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Based on review of facility policies and medical record review (MR), and staff interview (EMP), it was determined the facility failed to ensure patient care plans were updated to include the use of restraints for two of five restraint patient records reviewed (MR1 and MR4)

Findings include:

Review of the facility policy "Nursing Assessment, Daily" revised September 2013 revealed, "...Patient Assessment...B...2. Changes noted during the shift should be reported in the narrative notes of the flowsheet and added to the Plan of Care as appropriate."

Review of the facility policy "Restraints" revised March 2013 revealed, "2. Restraint for Acute Medical and Surgical Care...7. The order must be in accordance with a written modification to the patient's plan of care..."

1. On March 4, 2014, at approximately 10:30 AM review of MR1 revealed the patient was admitted to the facility from December 18, 2013 - January 20, 2014. The patient was initially placed in bilateral wrist restraints on December 22, 2013. Restraints were again applied on December 26, 2013, and were in use almost continuously throughout the rest of the patient's hospitalization.

On March 5, 2014, at approximately 1:30 PM review of the the "Transdisciplinary Plan of Care" revealed, "Problem 17: Restraints." The restraint care plan was not initiated during this patient's hospitalization.

On March 5, 2014, at approximately 2:00 PM EMP7 confirmed the above information.

2. Review of MR4 on March 5, 2014, at 1:30 PM revealed the patient was in soft bilateral wrist restraints from February 27, 2014, through March 4, 2014.

Continued review of MR4 revealed a Critical Care Flow sheet that documented restraint observations at different times between February 27, 2014, thorough March 4, 2014.

Interview with EMP8 on March 5, 2014, at 1:30 PM confirmed that there was no restraint care plan for MR4.

Based on review of facility policy and medical record review (MR), and staff interview (EMP), it was determined the facility failed to ensure documentation of the rationale for discontinuation of restraints per facility policy on one of five restraint records reviewed (MR4).

Findings include:

Review of facility policy "Restraints" revised March 2013 revealed, "...Procedure...H. document the decision-making process for the use or removal of restraints in the medical record."

1. Review of MR4 revealed the patient was in soft bilateral wrist restraints from February 27, 2014, through March 4, 2014. An order for soft wrist restraints dated March 2, 2014, indicated, "...Restrain patient for 24 hours (not to exceed 24 hours) from 3/2/14 to 3/3/14...Date 3/2/14 Time: 0700 ..."

2. Continued review of MR4 revealed a Critical Care Flow sheet that documented restraint observation from 8 AM on March 2, 2014, to 6 PM on March 2, 2014. The form also indicated, "Continued need for Restraints No (restraints discontinued by ...@1930."
There was no further documentation regarding the decision making process that occurred for the discontinuation of the restraint.

Interview with EMP5 on March 4, 2014, at 10:30 AM, revealed, "No, I do not see any other notes about why the restraint was discontinued."

Based on review of facility policy, medical record review (MR) and staff interview (EMP), it was determined the facility failed to ensure there was a physician order relevant to the use of restraints for two of five restraint records reviewed (MR1 and MR12).

Findings include:

Review of facility policy "Restraints" revised March 2013 revealed, "...2. Restraint for Acute Medical and Surgical Care...14. A new order must be obtained if the patient was recently released from the restraints and the patient suddenly exhibits behavior that can only be handled by reapplication of the restraint."

1. Review of MR1 revealed a physician order dated December 31, 2013, at 7:00 AM for bilateral wrist restraints. There was no documentation of restraint use on this date until 8:00 PM. There was no physician order relevant to the initiation of restraints at 8:00 PM this date.

Review of nursing documentation revealed the patient of MR1 was restrained from 7:00 PM January 13 - 5:00 AM January 14, 2014. There was no physician order for the application of restraints on this date.

Review of nursing documentation revealed the patient of MR1 was restrained from 8:00 AM January 16 - 6:00 AM January 17, 2014. There was no physician order for the application of restraints until 1:00 PM on January 16, 2014.

