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LEGACY MOUNT HOOD MEDICAL CENTER 24800 SE STARK STREET GRESHAM, OR 97030 June 17, 2014
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, documentation in 5 of 6 patient medical records reviewed (Patients 1, 2, 3, 5 and 6), staff interviews, and review of policies and procedures, it was determined the hospital failed to ensure that patient nursing care needs related to diabetic management, skin conditions, and vital signs were supervised and managed by the RN in accordance with appropriate assessments, physician orders, and hospital policies and procedures.

Findings included:

1. Review of a patient care policy titled "*Adult Inpatients," dated "Last Revision Date: August 2011" reflected "...The RN coordinates the interdisciplinary plan of care and applies the nursing process...Complete initial bio-psychosocial nursing assessment within approximately (4) hours of admission and document findings. Assessment parameters include...Braden...Assess patients transferred between patient care areas: within approximately one hour (1) prior to and approximately one hour (1) following transfer and document findings...Reassess vital signs...with a maximum duration of approximately six (6) hours between observations as warranted by the patient's condition and nursing judgement, current or potential problems and document findings...Assess and document skin integrity, including all bony prominences and under medical devices, on admission and each shift thereafter. Obtain Braden Score on admission, transfer, and every shift. Request referral for WOCN consultation for any patient who is admitted with a pressure ulcer, or develops a pressure ulcer at Stage II or above, and for suspected deep tissue injury and unstageable ulcers...Document presence of skin breakdown and wounds utilizing descriptors (location, size, condition) including staging of pressure ulcers with each shift assessment (Q12) and reassessment (Q6 hours) as needed..."

2. Review of a patient care "Standard of Care: 900.1411" policy titled, "Adult Patients With Type 1 or Type 2 Diabetes" dated "Last Review Date: December 2012" reflected on page 2
"1. Drug Administration:
a. Give nutritional aspart (Novolog) or lispro (Humalog) insulin with meal or shortly after meal if patient's appetite is in question. Nutritional dose should be given in accordance with the percentage of CHO intake...Adjust administration time accordingly. NOTE: Supplemental insulin dose (based on current CBG) can be given at the same time...Key Note: Lispro and aspart are insulin analogs that are very fast acting. They start working within 5 minutes of injection, peak in 60-90 minutes, and last 3-5 hours. Do not give unless meal tray is being served to the patient."

The "[DIAGNOSES REDACTED] Protocol" on page 4 of the policy reflected that the treatment for patients who were "Conscious with CBG less than 70" was
"Turn off insulin drip if present
Give one of the following (15 g carbohydrate):
4 oz. (1/2 cup) of 7-up or other non-diet soda (preferred fluid choice)
4 oz. (1/2 cup) of fruit juice (no O.J. for renal patients)
Three Glucose tablets OR 1/2 tube Glucose gel...
Recheck CBG in 15 minutes. If CBG less than or equal to 70, repeat same treatment
After initial treatment and CBG less than or equal to 70 and more than 1 hr. to next meal, give 1/2 meat or cheese sandwich and 1/2 c. juice, or 3 graham cracker squares and 1 c. milk".

The protocol reflected that the treatment for patients who were "Conscious but NPO with CBG less than 70" was
"Turn off insulin drip if present
If IV access available, give 50 mL D50** IV, flush with NS, then hang IV D5W at TKO (to keep open) rate - or continue present IV if contains dextrose.
If no IV access available, give 1 mg glucagon IM STAT. Then attempt to start an IV with D5W at 100mL/hr."

The protocol further reflected that the treatment for patients who were "Conscious but NPO with CBG less than or equal to 70" was
"Give 25-50 mL D50IV, flush with NS, then continue present IV if contains dextrose
Recheck CBG in 15 minutes. If less than or equal to 70, repeat same treatment.
After treatment, notify LIP for adjustment of IV."

3. The medical record for Patient 2 was reviewed. The record reflected the patient (MDS) dated [DATE] at 1216 with a chief complaint of "Ankle/foot injury" and a history of diabetes mellitus, MRSA and hypertension. The ED physician notes reflected that the patient had a diagnosis of [DIAGNOSES REDACTED]

a. Review of the record reflected the patient's diabetic condition was not monitored and addressed by the RN in accordance with physician orders and hospital policy.

