrial Fibrillation, History of Mild Peripheral Vascular Disease, History of Gastroesophageal Reflux disease, History of Anemia and History of Nonsustained Ventricular Tachycardia according to the Psychiatric Evaluation completed 10/17/12.

The information from the medical floor admission included the following from 10/11/12:
" Patient was transferred from local nursing home because according to the nurses his feet were progressively swelling also he was complaining of worsening shortness of breath.
Impression:
1. Shortness of breath, congestive heart failure exacerbation, bilateral pleural effusion. The patient was started on intravenous Lasix. We will monitor strict inputs and outputs and fluid restriction by mouth..."

The orders for admission to the Unit included, " 2 GM (gram) Sodium/cardiac diet, limit fluid to 100 ml (milliters) per 24 hours. Have wound care nurse instruct patient on discharge wound care. Cleanse wound left foot with wound cleanser, Safegel to ulcers and change dressing every other day. Weight on admission and twice weekly, height on admission only."

The skin assessment tool completed 10/17/12 at 11:00 PM documented, " 2 reddened almost raw pressure areas to the coccyx and sacrum area, to the right thoracic area a site of thoracentesis with a bandaid and area to the left foot." The areas were not measured or described other than the information on the form.

The skilled nurse assessment dated 10/17/12 failed to document a weight, a height or correct wound care performed.

The skilled nurse note dated 10/18/12 documented under Genitourinary: Voiding: Stress Incontinence, efforts to get urinalysis and culture and sensitivity unable to void in cup.

A Nutritional Assessment dated 10/19/12 at 8:22 AM documented, " Current weight 47.267 kg (kilograms) [ equals to 104.77 pounds], ideal body weight(IBW) 172 pounds." The nutritional risk was documented as IBW 61% or less than 80% of Ideal Weight- severely depleted weight status per standards; depression and dementia noted; on low sodium diet ate approximately 75 % of breakfast this morning, will add Ensure Plus to trays." There was no information in the record to indicate how the weight was obtained.

An order was written by the dietitian 10/19/12 to add Ensure Plus to all trays.

The skilled nurse note dated 10/20/12 documented under Genitourinary: Voiding: Hesitancy/ incontinent.

Problems identified 10/20/12 at 11:45 AM and documented in the medical record include, " In recliner in group room, numerous attempts to get up by himself and void... difficulty following instructions, hyperverbal and anxious. Zyprexa 5 mg (milligrams) IM (intramuscular) given... urinal and items in easy reach. 12:30 AM more relaxed, still attempting to get to BR ( bathroom) without assistance. Constant reminding not to get up OOB ( out of bed) alone... 5:47 PM has attempted to get up many times during the shift to void. When standing at the commode, he is usually unable to void becomes frustrated... bladder is non distended."

The medical doctor (unable to read name) ordered a Prostate ultrasound with residual on 10/20/12.

The skilled nurse note dated 10/21/12 documented under Genitourinary: Voiding: Hesitancy/ incontinent.

Evaluation of the patient needs 10/21/12 documented, " Pt was unresponsive to staff redirection. He would yell out and was fixated on using the bathroom constantly. Staff attempted to place pt on a toileting schedule but he was uncooperative...The patient was given Zyprexa 5 mg IM at 11:53 PM..."

A complaint was filed 10/21/12 by the patient, " Patient states that he took his dentures out of his mouth after breakfast and left them on his tray. "
Unable to find the dentures in his room or on the unit was the comment at the bottom of the complaint.


The 10/22/12 and 10/23/12 nurses notes failed to document anything regarding the genitourinary problems the patient was experiencing.

The Medical Doctor, # 1 ordered 10/23/12, " Consult Doctor (# 2)... for prostate ultrasound..."

The progress note dictated by the medical doctor dated 10/23/12 documented, " Prostate ultrasound was ordered by Dr # 4. We will consult Dr # 2 since this is not a procedure done by the interventional radiologist..."

The 10/24/12 nurses assessment documented genitourinary, " Frequency. Has been isolated and withdrawn in room to self all shift... refusing to eat."

