HospitalInspections.org

Based on medical record review, observation and staff interview the facility failed to ensure physician orders were carried out by nursing (A392), develop and keep current nursing care plans (A396), and administer medications as ordered by the physician (A405). The cumulative effect of this systemic practice resulted in the facility's inability to provide nursing services according to physician orders and utilizing a care plan reflective of the patient's current needs.

Based on medical record review, observation and staff interview the facility failed to ensure nursing staff followed physician orders for sequential compression devices (SCD'S) for Patient #3, #5, #8 and #10, bathing orders for Patient #3, #5 and #9 and vital signs orders for Patient #8, #9 and #10. The total sample size was ten medical records reviewed. The current census at the time of the survey was 22.

Findings include:

1. The medical record review for Patient #3 was completed on 2/22/18. Patient #3 was admitted to the facility on 11/29/17 with diagnoses that included chronic respiratory failure and hemorrhagic stroke. Physician orders at the time of the patient's admission included orders for EPC cuffs (an intermittent compression device applied to lower legs to prevent blood stasis/pooling). Nursing documentation for the 25 day hospital stay lacked evidence the EPC cuffs were used.

Physician orders at the time of admission included orders for the patient to be bathed daily during the 25 day hospital stay. Review of the nurse aide documentation revealed the patient was not bathed on 12/08/17, 12/12/17, 12/17/17, 12/19/17 and 12/21/17.

These findings were confirmed with Staff A on 2/21/18 at 2:00 PM.


21521

2. The medical record review for Patient #5 was completed on 02/22/18. The medical record review revealed the patient was admitted to the facility on 09/20/17 with diagnoses of cirrhosis with ascites and gastroesophageal reflux disease.

The medical record review revealed an admission data base dated 09/20/17 that stated the patient required the assist of two people to walk.

The medical record review revealed the patient was assessed as having a very high risk for deep venous thrombosis.

The medical record review revealed a physician's order dated 09/20/17 at 2:37 PM that ordered a sequential compression device that helps circulate blood in the legs of immobile patients to prevent the formation of blood clots, i.e. deep venous thrombosis-to the legs.

The medical record review lacked evidence the sequential compression device was applied on 09/21/17, 09/22/17, 09/23/17, 09/24/17, 09/25/17, and 09/26/17.

The medical record review revealed on 09/27/17 +4 pitting edema was observed to the right pretibial area on both the day and night shift.

The medical record review revealed on 09/28/17 +3 pitting edema to the right pretibial area plus pitting pedal pitting edema was observed on the day shift (a night shift assessment was not documented).

The medical record review revealed on 09/29/17 edema persisted to the lower extremities.

The medical record review revealed on 09/30/17 the patient was diagnosed with a deep venous thrombosis to the right leg.

On 02/21/18 at 9:52 AM in an interview, Staff A confirmed there was no evidence the sequential compression device was ever applied prior to the development of the deep venous thrombosis.

The medical record review revealed a physician's order dated 09/18/17 at 1:45 PM that directed staff to bathe the patient every day.

The medical record review revealed the patient did not receive a bath on 09/27/18, 09/28/18, and 09/29/18.

On 02/21/18 at 9:52 AM in an interview, Staff A confirmed there wasn't evidence the patient had received a bath on 09/27/18, 09/28/18, and 09/29/18.


3. The medical record review for Patient #8 was completed on 02/22/18. The medical record review revealed the patient was admitted to the facility on 01/30/18 with a diagnosis of renal failure, chronic obstructive pulmonary disease, hypertension, and chronic respiratory failure. The medical record review revealed on 01/30/18 at 11:15 PM the physician ordered the patient to have a sequential compression device for the prevention of deep venous thrombosis.

On 02/21/18 at 1:45 PM the patient was observed not to have sequential compression device on the legs.

On 02/21/18 at 1:45 PM in an interview, Staff A confirmed the observation and noted a sequential compression device could not be found in the room.

