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Based on a review of clinical records, staff interviews, and policy review for two of two patients reviewed for oxygen (O2) orders, (Patients #12 and #17), the hospital failed to ensure that physician orders for oxygen therapy included titration parameters. The findings include:

a. Patient #12's diagnoses included COPD. The annual assessment dated 9/7/16 identified that the Patient had shortness of breath (SOB) and treatments included O2 therapy. Physician orders renewed on 12/27/16 directed O2 at 2-4 liters/minute as needed for SOB or O2 saturations <90%. The order failed to reflect parameters for the titration of the Oxygen. Respiratory Therapy progress notes by Nursing and/or the Respiratory Therapist and/or vital sign records dated 1/17/16 through 1/23/17 identified that although O2 was administered at 2 or 3 liters/minute on a 24 hour basis, the O2 saturation level and/or respiratory rate were not assessed at least once per shift to ascertain the Patient's O2 level requirement.

Interview with Nurse Supervisor #1 on 1/24/17 at 1:00 PM indicated the physician's orders failed to direct how frequently oxygen saturation levels should be conducted and/or the hospital failed to have a protocol that directed the titration of oxygen with corresponding oxygen saturation levels. Further interview with Nurse Supervisor #1 identified oxygen saturation levels should have been obtained at least once a shift and with a change in condition.

b. Review of the clinical record identified Patient #17 was admitted to the facility on 9/25/15 with diagnoses that included chronic obstructive pulmonary disease (COPD) and peripheral vascular disease. A physician's order dated 11/29/16 directed oxygen via nasal cannula at 2-4 liters as needed for shortness of breath or oxygen saturations that were < 90%. The order failed to reflect parameters for the titration of the Oxygen.

Review of the Oxygen Administration Procedure directed that except in an emergency, the PCP or on-call physician must order oxygen, including rate, method of delivery and equipment.

29049

Based on a review of clinical records, staff interviews, and policy review for two of three patients reviewed for nursing assessment (Patients #12 and #17), the hospital failed to ensure that nursing staff assessed oxygen (O2) saturation levels to determine oxygen requirements and/or contacted the physician for clarification of incomplete O2 orders prior to implementing care. The findings include:

a. Patient #12's diagnoses included COPD. The annual assessment dated 9/7/16 identified that the Patient had shortness of breath (SOB) and treatments included O2 therapy. Physician orders renewed on 12/27/16 directed O2 at 2-4 liters/minute as needed for SOB or O2 saturations <90%. The order failed to reflect parameters for the titration of the Oxygen. Respiratory Therapy progress notes by Nursing and/or the Respiratory Therapist and/or vital sign records dated 1/17/16 through 1/23/17 identified that although O2 was administered at 2 or 3 liters/minute on a 24 hour basis, the O2 saturation level and/or respiratory rate were not assessed at least once per shift to ascertain the Patient's O2 level requirement.

Interview with Nurse Supervisor #1 on 1/24/17 at 1:00 PM indicated the physician's orders failed to direct how frequently oxygen saturation levels should be conducted and/or the hospital failed to have a protocol that directed the titration of oxygen with corresponding oxygen saturation levels. Further interview with Nurse Supervisor #1 identified oxygen saturation levels should have been obtained at least once a shift and with a change in condition.

b. Review of the clinical record identified Patient #17 was admitted to the facility on 9/25/15 with diagnoses that included chronic obstructive pulmonary disease (COPD) and peripheral vascular disease. A physician's order dated 11/29/16 directed oxygen via nasal cannula at 2-4 liters as needed for shortness of breath or oxygen saturations that were < 90%. The order failed to reflect parameters for the titration of the Oxygen.

Review of the Oxygen Administration Procedure directed that except in an emergency, the PCP or on-call physician must order oxygen, including rate, method of delivery and equipment.

