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OCEANS BEHAVIORAL HOSPITAL OF ABILENE 6401 DIRECTORS PARKWAY ABILENE, TX 79606 June 5, 2018
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview, and record review, the facility failed to provide an organized nursing services when:


- The nurses failed to conduct and document skin assessments on (2) two patients, receiving anticoagulation therapy, and did not perform daily monitoring for bleeding as the facility's policy required, leaving the patients at risk for worsening conditions. (Patients #2 and 4)


- A patient, on anticoagulation therapy, fell out of bed on 5/19/18. The nurse did not conduct a physical assessment for injuries or initiate an incident report, possibly causing a delay in treatment and serious physical harm. On 5/24/18, the patient was experiencing pain, bruising and swelling to the left eye and was sent to the hospital to rule out a facial fracture. (Patient #2)


- The nursing team provided inappropriate wound care to patient #2's hospital acquired skin tears when facility protocol for patient skin tears were not followed, nursing staff failed to obtain a physicians order for the Tegaderm placed on patient #2's skin tears, possibly causing further trauma to the patients already fragile skin.


Refer to A0386
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on observation, interview and record review the facility failed to provide nursing services in an organized manner when,

a.) The nurses failed to conduct and document skin assessments on (2) two patients, receiving anticoagulation therapy, and failed to perform daily monitoring for bleeding as the facility's policy required, leaving the patient at risk for worsening conditions. (Patients #2 and 4)

b.) A patient, on anticoagulation therapy, fell out of bed on 5/19/18. The nurse failed to conduct a physical assessment for injuries and failed to initiate an incident report, possibly causing a delay in treatment. On 5/24/18, patient #2 was experiencing pain and had bruising and swelling to the left eye and was sent to the hospital to rule out a facial fracture.

c.) The nurse provided inappropriate wound care to Patient #4's, hospital acquired, skin tears. The nurse failed to follow facility protocol's for skin tear treatment and failed to obtain a physician's order to provide alternative treatments for patient #4's skintears.


Findings include:

a.) Review of the facility provided Skin/Wound Care Protocol (Revision date 12/01/16) reflected, "... A skin assessment is completed by the nurse on all patients upon admission, weekly, after a fall/injury...."

Review of the facility provided Anticoagulation Therapy, Indications, Side Effects, and Treatment (Revision date 9/01/2017) reflected, "...The physician must be notified of any signs of bleeding....
BLEEDING PRECAUTIONS:
Daily assessment by nursing for signs of increased bleeding such as bruises, tarry stools, pinpoint red spots on skin, blood in urine...."


Review of Patient #2's medical records reflected a [AGE]-year-old female admitted on [DATE] with a diagnosis of Dementia, Hypertention, Hypothyroid, depression and CAD. The patient was placed on bleeding precautions due to anticoagulation therapy and increased risk for bleeding.


Review of Patient #2's Admission Nursing Notes dated 5/19/18 at 2:18 pm reflected, "... Attempted to do a skin assessment to no avail ...."


An observation on the afternoon of 6/4/18, on the Geriatric Patient unit, revealed Patient #2 lying on a bed. The patient had a very light yellowish bruising to the left lower eye lid. The patient's interior right wrist had a 2 cm. x 2 cm. purple bruise.


Patient #2's nursing skin assessment sheets were not completed daily and did not indicate the nursing staff were monitoring for signs of bleeding as the physician ordered bleeding precautions required. The bruising to the face and the wrist were not documented.



Review of Patient #4's medical record reflected an 86-year-old- male admitted on [DATE]. The patient was at risk for bleeding due to being on anticoagulation therapy.


Review of Patient #4's Physician's order's dated 5/27/18 reflected the patient was placed on Bleeding Precautions.


An observation on 6/4/18 revealed a Tegaderm dressing on the right forearm dated 5/28/18. There was dark red blood noted covering the arm under the Tegaderm, the size of the wound was obscured by the blood. The patient's left forearm wound had a gauze dressing that had become soaked through with serosanguineous drainage and was covered with Tegaderm. The dressing contained no date of when it was applied or no initials of whom applied the dressing.


Review of Patient #4's nursing skin assessment sheets reflected they were not completed daily and did not indicate the nursing staff were monitoring for signs of bleeding per physician's orders. Patient #4's skin assessments did not contain a description or measurements of the wounds to ensure the wounds were healing properly.


During an interview in the afternoon of 6/5/18, in the conference room, , the Clinical Care Coordinator confirmed the findings.


b.) Review of the facility provided policy Incident & Occurrence Reporting (dated 1/11/16) reflected, "Facility staff will report all patient occurrences through the use of the facility's incident reporting form ....A patient incident or occurrence is anything that is out of the expected norm for the patient (ex: elopement, fall, medication error, altercation, psychiatric emergency).... PI coordinator or Department Manager ... Recommends corrective action and follow-up with appropriate Department Manager for implementation and follow-through for immediate safety measures, Utilized data for performance improvement activities monthly ..."