The medical record review did not reveal any evidence the patient ever had a sequential compression device applied to the legs.

On 02/21/18 at 1:45 PM in an interview, Staff A confirmed the documentation.

The medical record review revealed a physician's order dated 01/30/18 at 11:15 PM that ordered vital signs to be taken every six hours.

The medical record review revealed this was not done. Vital signs were taken on 02/05/18 at 6:50 AM and at 8:20 PM, when the temperature was 101 degrees Fahrenheit, and not taken again until 02/06/18 at 7:00 AM when it was 99.6 degrees Fahrenheit. Vital signs were taken on 02/09/18 at 11:10 PM (temperature was 101.3 degrees Fahrenheit) and not again until 02/10/18 at 100.8 degrees Fahrenheit.

On 02/22/18 at 11:30 AM in an interview, Staff A confirmed the lack of vital signs as ordered.


4. The medical record review for Patient #10 was completed on 02/22/18. The medical record review revealed the patient was admitted to the facility on 02/08/18 with diagnoses of chronic obstructive pulmonary disease, acute respiratory failure, neuropathy, anxiety, diabetes mellitus, and post cardiac arrest.

The medical record review revealed a physician's order dated 02/08/18 at 10:50 PM to place sequential compression device on the patient legs.

On 02/21/18 at 1:54 PM the patient was observed to be without the sequential compression device.

On 02/21/18 at 1:54 PM in an interview, Staff A confirmed the patient did not have a sequential compression device applied and could not find one in the room.

The medical record review did not reveal where sequential compression device were ever applied from admission to 02/21/18.

On 02/22/18 at 11:30 AM in an interview, Staff A confirmed the documentation.

The medical record review revealed a physician's order dated 02/08/18 that directed the facility to take vital signs every four hours.

The medical record review revealed vital signs were not taken between 02/14/18 at 11:20 PM and 02/15/18 at 6:45 AM, between 02/15/18 at 6:45 AM and 7:20 PM, and between 02/15/18 at 7:20 PM and 02/16/18 at 7:00 AM, and between 02/16/18 at 11:10 AM and 9:55 PM, and 02/19/18 at 7:10 PM and 02/20/18 at 7:00 AM.

On 02/22/18 at 11:30 AM in an interview, Staff A confirmed the vital signs were not taken as ordered.

5. The medical record review for Patient #9 was completed on 02/22/18. The medical record review revealed the patient was admitted to the facility on 02/02/18 with diagnoses of respiratory failure secondary to chronic obstructive pulmonary disease, diabetes mellitus, and pneumonia.

The medical record review revealed a physician's order dated 02/02/18 at 2:20 PM to bathe the patient daily.

The medical record review revealed the patient was not bathed on 02/09/18, 02/10/18, 02/12/18, 02/13/18, and 02/14/18.

The medical record review revealed a physician's order dated 02/02/18 at 2:20 PM that directed staff to take vital signs every eight hours.

The medical record review revealed vital signs were not taken between 02/15/18 at 7:30 PM and 02/16/18 at 7:00 AM, between 02/12/18 at 7:03 PM and at 02/13/18 at 7:05 AM, and between 02/11/18 at 6:55 AM and 02/12/18 at 7:03 PM.

On 02/22/18 at 11:30 AM in an interview, Staff A confirmed vital signs were not taken as ordered and the lack of daily baths.

Based on medical record review and staff interview the facility failed to ensure the nursing care plan was updated after a fall (Patient #1 and #7) and failed to develop a care plan for Patient #4's history of IV drug abuse. The total sample size was ten. The current census at the time of the survey was 22.

Findings include:

1. The medical record review for Patient #1 was completed on 02/22/18. Patient #1 was admitted to the facility on 02/02/18 with diagnoses that included small bowel perforation and peritonitis. Nurses notes dated 02/15/18 revealed at 11:20 PM the patient fell trying to use the commode. Problem #3 listed on the nursing care plan was "risk for injury" with a start date of 02/02/18. Interventions for the injury risk was "rounds every 2 hours and call light in reach". The Outcomes for problem #3 stated, "Safety maintained".