The 05/02/2014 "All Meds and Administrations [MAR]" records at 1746 reflected the patient's blood glucose level was 355 and the RN gave the patient "aspart Novolog" insulin 18 units subcutaneously. There was no documentation in the record reflecting that the insulin was administered to the patient with or after a meal.

The 05/02/2014 "All Flowsheet Data" notes documented at 1926 by the RN reflected the patient's blood glucose level was low at 34.

The 05/02/2014 MAR records reflected the RN administered the patient 50 mL "dextrose 50%" 50 mL intravenously at 1932 to address the patient's low blood glucose level.

Physician orders dated 05/02/2014 at 1623 reflected an order for sliding scale "insulin aspart (NovoLOG) injection 3-24 Units...[four times] Daily WC [with meals] & HS..." However, physician orders dated 05/02/2014 at 1623 reflected a conflicting order which stated the patient's diet was "NPO [nothing by mouth]". There was no documentation to reflect that the RN contacted the physician to clarify the conflicting orders in relation to the patient's insulin medication and restricted "NPO" diet order.

During an interview conducted 06/16/2014 at 1500, the Manager of Specialty Services acknowledged the record reflected that a medication error occurred related to the conflict between the patient's insulin order and diet order.

Review of 05/03/2014 MAR records reflected the RN gave the patient "aspart Novolog" insulin 5 units subcutaneously at 0815.

The 05/03/2014 "All Flowsheet Data" notes documented by the RN at 1017 reflected the patient's blood glucose level was low at 52. There was no documentation reflecting any interventions or actions taken by the RN to address the patient's low blood glucose level.

The record reflected the next blood glucose level was recorded on 05/03/2014 at 1052, 35 minutes later and was recorded as 85. During a review of the patient's medical record on 06/16/2014 at 1510, the ICU manager acknowledged that although the record reflected the patient's blood glucose level had increased, it lacked documentation reflecting actions taken by the nurse to address the low blood glucose level.

Review of 05/08/2014 "All Flowsheet Data" notes documented by the RN at 1043 reflected the patient's blood glucose level was low at 56.

The physician discharge summary dated 05/08/2014 at 1107 reflected "...Patient was hypoglycemic the morning of discharge [05/08/2014] as [he/she] had inadvertently been given 25 units of lantus (instead of 10 units as ordered) the night prior [05/07/2014]." During an interview with the Manager of Specialty Services on 06/16/2014 at 1500, he/she acknowledged the record reflected the patient was administered the wrong dose of insulin.

b. Review of the record reflected the patient's skin conditions were not assessed by the RN in accordance with hospital policy.

Review of 05/02/2014 "All Flowsheet Data" notes documented by the RN at 1707 reflected "Skin Details Location" as "Extremity, Left Lower" and "[DIAGNOSES REDACTED]/redness; Swelling; Other (comment) Wound...Left fifth toe amputation." There was no documentation of the size of the wound.

The 05/03/2014 "All Flowsheet Data" notes documented by the RN at 1422 reflected "5th toe decub [dressing]..." There was no documentation of the size of the wound.

The patient's medical record was reviewed with the ICU manager on 06/16/2014 at 1400, and he/she was unable to locate any documentation reflecting the size of the patient's left lower extremity [DIAGNOSES REDACTED] or toe wound.

c. Review of the record reflected the patient's VS were not collected in accordance with hospital policy:

The 05/03/2014 "All Flowsheet Data" notes reflected the patient's VS were collected at 0239. The next set of VS collected for the patient was 05/03/2014 at 0803 but did not include a pulse rate. There was no documentation of a pulse rate until 05/03/2014 at 1742 for this patient who was experiencing unstable blood glucose levels.

The 05/04/2014 "All Flowsheet Data" notes reflected the patient's VS were collected at 1941. The next complete set of VS was not documented until 05/05/2014 at 1305, more than 17 hours later.

The patient's medical record was reviewed with the ICU manager on 06/16/2014 at 1400, and he/she confirmed the lack of documented VS.