Problems identified 10/25/12 at 2:00 PM and documented in the medical record include, " Poor appetite, eating approximately 25 % of meals. Drinks all of Ensure. Dressing left foot to be changed QOD (every other day)Small amount of greenish drainage noted on old dressing. 2 ulcerated areas on top of foot have a yellowish appearance and do not appear to be healing. "

The dietitian documented an order 10/25/12," Continue Ensure Plus all trays, add ensure plus between meals (total 6 daily)."

The 10/28/12 nurses note documented, " Problem- Nutrition: No problems noted with ability to eat/swallow but eats 25-50% of meals. Drinks 50 % of supplement. Enjoys ice water. States he just does not want to eat and he is not going to make himself eat when he doesn't want it."

The 10/29/12 nurses note documented, " Eating only 10 % of meals... has had more episodes of incontinence today than usual."

The 10/30/12 nurses note documented, " Staff put in top dentures this morning and patient ate 100%; doing good with low sodium diet with Ensure plus each tray and one between each meal; will also add Ensure pudding to lunch and supper trays; does good with supplements even when intake by mouth is down at meals."


The dietitian documented an order 10/30/12," Ensure Pudding on lunch and supper trays."

The 10/31/12 nurses note documented at 3:08 AM, " Awakened with urinary incontinence and staff provided care... awakened several times in latter part of shift. Briefs changed and care provided..."

The staff documented good intake of supplements but failed to document the amount of supplements he was consuming, no intake and output was documented while the patient was on the Senior Care Unit. All supplement amounts were recorded with the general intake from trays. The patient's output was recorded as incontinent the month of October.


The correct wound care ordered was provided twice in October, on 10/21/12 and 10/26/12 to the left lower leg/foot.

On 10/22/12 wound care," Cleaned with wound cleanser, applied xeroform, wrapped with Kerlix, secured with paper tape."

10/25/12 wound care," Left foot cleansed with wound cleaner. Wound gel applied, non-adherent pad applied and wrapped with Kerlix. Foot then elevated will re-consult wound care for eval (evaluation) of foot sores."

The wound care provided 10/22/12 and 10/25/12 did not follow the orders for wound care from 10/17/12.

There was no assessment or documented wound measurement in October of the sacrum/coccyx wound observed 10/17/12.

The medical doctor ordered 10/26/12, " We will reconsult wound care nurse to re-evaluate patient wounds."

The 11/1/12 nurses note at 11:14 PM documented, " While being assisted to bathroom per MHT (Mental Health Technician) he stated to her he was about to fall. She eased him to the floor. During the easement he bumped his head on wall. No apparent injury noted. Dr # 4 notified and ordered a CT (Computed Tomography) of head." The medical doctor also ordered neurochecks per protocol on 11/1/12.

At 2:00 PM on 11/3/12 the medical doctor ordered, " After next urine void, straight cath fro residual. Document residual volume in chart. Urine for culture and sensitivity, PSA (Prostate Specific Antigen)."

The 11/3/12 nurses note at 6:50 PM documented, " Attempt to straight cath after void as written per Dr # 1. Zero urine resulted. Patient tolerated procedure with out difficulty."

A second entry on 11/3/12 documented at 11:08 PM, " From 7:00 PM until 11:00 PM the patient had not voided. Nurse noted that patient's bladder was distended and his abdomen firm. Patient stated that he could not void. Nurse attempted to cath patient from previous order from Dr # 1. 2 attempts were made but were unsuccessful. House supervisor also made an attempt but was unsuccessful. Dr # 3 notified and orders given to consult urology and surgery. Nurse attempted to call Dr # 2 (Urologist)... Dr # 2 called and notified nurse that he was out of town and there was no MD on call for surgery. Dr # 1 notified of the situation at 00:40 AM. Dr # 1 stated that nurse was to watch patient and that he would see him in the morning. At 1:00 AM the patient was able to pass some urine. He also voided a small amount again at 6:50 AM. Nurse continuing to monitor patient. On coming shift notified and will continue to keep MD aware of situation."