The nursing care plan was not reviewed and/or updated during the nursing shift 02/15/18 at 7:15 PM through 02/16/18 at 6:45 AM.

2. The medical record review for Patient #7 was completed on 02/22/18. Patient #7 was admitted to the facility on 01/08/18 with diagnoses that included respiratory failure, sepsis and history of narcotic dependence. Nurses notes dated 01/23/18 revealed at 3:20 PM the patient was found on the floor. Problem #1 listed on the nursing care plan was "risk for injury" with a start date of 01/08/18. Interventions for the injury risk was "restraints, hourly rounding, call light in reach". The Outcome during the nursing shift from 6:45 AM through 7:15 PM for problem #1 stated, "no injury". The nursing care plan was not updated to reflect the fall during the nursing shift 01/23/18 at 6:45 AM through 7:15 PM.
The nurses notes dated 01/23/18 revealed the patient fell again at 10:50 PM. Interventions for the injury risk was "restraints, hourly rounding, call light in reach." The Outcome during the nursing shift from 7:15 PM to 6:45 AM (01/24/18) for problem #1 stated, "fall x 2, no injuries".

The nursing care plan was not updated (interventions) to address the falls during the nursing shift 01/23/18 at 7:15 PM through 6:45 AM on 01/24/18.

These findings were confirmed with Staff A on 2/22/18 at 12:00 PM.




21521

3. The medical record review for Patient #4 was completed on 02/22/18. The medical record review revealed the patient was admitted to the facility on 11/16/17. The medical record review revealed a history and physical dated 11/17/17 that stated the patient was admitted for completion of antibiotics for subacute infective endocarditis. The history and physical notes the patient has a medical history of pulmonary embolism, left trochanteric abscess, aortic aneurysm repair with graft, and intravenous drug use, with last use 48 days prior to admission.

The medical record review revealed a nursing data base dated 11/16/17 at 6:30 PM that stated the patient abused intravenous heroin and crack, with last use being 47 days prior to admission.

The medical record review of Patient #4 revealed a physician discharge summary dated 12/19/17 that stated, "On 11/21/17 night, patient was noted by one of the nearby patients to be unresponsive in his room and cardiopulmonary resuscitation was initiated. He received Narcan multiple times because of suspicion of intravenous heroin abuse as his (peripherally inserted central catheter) line was open and there was suspicious syringe in his room. Patient became responsive after intravenous Narcan use. Emergency medical services arrived and patient was taken to hospital."

On 02/21/18 at 2:01 PM Staff E, registered nurse, was made aware the medical record review did not reveal a comprehensive, individualized nursing care plan that addressed the drug abuse. Staff E explained they are trying to coordinate substance abuse care with an outpatient care center, but nothing has come of that yet.

Based on medical record review and staff interview the facility failed to ensure nursing staff administered medications as ordered by the physician. This affected one (Patient #3) of ten records reviewed. The facility census at the time of the survey was 22.

Findings include:

1. The medical record review for Patient #3 was completed on 2/22/18. Patient #3 was admitted to the facility on 11/29/17 with diagnoses that included chronic respiratory failure and hemorrhagic stroke. Physician orders at the time of the patient's admission included for the patient to be given Tylenol rectal suppository 650 mg. for mild pain or fever over 100.4 F. On 12/23/17 at 7:00 PM the nursing documentation noted the patient's temperature to be 100.6 F. On 12/24/17 at 4:15 AM and 4:30 AM the patient's temperature is documented as 100.7 F. The medication administration record dated 12/23/17 at 7:00 AM through 12/24/17 at 6:59 AM did not have a documented dose of Tylenol for fever given as ordered.

This finding was confirmed with Staff A on 2/21/18 at 2:00 PM.