On March 5, 2014, at approximately 2:00 PM EMP1 confirmed the above findings.

2. Review of MR12 on March 5, 2014 at 2:00 PM revealed the patient was ordered mitt restraints on February 28, 2014, at 7:00 AM through March 1, 2014, and mitt restraints from March 1, 2014, at 7:00 AM through March 2, 2014. The mitt restraint orders indicated, "...Restrain patient for 24 hours (not to exceed 24 hours)."

Continued review of MR12 revealed a Critical Care Flow sheet dated February 28, 2014, which revealed that mitt restraints were not applied until 4:00 PM. The flow sheet indicated that the restraint was applied at 4:00 PM and then not again until 8:00 PM through 6:00 AM on March 1, 2014. There was no order for the restraints to be applied at 4:00 PM on February 28, 2014.

The Critical Care flow sheet for MR12 dated March 1, 2014, indicated that the mitt restraint was not applied until 8:00 PM. The restraint was applied from March 1, 2014, at 8:00 PM through March 2, 2014. There was no physician order for the restraint to be applied at 8:00 PM on March 1, 2014.

Interview with EMP8 on March 5, 2014, at approximately 2:00 PM confirmed that MR12 did not contain an order for the mitt restraints for February 28, 2014, from 4:00 PM through 6:00 AM on March 1, 2014, and did not contain an order for March 1, 2014, at 8:00 PM.

Based on review of facility policy, medical record review (MR) and staff interview (EMP), it was determined the facility failed to ensure patients were monitored every two hours during restraint use according to facility policy for one of five restraint records reviewed (MR1).

Findings include:

Review of facility policy "Restraints" revised March 2013 revealed, "...6. a. Patients will be monitored during the use of restraint to determine their well being and assessed for the continuing need for restraints. b. Monitoring will include, but is not limited to, the assessment of peripheral circulation, sensation, movement, and skin integrity. c. Patients will be assessed for evidence of skin breakdown and impaired circulation/sensation related to a restraint at least every two hours. d. Patients will be offered food/fluid, toileting, and hygiene at least every two hours. PROM exercises or position changes will be provided at least every two hours. e. Patients will be assessed for pain at least every two hours...7. Appropriate Documentation and Reporting...4. Results of patient monitoring are documented on the appropriate monitoring flowsheet."

1. On March 4, 2014, at approximately 10:30 AM review of MR1 revealed the patient was in restraints continuously on December 27 and December 28, 2013. There is no documentation of patient monitoring from 4:00 AM - 8:00 AM on December 28.

2. Further review of MR1 revealed the patient was in restraints on January 3, 2014. There was no documentation of patient monitoring from 2:00 PM - 7:00 PM on this date.

3. Continued review of MR1 revealed the patient was in restraints on January 12, 2014, at 8:00 AM. Nursing note at 8:00 PM states, "Restraints released now. Calm & cooperative now." Patient monitoring was not documented every two hours as required from 8:00 AM - 8:00 PM.

EMP1 confirmed the above findings at the time of discovery.

Based on review of facility policy, medical records (MR) review, and employee interview (EMP) it was determined that the facility failed to ensure effective implementation of a wound care plan for one of seven patients. (MR15)

Findings include:

Review of facility policy "Nursing Assessment, Daily" revised September 2013 revealed, "...B. Planning...4. Nursing Plan of Care a. the Registered Nurse is responsible for the initial identification of nursing care issues and goals. These are identified on the initial nursing assessment flow sheet and incorporated into the Transdisciplinary plan of Care. b. Individual nursing interventions are developed to achieve expected patient outcomes. c. Transdisciplinary care planning will include the nursing plan of care...Patient Assessment...2. Changes noted during the shift should be reported in the narrative notes of the flowsheet and added to the Plan of Care as appropriate."