1. Based on a review of clinical records, interviews and a review of policies, for three of three Patients' reviewed for implementation of the nursing care plan (Patient #2, #11, and #12), the facility failed to conduct skin assessments and/or complete dressing changes in accordance with the plan of care. The findings include:

a. Review of the clinical record identified Patient #2 was admitted to the facility on 2/16/16 with diagnosis that included cerebral vascular accident, chronic obstructive pulmonary disease (COPD) and anemia. Review of the nursing care plan dated 12/14/16 identified Patient #2 was at risk for a pressure ulcer with interventions that included skin assessments every week and as needed, pressure relieving device to the bed, a gel cushion to the chair, off load heels while in bed and reposition the patient every two hours. Review of the treatment kardex dated 12/14/16 to 1/24/17 identified that although weekly skin assessments were conducted on 12/14/16, 12/21/17, 12/28/16, 1/4/17 and 1/18/17 they failed to be conducted on 1/11/17. Interview with Nursing Supervisor # 1 on 1/24/16 at 11:00 AM indicated weekly skin assessments should have been conducted in accordance with the plan of care.

b. Patient #11's diagnoses included stage IV left heel ulcer and left hip replacement. The quarterly assessment dated 1/9/17 identified that the patient had pressure reduction devices on the bed and chair and did not have pressure ulcers. The plan of care initiated on 1/2/17 noted to assess skin every week, weekly assessment/measurement/documentation, and wound care as ordered. Physician orders dated 1/3/17 directed to continue protective dressing to left heel. Physician orders renewed on 1/5/17 directed Biotin dressing to left hip every 3 days. Observation of Patient #11 on 1/24/17 at 9:33 AM indicated a dry gauze dressing to the left heel dated 1/23/17 and a Biotin dressing to the left hip dated 1/17/17. Review of the patient's treatment record and interview with RN #3 on 1/24/17 at 10:01 AM identified that the left hip dressing was incorrectly documented as being changed on 1/20/17, should have been changed again on 1/23/17 and was not. RN #3 changed Patient #11's left hip dressing on 1/24/17.

c. Patient #11's diagnoses included left heel ulcer. The skin breakdown risk assessments dated 8/19/16 and 1/18/17 identified that the patient was at medium risk for skin breakdown and required weekly skin monitoring. The weekly tracking forms identified that the patient had two (2) ulcers on the left heel and that assessments of both areas were performed on 12/19/16. The record lacked evidence that the heel wounds were assessed the week of 12/26/16, however were assessed on 1/2/17. Record review and interview with RN #3 on 1/24/17 at 10:01 AM indicated that wounds were assessed every Monday and the patient's left heel ulcers should have been assessed on 12/26/16.

d. Patient #11 had a physician's order dated 1/5/17 directed Clotrimazole cream (antifungal) apply to groin three times/day. Observation and interview with RN #3 on 1/24/17 at 9:33 AM identified that Patient #11 had redness to both groins and RN #3 applied the cream as ordered. Review of the patient's record on 1/24/17 at 10:01 AM lacked documentation for consistent weekly groin skin assessments. Interview with RN #3 on 1/24/17 at 10:01 AM noted that rashes were not routinely monitored and the physician would just be informed of the need for continued treatment.

The facility policy for skin ulcers identified that if a skin lesion was found, e.g. rash, document the wound type size, location in a nursing note. If a skin ulcer is found, document on the skin ulcer weekly monitoring form.

e. Patient #12's diagnoses included venous stasis dermatitis to bilateral lower legs. The skin breakdown risk assessment dated 8/1/16 indicated that the patient was at low risk for skin breakdown and required monthly skin checks. Record review and interview with RN #3 on 1/24/17 at 10:01 identified that the monthly skin check was not completed. Interview with RN #3 at 12:28 PM indicated that an assessment of the patient's skin was not performed unless the patient had a skin problem.

The facility policy for skin ulcers identified that the frequency of the skin check is determined by the patient's risk for skin breakdown level. Skin checks should be documented on the patient ' s treatment kardex according to the frequency identified.



