HospitalInspections.org

Based on medical record review, observation, policy review, and staff interview the facility failed to ensure care was provided per physician's orders and nursing care interventions were identified for all patients. This affected five of 11 medical records reviewed (Patients 5, 6, 9, 8, and 7). The facility census was 62 at the time of the survey.

Findings include:

1. Patient #5's medical record was reviewed on 07/18/13 with Staff B and C (Directors of Quality). The patient was admitted on 04/22/13 with diagnosis of renal insufficiency, congestive heart failure, high blood pressure, spinal cord injury, pancreatitis, and alcohol abuse.

At the time of admission, the patient had a community acquired Stage II open pressure sore which measured 1.5 centimeters (cm) long and wide, and depth unable to be measured. The medical record revealed a nursing assessment dated 04/24/12 at 10:47 PM, revealed a new open pressure area on the coccyx which measured 5.5 cm long by 7 cm wide by 0.1 cm deep. The nursing assessment stated this open area was community acquired. The medical record revealed on 04/26/13, orders were obtained from the nurse practitioner for a treatment to this open area. An interview conducted with Staff B on 07/18/12 at 10:20 AM revealed the coccyx open area was not documented on the initial nursing assessment on 04/22/13, and an order was not obtained for 2 days after the pressure sore was identified on 04/24/13. The patient was discharged to an acute care facility on 04/27/13 for frank bleeding at the tracheostomy site.
Patient #5 was readmitted to this facility on 04/30/13 with a Stage II pressure sore on the sacrum which measured 4 by 4 cm, which was without depth. The patient was currently in the inpatient unit during this visit on 07/18/13.

The patient developed the following pressure sores during this inpatient stay:
a) On 05/22/13 left ischial tuberosity which measured 1.8 cm long by 1.5 cm wide by 11.7 cm deep.
b) 06/17/19 Stage II on the right hip which measured 0.9 cm long by 0.5 cm wide and 0.1 cm deep.
c) On 06/19/13 left buttock which measured 1 cm long by 0.7 cm wide, deep tissue injury.
d) On 06/24/13 right gluteal fold measured 2.8 cm long by 2.4 cm long, and 0.1 deep, Stage II.
e) On 07/08/13 right buttock, Stage II which measured 4 cm long, 5 cm wide, by 0.1 cm deep.
On 06/17/13 at 12:23 PM, the medical record documented a skin tear on the right buttock which measured 3.5 cm long by 1.5 cm which by 0.1 cm deep. The medical record was silent to how the skin tear occurred.

Patient #5's medical record also documented on 05/01/13 the patient was at risk for pressure sore development. The nurse practitioner's plan for pressure sore treatment, dated 07/01/13, and 07/08/13 revealed the patient should be turned and repositioned every 2 hours. An interview with Staff B, on 07/18/13, at 11:00 AM, revealed turning and repositioning should be documented in the medical record, and if the patient was not turned every 2 hours, the reason should be documented. A review of the flow sheets in the medical record revealed the patient was not turned and repositioned every 2 hours, and the reasons were not documented, as follows:
On 07/04/13 between 10:18 PM and 2:00 AM on 07/05/13,
On 07/05/13 between 2:19 PM and 5:56 AM, between 11:17 AM and 2:00 PM,
On 07/06/13 between 12:36 PM and 3:07 PM.
On 07/13/13 between 4:51 AM and 9:32 AM.
On 07/14/13 between 11:38 AM and 2:52 PM.


