HospitalInspections.org

Based on record reviews, observations, and interviews, the hospital failed to ensure the patient or his/her representative was informed of their rights.
Findings:

Review of the admission packet given to all patients upon admit, provided by S4AdminCoord revealed in the event of a complaint, you may contact the State of Louisiana Department of Health and Hospital. The State of Louisiana Department of Health and Hospital's telephone number was not listed.

Review of the hospital policy titled Patient Rights and Responsibilities presented as current policy revealed in part:
1. The list of Patient Rights and Responsibilities is provided to each patient at admission as part of the admission packet ....
2. The list is also posted prominently in the hospital where patients, families and their legal representatives can view it.

On 12/18/18 at 10:00 a.m. a tour of the first floor lobby revealed patient rights was not posted. Tour of the patient floor revealed there was no postings of patient rights in the nursing station, halls or in patient rooms.

On 12/18/18 at 11:20 in an interview with S4AdminCoord verified the admission packet failed to include the State of Louisiana Department of Health and Hospitals' contact telephone number.

On 12/18/18 at 11:30 a.m. an observation with S4AdminCoord revealed patient rights was not posted in the main lobby of the hospital. The hospital tour further revealed the patient floor had no postings of patient rights at the nursing station, halls or patient rooms.

Based on record reviews and interviews, the hospital failed to ensure the patient or his/her family/representative had the right to make informed decisions regarding his/her care. This deficient practice was evidenced by failing to have documented evidence of a discussion with a patient and/or his/her family/representative regarding a DNR order and the decision to have the DNR order written in accordance with hospital policy for 1 (#3) of 1 patient record reviewed with an order for DNR from a sample of 6 patients.

Findings:

Review of the policy titled "Do Not Resuscitate (DNR)", presented as a current policy by S2DON/QA, revealed the following, in part: Purpose: A. To establish a mechanism for reaching decisions about withholding resuscitation services from individuals. C. To clarify the roles of physicians, facility staff, family members, and the patient in the decision to withhold resuscitation services. Procedure: B. When a patient has decision making capacity, DNR decisions should be reached consensually by the patient and the attending physician. Discussions regarding resuscitation status should occur during a conversation about the plan of care and treatment. H. Once the DNR decision has been made, the order will be written by the attending physician. The order will be accompanied by documentation by the attending physician as to the patient's medical condition, the patient's concurrence, if obtained, and all other facts and considerations relevant to this decision.

Review of Patient #3's physician's orders revealed an order written by S3MD on 12/14/18 at 7:00 p.m. to "make pt. (patient) DNR."

Further review of Patient #3's medical record revealed no documented evidence of a discussion by S3MD with Patient #3 or any family members/representatives regarding the decision to make Patient #3 DNR status.

S5RN reviewed Patient #3's medical record on 12/16/18 at 2:00 p.m. and confirmed there was no documented evidence of a discussion by S3MD with Patient #3 or any family members/representatives regarding the decision to make Patient #3 DNR status. S5RN indicated Patient #3 was capable of communicating non-verbally by responding to "yes" or "no" questions with head movement when he was asked if the patient was capable of communicating her wishes.

In an interview on 12/18/18 at 10:30 a.m. with S2DON/QA, she confirmed there was no documented evidence, in Patient #3's medical record, of a discussion by S3MD with Patient #3/ family members/representatives regarding the decision to make the patient DNR status. She agreed there should have been supporting documentation, such as discussions with the patient/patient's family/representative, relative to the patient's wishes regarding resuscitation. S2DON/QA confirmed hospital policy required documentation of discussions between the physician and the patient/patient's family/representatives when making the decision to make a patient DNR status.

An attempt was made to schedule an interview with S3MD on 12/18/18, prior to survey team exit, but the physician indicated to S2DON/QA that his schedule would not permit time for an interview.

