HospitalInspections.org

Based on review of one (1) of two (2) medical records (Medical Record #8), staff interview, and review of other pertinent documentation, it was determined that the facility failed to ensure that physicians document in accordance with Medical Staff Bylaws and Regulations.

Findings include:

Reference: The facility Medical Staff and Regulations of the Medical Staff Bylaws states, "...
Conduct of Care ...
17. The minimal content of a history and physician examination shall include the following: ... i) Physical examination ...
Medical Records
1. The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient ...
3. ... Notes should be written daily ... Patients' condition or changes in the condition, and response to treatment should be noted.

1. The medical record of Patient #8, who was admitted to the facility on the afternoon of 5/13/20, revealed the following:

a. The House Physician Event Notes, dated 5/13/20 at 18:24 and signed by the practitioner on 5/14/20 at 01:44, stated the patient complained of pain in the right forearm and asked for ice chips. He/she indicated that the right forearm was wrapped with an ace bandage and that the patient did not know what happened. Nursing to obtain initial admitting orders from primary physician.

(i) There was no evidence that the patient's right arm was assessed/examined.

b. On 5/13/20 at 19:26, the Internal Medicine Consultant Notes does not reference the patient's right forearm in his/her physical examination of the patient.

(i) There was no evidence that the patient's right arm was assessed/examined.

c. The Pulmonologist Consultant Notes dated 5/14/20 at 12:12 indicated in his/her physical examination of the patient "... Ext (extremities): RUE [right upper extremity] + swelling, ecchymosis;" and under Impression/Assessment ... "F/U [follow up] UE [upper extremities] doppler results."

d. On 5/14/20 at 18:47, the primary physician History and Physical does not reference the patient's right forearm in his/her physical examination of the patient.

(i) There was no evidence that the patient's right arm was assessed/examined.

e. On 5/15/20 at 08:51 the House Physician Event Notes indicated that the patient was assessed for desaturation. He/she indicated that there was "marked swelling of the right upper forearm, extremely tender. no color change in hand. feeble pulse. Compartment Syndrome?? Will call PMD [primary medical doctor]. Needs imaging study and vascular assessment ... Spoke to daughter and PMD. Transferring tp [sic] __ [initial of hospital] ER for CT [computerized tomography]."

f. There was no evidence in the physician's order of any interventions to include diagnostic study for the patient's right upper extremity with the exception of pain medication, on 5/14/20.

2. The above was confirmed by Staff #3 on 6/25/20 at 2:00 PM.

A. Based on review of one (1) of two (2) medical records (Medical Record #8) and staff interview, it was determined that the facility failed to ensure that the registered nurse communicates abnormal patient findings to the physician.

Findings include:

1. On 6/25/20, the medical record of Patient #8 revealed the following:

a. Patient #8 was admitted to the facility on the afternoon of 5/13/20.

b. The nursing admitting Patient Take Over Narrative signed at 18:57 on 5/13/20, stated at 1600 that the patient's right arm was bruised and swollen, and that the patient did not recall how this occurred.

(i) There was no evidence that the above findings were communicated to the physician.

c. The nursing Patient Take Over Narrative for the day shift on 5/14/20 at 0800 indicated the right upper extremity was "painful, edematous. Awaiting US [ultrasound) to rule out DVT (deep vein thrombosis). No intravenous access at this time ..."

(i) Upon review of the physician orders, there was no evidence that an ultrasound was ordered for the patient.

(ii) There was no evidence that this information was communicated to the physician.

d. The nursing Patient Take Over Narrative for the evening/night shift on 5/14/20 at 20:00 stated, "Pt [patient] R [right] arm noted to be very swollen and warm to touch ..."

(i) There was no evidence that the physician was notified of the change to the right arm.

e. The above was confirmed by Staff #3 on 6/25/20 at 2:00 PM.


