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Based on observation, record review, and interview the facility failed to:

A.

to ensure the nursing staff documented the assessment of voided urine output and residual catheterized output, correlated assessment findings when Pt #1 began exhibiting a low-grade temperature over three consecutive days, and notified the physician of these findings for changes of condition in 1 (patient #1) of 20 patients.

Refer to tag 0395


B.

A) include the patient #1 through #20 or their representative in the care planning process,

B) include the patient's treatment for bladder training into an interdisciplinary care plan/nursing plan of care for 1 (#1) of 20 patients from 08/01/2023 through 08/31/2023.

Refer to tag 0396

Based on record review and interview, the facility staff failed to include the patient or patient representative in the interdisciplinary care planning process from 08/01/2023 through 08/31/2023 for 20 of 20 (Patients #1 through #20). It is the patient/family representatives right to participate in this care planning process.

This deficient practice had the likelihood to harm all patients of the facility.


Findings include:


On 08/28/2023 patient medical records #1 through #20 were reviewed. The review found no signature or telephone notification that the patient or family had participated or were included in the care planning process.

A review of the policy titled, "Care Planning policy #230" revealed the following:

"PURPOSE:

To define the mechanism to document an individualized Interdisciplinary Plan of Care for the patient.

All inpatients will have a plan of care developed by the interdisciplinary team responsible for their care, which includes provider's orders". During the above review the CNO confirmed the nursing care plan was included in the interdisciplinary care plan.

"DEFINITION:
Care planning involves planning for patient's needs from the perspective of the patient and caregiver, and include but is not limited to physical needs, cognitive needs, functions needs, and the potential limitations from co-morbid conditions".


The Chief Nursing Officer (CNO), staff #1, was asked if patients and/or their representatives participated in the care planning process. CNO stated, "We have never included the patient or family in the care planning meeting".

Based on observation, record review, and interview, nursing staff failed to ensure staff documented assessment of voided urine output and residual catheterized output according to physician orders. Nursing staff also failed to correlate assessment findings and notify the physician of a change in condition when patient began exhibiting a low-grade temperature over three consecutive days for 1 (Pt #1) of 20 patients (Pt's #1 through #20) whose records were reviewed.


These deficient practices had the likelihood to harm all patients of the facility.

Findings included:


On 08/28/2023, in the conference room, the clinical manager, staff #3, assisted with the medical record review for patient #1. Patient #1 was admitted on 08/12/2023 from the acute hospital setting with a primary diagnosis of Left Below the knee amputation and a secondary diagnosis of a history of chronic Urinary Tract Infection (UTI). On admission Pt #1 had a white blood cell count of 11.4. During Pt #1's four-day admission, his voided urine output decreased, while his catheter-obtained residual urine increased. Pt #1's WBC was 16.2 on 08/14/2023. Pt one (#1) was admitted with a documented temperature of 97.8 degrees. Pt #1's temperature rose and maintained just below 100 degrees during the four-day admission period.

On the morning of 08/28/2023, in the board room, the medical record for pt #1 was reviewed and confirmed pt #1 was admitted with a physician's order for bladder training program.

A review of facility policy titled, "Bladder Program #190" revealed the following:

"POLICY: It is the policy of this hospital to engage in a bladder training program on all patients who may be physically or cognitively capable of obtaining bladder control.

1. Upon admission all individuals are evaluated concerning their bladder status. Information includes.
Significant medical history
History of urological function
Motivation to comply with bladder training
Activity Level
Neurological function

2. Assess individual for any factors which could affect bladder functioning.
Fluid intake
Fluid output
Mental alertness
Emotional status
Sensation
Medications which may affect bladder training".

On 08/28/2023 a review of the medical record revealed all staff nurses were documenting that patient #1 was alert oriented and continent of his bladder throughout his hospital admission. Patient was able to use a urinal to void and once he was able to stand; could void into the toilet". Patient #1 did not qualify as needing bladder training. The facility nursing staff failed to document every two hours for continence or need to void. The physician failed to document why the patient needed bladder training program.

The admitting orders for the bladder training program revealed the following:

The physician's order dated 08/12/2023, at 1:39 PM was written, "Time void Q (every) 2 Hours (every 2 hours), then check PVR (Post void Residual) Q 6 hours (every 6 hours) times 4, if greater than 250 ML's (Milliliters) then I/O (in and out catheter). If normal after 4 checks then DC (discontinue), if abnormal continue Q 6 hours until problem resolved".

An interview with the Registered Nurse Manager (staff #4) revealed her nursing interpretation of the above physician's order:
The physician's order read, "Check patient every two hours for voiding. This meant that after checking the patient every two hours, three times would bring you to the six-hour mark, where residual urine would be assessed. Post-voiding residual urine (with sonography) would then be used as the assessment tool every six hours four times. If the residual urine is greater than 250, do an in and out catheter to drain the residual urine. If normal after four checks, then discontinue. If abnormal, continue to check residual every six hours until the problem has resolved".

A summary of the daily urinary output may be found below. The record revealed nursing staff documented the total voided urine per shift and the total residual urine after categorization for each shift rather than every 2 hours. There was no record where Pt #1 was encouraged to void every 2 hours. There was no record of every 2 hours voided amount. The nursing staff failed to follow the physician's order.

