HospitalInspections.org

Based on observation, interview and record review the hospital failed to ensure nursing supervised the care of 7 of 30 sampled patients. Skin assessments were not documented every shift, pressure ulcers were not measured according to policy, wound treatments were not documented as ordered, weights were not documented as ordered, oxygen therapy was administered without an order, and blood glucose testing was done as ordered. (Patient ID# ' s 1, 3, 5, 6 , 10, 11, and 20)
Findings include:

Patient ID# 6

Observation 2/12/13 at 11:00 a.m. revealed patient ID# 6 in bed with an oxygen nasal cannula at 2 liters per minute.

Record review of patient ID# 6's medical record revealed she was admitted to the hospital on 2/6/13. Physician orders from 2/6/13 to 2/12/13 revealed no physician order for oxygen. The admitting diagnoses listed: Sepsis, Sacral Pressure Ulcer, possible Osteomylitis, right hip wound, Dementia, Hypertension, and Diabetes.

Interview 2/12/13 at 12 noon with a Respiratory Therapist (ID# 8) revealed that patient ID# 6 should have had a physician order for the oxygen treatment.

Admission physician orders dated 2/6/13 stated "Weight Daily."

Record review 2/12/13 of nursing flow records for patient ID# 6 revealed the patient was only weighed twice since admission (2/6/13 = 132 pounds and 2/11/13 = 139 pounds).

Interview 2/12/13 at 11:00 a.m. with a nurse (ID# 5) revealed that patient ID# 8 should have been weighed daily and the night shift is responsible for weighing patients daily.

Observation 2/13/13 at 9 a.m. of patient ID# 8 during a sacral dressing change revealed a large, gapping, stage four pressure ulcer on the sacrum.

Record review of "Wound Treatment and Progress Record" for patient ID# 8 from admission 2/6/13 to present (2/13/13) revealed no wound measurements of the sacral pressure ulcer.

The Wound Care Nurse (ID# 10) acknowledged 2/13/13 at 9:30 a.m. that she has not taken any measurements of the sacral pressure ulcer. The Wound Care Nurse explained that she usually waits on the physician to take measurements because they are more accurate.

Record review of a policy titled "Hospital Wound Care Policies and Procedures: Evaluation" dated 2009 stated "Policy: Evaluation of wounds will be performed on admission, weekly and on discovery....Objective evaluation components include Location, Measurements, Appearance...."


11754

Patient #5

Review of Patient's medical records revealed an 89 year old female admitted on 1/14/13 with the diagnoses Osteomyelitis, Diabetes, ESRD, and on dialysis three times a week (MWF). Review of admitting orders dated 1/14/13 on 2/12/13 revealed an order for daily weights.

Review of the patient's flow sheet/nurse's notes/graphic sheet on 2/12/13 revealed weights were not recorded for the following dates: 1/15/13, 17/13, 1/19/13, 1/20/13, 1/24/13, 1/28/13, 1/29/13, 1/31/13, 2/1/13, 2/3/13, 2/7/13, 2/8/13, 2/10/13, and 2/12/13.

Patient #5's medical record was reviewed with the staff #5 on 2/12/13 and she confirmed no documentation of daily weights and stated during an interview at this time that patient was a dialysis patient and that "she is weighed on the morning of dialysis days".

Patient #20

Review of patient #'s medical records dated 11/8/12 on 2/14/13 revealed patient was 63 years old male admitted on 11/8/12 with the diagnoses Pneumonia, Diabetes, Hypertension and Throat Cancer.

Review of admitting orders dated 11/812 on 2/14/13 revealed an order for weekly weights. Review of the patient's flow sheet/nurse's notes/graphic sheet on 2/14/13 revealed weights were not recorded for the following weeks: The week of 11/18/12 and 11/25/12. This patient was discharged on 12/6/12.

Review of facility policy on 2/14/13 titled "Patient Weights" revised on 11/2011 revealed the following:

1. "Patient will be weighed on admission to the hospital
2. "Weights will be obtained on a weekly basis thereafter, unless ordered otherwise"
4. "The actual weight of the patient will be documented on the graphic record sheet" .



32043

Patient #11

Review of Patient's medical records revealed a 96 years old female admitted on 2/4/13 with the diagnoses Aspiration Pneumonia, Sepsis/Severe Acute Respiratory Syndrom (SARS), dehydration. Admitting orders included an order for daily weights.

Review of the Flow Sheet showed that weights were not recorded for 2/4/13, 2/10/13, 2/11/13 and 2/12/13. Medical records reviewed with staff #24 Charge Nurse who acknowledge the findings and stated " I don ' t know why the weights were not recorded " .

Patient #10

Review of Patient ' s medical records revealed a 77 years old female admitted on 12/1/12 with the diagnoses Pneumonia and Congestive Heart Failure. Patient also has a medical history of hypertension, diabetes type II, COPD and chronic renal insufficiency.

