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OHIO HOSPITAL FOR PSYCHIATRY 880 GREENLAWN AVENUE COLUMBUS, OH Sept. 26, 2012
VIOLATION: NURSING SERVICES Tag No: A0385
Based on clinical record reviews and staff interviews, the facility failed to supervise and evaluate nursing care related to assessments, vital signs, activities of daily living, and medication administration, for 6 of 10 patients reviewed (Patients #7, #5, #6, #3, #4, and #10). The total census during this visit was 74 patients.

Findings include:

For Patient #7, the facility failed to assess the patient's head wound, right foot infection and diabetic lesions, and elevated vital signs, and failed to administer physician ordered topical creams to the patient. Refer to A0395.

Patient #5 was not assisted with activities of daily living including incontinence care. Refer to A0395.

Patient #6 experience a fall with bruising during their hospitalization . There was no documented evidence that the physician was notified of the patient's new bruising. The clinical record revealed no documented evidence that incontinence care was provided to this incontinent patient. The clinical record revealed assessments were unable to be done for this patient on the 7:00 PM to 7:00 AM shifts; however, the patient was on every 15 minute checks. Refer to A0395.

Patient #3 was admitted to the psychiatric hospital 9/23/12 with a suicide attempt and a diagnosis of Methicillin-resistant Staphylococcus aureus (MRSA) (an infection in a wound which is resistant to certain antibiotics). The clinical record lacked physician's orders for the care of this wound, and lacked documentation of wound care by nursing in accordance with physician's orders. Refer to A0395.

Patient #4's clinical record revealed the patient was dependent upon staff for bathing, dressing, and toileting. The clinical record lacked documentation of assistance by staff related to these activities of daily living. Refer to A0395.

Patient #10's clinical record revealed either shingles or cellulitis on the right calf.
The clinical record lacked documentation of any intervention or of a physician's order and nursing care for this skin condition. Refer to A0395.

These findings substantiates complaint number OH 863.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record reviews and staff interviews, the facility failed to ensure registered nurses supervised and evaluated the nursing care for 6 of 10 patients reviewed (Patients #7, #5, #6, #3, #4, and #10). The total census during this visit was 74 patients.

Findings include:

On 09/26/12, a review of Patient #7's clinical record revealed the patient was admitted to this facility on 05/01/12 per ambulance from an assisted living facility. The patient's diagnoses at the time of admission included psychotic disorder, with an admission reason of dementia with delusions. The admission reason listed in the clinical record was for an adjustment of medications. The patient also had diagnoses of [DIAGNOSES REDACTED]

Physician's orders, at the time of admission, included a topical antibiotic cream along with a dressing change on the patient's head once a day to a skin tear on the top of the patient's head. The physician also ordered a debriding cream to the patient's bilateral feet topically one time a day. The admission nursing assessment, on 05/01/12 at 5:30 PM, by a registered nurse, documented the patient had a dressing to the head, was confused, required total assistance with walking, eating, dressing, bathing, and toileting, and used a wheelchair. The nursing assessment lacked documentation of the size and appearance of the open area on the patient's head. The nursing reassessment note, on 05/02/12 at 6:44 AM, documented a wound with sterile strips on the patient's head. Additional nursing reassessment notes on 05/02/12, 05/03/12, 05/04/12, 05/05/12, and throughout the patient's stay, stated the patient's skin was either intact, or was silent to any skin assessment. The nursing note on 05/07/12 at 12:30 PM stated the patient had an open area with old dressing on top of the head. Throughout the patient's stay, between 05/01/12 and 05/21/12, the clinical record was silent to an assessment of the patients skin status. The reassessment nursing notes documented the patient had a laceration on the head on 05/12/12, an open area on the top of the head on 05/19/12, and an abrasion on the head on 05/21/12 at 3:00 PM. According to the medication administration record (MAR), the patient did not receive the physician ordered antibiotic cream to the open head wound during their hospitalization due to the cream not being available. An interview with Staff D (registered pharmacist), on 09/26/12 at 10:10 AM, revealed the cream was available and filled in the pharmacy on 05/02/12.

