HospitalInspections.org

Based on review of medical records and interview, the facility did not supervise and evaluate the nursing care on 1 of 1 patient (Patient #1) who was bedfast, in that the patient was:
1) not turned and reposition every 2 hours, and
2) the reassessment of the blood sugar (BS) was not performed as ordered by the physician.

Findings:

1. The physician's notes on 06/27/10 indicated that Patient #1 was admitted from home on 05/18/10 for "left calf and ankle wounds." The nurse's notes on 06/05/10 indicated that Patient #1 had the following wounds: left thigh donor site (used for graft), right inner thigh, and excoriated peri-area. The patient also had open areas of the skin where a PICC (peripherally inserted central catheter) in the right upper extremity and a PEG (percutaneous endoscopic gastrostomy) for the delivery of her medications and nutrition.

The initial nursing assessment indicated a score of "11" in the "Braden Scale" which required to implement the nursing "care plan" to turn and reposition the patient every 2 hours. The patient was not turned and repositioned every 2 hours on the following dates and times:
05/20/10 at 1400 to 1800
05/21/10 at 0200 to 0600
05/22/10 at 2000 to 0600 (05/23/10)
05/23/10 at 2000 to 0600 (05/24/10)
05/25/10 at 0800 to 1800
05/26/10 at 0200 to 1800
05/27/10 the patient was not turned and reposition for 24 hours.
05/29/10 at 0800 to 1800
05/30/10 at 2000 to 0600 (06/01/10)

Complaint Log Book indicated that on 05/24/10 a complaint was filed by a family stating that she was " not happy " with the bolus-push tube feeding and that the patient "was not turned every 2 hours." On 06/02/10, a letter from the CEO (chief executive officer) was sent to the complaint stating the following resolutions: the nurse was to supervise the nursing assistants in " turning the patient every 2 hours " and the patient was placed on " continuous feeding ... "

In an interview the afternoon of 09/16/10 via phone, Personnel #1 was asked to confirm if the above dates and times were accurate with regard to not turning and repositioning Patient #1. Personnel #1 stated "yes."

Policy "Pressure Ulcer - Use of Braden Risk Assessment Tool dated 2003 indicated "...reflect degrees of sensory perception, skin moisture, physical activity...friction and shear, and ability to change and control body position..."Adult patient with a score of 18 or below are considered at risk."

Policy: "Admission, Assessment, and Reassessment" dated 2003 required "The nursing staff will perform an assessment of the patient's needs for nursing care...Nursing care will be based on documented assessment of the patient's needs...

2) On 06/09/10, at 1630 " BS 55 D50 IV 1/2 amp ... " At 1700 " Scheduled meds given ... " The medication administration record (MAR) indicated a BS of 239 (30 minutes after BS 55). The physician ' s order dated 05/29/10 was to " repeat FS (fingerstick) BS in 10 minutes; sent serum BS STAT to lab. " The FSBS was not performed in 10 minutes as ordered and the laboratory work was not performed.

In an interview the afternoon of 09/16/10 via phone, Personnel #1 was asked to confirm if the the nurse's notes dated 06/09/10 were accurate with regard to not performing a fingerstick 10 minutes after the administration of the D50 1/2 amp. Personnel #1 stated
"yes."

Policy: " Treatment of Hypoglycemia " 2003 required " Standard: Hypoglycemia will be treated ...glucose level equal or less than 70 ... III. Practice Guidelines 2. Perform and document bedside blood glucose level ...from Bedside Blood Glucose Monitoring ...6. Monitor the blood glucose level according to physician ' s orders ... "