Based on record reviews and interviews the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:
1) failure of the RN to ensure the physician and the wound care nurse were notified/consulted in a timely manner when a change (development of a pressure wound) in a patient's skin (#2) occurred for 1 (#2) of 2 (#1,#2) sampled patients reviewed for wounds from a total patient sample of 6.;
2) failure of the RN to ensure the condition of patients' skin was accurately assessed, as per policy, for 1 (#2) of 3 (#1,#2,#3) sampled patients reviewed for skin assessments out of a total patient sample of 6; and
3) failure of the RN to ensure every 2 hour patient turning/repositioning and every 2 hour incontinence checks had been performed/documented for 3 ( #2, #3, #4) of 6 sampled patient records reviewed.

Findings:

1) Failure of the RN to ensure the physician and the wound care nurse were notified/consulted in a timely manner when a change (development of a pressure wound) in a patient's skin occurred.

Review of Patient #2's medical record revealed an admission date of 1/11/18 with admission diagnoses of Acute on Chronic Respiratory Failure with hypoxia and Acute Kidney Injury. Further review revealed the patient had been admitted to the long term acute hospital for respiratory management (ventilator weaning), IV therapy, nutritional support, and infectious disease management.

Review of Patient #2's pre-admission screen/referral documentation, dated 12/29/17, revealed the following, in part: Patient #2 had been hospitalized in an acute care hospital for 37 days (12/4/17-1/10/18) due to septic shock related to Cholangitis requiring ECRP to remove and replace a biliary stent. The patient had required multiple vasopressors for circulatory support and mechanical ventilation. The patient had distal ischemia (blackened toes) secondary to septic shock. The patient was a functional quadriplegic with no spontaneous movements in any limb. Staff was unable to elicit deep tendon reflexes and the patient was non-verbal. Patient #2's current function (at the time of admission to the LTAC) had been assessed as follows: Dependent for oral care, toileting, hygiene, and mobility (changing positions- rolling left/right, going from siting to lying, and lying to sitting on bed. The patient did not walk and did not use a wheelchair or scooter at that time.

Review of Patient #2's Braden Skin Risk Assessment, dated 1/11/18, revealed a score of 9 which indicated the patient was at high risk for skin breakdown ( a score of 9 or lower= High Risk for skin breakdown).

Review of Patient 2's initial nursing assessment, dated 1/11/18 at 8:25 p.m., revealed the following: bandages to buttocks bilaterally with no further description of the patient's skin.

Review of Patient #2's medical record revealed photos of the patient's skin in his sacral area. The initial photo, dated 1/12/18 (admit photo), revealed a pinkish colored area approximately the size of a dime that was intact.

Further review revealed a photo dated 2/19/18 of the patient's sacral/coccyx area. An area of breakdown which was 4.5 cm in width and 5.25 cm in length was noted. The wound had irregular borders and had areas of blackened tissue (Eschar) and bone visible in 2 places within the wound. Other areas within the surface of the wound were bright red and moist/wet in appearance.

Review of Patient #2's physician progress notes from 1/12/18 - 2/19/18 revealed no documented evidence that the patient's physician had been notified of Patient #2's sacral wound.

Review of Patient #2's daily nursing assessment notes from 1/12/18 - 2/19/18 revealed no documented evidence that the wound care nurse had been notified of Patient #2's sacral wound.

In an interview on 12/18/18 at 11:43 a.m. with S2DON/QA, she confirmed Patient #2 had developed a sacral pressure ulcer while being treated in the LTAC. She also confirmed, after review of Patient #2's medical record, that there were no skin assessments performed by the wound care nurse between 1/13/18 and 2/19/18 (when the wound care nurse 1st assessed the sacral pressure ulcer). S2DON/QA further confirmed she could find no documented evidence that the patient's nurses had notified the wound care nurse and the patient's physician of the change in the patient's skin (development of a pressure ulcer) prior to the assessment by the wound care nurse on 2/19/18. S2DON/QA reported she could not find Patient #2's initial skin assessment documentation. She reported the pinkish area noted on the 1/12/18 photo of Patient #2's sacral/coccyx area had been an old, healed wound that was intact on admit. S2DON/QA agreed Patient #2 had been at high risk for skin breakdown. S2DON/QA reported the nurses on the floor had been treating the wound with cream and the patient's mother had been applying honey to the wound. S2DON/QA explained the hospital had no formal process in place for ordering a wound consult, but the wound care nurse was there all the time and staff had her cell number so she was available at all times for consults. S2DON/QA further explained the hospital had no system in place for follow up to ensure the wound care nurse had been notified and was involved in patient wound care.