2. A medical record review was conducted for Patient #6 on 07/19/13 between 9:00 AM and 11:30 AM with Staff B. This patient was admitted on 03/13/13 with diagnoses of respiratory failure, pneumothorax, and status post trauma. On 04/26/13 at 6:02 PM, the medical record documented a nursing note by a licensed nurse which revealed a hospital acquired Stage III pressure ulcer which measured 4 cm long by 4.5 cm wide, and 0.2 cm deep. Although an order was received by the wound care nurse practitioner on 04/26/13 at 6:02 PM, the order documented starting the treatment on 04/29/13 (3 days later) at 5:00 PM three times a week. The nurse practitioner ' s (Staff H) assessment/progress note, dated 05/06/13, documented this open area as an unstageable area measuring 2.6 cm long by 2.3 cm wide by 0.2 cm. This assessment/progress note stated the following positioning/pressure reduction devices: Boots, heel suspension bilateral lower extremities, alternating pressure mattress, reposition every two hours.

The nurse practitioner's assessment/progress dated 07/16/13 documented this open coccyx pressure area as Stage IV (worse than Stage (III), which measured 5.4 cm long by 3.5 cm wide by 2.80 cm deep. Although this pressure sore increased in length and depth since 05/06/13, Staff H's documentation stated this site was healing. The 07/16/13 assessment by Staff H revealed the patient developed two new hospital acquired deep tissue injury pressure areas as follows:

a) On 07/01/13, on the right, which measured 1.6 cm long by 1.5 cm wide, without depth, and
b) On 07/15/13 on the left heel, which measured 3.6 cm long by 3.4 cm wide, and no depth.

The medical record documented a physician's order dated 05/15/13 at 2:10 PM which stated "Please position patient OFF of back; only position left or right". This was verified with Staff B at 11:00 AM. This employee stated the medical record should include turning and repositioning of the patient every 2 hours, and should contain documented reason when this was not done every 2 hours.

A review of the flow sheets for turning and repositioning revealed the patient was not positioned off their back and buttocks on all of the following dates:

On 07/02/13 through 07/19/13.

The medical record was silent to a position change every 2 hours, or was silent to the reason the position change was not done, as follows:

07/05/13 between 6:01 AM and 9:33 AM, the patient was on their right side, and left side between 07/05/13 at 10:18 PM and 07/06/13 at 1:18 AM,
On 07/08/13 between 4:34 PM and 7:08 PM,
On 07/09/13 between 12:00 PM and 4:00 PM,
On 07/13/13 between 1:55 PM and 5:33 PM,
On 07/14/13 between 8:00 AM and 2:00 PM (supine or sitting),
On 07/15/13 between 11:30 AM and 2:00 PM (sitting), and from 4:00 PM to 8:00 PM (left side), and
On 07/18/13 between 12:01 PM and 8:20 PM (sitting).

This medical record was verified with Staff B on 07/19/13 at 11:15 AM with Staff B.



3. Medical record review for Patient #9 was completed on 07/18/13. The medical record revealed a medication order for acetaminophen every six hours for a temperature greater than 100 degrees or pain and this medication was given on 06/09/13. The pain assessment did not show pain as an issue for this date. No temperature was noted before the medication was given. A temperature of 99.6 was noted for an outcome of the medication. Interview with Staff A completed on 07/19/13 at 8:45 AM revealed the temperature before the administration of acetaminophen was not documented in the medical record but a temperature of 100 was passed on in report to the oncoming shift.



4. The medical record review in its electronic form for Patient #8 was completed on 07/18/13. The record review revealed the patient was admitted to the facility on 07/05/13. The record review revealed a history and physical dictated on 07/06/13 that stated the patient was originally admitted to another local facility with a chief complaint of worsening mental status. The patient was then transferred from that facility to this facility. The history and physical stated the patient was admitted to this facility assessed for acute stroke status post occipital craniectomy, status post emergency shunting and ventriculostomy, revised tracheostomy, and revised percutaneous endoscopic gastrostomy-which had been infected.

On 07/18/13 at 2:00 P.M. the patient was observed to be awake, breathing via a tracheostomy, and bedfast.

The record review, (again in its electronic form), revealed the nurse practitioner note dated 07/17/13 at 10:22 P.M. that stated the patient had a wound to his/her occiput and to dress it with alginate and foam dressing three times a week and as needed.

