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Based on record review, patient interview and staff interview, the facility failed to ensure that patient rights were upheld for the expression and resolution of grievances for 1 of 9 sampled patients (#1).

The findings include:
Patient #1 was admitted to the facility on 11/3/2010 via the emergency department with generalized weakness, an increase of falls in the home and pain in the lower extremities. Per the history and physical, the patient is a deceased donor kidney transplant in 2003, recently developed worsening edema and worsening renal functioning, biopsy showing nephrosclerosis.

During the hospital stay, the patient developed a fever of unknown origin, and was found to have gas gangrene and osteomyelitis of the second and third toes of the left foot, necessitating an above the knee amputation of the left leg on 11/20/10.

Post operatively, the patient was sent to the surgical progressive care unit and then transferred to 7SR on 11/25/2010. Per the patient's health care surrogate, she was not satisfied with the care the patient was receiving and went to the Guest Relations Department on Thursday 12/2/2010 to discuss her concerns.

An interview was conducted with the Patient Relations Representative on 12/8/2010 at 1:45pm, and revealed that he remembered speaking with this person on 12/2/10. He stated that he had sent her back up to the patient's unit to speak with the Nurse Manager. No call was made to the unit to make the Nurse Manager aware of the issues.

Interview with the Nurse Manager on 12/8/2010 at 2:00pm revealed that she was not aware of any issues with the patient and that the health care surrogate did not speak with her.

Review of the facility Grievance Log on 12/8/2010 at 12:40 pm did not reveal a grievance or complaint from this patient or health care surrogate.

An interview was conducted with the Supervisor of Patient Relations on 12/8/2010 at 12:48pm. Per the Supervisor, she was aware that the family of Patient #1 came to the Patient Relations Office within the past week. The person at the desk spoke with the family and did not log the conversation as a complaint or grievance and the family went to speak with the Nurse Manager. There was no follow-up done to determine if this grievance was resolved.

Review of facility policy on Patient and Family Complaints and Grievances on 12/9/2010 at 3:00pm revealed that a verbal complaint is a concern made to the hospital by a patient or the patient's representative. If the patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further action for resolution then the complaint is a grievance. Responses to grievances shall be made in accordance with the following specified timeframes: The hospital shall review, investigate and resolve patient grievances within a reasonable timeframe. Although every effort should be made to resolve the grievance within 7 days, in the event it is not resolved, the hospital should inform the patient/patient representative that the hospital is still working to resolve the grievance and follow-up with a written response within 30 days.

Based on observation, patient interview, record review and staff interview, this Condition was found to be out of compliance due to lack of patient on-going assessments, lack of assessments of response to interventions, lack of care planning and lack of ensuring that drugs and biologicals were administered in accordance with professional standards of practice for 7 of 9 sampled patients (#1,4,5,6,7,8 &9).

The findings include:

Patient sample #1 -lack of assessment to patient interventions, lack of on-going assessments for sequential compression devices (see A392, 395).

Patient sample #4-lack of ongoing assessment for the need of a sequential compression device, lack of care planning for the device (See A392, 396).

Patient sample #5-lack of documentation for the monitoring of sequential compression devices for 17/33 days and partial documentation for 6/33 days (see A395).

Patient sample #6,7, 8- Lack of care planning for the use of sequential compression devices (see A396).

Patient sample #9-Lack of following acceptable standards of practice for the administration of intravenous medications through an existing line (see A404).

Based on record review, patient interview and staff interview, the facility failed to ensure that patient needs were met by ongoing assessments for 2 of 9 sampled patients (#1& 4).

The findings include:

1. Patient sample #1 was admitted to the facility on 11/3/2010 via the Emergency Department (ED) with generalized weakness, an increase of falls in the home and pain in the lower extremities. Per the history and physical, the patient is a deceased donor kidney transplant in 2003, has hypertension, benign prostatic hypertrophy, end stage renal failure, currently receiving dialysis three times per week, peripheral vascular disease, intermittent claudication and diabetes mellitus.

Initial evaluation showed the patient to have mild erythema and evidence of chronic venous insufficiency to bilateral lower extremities and 1+ bilateral lower extremity edema. During the hospital stay, the patient developed a fever of unknown origin, and was found to have gas gangrene and osteomyelitis of the second and third toes of the left foot, necessitating an above the knee amputation of the left leg on 11/20/10.

Post operatively, the patient was sent to the surgical progressive care unit and was transferred to 7SR on 11/25/2010. On 12/2/2010, there was documentation in the physicians' notes stating to discontinue the sequential compression devices, the patient had developed right leg ulcers, re-consult wound care. Wound care notes stated the patient had a 20.5x7cm unstageable wound on the right leg, re-consult vascular surgery.