1. Review of MR15 on March 5, 2014, at 2:00 PM revealed a physician order dated February 27, 2014, at 1337 for Silvadene to be applied to coccyx and right hip twice daily.

2. There was no documentation of a wound care plan for MR15.

Interview with EMP8 on March 5, 2014, at approximately 1:30 PM confirmed that there was no wound care plan for MR15.

Based on review of facility policy, medical records (MR) review, and employee interview (EMP), it was determined that the facility failed to ensure that each drug administered is recorded in the medical record of the patient and properly signed after the drugs have been administered for five of seven respiratory medical records, (MR5, MR8, MR9, MR10, and MR11) and two of seven wound care medical records. (MR2 and MR15)

Findings include:

Review of facility policy on March 5, 2014, at approximately 2:00 PM revealed, "Aerosol Therapy: Hand Held Nebulizer...Revision Date August 2010...Purpose: To describe the method for administering aerosolized medication without the use of a positive pressure device. Hand held nebulizer therapy shall be powered by a pneumatic source of compressed oxygen and/or an air compressor for home care teaching or severe CO2 retainers with oxygen sensitivity. Policy...Therapy shall be delivered only upon a physician order...Procedure...G. Medication delivery shall be documented with the correct time on the MAR..."

Review of facility policy on March 5, 2014, at approximately 2:30 PM revealed, "Medication Administration Record...Revision date September 2012...Policy the Medication Administration Record (MAR) will be computer generated by Pharmacy and will be utilized by nursing...Procedure...A. Obtain a Physician Order for required medication. 1. Nursing will transcribe the order onto the patient's MAR. 2...C. The MAR will contain the following: 1. Routine Medications 2. PRN Medications 3. Respiratory Medications..."

1. Review of MR2 on March 4, 2014, at approximately 10:30 AM revealed a physician order dated February 20, 2014, at 0920, which indicated, "...dry dressing to Left great toe change q[every] Mon and Thurs..."

Continued review of MR2 revealed that on February 24, 2014, there was no documentation that the left toe dressing was applied.

Interview with EMP7 on March 5, 2014, at approximately 1:00 PM confirmed that the left toe dressing was not documented.

2. Review of MR15 on March 5, 2014, at 2:00 PM revealed a physician order dated February 27, 2014. The order indicated for the wound to be treated with Silvadene to coccyx and right hip twice a day.

Continued review of MR15 revealed that the dressing was not applied on February 27, 2014.

Interview with EMP8 on March 5, 2014, at approximately 1:30 PM confirmed that the Silvadene dressing to the coccyx and right hip was not documented in the evening of February 27, 2014.

3. Review of MR5 on March 5, 2014, at approximately 9:00 AM revealed a physician order for Pulmicort to be administered every 12 hours and Duoneb to be administered every six hours while awake. The MAR for MR5 dated March 4, 2014, was blank for the 1900 treatment of Pulmicort and blank for the 1300 and 1900 Duoneb treatments.

4. Review of MR8 on March 5, 2014, at approximately 9:00 AM revealed a physician order for Pulmicort to be administered every 12 hours and Duoneb to be administered every six hours while awake. The MAR for MR8 dated March 4, 2014, was blank for the 1900 treatment of Pulmicort and blank for the 1300 and 1900 treatments of Duoneb.

5. Review of MR9 on March 5, 2014, at approximately 9:00 AM revealed a physician order for Pulmicort to be administered twice a day, Proventil to be administered every 6 hours, and Spiriva to be administered every day. The MAR for MR9 dated March 4, 2014, was blank for 1900 Pulmicort and blank for the 1300 and 1900 Proventil treatments, and blank for the 0800 Spiriva treatments.

6. Review of MR10 on March 5, 2014, at approximately 9:00 AM revealed a physician order for Proventil to be administered four times a Day, Pulmicort to be delivered every 12 hours, and Spiriva to be administered every day. The MAR for MR10 dated March 4, 2014, was blank for the 1100, 1500, and 1900 doses of Proventil, blank for the 0700 and the 1900 dose of Pulmicort, and blank for the 0800 dose of Spiriva.