08/12/2023 Day shift Pt #1 voided 600 ml (Milliliters) with no catheterization
08/12/2023 Night shift Pt #1 voided 2070 ml, with 950 ml via catheterization
08/13/2023 Day shift Pt #1 voided 0 ml with no catheterization
08/13/2023 Night shift Pt #1 voided 350 ml, with 700 ml via catheterization
08/14/2023 Day shift Pt #1 voided 200 ml with no catheterization
08/14/2023 Night shift Pt #1 voided 100 ml, with 500 ml via catheterization
08/15/2023 Day shift Pt #1 voided 0 ml with 600 ml via catheterization
08/15/2023 Night shift Pt #1 voided 80 ml, with 800 ml via catheterization
08/16/2023 Day documented no shift output. Pt. was transported to vascular outpatient services for the first follow-up after amputation and did not return to the facility.

A review of the nursing documentation found in the MR for Patient #1 did not reveal nursing notified the physician when Pt #1's urine output shifted from voided urine to catheter-acquired urine.

On the morning of 08/28/2023, the vital signs documented in the medical record were
reviewed.
08/12/2023 pt #1's temperature was 97.8, (admission date)
08/13/2023 99.6 temperature
08/14/2023 99.6 temperature
08/14/2023 99.3 temperature
08/15/2023 98.8 temperature

On the morning of 08/28/2023, during an interview with the Chief Nursing Officer (CNO), staff #1, the MR was reviewed. It was brought to Staff #1's attention that Pt. #1's temperature was consistently low grade. The CNO stated, "The temperature was never above 100 degrees, which would necessitate notifying the physician". Pt #1 had received routine narcotic pain control during the four days of admission.

On the morning of 08/28/2023, a review of Pt #1's medical record revealed he had been treated with Oxycontin narcotic pain medicine and Hydrocodone narcotic pain. Both Oxycontin and Hydrocodone contained 325 mg of acetaminophen along with the narcotic pain medication, which would reduce the patient's temperature.

On 08/28/2023, the Chief Nursing Officer (CNO) reported that she had questioned the attending physician after he declined to be interviewed by the surveyor and asked why the elevated white blood cell count had not been addressed. The CNO reported to the surveyor that the attending physician stated, "Pt #1 had just had a below-the-knee amputation (BKA). You would expect to see that". The CNO further stated, "The physician did not feel intervention was warranted. If intervention was needed, the vascular surgeon would do it".

Patient #1's medical record indicated the patient had a scheduled follow-up physician's appointment with his vascular surgeon on 08/16/2023. The vascular surgeon documented in his progress notes- "Pt's surgical site is clean, dry, and intact, but the patient is not. Patient #1 did not recognize me. He did not know what town he was in. He was generally confused". Pt #1 was transported via EMS from the vascular surgeon's office to the Emergency Department of a local acute hospital and was admitted with a diagnosis of urinary tract infection with a high bacteria count in urine.

Based on record review and interview, the facility failed to:

A) Include patients (Pt.) #1 through #20 or their representative in the care planning process,

B) include the patient's treatment for bladder training into an interdisciplinary care plan/nursing plan of care for one (Pt. #1) of 20 patients (#1 through #20) from 08/01/2023 through 08/31/2023.

This deficient practice had the likelihood of harming all patients of the facility.

Findings included:

A)

On the morning of 08/28/2023, an interview was conducted with the Chief Nursing Officer, which revealed the following:

On 08/28/2023, the Chief Nursing Officer (CNO) was asked if the patient or patient representative participated in the care planning process, The CNO stated, "No".

When the surveyor questioned how the patient could participate in the plan of care process, the CNO stated, "We have never had patients attend or otherwise be involved in the care planning process. You won't find that in any of our patient care planning meetings".

The medical record review for patient #1 revealed no evidence the patient or patient representative had participated in the care planning process. Also, further review of patient's medical records #2 through #20 found there was no evidence of the patient or patient representative's participation in the care planning process.


A review of the policy titled "Care Planning Policy #230" revealed the following:

"PURPOSE:

To define the mechanism to document an individualized Interdisciplinary Plan of Care for the patient.

All inpatients will have a plan of care developed by the interdisciplinary team responsible for their care, which includes provider's orders". During the above review, the CNO confirmed the nursing care plan was included in the interdisciplinary care plan.

"DEFINITION:
Care planning involves planning for patient's needs from the perspective of the patient and caregiver, and include but is not limited to physical needs, cognitive needs, functions needs, and the potential limitations from co-morbid conditions".



B)
On the morning of 08/28/2023, the medical record for patient #1 was reviewed with the assistance of nurse manager staff #3. The interdisciplinary care plan was reviewed. The problems identified in the care plan were mobility, self-care, and infection prevention.

Patient #1 was admitted with a physician's order for Bladder Training with post-void residual check per intermittent use of straight catheterization.

The interdisciplinary care plan/nursing care plan for Pt #1 did not identify the physician-ordered "Bladder Training with post residual checks per intermittent straight catheterization" as required by the Care Planning policy.