The following day, vascular surgery visited the patient, and stated there was a new wound to the right calf, 5x6 cm with irregular eschar and mild surrounding erythema. Continued wound care to right lower extremity, may need sharp debridement for right eschar in the near future. Recommend ultrasound of bilateral lower extremities to rule out deep vein thrombus.

Medicine consult on the same day stated the patient had right leg ulcers secondary to ischemia from peripheral vascular disease, recent ultrasound showed no deep vein thrombus, significant peripheral vascular disease with slow healing wound. Right leg ulcers may need debridement, will discuss with attending.

On 12/9/2010 at 10:50am, the patient and the health care surrogate were interviewed in the patient's room. The patient was questioned as to whether he ever had on the sequential compression device. Per the patient and the health care surrogate, the patient had the devices placed on the right leg since surgery on 11/20/2010. The health care surrogate then went to the patient bedside, lifted a compression device sleeve still attached to the pump and stated "This is the one the patient had on". The sleeve was noted to have dried bloody drainage on the top of the sleeve.

An interview was conducted with the unit nurse on 12/9/10 at 11:00am to determine whether Patient #1 ever had a sequential compression device on the right leg. Per the nurse, she could not recall if the patient ever had the device on or if the patient has an order for the device.

An interview was conducted with the nurse manager on 12/9/10 at 12:30 regarding the facility practice of documenting the use of the sequential compression device. Per the nurse manager, the sequential compression devices area to be documented on the nurses' flow sheets, was not done for this patient. In addition, there was no physician's order for the use of the device.

2. Patient sample #4 was admitted to the facility on 12/1/2010 with acute renal failure, status post cadaveric transplant with graft rejection, lupus and dysphagia, hemoglobin drop and bright red blood per rectum with clots. The patient was noted in the medical record to be alert and oriented. Sequential compression devices were ordered on 12/6/2010.

Interview was conducted with the unit nurse on 12/9/2010 at 12:30pm regarding the patient using the sequential compression devices. Per the nurse, the patient has never used the devices, the patient declined to use them.

An interview was conducted with the patient on 12/9/10 at 12:35pm regarding the use of the sequential compression devices. Per the patient, she has never declined the use of the device; she stated "I never used the device because the nurses never brought in the pump to accompany the device sleeve".

Review of the patient's medical record at 12:40pm revealed that the sequential compression devices were not listed on the care plan, nor was there any documentation of the patient declining the use of the device.

Based on observation, patient interview and record review, the facility failed to ensure for 2 of 9 sampled patients (#1 & 5), that the Registered Nurse assigned to the patient assessed the care of each patient on an ongoing basis to evaluate the care provided. Evaluation of care would include assessing the patient's care needs, patient's health status/conditioning, as well as the patient's response to interventions. Information regarding the patient's care and response to interventions should be documented in order to determine the patient's health status and allow for the physician to make changes as needed for the care of the patient.

The findings include:

1. Patient sample #1 was admitted to the facility on 11/3/2010 via the Emergency Department (ED) with generalized weakness, an increase of falls in the home and pain in the lower extremities. Per the history and physical, the patient is a deceased donor kidney transplant in 2003, has hypertension, benign prostatic hypertrophy, end stage renal failure, currently receiving dialysis three times per week, has peripheral vascular disease, intermittent claudication and diabetes mellitus. Initial evaluation showed the patient to have mild erythema and evidence of chronic venous insufficiency to the bilateral lower extremities and 1+ bilateral lower extremity edema.

During the hospital stay, the patient developed a fever of unknown origin, and was found to have gas gangrene and osteomyelitis of the second and third toes of the left foot, necessitating an above the knee amputation on the left leg on 11/20/10.

Post operatively, the patient was sent to the surgical progressive care unit and was then transferred to 7SR on 11/25/2010. On 12/2/2010, there was documentation in the physicians' notes stating to discontinue the sequential compression devices, the patient had developed right leg ulcers, re-consult wound care.

Wound care notes stated the patient had a 20.5x7cm unstageable wound on the right leg, re-consult vascular surgery. The following day, vascular surgery visited the patient, and stated there was a new wound to the right calf, 5x6 cm with irregular eschar and mild surrounding erythema. Continued wound care to right lower extremity, may need sharp debridement for right eschar in the near future. Recommend ultrasound of bilateral lower extremities to rule out deep vein thrombus.

Medicine consult on the same day stated the patient had right leg ulcers secondary to ischemia from peripheral vascular disease, recent ultrasound showed no deep vein thrombus, significant peripheral vascular disease with slow healing wound. Right leg ulcers may need debridement, will discuss with attending.

On 12/9/2010 at 10:50am, the patient and the health care surrogate were interviewed in the patient's room. The patient was questioned as to whether he ever had on the sequential compression device. Per the patient and the health care surrogate, the patient had the device placed on the right leg since surgery on 11/20/2010. The health care surrogate then went to the patient's bedside, lifted a compression device sleeve still attached to the pump, and stated "This is the one the patient had on". The sleeve was noted to have dried bloody drainage on the top of the sleeve.