In an interview on 12/18/18 at 2:31 p.m. with S6WC (wound care nurse), she reported she had been wound care nurse at this facility for about a year. She further reported she had performed wound care at another area hospital and had been trained by a certified wound care practitioner. S6WC indicated she assessed all patients on admit but she would not perform a follow up assessment unless she was notified there had been a change in the patient's condition.. S6WC reported Patient #2's skin change information had not been communicated to her until the patient's wound had been very progressed. S6WC reported on admit Patient #2 had a healed area on his buttock and he had healed areas from medication IV burns that were closed. She reported the wound on his sacrum was unstageable by the time she was notified and had an opportunity to assess the wound. She reported the patient's nurses had never notified her about Patient #2's wound. She reported a CNA had asked her to go to the patient's room to assess the patient's sacral area.

2) Failure of the RN to ensure the condition of a patient's skin was accurately assessed, as per policy.

Review of the hospital policy titled "Wound Assessment" presented as current policy revealed in part:
Rationale:
1. Wound Assessments provide the foundation for an individualized plan of care
2. Data to inform CMS mandatory reporting Care Data Set elements as well as other quality indicators.
Procedure:
A. RN conducts a skin assessment on all patients upon admission, weekly, and with any significant changes.
B. The skin assessment includes identification of major wounds present on admission (documentation must include location, etiology and worst tissue type of each wound) ....
C. Wound Care nurse completes initial assessment within the Admission Reference Date (admission + 2 calendar days) ....
M. Assess for and document changes in skin/wound status, signs and symptoms of infection: pain, tenderness, redness, swelling, etc. Notify MD/Provider, patient/family, other healthcare staff as indicated.

Review of Patient #2's Daily Nursing Assessments revealed the following skin assessment entries:
1/22/18
7:00 a.m. shift: Skin intact: No; Describe: Dime sized Stage II to buttocks.
7:00 p.m. shift: Skin intact: No; Describe: Stage II to buttocks.
1/31/18
7:00 a.m. shift: Skin intact: No; Describe: Blank
7:00 p.m. shift: Skin intact: No; Describe: Blank
2/1/2018
7:00 a.m. shift: Skin intact: No; Describe: Blank
7:00 p.m. shift: Skin intact: No; Describe: Blank
2/3/18
7:00 a.m. shift: Skin intact: No; Describe: Buttocks.
7:00 p.m. shift: Skin intact: No; Describe: Buttocks.
2/4/18
7:00 a.m. shift: Skin intact: No; Describe: Buttocks.
7:00 p.m. shift: Skin intact: No; Describe: Buttocks.
2/6/18
7:00 a.m. shift: Skin intact: No; Describe: Blank.
7:00 p.m. shift: Skin intact: No; Describe: Left Buttock skin tear
2/9/18.
7:00 a.m. shift: Skin intact: No; Describe: Left Buttock excoriation
7:00 p.m. shift: Skin intact: No; Describe: Buttocks excoriation
2/10/18
7:00 a.m. shift: Skin intact: No; Describe: Buttock excoriation
7:00 p.m. shift: Skin intact: No; Describe: Right Buttocks, Right lateral chest, toe tips black.
2/12/18
7:00 a.m. shift: Skin intact: No; Describe: Left Buttock skin tear.
7:00 p.m. shift: Skin intact: No; Describe: Excoriation to Buttocks
2/13/18
7:00 a.m. shift: Skin intact: No; Describe: Sacrum
7:00 p.m. shift: Skin intact: No; Describe: Sacrum
2/14/18
7:00 a.m. shift: Skin intact: No; Describe: Buttocks.
7:00 p.m. shift: Skin intact: No; Describe: Buttocks.
2/15/18
7:00 a.m. shift: Skin intact: No; Describe: Buttocks.
7:00 p.m. shift: Skin intact: No; Describe: Sacral area.
2/16/18
7:00 a.m. shift: Skin intact: No; Describe: Left Buttocks excoriation.
7:00 p.m. shift: Skin intact: No; Describe: Excoriation to buttocks- left.
2/17/18
7:00 a.m. shift: Skin intact: No; Describe: Left Buttocks decubitus.
7:00 p.m. shift: Skin intact: Yes; Describe: Buttock
2/17/18
7:00 a.m. shift: Skin intact: No; Describe: Left Buttock decubitus.
7:00 p.m. shift: Skin intact: Yes; Describe: Buttock
2/19/18
7:00 a.m. shift: Skin intact: No; Describe: Sacrum
7:00 p.m. shift: Skin intact: No; Describe: Sacrum
2/20/18
7:00 a.m. shift: Skin intact: No; Describe: Sacral
7:00 p.m. shift: Skin intact: No; Describe: Sacral