On 05/06/12, on the 11:00 PM to 7:00 AM shift, a registered nurse (Staff K) documented the patient had a small abrasion with a band aid on the right large toe, and dry skin on the feet. A progress note, authored by Staff K, on 05/06/12 at 7:00 PM, stated per the patient's spouse, the patient was under the care of a podiatrist for diabetic complications, the patient's right big toenail was infected, and the right toe next to the great toe had a lesion in stage of healing. The progress note also stated the patient's left foot, heel, and mid sole had deep dry skin cracks that bleed. However, the clinical record lacked documentation of the physician being notified of this abrasion, and an order was not obtained until 5:00 PM on the same day, from the nurse practitioner, for lotion to bilateral feet and soles at every bedtime. The order also stated to assess between the patient's toes at bedtime for diabetic lesions. The clinical record was silent to discontinuation of the debriding foot cream that had been ordered on admission on 05/01/12. The MAR documented the debriding cream was not available during the patient's entire hospitalization . After the documentation on 05/06/12 regarding the patient's right toe infection and lesion, the clinical record was silent to the patient's toes and feet until an entry on 05/21/12 at 3:00 PM, by a registered nurse, documented the patient's skin the both feet were dry and reddened. The clinical record was silent to an assessment of the right great infected toenail and diabetic lesions on the right second toe after the documentation on 05/06/12. The clinical record revealed the facility was performing accuchecks on the patient twice a day and administering an oral blood sugar medication daily.

The interview with Staff D (registered pharmacist), on 09/26/12 at 10:10 AM, revealed the MAR revealed the antibiotic (for head) and debriding cream (for feet) cream were not administered by nursing staff during the patient's entire hospitalization . Staff D also stated that the debriding lotion should have been discontinued when staff received the order for lotion to the patient's bilateral feet every night at bedtime.

On 09/26/12 a review Policy CS-300.25, regarding medication administration, stated if several doses of a vital medication are withheld or refused, the physician and responsible party are notified and documentation of notifications is made.

On 05/05/12, the patient's blood pressure was elevated at 197/106 and pulse rate was 97. There was no recheck of the vital signs until 05/06/12 on the 3:00 PM-11:00 PM shift at which time they were still elevated at 166/97 and 97.

On 05/10/12 at 1:30 PM, the patient's blood pressure (178/103) and pulse (93) were elevated. The next vital sign assessment was not conducted until 11:00 PM, at which time the blood pressure was elevated at 170/101 and pulse was 98. The next vital sign assessment was not until 05/11/12 on the 3:00 PM-11:00 PM shift, at which time the blood pressure and pulse were still elevated at 150/90 (blood pressure) and 99 (pulse).

On 05/15/12 at 7:30 PM, the patient's blood pressure was elevated to 168/96 and pulse was 92. The next check of the patient's vitals signs was not done until 05/16/12 at 9:35 AM, at which time the patient's blood pressure was 158/82 and pulse was 87.
On 05/18/12, at 3:00 PM, the patient's blood pressure (149/103) and pulse (115 per minute) were elevated. The next vital sign check was not done until the 3:00 PM-11:00 PM shift (no time listed), and the blood pressure remained elevated at 160/100. Although a recheck was done, the clinical record lacked the results, only documenting the blood pressure was within normal limits. There was no check of vital signs on the 11:00 PM-7:00 AM shift that same night. The next vital sign check was not done until 05/19/12 at 2:30 PM, which revealed the patient's blood pressure was 159/99 (elevated), and pulse was 88. Again, there was no recheck of the blood pressure until 9:10 PM that same date, at which time it was 106/66 and pulse was 68 per minute. On 05/21/12, at 7:20 PM, the licensed practical nurse failed to document the patien't diastolic (lower) blood pressure reading, documenting 136/. On 05/13/12, the diastolic was not recorded on the 3:00 PM-11:00 PM shift as follows: 155/. This occurred after the blood pressure was elevated to 168/98 and pulse was 93, at 1:15 PM on the same date.

The clinical record was silent to notification of the patient's physician for these elevated blood pressures and pulse rates. The patient had a diagnosis of [DIAGNOSES REDACTED]

An interview was conducted with Staff A, on 09/25/12, at 4:20 PM, regarding Patient
#7's clinical record. This employee verified the lack of skin assessments for the wound on the head and right foot. Staff A also verified the MAR and clinical record revealed the two creams ordered by the physician for this patient's head wound and feet were not administered as ordered by the physician. Staff A verified the lack of timely reassessment of the patient's elevated blood pressures and pulse rates, and verified the lack of physician notification when they were elevated.

On 09/26/12, a review of the facility's policy titled Admissions Assessment, Policy CS-100.3 stated the nurse should complete the Nursing Assessment within eight hours of the admission. The components of the assessment lacked criteria related to skin status and wounds. An interview was conducted with Staff E (registered nurse) on 09/25/12 at 11:10 AM regarding assessment of skin wounds and facility practice related to measuring and reassessing the wounds. This employee stated this would be done by the patient's medical physician, and not by nursing staff.






