The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|SPECTRUM HEALTH||100 MICHIGAN ST NE GRAND RAPIDS, MI 49503||Feb. 7, 2013|
|VIOLATION: NURSING CARE PLAN||Tag No: A0396|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review and interview the facility failed to keep current a nursing plan for 1 out of 4 (#20) adult patients.
On 2/7/13 at approximately 10:30 a.m. during medical record review it was revealed that the care plan for patient #20 was not updated to address new occurrences of skin breakdown . Patient #20 was admitted on [DATE] for altered mental status. The initial skin assessment upon arriving to the inpatient floor on 11/20/12 documented a Stage 1 pressure ulcer on the right hip. On 11/23/12 nursing staff documented in the "Skin" area on the assessment flow sheet "rash, reddened, bilateral anterior scrotum and head". On 11/25/13 nursing staff documented in the "Skin" area on the assessment flow sheet "rash, reddened, bilateral anterior, groin, scrotum, head". The plan of care has a section titled "Tissue Integrity Skin" which gives a scoring range of 1-5 with 1 being severely compromised, 5 being not compromised. The patient's initial care plan rated him a 4 and this score remained unchanged throughout his length of stay.
On 2/7/13 at approximately 1:00 p.m. during an interview with Staff B the following was revealed. This surveyor asked "It appears that during this stay this patient developed new skin breakdown, would you agree?" Staff B responded "Yes." This surveyor asked "it also appears that the physician was not notified and that the care plans for this patient were not updated, would you agree?" Staff B responded "Yes." This surveyor asked "Would a change in skin condition prompt a change in score under the Tissue Integrity Skin portion of the care plan?" Staff B responded "Yes." This surveyor asked "It also appears that there were no interventions documented for this new breakdown, would you agree?" Staff B responded "Yes."