An interview was conducted with the unit nurse on 12/9/10 at 11:00am to determine whether Patient #1 ever had a sequential compression device on the right leg. Per the nurse, she could not recall if the patient ever had the device on or if the patient has an order for the device.

2. Patient sample #5 was admitted to the facility with altered mental status, alcohol abuse and possible gastrointestinal bleeding on 11/5/2010. There was a physician's order for sequential compression devices on the day of admit. Nursing monitoring sheets were reviewed on 12/9/2010 at 1:15pm. Of the 33 days to document the monitoring of the patient assessment for use of the devices, 17 days lacked any documentation and 6 of the 33 days had partial documentation.

An interview was conducted with the nurse manager on 12/9/2010 at 12:30 regarding documenting the use of the sequential compression device. Per the nurse manager, the sequential compression devices are to be documented on the nurses flow sheets, and was not done for this patient. .

Based on record review, the facility failed to ensure for 4 of 9 sampled patients (#4, 6, 7, 8) that the nursing staff develop and keep current a nursing care plan for each patient.

The findings include:

1. Patient #1 was admitted to the facility on 11/3/2010 for status post cadaveric renal failed transplant, renal failure, peripheral vascular disease, diabetes mellitus. During the hospitalization, the patient developed a fever of unknown origin and was diagnosed with gas gangrene of the left foot.

On 11/20/10 the patient underwent an above the knee amputation and per the patient and health care surrogate had sequential compression device placed on the right leg from 11/20/10 until 12/2/10, when a physician found the right leg with an open wound.

On interview on 12/9/2010 at 10:50am, the health care surrogate provided a sequential compression device sleeve in the patient room with stained sero-sanguineous material. She stated "This is the one the patient had on". Review of the patient's medical record revealed the device was not listed on the patient nursing care plan.

2. Patient #4 was admitted to the facility on 12/1/2010 with acute renal failure, status post cadaveric transplant with graft rejection, lupus and dysphagia, hemoglobin drop and bright red blood per rectum with clots. The patient was noted in the medical record to be alert and oriented. Sequential compression devices were ordered on 12/6/2010.

The unit nurse was interviewed on 12/9/2010 at 12:30pm regarding this patient using the sequential compression devices. Per the nurse, the patient had never used the devices, as the patient declined to use them.

An interview was conducted with the patient on 12/9/10 at 12:35pm regarding the use of the sequential compression devices. Per the patient, she has never declined the use of the device, she stated "The nurses never brought in the pump to accompany the device sleeve".

Review of the patient's medical record at 12:40pm revealed that the sequential compression devices were not listed on the care plan, nor was there any documentation of the patient declining the use of the device.

3. Patient #6 was admitted to the facility on 11/29/10. Review of the patient's medical record revealed that there were no orders for sequential compression devices. Nurses' monitoring sheets were reviewed and documentation was present for the use of the devices, however, there was no mention of the use of the device on the patient care plan.

4. Patient #7 was admitted to the facility on 4/21/10. Physicians' orders were written for the use of the sequential compression devices. Nursing monitoring sheets were reviewed and met the Standards. The use of the sequential compression devices were not listed on the patient's care plan.

5. Patient #8 was admitted to the facility on 12/7/10. Physician orders for the use of the sequential compression devices were appropriate, along with nursing monitoring for the use of the device. The sequential compression devices were not listed on the nursing care plan.

Based on observation and staff interviews, the facility failed to ensure that drugs and biologicals were prepared and administered in accordance with accepted standards of practice for one of 9 sampled patients (#9).

The findings include:

During medication pass observation on 12/8/2010 at 11:00, the unit nurse was observed to pull the prescribed medication vial of Ativan 2mg/ml from the Omnicel. She then proceeded to take the vial to the medication cart, checked the physician's order and cleansed the top of the vial with alcohol. Next, she proceeded to inject 0.5ml of air into the vial and withdrew 0.5ml (1mg) of the medication into the syringe. She then obtained a 10ml syringe of normal saline 0.9% flush from the cart. The nurse then entered the patient's room, identified the patient by name and arm band, clamped the existing intravenous line, flushed the line with 5ml of normal saline, administered the Ativan, and then flushed the line again with the same syringe of normal saline. After the nurse was finished, she discarded the empty syringes in the Sharps container. The nurse was then questioned about using the same syringe of normal saline for flushing the intravenous line before and after the administration of the medication. Per the nurse, she was aware she should not flush the intravenous line before and after with the same syringe of normal saline.

An interview was conducted with the charge nurse for the unit on the same date at 11:15am, on facility policy for flushing existing intravenous lines. Per the charge nurse, the nurse was not supposed to use the same syringe to flush the line before and after the administration of medication. Per the charge nurse, the policy on flushing intravenous lines is currently under review with the Clinical Practice Team.