The 11/4/12 nurses note at 6:50 PM documented, " Voiding small amounts intermittently in diaper. Bladder remains distended. Prior shifts unable to insert catheter due to resistance. # 18 Coude catheter inserted without difficulty. Tolerated well, immediate return of amber urine 1200 ml. Tubing clamped for 25 minutes and then unclamped with 450 ml in return. Left catheter in place to bedside drainage bag. Tubing secured to thigh. Urine sent to lab for urinalysis and C&S. Consult Dr... Monday for evaluation of elevated PSA and urinary retention."

At 2:30 PM on 11/5/12 the medical doctor ordered, " Medically cleared for discharge to nursing home, Foley to drainage. Urology consult after admission to nursing home."

The 11/6/12 nutritional assessment documented, " Current weight 47.267 kg (kilograms) [ equals to 104.77 pounds], ideal body weight(IBW) 172 pounds." This is the exact same information documented on 10/19/12. The medical record failed to document a weight from 10/17/12 to 11/6/12 when the patient was transferred to the nursing home.

In an interview with the nursing home staff that transferred the patient to the hospital on 10/10/12, the weights recorded at the skilled nursing facility on 9/21/12 were 126.8 pounds and 132 pounds on 10/5/12.

The 11/6/12 nutritional note documented, " Patient on low sodium diet with oral intake 25-100% at most meals per round report; patient getting Ensure clinical strength and ensure pudding to supplement diet; noted wound care saw patient for ulcer left foot; no albumin available; recommend prostat AWC (Advanced Wound care liquid protein) 30 ml TID (three times a day) to promote healing..."

There was no wound care nurse assessment in the medical record provided to the surveyor on 12/27/12.

Dr # 1 ordered a Stat CBC (immediate complete blood count) at 10:45 AM on 11/6/12. Results reported 11:47 AM: WBC (white blood count) 16.3 High, RBC (red blood count) 3.54 Low, Hgb (hemoglobin) 9.6 Low, Hct (hematocrit) 29.4 Low and Platelet 138 Low.

The nurse notified the medical doctor of the results at 12:42 PM on 11/6/12 and the order was received, " Medically cleared for discharge to the nursing home. Foley to GU ( genitourinary) bag, urology consult after admission to nursing home."

The patient had a consult ordered by the medical doctor for the urologist to see 10/23/12, a Tuesday and again 11/4/12 when further problems existed. The patient was never seen by the Urologist.

The urinalysis results obtained 11/4/12 when the catheter was inserted were as follows:
2-5/HPF-WBC (High Power Field- White blood count), 2-5/ HPF- RBC ( Red Blood Count) and a small amount of bacteria. The results were reported 11/4/12 at 10:10 AM.

The Microbiology report of the culture and sensitivity was verified with a preliminary report 11/5/12 at 9:21 AM: Colony count > 100,000 cfu/ml ( colony forming units/ militer)- Enterococcus faecalis... sensitive to Nitrofurantoin, Penicillin and Vancomycin. The final report verified at 12:00 PM on 11/6/12.

The nurse documented on 11/6/12 at 8:08 AM, " Foley draining blood tinged to bloody urine with small clots."

The patient was not treated for a urinary tract infection by the hospital. The results were available and on the medical record prior to the discharge 11/6/12 at 12:42 PM.

The patient lost weight in the facility. PI # 1 had wounds that were treated only 4 times in the 21 days he was a patient on the Unit. PI # 1 had urinary retention and had to wait for treatment because no physician was on call, resulting in 1450 cc (cubic centimeters) of urine to be obtained when a catheter was passed and was not treated for a urinary tract infection while on the Unit.

In an interview on 12/28/12 at 10:10 AM with Employee Identifier # 1, Executive Director of Psychiatric Services the above information was confirmed.

The patient was transferred from the admitting nursing facility to the Emergency Room of a local hospital 11/7/12 at 2:04 PM. The physician documented on the History and Physical 11/7/12 the Impression:

1. Gross hematuria, etiology uncertain probably secondary to trauma from Foley catheter.
2. Marked mental obtundation probably secondary to medication plus dementia plus effects of dehydration..."