Further review of the above referenced daily nursing notes revealed no evidence of further assessment of the areas of skin breakdown and failure to document the appearance of the skin breakdown, in descriptive terms, indicating size, color, and whether odor was present or not.

In an interview on 12/18/18 at 11:43 a.m. with S2DON/QA, she confirmed, after review of Patient #2's medical record, that the skin assessments documented every shift by the patient's primary nurses were incomplete. S2DON agreed the skin assessments should have been documented in descriptive terms and verified the skin assessments were not descriptive and at times were completely absent.

In an interview on 12/18/18 at 2:31 p.m. with S6WC, she reported on admit Patient #2 had a healed area on his buttock and he had healed areas from medication IV burns that were closed. She reported the wound on Patient #2's sacrum had progressed to the point of being classified as unstageable by the time she was notified and had an opportunity to assess the wound on 2/19/18.


Based on record reviews and interviews the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:
1) failure of the RN to ensure the physician and the wound care nurse were notified/consulted in a timely manner when a change (development of a pressure wound) in a patient's skin(#2) occurred for 1 (#2) of 2 (#1,#2) sampled patients reviewed for wounds from a total patient sample of 6.;
2) failure of the RN to ensure the condition of patients' skin was accurately assessed, as per policy, for 1 (#2) of 2 (#1,#2) sampled patients reviewed for skin assessments out of a total patient sample of 6; and
3) failure of the RN to ensure every 2 hour patient turning/repositioning and every 2 hour incontinence checks had been documented for of 6 sampled patient records reviewed.

Findings:

1) Failure of the RN to ensure the physician and the wound care nurse were notified/consulted in a timely manner when a change (development of a pressure wound) in a patient's skin occurred.

Review of Patient #2's medical record revealed an admission date of 1/11/18 with admission diagnoses of Acute on Chronic Respiratory Failure with hypoxia and Acute Kidney Injury. Further review revealed the patient had been admitted to the long term acute hospital for respiratory management (ventilator weaning), IV therapy, nutritional support, and infectious disease management.

Review of Patient #2's pre-admission screen/referral documentation, dated 12/29/17, revealed the following, in part: Patient #2 had been hospitalized in an acute care hospital for 37 days (12/4/17-1/10/18) due to septic shock related to Cholangitis requiring ECRP to remove and replace a biliary stent. The patient had required multiple vasopressors for circulatory support and mechanical ventilation. The patient had distal ischemia (blackened toes) secondary to septic shock. The patient was a functional quadriplegic with no spontaneous movements in any limb. Staff was unable to elicit deep tendon reflexes and the patient was non-verbal. Patient #2's current function (at the time of admission to the LTAC) had been assessed as follows: Dependent for oral care, toileting, hygiene, and mobility (changing positions- rolling left/right, going from siting to lying, and lying to sitting on bed. The patient did not walk and did not use a wheelchair or scooter at that time.

