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 document review and interview, nursing staff were unsure if hot pack application required a provider order and the time frame for skin assessment after hot pack application. This could lead to untoward patient outcomes.

Findings include:

-- Review of the hospital's policy and procedure (P&P) titled "Heat Application: Lippincott," approved 1/2017, indicated to follow the manufacturer's directions, to strike, squeeze, or knead a chemical hot pack to activate the heat producing chemicals. Place the pack in a protective cloth covering and secure the cover with tape or roller gauze. Assess the patient's skin condition frequently and remove the device if you observe increased swelling or excessive redness, blistering, maceration, or pallor or if the patient reports discomfort. Remove the device after 20-30 minutes or as ordered. Document the time and date of heat application, type, temperature, duration and site of application, skin condition before, during and after treatment and tolerance of the treatment. The P&P did not indicate if a provider order is needed for hot pack application.

-- Review of information and instructions on Dynarex Instant Hot Pack indicated the pack reaches temperature of 122 degrees Fahrenheit (F). Do not apply to skin if impaired in any way. Do not apply pack directly to unprotected skin, wrap pack in a soft cloth before using. Applying the pack directly to the skin will result in injury. Individuals with problems in sensing heat or cold should use extreme caution with this product. Stop use if the temperature of the pack is or becomes uncomfortable. To prevent injury, do not use hot packs for longer than 30 minutes.

-- During interview of Staff A, Registered Nurse (RN) on 2/26/19 at 11:10 am, a physician order is needed for application of an instant hot pack, you may be concerned about vasodilation.

-- During interview of Staff B, Nursing Instructor on 2/26/19 at 11:45 am, a physician order is needed to apply a hot pack. You wouldn't leave a hot pack on longer than 20 minutes or would take off sooner if the patient had complaints.

-- During interview of Staff C, RN on 2/27/19 at 8:55 am, a physician order is not needed for hot pack application. Hot packs are always put in a protective coating like a pillowcase, not directly applied to the skin. The heat doesn't last that long. He/she would reassess the patient's skin within one hour of application.

-- During interview of Staff D, RN on 2/26/19 at 9:40 am, a hot pack is placed in a pillowcase as a skin barrier, they stay hot for approximately 30 minutes. He/she would check a patient's skin 15 minutes after application or more frequently if needed.

-- During interview of Staff E, RN on 2/27/19 at 9:15 am, hot packs are wrapped in protective covering, never put directly on a patient's skin and the skin is reassessed after application.

-- During interview of Staff F, Director of Quality Management and Regulatory Affairs on 2/27/19 at 3:00 pm, he/she acknowledged these findings.