The emergency room abnormal lab results on 11/7/12 were as follows:
BUN 40 high, Calcium 8.0 low, Albumin 2.1 low, Total Protein 5.2 low, Sodium 128 low, Chloride 87 low, WBC 14.7 high, RBC 3.23 low, Hemoglobin 8.7 low and Hematocrit 26.9 low. The urinalysis results 11/7/12 from the emergency room were as follows: Color-red, Blood- 4+, Protein-4+, RBC to numerous to count and bacteria moderate amount.

A urine culture and sensitivity was collected in the emergency room 11/7/12. Report revealed: Colony count > 100,000 cfu/ml ( colony forming units/ militer)- Enterococcus species... sensitive to Nitrofurantoin, Penicillin, Tetracycline and Vancomycin.

The patient was admitted to the Intensive Care Unit (ICU) for treatment. The ICU nurse documented as part of the assessment 4 wounds. An open breakdown area to the left dorsal foot, breakdown to the right heel, open area of breakdown to the mid back and open areas of breakdown to the coccyx/sacrum.


2. PI # 2 was admitted to the Geriatric psychiatric unit of the hospital on 10/15/12 from a long term care facility with an Axis I diagnosis of Dementia
with behavioral disturbances.

PI # 2 was discharged from the Unit and admitted to the medical care of the hospital 11/24/12 with diagnoses of Chronic Obstructive Pulmonary Disease with acute exacerbation, Gastroesophageal Reflux, Hypothyroidism and Anxiety/ Depression.

Dr # 1 documented the treatment plan for 11/24/12, " Duoneb breathing treatments every 4 hours, Solu-Medrol IV (intravenous), place on supplemental Oxygen (O2) to maintain an O2 saturation greater than 92%. Continue medications from the Senior Care Unit."

On 11/24/12 at 9:51 PM the nurses note documented, " On admission 1 wound, rash to buttock... Suction set up for extra secretions patient unable to cough up secretions..."

The physician's progress note dated 11/25/12 documented, " Plan to continue supplemental O2, IV steroids... hold her blood pressure medicines secondary to her decreased blood pressure."

On 11/25/12 at 8:10 AM the nurses note documented, " Difficulty swallowing... 1/2 dose of Duoneb was given due to heart rate being 124... wound comment to left heel- healed pressure ulcer surrounded by intact mushy skin..."

On 11/25/12 at 2:21 PM the nurses note documented, " Patient sleeping, patient was turned... changed diaper... patient needs total care..."

On 11/25/12 at 4:22 PM the nurses note documented, " Notified Dr # 1 by phone BUN (blood urea nitrogen) 90 Creatinine 2.38, no new orders received."

On 11/25/12 at 10:29 PM the nurses note documented, " Diaper changed, cream applied to coccyx. Pillow used to brace turn. Pillow placed between knees."

A nutritional assessment was documented 11/26/12, " Current weight 57 kg (125 pounds) ideal body weight 140.45 pounds. Difficulty swallowing; albumin low 2.4; patient on a pureed diet; noted left heel healed ulcer and black soft spot on right heel...will add Ensure Clinical strength TID (three times a day); will monitor intake by mouth and assist PRN (as needed)."

A wound care consult was ordered 11/26/12 at 6:00 AM.

On 11/26/12 at 8:20 AM the nurses note documented, " Skin turgor poor."

On 11/26/12 at 2:00 PM the nurses note documented, " Wound right heel DTI (deep tissue injury), skin intact, dark purple appearance, soft to touch, instructed RN to apply heel protectors and float heels. Wound # 2, left heel, DTI, skin intact, dry in areas, dark purple areas soft to touch. Instructed RN to apply heel protectors, apply aloe Vesta to dry areas and float heels."

PI # 2 was discharged back to the Unit 11/26/12 with Dr # 1 documenting in the discharge summary, " Her lungs gradually returned to baseline... Patient was alert and awake without complaints at the time of the transfer back to the Senior Care Unit."

The patient was readmitted 11/26/12 with an Axis I diagnosis of Dementia
with behavioral disturbances.

The nurse documented 11/26/12, " Patient admitted to the Unit from 3rd floor... confusion, loud yelling out hyperverbal and manic... the nurse did a skin assessment which revealed 1 bruise to the left arm, redness and inflammation to the coccyx, both heels and edema to the toes and lower legs."