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B. Based on review of two (2) of three (3) medical records (Medical Records #1, #7), review of facility documents and staff interview, it was determined that the facility failed to ensure that the staff document changes in skin/wound care assessments.

Findings include:

Reference #1: Facility policy "SKIN CARE, ASSESSMENT AND MAINTENANCE OF" states, " ...POLICY: ...Skin assessment shall be performed at least every 12 hours. All bedfast patients shall be turned every 2 hours ...GENERAL STATEMENTS: ...4. The effectiveness of all wound care treatment will be reassessed on a weekly basis ...This reassessment will be performed by a designated nurse and may include other members of the treatment team as appropriate. The physician will be contacted to discuss any changes in the treatment plan. 5. ...The status of the wounds will be compared to wound status documentation from previous wound assessment. ...6. Nurses will implement preventative measures for wound care protocols. ..."

Reference #2: Facility email document "Sent: Apr-13, 2020 04:40 PM ", "Subject: URGENT - CRISIS CHARTING - EFFECTIVE IMMEDIATELY 4/13/2020" states, "ATTENTION ALL, Due to recent surge in our patient census and acuity in order to help provide documentation relief to our staff at this crucial time it has been decided that we will allow nurses to perform crisis charting. During the COVID19 pandemic and ONLY during this time period we are allowing you to document in the following manner. Required: 1. Take over narrative not-ONLY- Note must include blood sugar, pain, safety. Chart any change in patient's condition or related events ... You DO NOT have to complete a: 1. Plan of Care 2. Shift Assessment form ..."

1. Upon review of Medical Record #7, the following was determined:

a. Patient #7 was admitted on 5/2/20. The nursing "PATIENT TAKE OVER NARRATIVE" on 5/2/20 states, " ...2035-Patient received from [name of transferring hospital] via ambulance ..."

(i) There was no documented evidence of a wound/skin assessment upon admission by nursing staff.

b. The initial "Wound Care Progress Assessment" on 5/4/20 states, " ...Wound Progress Report Present on Admission: Yes" for the following sites:

(i) surgical wound, neck, trach site

(ii) surgical wound, abdomen, tube/peg site

(iii) scab, left ear

(iv) scab, right ear

(v) unstageable-slough and/or eschar, sacral; length 7.5 centimeters (cm), width 5.5 cm

c. The "Wound Care Progress Assessment" on 5/14/20 states, " ...Unstageable-Slough &/or Eschar Sacral ...Length (cm): 6.5 Width (cm): 7.0 ...Peri-wound is now bigger in size."

(i) The wound care was reassessed ten (10) days later, not weekly, per facility policy (Reference #1).

(ii) There was no evidence of nursing staff documenting changes of the sacral wound, per the above References.

d. The "Wound Care Progress Assessment" on 5/28/20 states, " ...Unstageable-Slough &/or Eschar Sacral ...Length (cm): 7.8 Width (cm): 6.0 ..."

(i) The wound care was reassessed fourteen (14) days later, not weekly, per facility policy (Reference #1).

(ii) There was no evidence of nursing staff documenting changes of the sacral wound, per the above References.

e. The "Wound Care Progress Assessment" on 5/28/20 states, "Wound Progress Report Present on Admission: Yes ..." for the following site:

(i) blisters, plantar, left; length 7 cm, width 5 cm: comment: noted popped blister on plantar foot

(ii) There was no evidence of nursing staff documenting changes in the skin assessment and/or a new wound, per the above References.

(iii) Upon interview on 6/25/20 at 4:20 PM, Staff #17 confirmed that the left plantar blister was not present on admission and "was marked incorrectly."

f. The "Wound Care Progress Assessment" on 6/4/20 states, " ...Unstageable-Slough &/or Eschar Sacral ...Length (cm): 15 Width (cm): 11.0 ...full thickness loss present with yellow slough present on wound bed ..."

(i) There was no evidence of nursing staff documenting changes of the sacral wound, per the above References.