Review of the clinical record of Patient #5 on 09/25/12 in the afternoon revealed the patient was admitted to the facility on [DATE]. A nursing assessment was completed on 09/24/12 that identified the patient had no genitourinary problems of bowel and bladder and assistance for toileting. Interview of Staff A at 2:15 PM revealed the patient was incontinent of bowel and bladder. Review of the clinical record revealed there was no evidence the patient was assisted with activities of daily living including incontinence care as of 2:15 PM on 09/25/12.

Review of the clinical record of Patient #6 on 09/25/12 in the afternoon revealed the patient was admitted to the facility on [DATE]. The admission assessment dated [DATE] indicated the patient had bruising on the right forearm, and a raised discolored area on the left face cheek approximately 2 inches in diameter. Review of the clinical record further revealed the patient was found on the floor after having fallen on 09/07/12. The nursing reassessment documentation at the time of the fall revealed the patient had no pain or sign of injury at the time of the fall and the physician was notified. The nursing reassessment dated [DATE] revealed documentation that described the patient as having a bruised left hip that was not present upon admission to the facility. The nursing reassessment dated [DATE] revealed documentation that described the patient as having a large bruise on the left outer thigh. There was no documented evidence that the physician was notified of the patient's new bruising noted on 9/14/12.

Interview of Staff A on 09/26/12 at 9:30 AM revealed the physician should have been notified of the new bruises and medically cleared this patient after new bruising was identified. Review of the physician's progress notes provided by the facility showed no evidence the patient had been observed by or addressed by the physician.

Further review of the clinical record of Patient #6 on 09/25/12 revealed the patient admission assessment on 09/07/12 indicated the patient had no genitourinary problems. Nursing reassessments dated 09/08, 09/09, 09/12, 09/13, 09/15, 09/16, 09/17, 09/18, 09/19, 09/20, 09/20, 09/21, 09/22, 09/23 and 09/24/12, revealed the patient was incontinent of bowel and bladder. Review of the Mental Health Technician's 15 minute check documentation for the dates from admission of 9/7/11, revealed no documented evidence that incontinence care was provided to this patient. This finding was confirmed by Staff A on 09/25/12 at 3:00 PM.

Review of the clinical record nursing reassessments of Patient #6 on 9/25/12 revealed the 7:00 PM to 7 AM nursing shift was marked as "Unable to assess" on the dates of 9/8, 9/9, 9/10, 9/12, 9/13, 9/14, 9/15, 9/17, 9/18, 9/19, 9/21, 9/22, and 9/24/12. This patient was on 15 min checks. Interview of Staff A on 9/25/12 at 3:00 PM revealed at some time in the 12 hours, the patient should have been assessed.




The review of the clinical record for Patient #3 was completed on 09/26/12 at 10:30 AM. Patient #3 was admitted to the psychiatric hospital 09/23/12 with a suicide attempt and a diagnosis of [DIAGNOSES REDACTED]" x 2 " in size with some drainage. The clinical record lacked documentation of any intervention on 09/23/12, or of a physician's order for care of this wound. The clinical record lacked documentation of the wound and/or wound care on 09/24/12. On 09/25/12 the nurse documented that he/she placed a clear dressing over the wound, however there was no documentation of the wound being cleansed or assessed by the nurse. This finding was verified with Staff B on 09/26/12 at 3:00 PM.

The review of the clinical record for Patient #4 was completed on 09/26/12 at 11:00 AM. Patient #4 was admitted to the psychiatric hospital 09/21/12 with diagnoses including dementia, anorexia (poor appetite), weight loss, and anxiety. Review of the clinical record revealed that upon admission, Patient #4 was assessed as needing assistance with bathing, getting dressed, and needing supervision when toileting. Review of the clinical record, from 09/21/12 through 09/26/12, lacked documentation that the staff of the psychiatric hospital assisted and/or supervised Patient #4 with bathing, dressing or toileting. This finding was verified with Staff A on 09/26/12 at 11:15 AM.

The review of the clinical record for Patient #10 was completed on 09/25/12 at 3:00 PM. Patient #10 was admitted to the psychiatric hospital 09/22/12 with diagnoses including bipolar disorder, polysubstance abuse, and shingles. The clinical record revealed that upon admission, Patient #10 had an area on the right calf that was undetermined as to whether it was shingles or cellulitis. The clinical record lacked documentation of any intervention or of a physician's order for care of this wound. The clinical record revealed that Patient #10 was receiving medications to treat both of these conditions: Valtrex (anti-viral) for shingles and Keflex (antibiotic) for the cellulitis. The clinical record lacked documentation of the wound and/or wound care. This finding was verified with Staff G on 9/25/12 at 3:15 PM. Staff G stated that it was the nurses' discretion to put a dry dressing on if a wound was draining.

These findings substantiates complaint number OH 863.