Admission orders on 12/1/12 included an order for blood sugar check every six hours. Medication orders also included sliding scale regular insulin for adequate control of patient ' s blood sugar. Blood sugar monitoring was scheduled for 12am, 6am, 12pm and 6pm.

Review of Medication administration record (MAR) where the blood sugar values are recorded revealed that:

· Blood sugar values were missing for 2/8/13 at 12pm and 6pm, and 2/11/13 at 12pm.
· On 2/9/13, Patient ' s blood sugar at 12pm was 194mg/dl and 230mg/dl at 6pm requiring 2 units and 3 units of regular insulin respectively per sliding scale insulin order. No record that insulin was administered.

Interview with Staff #24 during this record review, she acknowledged the missing blood sugar values and also stated that insulin should have been administered to the Patient for the above values according to the MAR.




23032


Patient ID # 1:

Record review on 02-12-13 of Patient ID # 1 ' s clinical record revealed she was a 66 year old female admitted to the facility on 01-21-13 for wound care and IV antibiotic administration. She had a history of Diabetes Mellitus (DM) and End Stage Renal Disease (ESRD). Patient ID # 1 underwent a recent left Above the Knee Amputation (AKA) and had an infected, non-healing left groin wound following a femoral artery bypass procedure.

Pressure Ulcer:

Interview on 02-12-13 at 10: 30 a.m. with the spouse of Patient ID # 1 he expressed concern that his wife had a " sore on the back of her bottom " and requested a nurse look at it. He said the sore had been there at least two (2) days and that no one had seen or treated it.

Observation on 02-12-13 at 11:15 a.m. revealed wound care nurse (RN ID # 10) perform a wound treatment on Patient ID # 1. At surveyor's request, RN # 10 assisted Patient ID # 1 to her right side to facilitate a skin inspection of the buttocks area. A quarter- sized opened area was noted to the right mid-buttock. It was uncovered. The wound care nurse (RN ID # 10) described it as a "Stage II pressure ulcer"and stated she was unaware of it. She went on to say she would get a treatment initiated right away.

Interview on 02-12-13 at 11:45 a.m. with RN ID # 4 she stated she was the nurse providing care to Patient ID # 1 that day. She went on to say she was unaware of the Stage II pressure ulcer to Patient ID # 1 ' s buttocks and it was not mentioned in the change of shift report. RN ID # 4 stated that skin assessments were conducted each shift and recorded on the daily flow sheet.

Record review of the " Nursing Daily Documentation " for Patient ID # 1 for February 9, 10, 11, 2013 failed to reveal documentation of a skin integrity issue on the buttocks. There was no documentation of this either in the designated area titled " SKIN " assessments or in the narrative charting.

Interview on 02-14-13 at 11:00 a.m with the facility Chief Nursing Officer (CNO) he stated the pressure ulcer should have been identified by the staff during the routine skin assessment each shift.

Record review of facility policy titled " Skin Care Assessment, " revised 11/2011, read ...every patient ' s skin integrity will be reassessed every day and /or as needed ... "

Wound Measurement:

Record review on 02-14-13 of the January & February 2013 " Wound Treatment & Progress Record " for Patient ID # 1 revealed only one wound measurement of Patient ID# 1 ' s left groin surgical wound. This measurement was taken on 01-28-13. There were no wound measurements recorded for February 2012, including a measurement of the Stage II pressure ulcer identified on 02-12-13.

Interview on 02-14-13 at 11:00 a.m. with the facility Chief Nursing Officer (CNO) he acknowledged the facility policy stated wounds were to be measured on admission and weekly thereafter.

Patient # 3

Record review on 02-12-13 of Patient ID # 3 ' s clinical record revealed she was an 83 year old female admitted to the facility on 01-26-13 following hospital admission for recent rectal and vaginal bleeding. Patient ID # 4 had a history of Diabetes Mellitus, Colon Cancer/ Colostomy, and a Stage II sacral decubitus ulcer.

Wound Measurement:

Record review on 02-14-13 of the February 2013 " Wound Treatment & Progress Record " for Patient ID # 3 revealed she had two (2) wounds: a " Sacral wound " and a wound to the " left medial thigh. " There was a measurement recorded on 02-01-13 but none for the following week. There was one measurement recorded for the sacral wound; this measurement was undated.

Wound Treatment:

Further review on 02-14-13 of the February 2013 " Wound Treatment & Progress Record " for Patient ID # 3 read: Sacral wound order dated 02-01-13: " Santyl application with dry protective dressing daily. Clean with Dakin ' s solution. " Review of the wound care documentation for Patient # 3 revealed treatments to the sacral wound had been omitted on the following dates in February 2013: 4, 5, 11, 12, and 13.

Further review on 02-14-13 of the February 2013 " Wound Treatment & Progress Record " for Patient ID # 3 read: Left Medial Thigh wound order dated 02-01-13 : " dry protective dressing daily-Silverdine (sic). " Review of the wound care documentation for Patient # 3 revealed treatments to the left medial thigh wound had been omitted on the following dates in February 2013: 4, 5, and 8, 9,10. 11, 12, and 13.

