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PEACHFORD BEHAVIORAL HEALTH SYSTEM OF ATLANTA 2151 PEACHFORD ROAD ATLANTA, GA 30338 March 20, 2019
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of medical records, review of facility policies, tour of the facility, and staff interview, it was determined that the facility failed to ensure that all patients received care in a safe setting.

Findings:

Pressure Ulcers
A review of Patient #1's medical record revealed that the Initial Nursing Assessment completed on 12/24/18 revealed no documentation of reddened, pressure ulcer areas; however, on 01/29/19 Progress Note entry on 01/29/19 at 04:22 a.m. RN #HH documented that during change of shift report, it was reported that Patient #1 had a reddened area on his sacral (tailbone) area. Further documentation revealed, that during rounds the patient was noted to be sleeping on his side, not on his back.

At 05:32 a.m. on 01/29/19, RN #GG documented that wound care was completed by the nursing staff with cleaning pads and Nutrashield (skin protection cream to create a barrier against moisture, from urine or feces), was applied to the tailbone and private area. Patient was placed in the medical internist book for consult on skin breakdown.

It was noted that prior to these entries there were no previous entries noting Patient #1 to have any reddened pressure areas. Additionally, on 01/29/19 just prior to discharge, the reddened pressure area was further classified on the Treatment Plan Problem as a Stage II decubitus (pressure blister, or a shallow crater or open sore has formed; the surrounding area of which may appear to be irritated and red in color). There were no pictures or notes of sacral or other area redness noted in Patient #1's medical record.

INTERVIEWS
The development of pressure ulcers was further confirmed during interviews with the Charge Nurse on 03/19/19 at 1:30 p.m. who recalled completing the Initial Nursing Assessment on Patient #1 when the patient was noted "clean" of scars or other abnormal skin changes. The Charge Nurse further explained that patients such as Patient #1, recognized as incontinent, toileting would be offered every two (2) by the RN or MHT; a patient with dementia or combative could be unaware of toileting need and refuse toileting. If such patients refused, the staff would not insist resulting in a patient remaining in urine or feces for extended periods. The Charge Nurse also recalled Patient #1 having a quarter size reddened area in the folds of the buttocks that was not present on admission.

Furthermore, during an interview with RN #HH at 03/19/19 at 3:15 p.m. via phone recalled caring for Patient #1 for approximately half of the 36-day admission. Described the patient as confused, frail, with dementia, using a wheelchair, agitated and incontinent. Further recalled, towards the end of the patient's admission there was a reddened area between the legs and around the groin area; could not recall reddened area in on the tailbone

POLICIES:
Review of facility policy Patient Comprehensive Assessment, Last Revised October 2018, Policy revealed on March 19, 2019 the facility admits patients and they receive a thorough assessment and evaluation. The results of the assessments are reviewed and integrated by the multi-disciplinary treatment team to prioritize identified problems within the Interdisciplinary Treatment Plan.

Review of facility policy Skin and Wound Care Protocol, Last revised on November 2018, Policy revealed the facilities Licensed Nurse as ordered by the physician cleans the wound and prevents infections and performs wound care initiation and continuous assessment. The Physician determines the level of intervention based on the wound care protocol order sheets.

Review of facility policy Continuous Nursing Assessment Process, last reviewed October 2018, Policy revealed the facility employs registered nurses that assess patients and formulates patient care goals using interdisciplinary treatment plan within eight hours of the admission related to the diagnosis, nursing care needs and standard of patient care. The Nursing staff document in the patient medical record, provide educational specific to the patient's healthcare needs, and initiate Discharge planning focusing on Self-care, knowledge deficit and learning needs.

Review of facility Policy Personal Hygiene Assistance, last reviewed November 2018, Policy revealed the facility nursing staff assist patients as needed with personal hygiene, to include tub baths, showers, or bed baths to ensure patients cleanliness in a manner that respects privacy. In addition, the policy addresses all patients having no or insufficient voluntary control over urination or defecation are cleaned promptly and privately.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, interviews, and review of facility policies, it was determined that the facility failed to ensure that a nursing care plan for each patient is developed and current to meet patient's individual needs while hospitalized and post discharge.

Specific The medical record review revealed Physician's Orders on 01/28/19 at 03:35 p.m. noted a verbal order for collection of urine sample to test for culture and sensitivity ([C&S] bacteria screen and antibiotic sensitivity). Patient #1 was started on Bactrim DS (antibiotic) 800/160 mg tablets by mouth twice daily for possible urinary tract infection. There were no laboratory results in the Patient's, as he was discharged the following day. There were no notes or orders for patient to have an indwelling urinary catheter (thin tube inserted through the sex organs into the bladder to drain urine). It was noted that patient was known to be incontinent (unable to hold urine or feces) and wore a pull-ups (diaper-like underpants). There was no previous documentation of UTI or UTI-like symptoms, medications or lab tests noted on Patient #1's medical record.

Physician's discharge summary lists medical discharge diagnosis as hypertension ([HTN] high blood pressure), [DIAGNOSES REDACTED] (high cholesterol), and UTI (urinary tract infection). Prior to the 01/28/19 order, there were no physician's progress notes, nursing assessments, treatment plan updates or physician's orders entries to indicate the presence of a UTI.

INTERVIEWS
The development of pressure ulcers was further confirmed during interviews with the Charge Nurse on 03/19/19 at 1:30 p.m. who recalled completing the Initial Nursing Assessment on Patient #1 when the patient was noted "clean" of scars or other abnormal skin changes. The Charge Nurse further explained that patients such as Patient #1, recognized as incontinent, toileting would be offered very two (2) by the RN or MHT; a patient with dementia or combative could be unaware of toileting need and refuse toileting. If such patients refused, the staff would not insist resulting in a patient remaining in urine or feces for extended periods. The Charge Nurse also recalled Patient #1 having a quarter size reddened area in the folds of the buttocks that was not present on admission.

POLICIES:
Review of facility policy Patient Comprehensive Assessment, Last Revised October 2018, Policy revealed on March 19, 2019 the facility admits patients and they receive a thorough assessment and evaluation. The results of the assessments are reviewed and integrated by the multi-disciplinary treatment team to prioritize identified problems within the Interdisciplinary Treatment Plan.

Review of facility policy Continuous Nursing Assessment Process, last reviewed October 2018, Policy revealed the facility employs registered nurses that assess patients and formulates patient care goals using interdisciplinary treatment plan within eight hours of the admission related to the diagnosis, nursing care needs and standard of patient care. The Nursing staff document in the patient medical record, provide educational specific to the patient ' s healthcare needs, and initiate Discharge planning focusing on Self-care, knowledge deficit and learning needs.

Review of facility Policy Personal Hygiene Assistance, last reviewed November 2018, Policy revealed the facility nursing staff assist patients as needed with personal hygiene, to include tub baths, showers, or bed baths to ensure patients cleanliness in a manner that respects privacy. In addition, the policy addresses all patients having no or insufficient voluntary control over urination or defecation are cleaned promptly and privately.