Review of Patient #2's Braden Skin Risk Assessment, dated 1/11/18, revealed a score of 9 which indicated the patient was at high risk for skin breakdown ( a score of 9 or lower= High Risk for skin breakdown).

Review of Patient 2's initial nursing assessment, dated 1/11/18 at 8:25 p.m., revealed the following: bandages to buttocks bilaterally with no further description of the patient's skin.
Review of Patient #2's medical record revealed photos of the patient's skin in his sacral area. The initial photo, dated 1/12/18 (admit photo), revealed a pinkish colored area approximately the size of a dime that was intact.

Further review revealed a photo dated 2/19/18 of the patient's sacral/coccyx area. Additional review revealed an area of breakdown which was 4.5 cm in width and 5.25 cm in length. The wound had irregular borders and had areas of blackened tissue (Eschar) and bone visible in 2 places within the wound. Other areas within the surface of the wound were bright red and moist/wet in appearance.

Review of Patient #2's physician progress notes from 1/12/18 - 2/19/18 revealed no documented evidence that the patient's physician had been notified of Patient #2's sacral wound.

Review of Patient #2's daily nursing assessment notes from 1/12/18 - 2/19/18 revealed no documented evidence that the wound care nurse had been notified of Patient #2's sacral wound.

In an interview on 12/18/18 at 11:43 a.m. with S2DON/QA, she confirmed Patient #2 had developed a sacral pressure ulcer while being treated in the LTAC. She also confirmed, after review of Patient #2's medical record, that there were no skin assessments performed by the wound care nurse between 1/13/18 and 2/19/18 (when the wound care nurse 1st assessed the sacral pressure ulcer). S2DON/QA further confirmed she could find no documented evidence that the patient's nurses had notified the wound care nurse and the patient's physician of the change in the patient's skin (development of a pressure ulcer) prior to the assessment by the wound care nurse on 2/19/18. S2DON/QA reported she could not find Patient #2's initial skin assessment documentation. She reported the pinkish area noted on the 1/12/18 photo of Patient #2's sacral/coccyx area had been an old, healed wound that was intact on admit. S2DON/QA agreed Patient #2 had been at high risk for skin breakdown. S2DON/QA reported the nurses on the floor had been treating the wound with cream and the patient's mother had been applying honey to the wound. S2DON/QA explained the hospital had no formal process in place for ordering a wound consult, but the wound care nurse was there all the time and staff had her cell number so she was available at all times for consults. S2DON/QA further explained the hospital had no system in place for follow up to ensure the wound care nurse had been notified and was involved in patient wound care.

In an interview on 12/18/18 at 2:31 p.m. with S6WC (wound care nurse), she reported she had been wound care nurse at this facility for about a year. She further reported she had performed wound care at another area hospital and had been trained by a certified wound care practitioner. S6WC indicated she assessed all patients on admit but she would not perform a follow up assessment unless she was notified there had been a change in the patient's condition.. S6WC reported Patient #2's skin change information had not been communicated to her until the patient's wound had been very progressed. S6WC reported on admit Patient #2 had a healed area on his buttock and he had healed areas from medication IV burns that were closed. She reported the wound on his sacrum was unstageable by the time she was notified and had an opportunity to assess the wound. She reported the patient's nurses had never notified her about Patient #2's wound. She reported a CNA had asked her to go to the patient's room to see the patient's sacral area.

2) Failure of the RN to ensure the condition of patients' skin was accurately assessed, as per policy.

