HospitalInspections.org

Based on interview and record review, the facility failed to ensure the nurses properly evaluated the nursing care needs for three of 10 patients reviewed, Patient #1, #9, and #10. The census was 82 patients, and the capacity was 106 patients.

Findings include:

1. The medical record review for Patient #10 was completed on 04/28/16. The review revealed the patient was admitted to the facility on 04/14/16 and discharged on 04/26/16. The medical record review revealed a history and physical dictated on 04/14/16 that stated the patient had septic shock secondary to pyelonephritis and encephalitis related to the use of benzodiazepine, methadone, and intravenous drug abuse. The history and physical also stated the patient had had a left nephrectomy. The history and physical stated the patient presents with acute on chronic renal injury requiring ongoing hemodialysis.

The medical record review revealed a physician's order dated 04/14/16 that stated to weigh the patient every day.

The medical record review revealed the patient was not weighed on 04/16/16, 04/19/16, 04/20/16, 04/22/16, and 04/25/16.

On 04/28/16 at 2:50 PM in an interview, Staff A confirmed the finding.

2. The medical record review for Patient #1 was completed on 04/28/16. The review revealed the patient was admitted on 04/18/16 with diagnoses of diabetes, cerebral vascular accident, aspiration pneumonia, and necrotizing fasciitis.

The review revealed a physician's order dated 04/18/16 to cleanse with normal saline the left scrotum, pat dry, cover with a dry sterile dressing, secure with mesh underpants, and change daily.

The medical record review did not reveal where the dressing was changed on 04/24/16, 04/25/16, and 04/26/16.

On 04/27/16 at 11:00 AM in an interview, Staff B said she didn't know whether the patient had a dressing to his scrotum or not.

3. The medical record review for Patient #9 was completed on 04/29/16. The medical record review revealed the 72-year-old patient was admitted to the facility on 03/01/16 with diagnoses of acute respiratory failure, encephalopathy secondary to respiratory failure, heparin induced thrombocytopenia, sepsis, deep venous thrombosis, anemia, thoracic spondylosis, renal failure, and history of alcoholism.

A review of the patient's history and physical dictated on 03/02/16 was completed on 04/29/16. The review revealed the patient was admitted for respiratory failure, hemodialysis, chronic medical conditions, and rehabilitation. The history and physical stated he had had a prolonged operation for spinal surgery after which he was difficult to extubate and what followed was a "complicated" course of hospitalization prior to admission to this facility. This included "profuse" tracheal bleeding that required a bronchoscopy after insertion of a feeding tube.

The medical record review revealed the patient was discharged to an extended care facility on 04/11/16.

A review of the patient's last three weeks of nursing flow sheets was completed. The review revealed incontinence care was not consistently performed. On 03/20/16 the patient was incontinent of stool three times and urine four times between 7:00 AM and 7:00 PM. The review did not reveal where any perineum care was given at those times:

On 03/21/16 the patient was incontinent of both bowel and bladder three times at 7:20 AM, 3:00 PM, and 5:45 PM. The review did not reveal where any incontinence care was given at those times.

The review revealed on 03/21/16 at 6:45 PM the patient was incontinent of urine twice, and perineum care was given at 12:45 AM.

The review revealed on 03/22/16 at 2:20 PM and 4:15 PM the patient was incontinent of urine. The review revealed the patient was given perineum care at 12:15 PM.

The review revealed on 03/23/16 from 7:00 PM to 3/24/16 at 7:00 AM the patient was incontinent of stool at 8:00 PM and 5:00 AM. The review did not reveal where any incontinence care was given at those times.

The review revealed on 03/26/16 at 10:00 AM the patient was given perineum care. The review also revealed he was incontinent of extra large and large stool at 12:08 PM and 12:43 PM respectively. The review did not reveal where any incontinence care was given at those times.

The review revealed on 03/27/16 at 11:10 PM the patient was twice incontinent of stool. The review did not reveal where any incontinence care was given at those times.

The review revealed on 03/31/16 at 12:00 AM and 5:00 AM the patient was incontinent of urine. The review did not reveal where any incontinence care was given at those times.

The review revealed on 03/31/16 from 7:00 PM to 04/01/16 at 7:00 AM the patient was incontinent of urine three times (the exact times are not noted). The review revealed incontinence care was given once at 9:25 PM.

The review revealed on 04/01/16 the patient was incontinent of urine at 10:40 AM and 4:30 PM. The review did not reveal where any incontinence care was given at those times.

The review revealed on 04/02/16 at 4:30 PM and 6:00 PM was incontinent of urine. The review did not reveal where any incontinence care was given at those times.

On 04/28/16 at 1:35 PM in an interview, Staff A confirmed the finding.