Review of Patient #2's nurse progress notes reflected on 5/19/18 at 3:05 p.m. "...patient was released immediately after the shot was given. This nurse stayed in room with patient uptill [sic] about 5:00 p.m. because pt was still physically aggressive... Finally got pt in bed as she began to get sleepy. As patient layed [sic] in bed this nurse came to nurse's station and a couple of minutes later MHT reported patient rolled from bed to floor mat and did not encure [sic] any injuries."

Review of Patient #2's nurse's notes dated 5/23/18 at 10:00 p.m. reflected, "During round, this nurse noticed an old bruise - yellow/green on left forehead and a black left-lower eye lid NS Patient do [sic] not know or recall how it happened...."

Review of Patient #2's CT report dated 5/24/18 reflected, "...Reason: Facial pain with trauma/injury.... Conclusion: No Acute Fx (fracture)..."

The nurse's notes and the facility provided documents did not reflect the nurse had assessed the patient for injuries or initiated an incident report following the fall. The nurse did not inform the family or the physician of the fall.


c.) Review of the facility provided Skin/Wound Care Protocol (Revision date 12/01/16) reflected, "...Other skin abnormalities such as skin tears and abrasions will be identified utilizing the nursing assessment process and documented on the skin assessment and wound assessment form as applicable.... B. Wound measurement: Measure wound in centimeters weekly and record using clock description.... Description of skin abnormalities should be documented according to assessed findings and initiate the impaired skin integrity treatment plan.... Guidelines are utilized in conjunction with physician orders and do not supersede orders....

Skin Tears: per medical staff order:

Clean gently with normal saline and pat or air dry.

Apply Skin Prep without alcohol to per [sic] wound skin.

Approximate flap if remaining.

Apply Xeroform (a non-stick moisturizing) gauze over skin tear.

Cover with gauze dressing (i.e. 4x4) and conforming bandage (i.e. Kling).

Secure with tape - no tape to skin.

Change daily or as ordered. If skin tear shows signs and symptoms of infection, apply antibiotic ointment (i.e. Triple Antibiotic Ointment) before covering with Xeroform...."


An observation on 6/4/18, on the Geriatric Psychiatric unit revealed Patient #4 sitting in a chair in the day room. A Tegaderm dressing was noted on the right forearm and was dated 5/28/18, there was dark red blood covering the arm under the Tegaderm, the size of the wound was obscured by the blood. The patient's left forearm wound had a gauze dressing that had become soaked through with yellowish-brown serosanguineous drainage and covered with Tegaderm. Both of the Tegaderms were in direct contact with the patient's fragile skin.

During an interview on the morning of 6/5/18, on the facility's Geriatric Unit Staff #4, RN stated, "We don't want to change it too often because taking off the Tegaderm is going to take off more skin.... the doctor wanted us to leave on the tegaderm and allow the blood to accumulate."

During an interview on the morning of 6/5/18, in the administrative conference room, Staff #3, Administrator when informed of Patient#4's multiple skin tears with tegaderm applied directly to the skin and asked why the facility's protocol had not been initiated, stated, "... Only the physician can determine the wound treatment...."

Review of Patient #4's Physician orders reflected no treatment orders for the skin tears.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based on interview and record review the facility failed to honor a patient's right to have a representative attend the treatment plan review meetings. (Patient #2)

Findings Include:

Review of the facility provided Patient Rights Texas Policy (dated 1/11/2016) reflected, " ...staff will document in the medical record that the parent, guardian, conservator or other person was notified of the date, time and location of each of the treatment team meetings in which periodic review of the individualized treatment plan was conducted so that he/she could participate."

Review of Patient #2's Physician's Certificate of Medical Examination for Mental Illness dated 5/21/18 reflected, " .... She is unable to make a rational and informed decision in regards to her treatment ...." The Medical Power of Attorney dated 5/16/16 designated the son as having the responsibility of Patient #2 treatments.

During a telephone interview on the afternoon of 6/2/18, Patient #2's son stated, " ...The facility called me and gave me general information about her mental status .... They did not tell me when the treatment plans were, I was never invited, I'm the MPOA."

The initial and updated treatment plans dated 5/19/18 and 5/25/18 did not include the Medical Power of Attorney; and the facility did not document the include the notification of the meeting dates and times so that they could attend.

During an interview on the morning of 6/5/18, in the facility conference room, Staff #1, Administrator when asked why the MPOA had not been invited to the treatment plans stated, " ...There was a conflict between the daughter and the son."