Review of the Wound Assessment policy presented as current policy revealed in part:
Rationale:
1. Wound Assessments provide the foundation for an individualized plan of care
2. Data to inform CMS mandatory reporting Care Data Set elements as well as other quality indicators.
Procedure:
A. RN conducts a skin assessment on all patients upon admission, weekly, and with any significant changes.
B. The skin assessment includes identification of major wounds present on admission (documentation must include location, etiology and worst tissue type of each wound) ....
C. Wound Care nurse completes initial assessment within the Admission Reference Date (admission + 2 calendar days) ....
M. Assess for and document changes in skin/wound status, signs and symptoms of infection: pain, tenderness, redness, swelling, etc. Notify MD/Provider, patient/family, other healthcare staff as indicated.

Review of Patient #2's Daily Nursing Assessments revealed the following skin assessment entries:
1/22/18
7:00 a.m. shift: Skin intact: No; Describe: Dime sized Stage II to buttocks.
7:00 p.m. shift: Skin intact: No; Describe: Stage II to buttocks.
1/31/18
7:00 a.m. shift: Skin intact: No; Describe: Blank
7:00 p.m. shift: Skin intact: No; Describe: Blank
2/1/2018
7:00 a.m. shift: Skin intact: No; Describe: Blank
7:00 p.m. shift: Skin intact: No; Describe: Blank
2/3/18
7:00 a.m. shift: Skin intact: No; Describe: Buttocks.
7:00 p.m. shift: Skin intact: No; Describe: Buttocks.
2/4/18
7:00 a.m. shift: Skin intact: No; Describe: Buttocks.
7:00 p.m. shift: Skin intact: No; Describe: Buttocks.
2/6/18
7:00 a.m. shift: Skin intact: No; Describe: Blank.
7:00 p.m. shift: Skin intact: No; Describe: Left Buttock skin tear
2/9/18.
7:00 a.m. shift: Skin intact: No; Describe: Left Buttock excoriation
7:00 p.m. shift: Skin intact: No; Describe: Buttocks excoriation
2/10/18
7:00 a.m. shift: Skin intact: No; Describe: Buttock excoriation
7:00 p.m. shift: Skin intact: No; Describe: Right Buttocks, Right lateral chest, toe tips black.
2/12/18
7:00 a.m. shift: Skin intact: No; Describe: Left Buttock skin tear.
7:00 p.m. shift: Skin intact: No; Describe: Excoriation to Buttocks
2/13/18
7:00 a.m. shift: Skin intact: No; Describe: Sacrum
7:00 p.m. shift: Skin intact: No; Describe: Sacrum
2/14/18
7:00 a.m. shift: Skin intact: No; Describe: Buttocks.
7:00 p.m. shift: Skin intact: No; Describe: Buttocks.
2/15/18
7:00 a.m. shift: Skin intact: No; Describe: Buttocks.
7:00 p.m. shift: Skin intact: No; Describe: Sacral area.
2/16/18
7:00 a.m. shift: Skin intact: No; Describe: Left Buttocks excoriation.
7:00 p.m. shift: Skin intact: No; Describe: Excoriation to buttocks- left.
2/17/18
7:00 a.m. shift: Skin intact: No; Describe: Left Buttocks decubitus.
7:00 p.m. shift: Skin intact: Yes; Describe: Buttock
2/17/18
7:00 a.m. shift: Skin intact: No; Describe: Left Buttock decubitus.
7:00 p.m. shift: Skin intact: Yes; Describe: Buttock
2/19/18
7:00 a.m. shift: Skin intact: No; Describe: Sacrum
7:00 p.m. shift: Skin intact: No; Describe: Sacrum
2/20/18
7:00 a.m. shift: Skin intact: No; Describe: Sacral
7:00 p.m. shift: Skin intact: No; Describe: Sacral

Further review of the above referenced daily nursing notes revealed no evidence of further assessment of the areas of skin breakdown and failure to document the appearance of the skin breakdown, in descriptive terms, indicating size, color, and whether odor was present or not.

