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.


Based on medical record review and interview the facility did not ensure that the registered nurse supervised and evaluated the nursing care for one of 9 patients (#2) reviewed, in that assessment of respiratory status and pressure ulcer prevention were not performed.

Findings include:

Review of the record of Patient #2 revealed that the patient was admitted on [DATE] at 0846 with a cough. Admitting diagnoses included [DIAGNOSES REDACTED]. Neuro consult note dated 3/28/18, at 0952 revealed that the patient had anoxic [DIAGNOSES REDACTED]. She subsequently developed respiratory distress, requiring reintubation and extubation several times and ultimately a tracheostomy was placed. The Operative Report, dated 4/20/18, documented a known history of very large left thyroid lobe with associated tracheal compression and deviation. Due to her very large goiter causing compression and tracheal deviation, left thyroid lobectomy was necessary to remove the large goiter prior to tracheostomy. Review of Nursing Documentation dated 4/21/18 at 2200 revealed that the RN had a received a report concerning this patient: the patient's family has always been at her bedside. The patient had been transferred from ICU to room 4003 at 11pm sharp, escorted by daughter, 2 nurses and respiratory therapist. The nurse assessed the patient with the transferring ICU nurses and documented that when the patient was turned to her sided she de-saturated from 91-91% oxygen to 82 %. She was immediately repositioned to supine and High Fowler's position and the oxygen saturation increased to 90%. The patient's daughter noted the patient's breathing was labored at 38 respirations/ minute and her tongue was sticking out. On 4/22/18, 0123, the daughter inquired about the labored breathing and stated "when she sticks out her tongue, it usually means something is wrong, she did it before her heart attack and when she couldn't breathe". At that time the oxygen saturation rate was decreased to 84%. Respiratory Therapy (RT) was notified and explained that the labored breathing was because the patient has muscles surrounding her lungs that are now being used, that had been used passively, due to being on a ventilator for approximately 3 weeks. He suctioned a small amount of bloody thin secretions from the trach and the oxygen saturation increased to 94%. Breathing was less labored at this time. At 0330 the daughter requested the patient be placed back on the ventilator. The respiratory rate was 38 and labored. RT and the charge nurse were notified. The oxygen saturation had decreased to 82% but after suctioning and readjusting the oxygen finger sensor the oxygen increased to 95%. The patient was determined to be stable, relaxed, decreased labored breathing noted. At 0400 the patient's daughter continued to request the patient be placed on a ventilator due to labored breathing. The nurse attempted to explain what the RT said, that the patient would have some labored breathing due to muscle awakening but the daughter still requested a ventilator. At 0500 the daughter was not at the patient's bedside. At 0530-upon going to check on patient the blood pressure was low at 63/40 with the chest barely rising and falling and no pulse. A "code" was called and the patient was resuscitated. At 0535 the daughter was called to inform of patient's change in clinical status, daughter spoke to Dr. at code on the phone. The Dr. expressed the idea the patient needed to be left on the ventilator longer for stronger respiratory support. Review of the record did not find that the patient was being monitored on telemetry. Based on the documentation above, the staff failed to accurately assess the patient's respiratory status. Interview with the Director of Patient Safety/Risk Management on 7/27/18, at 1:00 pm revealed that the patient's daughter had filed a complaint regarding the above, confirmed by review of the complaint she filed on 4/21/18.
Review of the record of Patient #2 revealed that the Plan of Care called for prevention of pressure ulcers. A low air loss mattress was documented as in place on 3-28-18 at 1500. Scant documentation regarding prevention and treatment of pressure ulcers was found in the record. A wound nurse consult was placed on 4-1-18 for "blisters" to the right upper extremity. On 4-2-18 at 0700 a "specialty bed" was ordered. On 4-13-18 a "routine" wound nurse consult was ordered but no consult note was found in the record. Nursing documentation on 4/20/18 revealed "excoriation of buttocks (stage II) and a foam dressing was applied. There is no documentation that the physician was notified. A wound nurse consult on 7-3-18 documented "saw patient for coccyx wound". There was documentation of stage II wounds to right and left buttocks. The physician was notified for treatment orders. A dressing change of the sacral-coccygeal pressure ulcer was observed on 7/25/17, at 2:40 pm. After the dressing was removed the wound was cleansed and a new foam dressing was applied. The wound appeared to be a stage II as the skin was broken. During the dressing change the patient continuously oozed liquid stool, making it difficult to provide wound care. On 7/26/18, at 1142 during the survey a rectal appliance device with rectal tube was applied to keep the area dry. Based on the documentation above, the facility failed to prevent development of pressure sores. Interview with the Informatics' lead on 7/27/18, at 10:30 am confirmed that there was no wound consult note on 4/13/18.