29049


2. Based on a review of clinical records, interviews and a review of policies for three of three patient's reviewed for nursing care plans (Patient #1, #17 and #12), the facility failed to assess the patient's respiratory status following a respiratory treatment in accordance with the plan of care and/or facility policy/practice. The findings include:

a. Review of the clinical record identified Patient #1 was admitted to the facility on 2/24/16 with diagnoses that included chronic obstructive pulmonary disease (COPD), hypertension and atrial fibrillation. Review of physician orders dated 12/20/16 directed Albuterol Sulfate 0.083% one ampule four times per day and Budesonide 0.5 milligrams (mg) two vials twice a day. Review of the nursing plan of care dated 12/29/16 identified COPD as a problem with interventions that included the assessment of lungs sounds, administer oxygen as ordered, encourage frequent rest periods between activities, administer medications as ordered and monitor their side effects, monitor for cyanosis, change in mentation and provide reassurance by staying with patient during respiratory distress. Review of the clinical record dated 1/19/17-1/21/17 identified rhonchi as an adventitious breath sound prior to three respiratory treatments. The clinical record failed to reflect that lung sounds were auscultated after each treatment was administered to assess the medications effectiveness.

b. Review of the clinical record identified Patient #17 was admitted to the facility on 9/25/15 with diagnoses that included COPD and peripheral vascular disease. Review of a physician's order dated 11/29/16 directed Albuterol 0.083% one ampule every six hours and every four hours as needed for shortness of breath or wheezing. Review of the nursing plan of care dated 1/11/17 identified COPD as a problem with interventions that included the assessment of lung sounds, administer oxygen as ordered, encourage frequent rest periods between activities, administer medications as ordered and monitor their side effects, monitor for cyanosis, change in mentation and provide reassurance by staying with patient during respiratory distress. Review of the clinical record dated 1/22/17-1/23/17 identified rhonchi as an adventitious breath sound prior to five treatments. The clinical record failed to reflect that lung sounds were auscultated after each treatment was administered to assess the medications effectiveness. Interview with Nurse Supervisor #1 on 1/24/17 at 2:00 PM identified that both nursing and respiratory therapists administered nebulizer treatments and it was the expectation that lung sounds would be auscultated prior to and subsequent to each respiratory treatment and with a change in condition as directed in the plan of care.

c. Patient #12's diagnoses included COPD and congestive heart failure. The annual assessment dated 9/7/16 identified that the patient had shortness of breath with exertion and received O2 therapy. The plan of care dated 9/7/16 included interventions to assess lung sounds every shift. Review of Patient #12's nursing and respiratory progress notes from 1/17/16 through 1/24/17 with RN #3 on 1/24/17 at 11:01 AM identified that the record lacked assessments of the patient's lung sounds on the night shift. Interview with the Lead Respiratory Therapist (RT) on 1/24/17 at 1:30 PM noted that RTs did not work on the night shift and therefore, nursing staff provided the respiratory care.

The facility nurse job description identified, in part, a duty to implement health care plans.

The facility policy entitled Care Planning directed in part that a registered nurse would assess the needs of the patient on admission and develop a comprehensive plan of care based on the needs of the patient. The delegation of nursing care interventions by the registered nurse would be conducted according to skill, training and the complexity of the patient care needs. The policy further directed that the registered nurse would evaluate the effectiveness of the plan of care and revise the plan as necessary. The registered nurse would be responsible to assess and plan the patient's need for nursing care in all setting where nursing care was provided.

Based on observation, review of hospital policies and procedures, and interviews, the hospital failed to ensure that nutritional supplement puddings distributed from the kitchen to the patient units had not expired beyond the use by date. The findings include:


