HospitalInspections.org

Based on review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure the patient representative's right to make informed decisions, to include involvement in care planning and treatment, regarding the patient's care for one of 10 medical records (MR1).

Findings include:

Review of the "Select Specialty Hospital Patient's Rights" revealed, "2. Informed Consent. The attending physician shall inform you of your medical condition. You shall be afforded the opportunity to participate in the planning of your medical treatment..."

1. Review of C41-N "Change in Patient Condition" policy revised October 2, 2007, failed to reveal any information regarding contacting the patient or patient's family/representative when the patient had a change in condition.

2. Review of MR1 revealed the patient to be on a ventilator, with current inpatient history of two cardiac/respiratory arrest events, and requiring intravenous medication to maintain a viable blood pressure. The medical record documented the development of an "unstageable" pressure ulcer, measuring 15x12 centimeters. There was no documentation that the patient's spouse was notified regarding the development and/or treatment of this ulcer.

3. Interview on March 3, 2010, at 9:55 AM with EMP5 confirmed the lack of documentation that the patient's spouse was notified regarding the development of an "unstageable" pressure ulcer. "If they (patients) have a wound, we don't usually tell the family."

Based on review of facility documentation and medical records (MR), and staff interview (EMP), it was determined that all information necessary to monitor the patient's condition was not documented for three of three medical records (MR1, MR2, and MR3).

Findings include:

Review of facility policy number S02-N, "Skin Care, Assessment And Maintenance Of" revised November 14, 2007, revealed, "Policy: ... Any impairment in skin integrity shall be documented in the Nursing Flowsheet [sic.] and Wound Documentation Form. ... Procedure: I. Assessment ... B. Assess skin upon admission and every 12 hours."

1. Review of 12 hour Wound Documentation Forms and progress notes for MR1, MR2 and MR3 revealed incomplete documentation for identified impairments in skin integrity to include wound assessment and progression, padding and daily bandage changes, skin treatments, foot and calf washes, and buttocks care.

2. On March 3, 2010, at approximately 2:00 PM, EMP7 confirmed incomplete Wound Documentation Form documentation for MR2 and MR3. "It appears some (12 hour assessments) are missing."