The psychiatrist visited the patient 11/28/12 at 10:30 AM and documented, " Some swallowing difficulty... nurse to do swallowing assessment."

On 11/28/12 at 11:15 AM, Dr # 3 ordered , " D 5 1/2 NS ( dextrose and 1/2 strength normal saline) 100 ml per hour now, CBC and CMP ( complete metabolic profile) now. Speech therapy consult for swallowing evaluation now. Address DNR ( do not resuscitate) status with family."

A swallowing evaluation was conducted 11/28/12 at 1:51 PM, " Patient coughed repeatedly after trial of applesauce. No cough with trial of chocolate pudding, 1/2 teaspoon. Cough is very weak and ineffective. Recommend pudding consistency foods and liquids. If coughing persists with this, recommend alternative feeding. Continue with very small bites and sips allowing plenty of time and encouragement."

On 11/28/12 at 1:10 PM, Dr # 3 ordered, " Bolus 300 ml 1/2 NS now."

Dr # 1 consulted 11/28/12 at 3:12 PM and documented, " Patient's oral intake has diminished over the last few days and mental status has gone worse. I received a phone call. We obtained labs that revealed a significant elevation in her BUN and creatinine, BUN is 130 and Creatinine is 2.6; on admission they were normal, sodium is 166. Assessment and plan: Acute renal failure due to severe dehydration and leukocytosis..."

On 11/28/12 at 3:27 PM the nurse documented , " Psychiatrist notified of need to transfer to medical floor."

Discharged to the medical floor 11/28/12 at 4:26 PM.


At 5:20 PM the nurse documented , " Called to room by PCA (patient care assistant) the patient appeared to have aspirated some vanilla pudding. Oxygen ordered, patient suctioned, order received for Morphine Sulfate, hospice and DNR was obtained. Hospice contacted and will come out and evaluate patient."

The physician's progress note dated 11/29/12 at 9:42 AM documented, " Called to pronounce patient, no heart rate, no respirations, pupils fixed and dilated. Patient pronounced at 9:20 AM."

The patient lost weight while in the Unit. The intake was decreased due to difficulty swallowing from 11/24/12 and the patient was documented as total care from 11/24/12. The requirement for assistance with meals and other total care needs were not documented as being managed with the limited staff available on the Unit (Refer to 482.23(b) Staffing deficiency).
The nurse failed to document if the heel protectors were obtained and applied or if the heels were floated off the bed.

Observations while on the Unit revealed no water or fluids at the bedside. As a result of interviews with staff it was determined the hydration was managed by water given to the patients when the nurse passed medications, fluids on the meal trays and activities offered fluids at 10:00 AM and 2:00 PM. The evening shift was to offer fluids at 8:00 PM.

Based on review of staffing schedules for the PPS (Prospective Payment System) excluded Geriatric psychiatric unit from December 7, 2012 through December 26, 2012, interviews with patient care staff and an interview with administrative staff it was determined the facility failed to ensure adequate numbers of staff were available to meet the needs of the patients housed in the psychiatric unit.

This had the potential to affect all patients served by the psychiatric units of the hospital and did affect the current 6 of 6, patients Patient Identifier (PI) # 3, # 4, # 5, # 6, # 7 and # 8 .


Findings include:

The Unit Staffing/ Acuity Report documented the following staffing patterns and census:

December 7, 2012 - One RN (Registered Nurse) and one Mental Health Technician (Tech) for the 7 AM until 7 PM shift.

December 7, 2012 - One RN and one Tech for the 7 PM until 7 AM shift. There was no census recorded for this day.

December 8, 2012 - One RN and one Tech for the 7 AM until 7 PM shift.

December 8, 2012 - One RN and one Tech for the 7 PM until 7 AM shift. There was no census recorded for this day.

December 9, 2012 - One RN and one Tech for the 7 AM until 7 PM shift.

December 9, 2012 - One RN and one Tech for the 7 PM until 7 AM shift. There was a census of 4 recorded for the 7 PM until 7 AM shift.

December 10, 2012 - One RN (written by the RN was 10:45 unsure if she worked until 10:45 AM or PM) and one Tech for the 7 AM until 7 PM shift.