7. Review of MR11 on March 5, 2014, at approximately 9:00 AM revealed a physician order for Duoneb to be administered every 6 hours. The MAR for MR11 dated March 4, 2014, was blank for the 1300 and 1900 dose.

During an interview on March 4, 2014, at approximately 9:00 AM, EMP10 indicated, "I talked with [person on the previous shift] and there is no documentation...they forgot to document..."

Based on review of facility policies, medical record review (MR) and staff interview (EMP), it was determined the facility failed to ensure that nursing documentation was pertinent, accurate and concise in order to contribute to the continuity of patient care for two of 11 medical records reviewed (MR1 and MR2).

Findings include:

Review of facility policy "Wound Care" revised December 2011 revealed, "D. The Wound Care Staff will be notified of appropriate patients admitted with wounds or patients who develop skin integrity impairment. 1. The Wound Care Staff will be responsible for completing a comprehensive wound assessment...E. The Wound Care Staff upon initial evaluation will photograph all wounds and then every week and prior to discharge...2. The photograph will be attached to the Wound Assessment and Documentation form, which includes written information describing the wound...H. The Wound Care Staff will make rounds weekly assessing skin, wound healing and providing wound care interventions."

Review of facility policy "Staging of Pressure Ulcers and Management" reviewed December 2011 revealed that nursing interventions for Stage II, Stage III and Stage IV wounds included, "Turning schedule - at least every two hours...Consult wound specialist." Stage III wound treatment includes "Consult with MD if necrotic - may need debridement."

Review of facility policy "Nursing Assessment, Daily" revised September 2013 revealed, "...Procedure A. Assessment 1. Initiated upon patient arrival, the initial admission assessment is to be completed within twenty-four hours...3. A complete physical reassessment will be conducted and documented every shift thereafter...Patient Assessment...B. 1. The system-based clinical assessment is based upon close observation, first hand evaluation and reflects the patient's status at the beginning of the 12 hour period...2. Changes noted during the shift should be reported in the narrative notes of the flowsheet and added to the Plan of Care as appropriate...E. 1. Nursing Interventions/Routine Patient Care: documentation of positioning, hygiene and care activities done by the nurse."

1. On March 4, 2014, at approximately 10:30 AM review of MR1 revealed the patient was admitted with a Stage II pressure ulcer to the gluteal fold and right buttocks area which was photographed upon admission. The "Wound Assessment and Documentation" form which was signed by the Wound Care Nurse did not include a written description of the photographed area. No other skin integrity issues were identified upon admission.

Continued review of MR1 revealed there were no subsequent wound photographs taken during this patient's hospitalization and there were no weekly skin assessments documented by the Wound Care Nurse on this patient.

On March 4, 2014, at approximately 11:35 AM EMP7 confirmed there were no subsequent wound photographs and no documentation of weekly skin assessments on MR1.

On March 5, 2014, at approximately 1:30 PM EMP9 stated "As long as there is a measurable area we would expect to see wound measurements. Our expectation is that the Wound Care nurse is looking at every patient weekly."

Further review of MR1 revealed erroneous documentation entered by the Wound Care Nurse dated January 9, 2014, which described wounds and wound treatment for a different patient.

Wound care shift assessments were not documented on December 19 and December 20, 2013, day shift; December 31, day shift; January 1, 2014, day shift; January 2 and January 3, day and night shift; January 4, day shift; January 9, 10 and 11, day shift; January 13 day and night shift; January 15, day shift and January 18, day shift.

On December 23, 2013, day shift documented "Mepilex Border to right shin CDI [clean, dry, intact]." There was no description of a wound to the right shin. There was no documentation of notification to the Wound Care nurse or physician related to the right shin.