The record review revealed a nursing progress note dated 07/17/13 at 6:29 P.M. that stated the wound care to the occiput was "performed by other discipline."

On 07/18/13 at 4:10 P.M. the patient was observed with Staff F and G. The patient's occiput was observed to be free of any dressing, yet boggy with a linear scar.

On Thursday, 07/18/13, at 4:10 P.M. Staff G and F were interviewed. Staff G stated he/she did not know the patient was to have a dressing there and it wasn't on her/his worksheet. Staff H explained Staff G wouldn't know a dressing would be there because it wouldn't be on the worksheet because the dressing was to be changed every Monday, Wednesday and Friday. He/she said the computer program required the dressing change to be entered twice for it to appear on the nurses' worksheet each day: first as Monday, Wednesday and Friday, and second as as needed. He/she said the nurse practitioner refuses to do this.

5. The medical record review, in its electronic form, for Patient #7 was completed on 07/18/13.

The record review revealed a history and physical dictated on 06/19/13. The review revealed the patient was diagnosed with, among other things, cellulitis of the left leg, gastrointestinal bleeding, diabetes, hypertension, and renal failure.

The record review revealed a physician's order dated 07/17/13 at 3:00 P.M. that directed the staff to start tube feeds via a nasogastric tube.

The record review revealed on 07/17/13 at 7:11 P.M. tube feed was infusing. The record review did not reveal where an x-ray was taken between placement of the nasogastric tube and initiation of the tube feeds.

On 07/17/13 at 11:00 A.M. in an interview Staff F confirmed there wasn't evidence an x-ray to verify proper placement of the nasogastric tube was performed prior to the initiation of the tube feed.

Review of the facility policy number h-pc-04-013 was completed on 07/19/13. The review revealed, "radiologic confirmation of tube placement to assure tube is properly positioned in the GI tract is completed and verified by a physician prior to initiating feedings."

The record review revealed a portable chest x-ray was completed on 07/18/13 at 5:25 P.M. which showed an endotracheal tube, nasogastric tube and pleural effusions, among other things.

On 07/17/13 at 11:00 A.M. in an interview Staff F stated if the nasogastric tube was not in the right place, then the above x-ray report would have said so.

This substantiates new allegation OH 00070481 and OH 00070482.

Based on medical record review, and staff interview, the facility failed to develop a nursing care plan for Patient #6 related to wound care and prevention. This affected one of five sampled patients who developed hospital acquired wounds. A total of 11 medical records were reviewed. The hospital census at the time of the survey was 62.

Findings include:

A medical record review was conducted for Patient #6 on 07/19/13 between 9:00 AM and 11:30 AM with Staff B. This patient was admitted on 03/13/13 with diagnoses of respiratory failure, pneumothorax, and status post trauma. On 04/26/13 at 6:02 PM, the medical record documented a nursing note by a licensed nurse which revealed a hospital acquired Stage III pressure ulcer on the coccyx.

This assessment/progress note stated the following positioning/pressure reduction devices: Boots, heel suspension bilateral lower extremities, alternating pressure mattress, reposition every two hours.

The nurse practitioner's assessment/progress dated 07/16/13 documented this open coccyx pressure area as Stage IV (worse than Stage (III). The 07/16/13 assessment by Staff H revealed the patient developed two new hospital acquired deep tissue injury pressure areas as follows:
On 07/01/13, on the right, which measured 1.6 cm long by 1.5 cm wide, without depth, and
on 07/15/13 on the left heel, which measured 3.6 cm long by 3.4 cm wide, and no depth.

The medical record documented a physician's order dated 05/15/13 at 2:10 PM which stated "Please position patient OFF of back; only position left or right".

A review of this patient's plan of care, with Staff B, on 07/19/13 at 11:00 AM revealed the care plan was silent to interventions for these pressure sores. At the time of the record review, Staff B verified the plan of care lacked interventions and goals for promoting healing and prevention of pressure sores.