2. Upon review of Medical Record #1, the following was determined:

a. Patient #1 was admitted on 4/7/20 at 11:40 PM.

b. The initial "Wound Care Progress Assessment" on 4/8/20 states, " ...Wound Progress Report Present on Admission: Yes" for the following sites:

(i) sacral, with no identified features of wound documented

(ii) IV (intravenous) site, left forearm

(iii) G-tube, superior abdomen

(iv) surgical wound, neck, trach site

c. The "Wound Care Progress Assessment" on 4/23/20 states, " ...Unstageable-Slough &/or Eschar Sacral ...Length (cm): 3 Width (cm): 1 ...with black devitalized tissue ..."

(i) There was no evidence of nursing staff documenting changes of the sacral wound, per the above References.

d. The "Wound Care Progress Assessment" on 4/23/20 states, " ..."Wound Progress Report Present on Admission: No ..." for the following site:

(i) unstageable-deep tissue injury, buttock, right, length 7 cm, width 5 cm, maroon discoloration, scant drainage.

(ii) There was no evidence of nursing staff documenting changes of the skin assessment and/or a new wound, per the above References.

e. The "Wound Care Progress Assessment" on 4/23/20 states, " ..."Wound Progress Report Present on Admission: No ..." for the following site:

(i) unstageable-deep tissue injury, buttock, left, length 3 cm, width 5 cm, black devitalized tissue, serosanguineous drainage

(ii) There was no evidence of nursing staff documenting changes of the skin assessment and/or a new wound, per the above References.

f. The "Wound Care Progress Assessment" on 4/30/20 states, " ...Unstageable-Slough &/or Eschar Buttock Left...Length (cm): 7 Width (cm): 5 ..."

(i) There was no evidence of nursing staff documenting changes of the buttock wound, per the above References.

g. The "Wound Care Progress Assessment" on 5/7/20 states, "Unstageable-Slough &/or Eschar Sacral ...Length (cm): 5 Width (cm): 3 ..."

(i) There was no evidence of nursing staff documenting changes of the sacral wound, per the above References.

h. The "Wound Care Progress Assessment" on 5/7/20 states, " ...Wound Progress Report Present on Admission: No ...for the following sites:

(i) groin, left, noted with redness due to incontinence

(ii) groin, right, noted with redness secondary to incontinence of bladder and bowel

(iii) anterior scrotum and penile, noted with redness secondary to incontinence of bladder and bowel

(iv) blister, anterior Achilles tendon (right or left not specified), length 7 cm, width 3 cm, reassessed today and noted with new open blister

(v) There was no evidence of nursing staff documenting changes of the skin assessment and/or a new wound, per the above References.

i. The "Wound Care Progress Assessment" on 5/7/20 states, " ...Wound Progress Report Present on Admission: No ...for the following sites:

(i) trauma wound, neck, trach site, length 1cm, width 2 cm, medical device related pressure injury due to trach face plate

(ii) There was no evidence of nursing staff documenting changes of the skin assessment and/or a new wound, per the above References.

j. The "Wound Care Progress Assessment" on 5/26/20 states, " ...Trauma Wound Neck (trach site) ...Length (cm): 1.5 Width (cm): 1.5 ..."

(i) There was no evidence of nursing staff documenting changes of the trach site wound, per the above References.

k. The "Wound Care Progress Assessment" on 6/2/20 states, "Unstageable-Slough &/or Eschar Sacral ...Length (cm): 4.5 Width (cm): 5 ..."

(i) There was no evidence of nursing staff documenting changes of the sacral wound, per the above References.

l. The next wound care assessment after 6/2/20 was completed on 6/13/20.

(i) The wound care was reassessed eleven (11) days, not weekly, per the above Reference #1.

m. The "Wound Care Progress Assessment" on 6/19/20 states, " ..."Unstageable-Slough &/or Eschar Sacral ...Length (cm): 8.5 Width (cm): 8 ..."