On December 24, 2013, night shift documented "Coccyx w/small 2cm St III pink & macerated edges. Cleaned & Mepilex border placed. On December 25, 2013, day shift documented "No open areas." Night shift on December 25 documented "Sm St III coccyx pink w/macerated edges. Cleaned & cream applied." There was no documentation of notification to the Wound Care nurse or physician related to the coccyx ulcer now being a Stage III ulcer.

On January 5, 2014, night shift documented "Sacral pressure ulcer yellow/pink, no odor." January 6, 2014 day and night shifts both documented "Skin intact."

January 11, 2014, day shift documented that the patient had no wounds. Night shift documented "Sacrum P [pressure ulcer] purple/black w/mild odor and no drainage. Surrounding tissue WNL (within normal limits). Mepilex border."

January 14, 2014, day shift documented "RLE (right lower extremity) scab OTA [open to air]. R [right] lateral foot St II Mepilex; R heel necrotic OTA; Sacral unstageable." There was no documentation of notification to the Wound Care nurse or physician related to new wounds on the right foot or the, now, unstageable coccyx ulcer.

Based on the above "Staging of Pressure Ulcers and Management" policy, the patient of MR1 should have been turned/ repositioned at least every two hours. There was incomplete documentation related to repositioning every two hours of this patient on December 26 and 31; January 2, 3, 4, 11, 12, 13 and 18.

Further review of MR1 revealed that meal consumption documentation was incomplete on December 21 and 31; January 1, 3, 10, 11, 13, 14, 15 and 17.

On March 5, 2014, at approximately 2:00 PM EMP1 confirmed the above missing and inconsistent documentation identified above.

2. Review of MR2, on March 4, 2014, at approximately 2:00 PM revealed an order dated February 20, 2014, which indicated, "...Dry dressing to L great toe..."

Continued review of MR2 revealed a nursing note dated February 21, 2014, at 8:00 AM, which indicated, "Right toe brown...surr tissue...4 Dressing dry, intact..."

Continued review of MR2 revealed a nursing note dated March 1, 2014, at 10AM, which indicated, "L anterior thigh drsg dry and intact." Another nursing note dated March 1, 2014, at 2000, indicated, "L thigh dressing intact.."

During an interview on March 5, 2014, at approximately 11:30 AM, EMP7 indicated, "There was no right toe wound... it is an error...and there was never a wound or skin issue to the hip that I was aware..."

Based on review of facility policy, medical record review (MR) and staff interview (EMP), it was determined the facility failed to ensure treatments were administered only upon physician order for one of seven medical records (MR1).

Findings include:

Review of facility policy, "Staging of Pressure Ulcers and Management" reviewed December 2011 revealed, "Stage II..Dressing *Thin dressing * Hydrocolloid * Foam * Wound gel...Stage III. Dressing *Calcium Alginate * Wound filling with saline and gauze *Foam * Antimicrobial *Wound gel." The policy also indicates that dressing items marked with an asterisk (*) require a physician order.

1. On March 4, 2014, at approximately 10:30 AM review of MR1 revealed the patient was admitted to the facility on December 18, 2013. At the time of admission MR1 was identified to have a Stage II pressure ulcer to the gluteal fold. Documentation on the "Initial Nursing Assessment" revealed, "...Picture of St II gluteal crease pressure ulcer taken - pt bathed, new linen change, Mepilex applied."

2. Continued review of nursing documentation during this patient's hospitalization revealed that a Mepilex dressing was documented on the above identified wound 18 of 33 days, excluding the day of admission.

3. Documentation in the medical record also indicated that Mepilex was applied to the patient's right shin and right lateral foot during this hospitalization.

4. There was no physician order for the use of Mepilex in the patient's record.

During an interview on March 5, 2014, at approximately 1:30 PM EMP9 confirmed that Mepilex would be considered a foam dressing and a physician order would be required for its use.