HospitalInspections.org

Intakes: TN00042176


Based on medical record review and interview, the facility failed to ensure nursing staff evaluated and assessed patient care needs for 1 of 3 (Patient #2) sampled patients.


The findings included:

1. Medical record review for Patient #2 revealed an admission date of 7/20/17 with a diagnosis of Thoracic Myelopathy/Paraparesis, and Spinal Cord Compression.

Review of the telephone admission orders dated 7/20/17 at 8:20 PM, revealed Order #18 Braces: TLSO (thoracolumbosacral) orthosis brace. The scheduled frequency for wearing the brace (Wear at all times or Wear when up) was not documented on the orders. The physician signed the orders on 7/21/17 at 9:00 AM.

Review of Nursing Shift Assessment documentation dated 7/20/17 through 8/8/17 revealed there was no documentation the patient was wearing the TLSO brace while out of bed.

The Physical Therapy note dated 7/23/17 revealed, "...Pt [patient] is seated in recliner chair on arrival without TLSO. Nurse at bedside issuing meds..."

The Nursing Care Plan dated 8/2/17 and 8/9/17 revealed: Precautions/Interventions: TLSO. The check block for Remove for Bathing or the check block for Don (put on) before sitting/standing was not marked. The Care Plan dated 8/10/17 did not have documentation marked related to the TLSO brace.

Review of the Treatment Administration Record revealed, "... TLSO start 7/20..." There was no documentation on 7/24 and 7/23, 7/27 through 7/31/17, 8/1/17 and 8/3/17 related to the TLSO brace.

The 8/3/17 physician progress notes revealed c/o [complaint of] increase pain with TLSO may need to switch from turtle shell type to softer with back support.

The 8/4/17 physician progress notes revealed Patient #2 was wearing a clam shell brace without complaint.

2. In a telephone interview on 8/29/17 at 3:00 PM, When asked about the TLSO brace Patient #2's daughter stated, "...I saw her in her wheelchair without her brace for extended periods of time...I came in when she was sitting up on the side of the bed. I told the nurse she needed her brace on and the nurse said she didn't know that...don't know the nurses name and not sure of the date...I came in once and the brace was on upside down..."

In an interview on 9/6/17 at 9:43 AM, the Chief Clinical Officer stated, "...I expect the nurse to document collar or brace on when patient is up ..."

In an interview on 9/6/17 at 12:29 PM, the Director of Physical Therapy stated, "...the standard of practice for a TLSO brace is for the patient to wear the brace whenever they are up. It's purpose is to avoid turning and twisting by the patient to prevent pain while up..."

In a telephone interview on 9/27/17 at 9:52 AM, the Chief Clinical Officer stated. "...the expectation should be for the frequency to be addressed on the orders by the physician ..."