December 10, 2012 - One RN and one Tech for the 7 PM until 7 AM shift. There was a census of 4 recorded for the 7 PM until 7 AM shift.

December 12, 2012 - One RN and one Tech for the 7 PM until 7 AM shift. There was a census of 7 recorded for the 7 PM until 7 AM shift.

December 14, 2012 - Two RN's and one Tech for the 7 AM until 7 PM shift with the Activity Therapist working from 8 AM until 4 PM, a census of 7 was recorded.

December 14, 2012 - One RN and one Tech for the 7 PM until 7 AM shift. There was a census of 7 recorded for the 7 PM until 7 AM shift.

December 16, 2012 - One RN and one Tech for the 7 PM until 7 AM shift. There was a census of 7 recorded for the 7 PM until 7 AM shift.

December 17, 2012 - Two RN's and one Tech for the 7 PM until 7 AM shift. The Tech worked from 7 PM until 12:00 midnight (5 hours). There was a census of 8 recorded for the 7 PM until 7 AM shift.

December 18, 2012 - One RN and one Tech for the 7 PM until 7 AM shift. There was a census of 7 recorded for the 7 PM until 7 AM shift.

December 19, 2012 - Two RN's and one Tech with the Activity Therapist working ( hours not recorded) the 7 PM until 7 PM shift. There was a census of 7 recorded for the 7 AM until 7 PM shift.

December 19, 2012 - One RN and one Tech for the 7 PM until 7 AM shift. There was a census of 6 recorded for the 7 PM until 7 AM shift.

December 22, 2012 -One RN and one Tech for the 7 AM until 7 PM shift.
There was a census of 6 recorded for the 7 AM until 7 PM shift.

December 22, 2012 - One RN and one Tech for the 7 PM until 7 AM shift. There was a census of 6 recorded for the 7 PM until 7 AM shift.

The surveyors arrived on the unit 12/26/12 at 1:15 PM, one RN (RN # 1) was present at the nurses station and a Tech was on the hall with a census of 5. The surveyor asked where all of the patients were located as only one male patient was standing in the group room alone. RN # 1, stated they were all in their rooms for quiet time.

In an interview on 12/27/12 at 7:45 AM, with Employee Identifier (EI) # 1, Executive Director Psychiatric Services, regarding staffing, EI # 1 stated that they are to always have 3 people working at a minimum.

The surveyors interviewed RN # 1 on 12/27/12 at 1:45 PM, regarding the staffing of the unit. RN # 1 stated that it was not unusual to have only 2 staff members with up to 7 patients.

The surveyors interviewed the Activity Therapist # 1 on 12/27/12 at 1:55 PM, regarding the staffing of the unit. The Activity Therapist stated that she felt they always needed two Techs during the day shift, example, " what if we have two feeders".

The surveyors interviewed the Mental Health Tech # 1 on 12/27/12 at 2:05 PM. The Tech revealed she had been working as the only Tech on the unit for the 7 AM until 7 PM shift for more than 6 months.


The surveyors interviewed RN # 2 on 12/27/12 at 2:15 PM, regarding the staffing of the unit. RN # 2 stated that it was not unusual to have only 2 staff members working. RN # 2 stated that they try very hard to keep everyone safe.

The surveyors interviewed RN # 3 on 12/28/12 at 9:50 AM, regarding the staffing of the unit. RN # 3 stated, "It is not unusual to have only 2 staff members working, it is well staffed today because you are here."

The patients observed on the unit 12/27/12 during the lunch time meal included 3 patients in wheelchairs, PI # 3, # 4 and # 6, 2 ambulatory patients, PI # 5 and # 8 and 1 patients, # 7, who required assistance with ambulation and encouragement to eat.

The unit was consistently understaffed to meet the needs of the patients(Refer to 482.13(c)(2)) .

Based on review of medical records, facility policies and procedures, and interviews with administrative staff, it was determined in 3 of 3 medical records reviewed with wounds the nurse failed to:

1. Provide wound care as ordered

2. Document measurements of the size and description of the wounds

3. Weigh patients on admission and 2 times a week as ordered.

This had the potential to affect all patients receiving wound care and did affect Patient Identifier (PI) #1, # 3 and #4.