4. The medical record for Patient 5 was reviewed. The record reflected the patient was admitted on [DATE] at 0115 with a diagnosis of [DIAGNOSES REDACTED]], and aphasia. The record reflected the patient had upper and lower extremity contractures, diarrheal episodes, incontinence of bowel and bladder, and was dependent for mobility. The patient was discharged on [DATE].

The 04/26/2014 "All Flowsheet Data" documented by the RN at 0600 reflected "Skin Details Location" as "Foot, Left [DIAGNOSES REDACTED]/redness redness [sic] on bony prominences of foot" and "Foot, Right [DIAGNOSES REDACTED]/redness redness [sic] on bony prominences of foot"
There was no documentation of the size of the patient's skin [DIAGNOSES REDACTED]/redness located over bony prominences.

The 04/27/2014 "All Flowsheet Data" documented by the RN at 1500 reflected the "Skin Details Location" as "Groin...[DIAGNOSES REDACTED]/redness; Excoriation." There was no documentation of the size of the patient's skin [DIAGNOSES REDACTED]/redness or excoriation.

The 04/27/2014 "All Flowsheet Data" documented by the RN at 2104 reflected the "Skin Details Location" as "Buttock, Left... [DIAGNOSES REDACTED]/redness," "Buttock, Right [DIAGNOSES REDACTED]/redness," and "Groin [DIAGNOSES REDACTED]/redness." There was no documentation of the size of the patient's skin [DIAGNOSES REDACTED]/redness.

The 04/28/2014 "All Flowsheet Data" documented by the RN at 0356 and 0626 reflected the "Skin Details Location" as "Buttock, Left [DIAGNOSES REDACTED]/redness; Excoriation," "Buttock, Right [DIAGNOSES REDACTED]/redness; Excoriation," and "Groin [DIAGNOSES REDACTED]/redness; Excoriation." There was no documentation of the size of the skin [DIAGNOSES REDACTED]/redness or excoriation.

Review of the record reflected a Braden score was not completed every shift on 04/27/2014 in accordance with hospital policy.

The patient's medical record was reviewed with the ICU manager on 06/17/2014 at 0940, and he/she confirmed the lack of documentation related to the size of the patient's skin [DIAGNOSES REDACTED]/redness and Braden score.

5. The medical record for Patient 6 was reviewed. The record reflected the patient was admitted on [DATE] at 0755 with a diagnosis of [DIAGNOSES REDACTED]

The 03/05/2014 "All Flowsheet Data" documented by the RN at 0500 reflected that the patient had a coccyx ulcer. The documentation reflected that the wound was fragile, bled easily and the periwound was red. There was no documentation of the size or stage of the ulcer. There was no documentation of whether or not a WOCN referral was needed or had been requested.

During an interview conducted on 06/17/2014 at 1120 the Manager of Specialty Services acknowledged there was no documentation of the size of the patient's coccyx ulcer. The manager stated that "technically" the nurse should have measured the ulcer. The manager stated that a WOCN would not be called for the patient because the patient was receiving comfort care. However, he/she also acknowledged that it was not reflected in the hospital's policies and procedures that a WOCN and wound measurements (size) may not be performed for a patient receiving comfort care interventions.

During an interview with the ICU manager on 06/17/2014 at 1145, he/she checked the patient's medical record and was unable to locate a care plan or other documentation addressing the limited interventions related to the patient's coccyx ulcer.

6. The medical record for Patient 3 was reviewed. The record reflected the patient was admitted on [DATE] at 1152 with a diagnosis of [DIAGNOSES REDACTED]

The 05/31/2014 "All Flowsheet Data" documented by the RN at 1549 reflected that the patient's right and left buttocks had [DIAGNOSES REDACTED]/redness and were "blanchable."

The 06/01/2014, 06/02/2014 and 06/03/2014 "All Flowsheet Data" documented by the RN reflected that the patient's buttocks had [DIAGNOSES REDACTED]/redness. There was no documentation of the size of the patient's buttocks [DIAGNOSES REDACTED]/redness.

7. The medical record for Patient 1 was reviewed. The record reflected the patient was transported from the ED to an impatient bed on 03/04/2014 at 1740 with a diagnosis of [DIAGNOSES REDACTED].

During an interview conducted 06/17/2014 at 1210 the Manager of Clinical Specialty acknowledged identifying a "theme" where patient skin conditions were not "measured."