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.

OLD VINEYARD YOUTH SERVICES 3637 OLD VINEYARD ROAD WINSTON SALEM, NC 27104 Oct. 15, 2015
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy, medical record review, observation, patient and staff interviews, the hospital nursing staff failed to reassess a wound for signs and symptoms of infection for 2 of 2 sampled patients with wounds (#10 and 3) and reassess a patient's response to medications given for behavior for 3 of 3 sampled "NOW" orders for medications (#5).

Findings include:

Policy manual review on 10/14/2015 revealed "Wound Care" reviewed 12/2012. The policy stated "Appropriate assessment and care of wounds will be provided by the nursing staff. . . The Registered Nurse will assess all admissions for any breaks in skin integrity. . . The wound assessment process is an ongoing assessment and will be continued through out the hospital stay. . . The nurse has the primary responsibility for reporting and documentation of the wound. The nurse will report the wound to the physician . . . Documentation of the wound will include the nature of the wound . . . response to treatment, and any special considerations . . . "

1. Open medical record review for Patient #10 revealed an involuntary hospital admission on 10/12/2015 with diagnoses of Mood Depressive Disorder, Severe Sedative and Hypnotic Use Disorder and Hypertension. Review of the nursing initial comprehensive assessment conducted on 10/12/2015 revealed the patient had an abdominal wound identified as a burn at the time of admission. Review of nursing progress notes for 10/12/15 through 10/14/2015 revealed no further assessment of the abdominal wound. Review of physician's orders for 10/12/15 through 10/14/2015 revealed no orders for wound care.

Observation and interview on 10/14/2015 at 1115 with Patient #10 revealed a right upper abdominal wound with clear serous drainage covered with a partially intact gauze bandage. The interview revealed a nurse had covered the wound earlier on the same day after the patient had showered. The interview also revealed the patient had been examined by a physician earlier the same day.

Interview on 10/15/2015 at 1440 with the Director of Nursing revealed wounds were to be assessed at admission and every shift. The interview revealed wound assessment is an ongoing process throughout the hospital admission.

2. Closed medical record review for Patient #3 revealed a hospital admission on 08/11/2015 with diagnoses of Depressive Disorder and Bipolar Disorder. Review of nursing progress notes for 08/11/2015 through 08/18/2015 revealed an inital comprehensive nursing assessment was conducted on 08/11/2015. Continued review revealed the assessment identified wounds with sutures intact, at time of admission, to the patient's left arm and right side of neck. Continued review of the nursing progress notes revealed no documentation the wounds were reassessed until 08/15/2015 when documentation revealed the sutured wounds were red and warm to touch.

Interview on 10/15/2015 at 1440 with the Director of Nursing revealed wounds were to be assessed at admission and every shift. The interview revealed wound assessment is an ongoing process throughout the hospital admission.





3. Review of hospital policy, "Medication Administration", with revision date of 04/2013, revealed "Medication orders written as 'STAT' (immediate) or 'NOW' are to be given as soon as possible." Further review revealed no nurses instructions for documentation of reassessment of a patient after 'Stat' medication administration.

Closed medical record review of patient #5 revealed a [AGE] year old female admitted to facility on 07/30/2015 from ER (emergency room ) with an involuntary commitment petition (process of the court to render person unable to make own decisions for care). Patient was discharged on [DATE] to another facility with diagnosis of schizophrenia.

Review of physician orders revealed verbal orders on 08/02/2015 at 1600 for Geodon (antipsychotic to treat agitation) 10 mg (milligrams) and Ativan (medicine to treat anxiety) 1mg IM x 1 (intramuscular one time only) for severe agitation. Review of the MAR (medication administration record) revealed a nurse administered Geodon 10 mg and Ativan 10 mg IM on 08/02/2015 at 1600. Review of the nurses notes revealed no nurse assessment for response of the medication after administration.

Review of physician orders revealed telephone orders on 08/09/2015 at 1955 for Geodon 20 mg IM for agitation. Review of MAR revealed a nurse administered ordered medication on 08/09/2015 at 2030. Further review revealed no nurse assessment of the response of the medication after administration.

Review of physician orders revealed verbal order on 08/13/2015 at 1935 for Geodon 20 mg IM and Benadryl (antihistamine used for sedative) 25 mg IM x 1 for severe agitation. Further review of MAR revealed documentation of administration on 08/13/2015 at 1945. Further review revealed no documentation of nurse assessment for response of the medication after administration.

Interview of AS #1 on 10/14/2015 at 1530 revealed no documentation of nurse reassessment of patient's response after administration of medication.