Findings Include:

Policy : Patient Assessment and Reassessment
Policy Number: CTZ - NRS 0015
Approved June 13, 2010

Policy

It is the Policy of Citizens Baptist Medical Center that the licensed nurse collects data in systematic and ongoing process involving the patient,, family, other healthcare providers, and environment, as appropriate, in holistic data collection. Data may include the following dimensions: physical, psychological, socio-cultural, spiritual, cognitive, functional abilities, developmental, economic, and lifestyle.. The registered nurse prioritizes data collection activities based on the patient's immediate condition, or anticipated needs of the patient or situation. The registered nurse synthesizes available data, information, and knowledge relevant to the situation to identify patterns and variances and documents relevant findings in a retrievable format.

Procedure

Initial Assessment:
1. An admission assessment will be completed by a registered nurse on a complete physical assessment and review of data collected by members of clinical team as directed by the registered nurse.

1.1 An admission physical assessment will be completed and documented by a Registered Nurse (RN) on all adult medical surgical patients within four (4) hours of admission....

2. An admission physical assessment must include a review of all body systems including:

........

2.8 Integument/Wound: Inspect skin noting turgor, presence or absence of nodules, wounds or other skin breakdown.....


The Senior Care Assessment Policy # CTZ-SCU 0137 includes:

A. Functional Assessment........

B. OT/AT (Occupational Therapy/Activity Therapy)....

C. Phycological Assessment........

D. Phycological Assessment........
and does not include a physical assessment.

Patient Findings:


1. PI # 4 was admitted to the SCU (Senior Care Unit) on 12/17/12 with a Diagnosis of Dementia Non specific.

Review of the assessment data dated 12/17/12 at 8:20 PM revealed documentation by the clinician the patient had a wound located on the right lower leg which was infected and was classified as Cellulitis.
Further documentation revealed the wound was a post I&D (incision and drainage) and wound care had been provided by the wound care nurse prior to being transferred to the SCU. There was no assessment of the wound to include size, color, or drainage.

Review of the physician's order dated 12/18/12 revealed for wound care to be performed to the right lower leg as follows: cleanse with wound cleanser, apply silver dressing and cover with Mepilex dressing daily.

Review of the daily assessments dated 12/18/12, 12/19/12, 12/20/12, 12/22/12, and 12/24/12 revealed no documentation of wound assessment or wound care.

The first time wound care was performed after being admitted to the SCU was documented on 12/22/12 at 8:00 PM.

Review of the assessment 12/23/12 at 805 PM revealed the Clinician documented "dressed wound". There was no documentation provided for what type wound care was provided. There was no assessment to include size of the wound, color, or drainage.

An interview was conducted with the Registered Nurse (RN), RN # 1, on 12/27/12 at 12:55 PM who verified the above findings.




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2. PI # 1 was admitted to the medical floor October 10, 2012 and discharged to the PPS (Prospective Payment System) excluded Geriatric psychiatric unit of the hospital on 10/17/12 with an Axis I diagnosis of Depressive disorder, not otherwise specified and rule out Dementia.

The orders for admission to the Unit included, " 2 GM (gram) Sodium/cardiac diet, limit fluid to 100 ml (milliters) per 24 hours. Have wound care nurse instruct patient on discharge wound care. Cleanse wound left foot with wound cleanser, Safegel to ulcers and change dressing every other day. Weight on admission and twice weekly, height on admission only."

The skin assessment tool completed 10/17/12 at 11:00 PM documented, " 2 reddened almost raw pressure areas to the coccyx and sacrum area, to the right thoracic area a site of thoracentesis with a bandaid and are to the left foot." The areas were not measured or described other than the information on the form.

The skilled nurse assessment dated 10/17/12 failed to document a weight, a height or wound care performed.

A Nutritional Assessment dated 10/19/12 at 8:22 AM documented, " Current weight 47.267 kg (kilograms) [ equals to 104.77 pounds], ideal body weight(IBW) 172 pounds." The nutritional risk was documented as IBW 61% or less than 80% of Ideal Weight- severely depleted weight status per standards; depression and dementia noted; on low sodium diet ate approximately 75 % of breakfast this morning, will add Ensure Plus to trays." There was no information in the record to indicate how the weight was obtained.