Tour of the nourishment kitchen on the Dementia Care Unit on 01/24/17 at 9:10 AM identified that three four packs and one two pack of single serve containers of nutritional supplement puddings had expired, with a use by date of 01/01/2017. Tour of the kitchen supply storage area with the Director of Food and Nutrition Services on 01/24/17 at 12:30 PM identified that one full case of nutritional supplement pudding containing forty eight, four ounce containers of nutritional supplement pudding had expired with use by dates of 12/2016. Additionally, five other full cases of supplement had expired with a use by date of 01/2017. There were no appropriately dated cases of pudding nutritional supplement visible on the shelves.
Interview with the Director of Food and Nutrition Services on 01/24/17 at 12:40 PM identified that he/she would discard and replace the expired supplements.
Subsequent to surveyor inquiry, the Director of Food and Nutrition Services identified that 31 cases of unexpired nutritional supplement pudding were currently on hand in inventory and available for use. The expired supplement was sequestered.
Review of the job description for the Supervisor of Food Services identified that he/she receives general direction from a Director of Food Services or other employee of higher grade and provides supervision to the food service staff. Duties include checking food and food service areas to ensure compliance with health regulations.

29049

Based on a review of clinical records, staff interviews, and policy review for three of three patients' reviewed for respiratory assessments (Patient #1, #17 and #12), the hospital failed to assess the effects of respiratory treatments in accordance with the hospital policy. The findings included:

a. Review of the clinical record identified Patient #1 was admitted to the facility on 2/24/16 with diagnoses that included chronic obstructive pulmonary disease, hypertension and atrial fibrillation. Physician orders dated 12/20/16 directed Albuterol Sulfate 0.083% solution, one ampule, four times per day and Budesonide 0.5 milligrams two vials twice a day. Review of respiratory progress notes dated 1/19/17 and 1/20/17 failed to identify on three (3) occasions that a heart or respiratory rate was taken prior to the respiratory treatments and failed to identify on eight (8) occasions that the heart or respiratory rate was taken subsequent to the treatment.

b. Review of the clinical record identified Patient #17 was admitted to the facility on 9/25/15 with diagnoses that included chronic obstructive pulmonary disease and peripheral vascular disease. A physician's order dated 11/29/16 directed Albuterol 0.083% solution, one ampule, every six hours in addition to every four hours as needed for shortness of breath or wheezing. Review of respiratory progress notes dated 1/22/17 and 1/23/17 failed to identify on five (5) occasions that a heart rate or respiratory rate was taken prior to the respiratory treatments and failed to identify on thirteen (13) occasions that the patient's heartrate, respiratory rate and/or O2 saturation was taken subsequent to the treatment. Interview with Nurse Supervisor #1 on 1/24/17 at 2:30 PM indicated nursing and/or respiratory therapy should have taken vital signs per the hospital policy and did not.

c. Patient #12's diagnoses included COPD and congestive heart failure. The annual assessment dated 9/7/16 identified that the patient had shortness of breath with exertion and received O2 therapy. Physician orders dated 12/27/16 through 2/25/17 directed Albuterol 0.083% one ampule every four hours for wheezing or shortness of breath. Respiratory therapy progress notes dated 1/22/17 to 1/24/17 at 7:15 AM identified that the patient received six (6) respiratory treatments by the respiratory therapist (RT), rhonchi was identified (via auscultation) prior to four of the treatments and a reassessment of lung sounds was not documented after three (3) of these treatments.

The treatments dated 1/22/17 at 12:02 PM and 1/23/17 at 11:57 AM lacked a pre- treatment assessment of the patient's heart rate (HR), respiratory rate (RR) and O2 saturation level (all left blank). Six of the respiratory treatments lacked documentation for post O2 saturation level assessments and five lacked post treatment HR and RR assessments. Interview with the Lead RT on 1/24/17 at 10:48 AM indicated that if lungs were not clear prior to a patient's respiratory treatment, the lungs should be reassessed after the treatment. He/she further indicated that he/she was not aware of the need to reassess the patients HR and RR following a respiratory treatment.

The facility policy entitled small volume nebulizer (SVN) directed to auscultate breath sounds prior to treatment and obtain apical HR, RR and pulse-ox saturation as indicated or necessary. The policy further directed to re-assess patient's apical HR and RR at the conclusion of therapy. The policy lacked direction for the performance of a post treatment lung reassessment.