(i) There was no evidence of nursing staff documenting changes of the sacral wound, per the above References.

3. Upon interview on 6/26/20 at 9:45 AM, Staff #1 confirmed that is the expectation with current crisis charting, to document wounds and changes in wounds, as it is a "change in the patients condition or related event."

C. Based on review of two (2) of two (2) medical records (Medical Records #1, #7), review of facility documents and staff interview, it was determined that the facility failed to ensure that every patient is turned and positioned, in accordance with facility policy.

Findings include:

Reference: Facility policy "SKIN CARE, ASSESSMENT AND MAINTENANCE OF" states, " ...POLICY: ...Skin assessment shall be performed at least every 12 hours. All bedfast patients shall be turned every 2 hours ...GENERAL STATEMENTS: ...4. The effectiveness of all wound care treatment will be reassessed on a weekly basis ...This reassessment will be performed by a designated nurse and may include other members of the treatment team as appropriate. The physician will be contacted to discuss any changes in the treatment plan. 5. ...The status of the wounds will be compared to wound status documentation from previous wound assessment. ...6. Nurses will implement preventative measures for wound care protocols. ..."

1. Upon review of Medical Record #7, the following was determined:

a. The 5/4/20 "Wound Care Progress Assessment" and all other dated assessments, states, " ...Wound Intervention Reposition Q [every] 2 Hours ..."

b. There was no evidence that Patient #7 was turned and repositioned every two (2) hours on the "Turn And Reposition" sheet completed by a medical assistant (MA) and/or the nursing "Patient Take Over Narrative" documents received, for the following dates/times:

(i) 5/7/20: the patient was turned at 11:45 AM, and not every 2 hours in accordance with facility policy, from 8:00 AM to 6:00 PM.

(ii) 5/21/20: the patient was turned at 11:40 AM, and not every 2 hours in accordance with facility policy, from 8:00 AM to 6:00 PM.

2. Upon review of Medical Record #1, the following was determined:

a. The 4/8/20 "Wound Care Progress Assessment" and all other dated assessments, states, " ...Wound Intervention Reposition Q2 Hours ..."

b. There was no evidence that Patient #1 was turned and repositioned every two (2) hours on the "Turn And Reposition" sheet completed by a medical assistant (MA) and/or the nursing "Patient Take Over Narrative" documents received, for the following dates/times:

(i) 5/1/20: no evidence of documentation from 8:00 AM to 6:00 PM

(ii) 5/20/20: no evidence of documentation from 8:00 AM to 6:00 PM

(iii) 5/31/20: no evidence of documentation from 8:00 AM to 6:00 PM

(iv) 6/7/20: no evidence of documentation from 8:00 AM to 6:00 PM

(v) 6/12/20: no evidence of documentation from 10:00 AM to 6:00 PM

(vi) 6/13/20: the patient was turned at 9:15 AM and 12:45 PM, and not every 2 hours in accordance with facility policy, from 8:00 AM to 6:00 PM

(vii) 6/15/20: the patient was turned at 10:00 PM, and not every 2 hours in accordance with facility policy, from 8:00 PM to 6:00 AM

(viii) 6/21/20: the patient was turned at 9:30 AM, 1:00 PM, 3:00 PM, and not every 2 hours in accordance with facility policy from 8:00 AM to 6:00 PM

3. Upon interview on 6/24/20 at 1:20 PM, Staff #11 (a medical assistant/MA) confirmed that the medical assistants/certified nursing assistants are responsible to turn and position the patients every 2 (two) hours, and document at the end of the shift.

4. Upon interview on 6/26/20 at 2:20 PM, Staff #14 (a Registered Nurse/RN) confirmed that it is the expectation of the MA to document turning and positioning of the patients.

5. Upon interview on 6/26/20 at 3:01 PM, Staff #3 (Administration) confirmed it was the responsibility of the MA to document turning and positioning of the patients.

6. The above findings were confirmed by Staff #1.