On 10/21/12 wound care was provided to the left lower leg/foot. Old dressing removed, lower leg and foot dry and flaking. Top of foot has 2 ulcerated areas, Stage II. Skin pink and has no visible drainage. Foot and leg cleaned then safe-gel applied to ulcerated areas. Aloe Vista applied to dry toes, wrapped foot and leg with kerlix.

On 10/22/12 wound care," Cleaned with wound cleanser, applied xeroform, wrapped with Kerlix, secured with paper tape."

10/25/12 wound care," Left foot cleansed with wound cleaner. Wound gel applied, non-adherent pad applied and wrapped with Kerlix. Foot then elevated will re-consult wound care for eval of foot sores."


Problems identified 10/25/12 at 2:00 PM and documented in the medical record include, " Poor appetite, eating approximately 25 % of meals. Drinks all of Ensure. Dressing left foot to be changed QOD (every other day)Small amount of greenish drainage noted on old dressing. 2 ulcerated areas on top of foot have a yellowish appearance and do not appear to be healing. "

The wound care provided 10/22/12 and 10/25/12 did not follow the orders for wound care from 10/17/12.

There was no assessment or documented wound measurement in October of the sacrum/coccyx wound observed 10/17/12.

The medical doctor ordered 10/26/12, " We will reconsult wound care nurse to re-evaluate patient wounds."

The 11/6/12 nutritional assessment documented, " Current weight 47.267 kg (kilograms) [ equals to 104.77 pounds], ideal body weight(IBW) 172 pounds." This is the exact same information documented on 10/19/12, the medical record from 10/17/12 through transfer to the nursing home 11/6/12 failed to document a weight.

In an interview with the nursing home staff that transferred the patient to the hospital on 10/10/12 originally before moving to the Unit 10/17/12 the weights recorded at the skilled nursing facility were 9/21/12, 126.8 pounds and 10/5/12, 132 pounds.

The 11/6/12 nutritional note documented, " Patient on low sodium diet with oral intake 25-100% at most meals per round report; patient getting Ensure clinical strength and ensure pudding to supplement diet; noted wound care saw patient for ulcer left foot; no albumin available; recommend prostat AWC (Advanced Wound care liquid protein) 30 ml TID (three times a day) to promote healing..."

There was no wound care nurse assessment in the medical record provided to the surveyor 12/27/12.

The patient lost weight in the facility and was never weighed as ordered. The wounds were treated only 4 times in the 21 days he was a patient on the Unit.

In an interview on 12/28/12 at 10:10 AM with Employee Identifier # 1, Executive Director of Psychiatric Services the above information was confirmed.


3. PI # 3 was admitted to the Unit 12/13/12 with an Axis I diagnosis of Depressive Disorder not otherwise specified and Dementia with behavioral disturbances.

The orders for admission to the Unit included, " Low sodium with chopped meat. Weight on admission and twice weekly, height on admission only."

A weight from the Emergency Room assessment to clear patient for admit to the Unit was 140 pounds stated.

The patient was not weighed from 12/13/12 until the surveyor requested the patient be weighed 12/27/12. Scales were brought from the Intensive Care unit to weigh the patients 12/27/12. The weight 12/27/12 was 125.8 pounds.

The patient was observed at the lunch meal 12/27/12 and ate poorly, only her small slice of pound cake and a few bites of mashed potatoes.

PI # 3 was weighed 12/28/12 with a result of 123.8 pounds.

In an interview with RN # 3 on 12/28/12 at 9:50 AM, the surveyor asked about weighing the patients. RN # 3 stated that they haven't weighed patients in 3 or 4 months. RN # 3 stated that they had told the Program Director and the Nurse Manager they needed equipment.

In an interview on 12/28/12 at 10:10 AM with EI # 1, Executive Director of Psychiatric Services the above information was confirmed. EI # 1 stated that the staff observe the patients closely and will assist or feed as necessary.