In an interview on 12/18/18 at 11:43 a.m. with S2DON/QA, she confirmed, after review of Patient #2's medical record, that the skin assessments documented every shift by the patient's primary nurses were incomplete. S2DON agreed the skin assessments should have been documented in descriptive terms and verified the skin assessments were not descriptive and at times were completely absent.

In an interview on 12/18/18 at 2:31 p.m. with S6WC, she reported on admit Patient #2 had a healed area on his buttock and he had healed areas from medication IV burns that were closed. She reported the wound on Patient #2's sacrum had been unstageable by the time she was notified and had an opportunity to assess the wound on 2/19/18.

3) Failure of the RN to ensure every 2 hour patient turning/repositioning and every 2 hour incontinence checks had been performed/documented.

Patient #2
Review of Patient #2's medical record revealed an admission date of 1/11/18 and a discharge date of 11/23/18. The patient was a functional quadriplegic with no spontaneous movements in any limb with no deep tendon reflexes. Patient #2 was dependent for mobility (changing positions- rolling left/right, going from siting to lying, and lying to sitting on bed and total care for hygiene/pericare with orders for turning every 2 hours.

Review of Patient #2's medical record revealed on 8/1/18 on the 7:00 p.m. shift, incontinence care had only been documented once at 10:00 p.m.

Further review revealed on 8/6/18 incontinence care had been left blank for both the 7:00 a.m. shift and the 7:00 p.m. shift. Additional review revealed turning had only been documented 3 times on the 7:00 p.m. shift at 8:00 p.m., 12:00 a.m. and 4:00 a.m.

Patient #3
Review of Patient #3's medical record revealed an admission date of 11/21/18 with an initial diagnosis of vent dependent. Further review revealed the patient was dependent/total care for hygiene and pericare and had orders for turn every 2 hours. Patient #3 was a current patient.

Review of Patient #3's medical record revealed on 12/11/18 on the 7:00 a.m. shift turning had not been documented for the entire shift. Further review revealed incontinence care had not been documented for the entire 7:00 p.m. shift.

Additional review of Patient #3's medical record revealed on 12/13/18 on the 7:00 a.m. shift turning had not been documented for the entire shift. Further review revealed incontinence care had not been documented for the entire 7:00 p.m. shift.

In an interview on 12/17/18 at 2:30 p.m with S5RN, he confirmed the above referenced incontinence checks and patient turns had not been documented. S5RN reported he could not verify whether the checks had been done or not based upon the lack of documentation.

In an interview on 12/18/18 at 1:37 p.m. with S8CNA, he reported it is mandatory that they turn every patient, regardless of their incontinent situation. He said they turn the patients every 2 hours and he said it is important to follow that policy to prevent skin breakdown. S8CNA indicated it was hospital policy to keep everyone dry. He reported the CNAs notified the nurses when patients had been turned and changed and the nurses charted the peri-care and incontinent care.

In an interview on 12/18/18 at 2:50 p.m. with S2DON/QA, she reported turning patients every 2 hours and performing incontinent checks at least every 2 hours were considered a standard of care for patients who had impaired mobility and/or were incontinent. She confirmed it was the hospital's expectation that the staff would adhere to those standards of care regarding turning and incontinent checks. S2DON/QA verified the performance of the patient turns and incontinence checks should have been documented in the patients' medical records.

Patient #4
Review of Patient #4's medical record revealed an admission date of 10/31/18 with a diagnosis of acute and chronic respiratory failure with a tracheostomy. Further review revealed the patient was dependent/total care for hygiene and pericare and had orders for turn every 2 hours. Patient #4 was a current patient.

Review of Patient #4's medical record revealed on 11/01/18 on the 7:00 a.m. shift turning had not been documented for the entire shift. Further review revealed incontinence care had not been documented for the 7:00 a.m. and 7:00 p.m. shifts.

Additional review of Patient #4's medical record revealed on 12/16/18 on the 7:00 a.m. shift turning had not been documented for the entire shift. Further review revealed incontinence care had not been documented for the entire 7:00 p.m. shift.




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