Based on record review and interview the facility failed to conduct a post transfusion assessment of patients according to their ''Blood & Blood Products Transfusion" Policy dated 8/2012. This failed practice had the potential to adversely affect patients who receive blood transfusion in the facility. Citing two (2) of four (4) sampled patients who received a blood transfusion. Patient #s 9 and 10.

Findings:

Review of the facility's ''Blood & Blood Products Transfusion" Policy dated 8/2012 revealed the following requirements for blood infusion monitoring:

"vital signs immediately prior to initiating transfusion, at 15 minutes for the first 30 minutes, then every hour ( initiation indicates when the blood actually enters the patient ), at completion and one hour post transfusion."

Patient # 9

Review of Nurses notes and blood transfusion records for Patient (#9) revealed the following information:

The first (1) unit of blood was initiated on 2/11/2013 at 15:00 hours and was completed at 18:20. The second unit was initiated on 2/11/2013 at 20:15 hours and was completed at 00:00 hours. There was no documentation on the blood transfusion record or on the nurses notes that a post transfusion assessment was ever conducted.

During an interview on 2/13/2013 at 8:45 am Charge Nurse on the High Occupancy Unit (HOU) and the Chief Nursing Officer they both stated a post transfusion assessment is required and that the place for the assessment was omitted from the transfusion record.

The patient was admitted to the facility on 2/6/2013. The patient had a Hemoglobin level of 7.4 There was an order dated 2/11/2013 for two (2) units of Packed Red Blood Cells(PRBC) to be transfused.


32043


Patient #10

Review of Patient ' s medical records revealed that:

· On 12/9/12 there was an order to transfuse two units of Packed Red Blood Cells (PRBC). First unit of blood was started at 7:45pm and completed at 11:30pm, and the second unit was transfused from 11:30pm to 3:00am, no post transfusion assessment documentation in the nurses ' note.
· On 1/12/13 at 5:20pm, order was written to transfuse two units of PRBC. Blood transfusion record showed that blood transfusion was started on 1/13/13 at 1:00am and completed at 8:00am. There was no post transfusion assessment recorded.

Based on interview and record review the hospital failed to ensure 3 of 30 medical records were complete regarding discharge summaries / history and physicals completed per policy, and verbal orders authenticated per policy. (Patient ID # ' s 13, 14, and 30)
Findings include:

Patient ID# 13

Medical record review revealed that patient ID# 13 was admitted on 11/19/12. Verbal admitting physician orders dated 11/19/12 were not signed by the physician. The physician orders listed "Cancer / Hospice care." Diagnoses listed " End Stage Dementia, Hypertension and Diabetes." Verbal Physician orders dated 11/23/12 were also not signed by a physician. The physician orders on 11/23/12 stated "start Roxanol prn pain or dyspnea." Roxanol is classified as a class II narcotic. The patient died on 11/24/12 and the medical record did not contain a physician discharge summary or a death summary.

Patient ID# 14

Medical record review revealed that patient ID# 14 was admitted on 12/5/12. Verbal admission orders stated "Hospice Care." Diagnoses included "Congestive Heart Failure, Dementia, Seizures, Sepsis, Respiratory Failure, and Pneumonia." A verbal physician order on 12/6/12 at 2:30 p.m. stated "No CPR." The physician order on 12/6/12 was not signed by a physician. The patient died on 1/21/13.

Interview 2/14/13 at 9 a.m. with the Director of Medical Records (ID# 23) revealed that "Hospice" is a contracted service for the hospital. The Director stated she was not sure if the Hospital or the Hospice provider is responsible for completion of medical records for Hospice patients.

Record review of "Medical Staff Bylaws" dated 12/22/11 stated "Medical Records:
- Orders for treatment: The responsible Practitioner shall authenticate verbal orders within 48 hours or the next visit...
- A discharge summary shall be written, or dictated, on all medical records within thirty days of discharge..."


23032

Patient ID # 30

Record review on 02-13-13 of discharged Patient # 30's clinical record revealed she was 81 years old admitted to the facility on 08-07-12 for Sepsis, Urinary Tract Infection, and Hypertension. Further review revealed she was discharged from the facility on 08-13-12.

Further review of Patient ID # 30's record revealed there was no admission History & Physical located in the record; and the Discharge Summary was dictated by the physician on 11-29-12, three months following patient discharge.

Interview on 02-12-13 with Medical Records Director, Staff ID # 23 she stated the record for Discharged Patient # 30 was in the incomplete record file and was in the process of being completed. She went on to say the majority of the facility's incomplete records were for physician signatures on orders.

Record review of "Medical Staff Bylaws" dated 12/22/11 stated "A complete History & Physical examination shall be written or dictated within twenty-four (24) hours of patient's admission ..and signed within 48 hours or next visit..."