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Based on observation, interview and record review the facility failed to provide organized nursing services which followed the nursing process of identifying and responding to patient needs through assessment, care planning and documentation resulting in adverse outcomes for three of 16 patients reviewed, and assured that Nursing staff were competent to perform assigned duties for one of 10 personnel files reviewed, resulting in the potential for less than optimal outcomes for all 33 patients in the facility. Findings include:

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A 0396 : The facility failed to ensure 1. Accurate Assessment of risk and Individualized Care Plans with targeted interventions to prevent Patient self dislodgement of medical devices not developed, implemented or updated after incidents for two of six patients reviewed for accidental decannulation events and, 2. Accurate Assessment of risk and Individualized Care Plans with targeted interventions to prevent and treat lip sores not implemented or updated for one of one patients observed with endotracheal intubation.

A 0397: Failed to ensure nursing staff were competent to perform assigned duties for 1 (Staff X) of 6 nursing personnel files reviewed out of a total of 10 personnel files reviewed.

Based on observation, interview and record review, the facility failed to timely and accurately assess, develop, implement and update an individualized Nursing Care Plan with targeted interventions to prevent non-planned tracheotomy decannulation and line/tube dislodgement for two (#1 and #3) of six patients reviewed for tracheotomy decannulation incidents and to prevent lip sores for one (#6) of one patients observed for endotracheal tube intubation, out of a total of 33 patients in the facility, resulting in adverse outcomes. Findings include:

On 11/14/18 at approximately 1100, during a tour of the facility with the Nursing shift Supervisor, Staff K, Patient #1 was observed in his room. Patient #1's care giver and his assigned nurse Staff M were in Patient #1's room preparing Patient #1 to be transferred to another facility to have a surgical procedure to drain an infected abscess (boil) on a discontinued Percutaneous Endoscopic Gastrostomy (PEG) tube site (surgical opening into the stomach with a feeding tube inserted) .

On 11/14/18 at approximately 1105 Staff K was asked about Patient #1's infected PEG site wound and he reported that Patient#1's PEG had "become dislodged", which caused a wound which became infected. Staff K stated that was the reason that Patient #1 had a naso-gastric tube for feedings now instead of a PEG tube. Patient #1 appeared emaciated (appeared severely underweight). Staff K and Staff M were questioned, and were unable to say how or why Patient #1's PEG tube got dislodged. Patient #1's family member caregiver was interviewed at this time, and stated that Patient #1 had pulled his PEG tube out. Patient #1's caregiver stated that she and her husband had cared for Patient #1 for 20 years and planned to take him home. The Caregiver stated that Patient #1's discharge home was delayed because of his abdominal abscess and an infected tooth..

During observation from 1100 to 1120 Patient #1 ground his teeth and thrashed from side to side in the bed. At approximately 1110 Patient #1's family caregiver said that Patient #1 had worn some bald spots in his hair from thrashing in the bed. There were two soft wrist restraints tied to the right bedrail, but Patient #1 was not wearing restraints at the time of the observation. Staff Nurse M said that was because she had removed his restraints to get him ready for his procedure, and she was in the room monitoring him. At approximately 1115 Patient #1's caregiver told Staff M that it looked like Patient #1 was in pain and needed medication before he went for his procedure. Staff M left the room without restraining Patient #1 and Patient #1's family (not employed by facility) caregiver remained at the bedside.

Patient #1 was in contact isolation for Clostridium difficile infectious diarrhea (a severe infectious diarrhea found in weakened patients who have received strong antibiotics). Patient #1 was unable to speak, did not follow simple directions, had contractures of both knees and hips, and had a tracheotomy (surgical opening into his airway through his throat) connected to oxygen through a tubing, and a pulse oximeter (device to measure tissue oxygen levels) on his finger. Patient #1 also had a Peripherally Inserted Central Catheter (PICC line - an intravenous line inserted through the skin and threaded up through the vein into a main vein leading to the heart) and a nasogastric tube (NG tube) connected to a tube feeding inserted through his right nostril. Patient #1's right nostril was scabbed, swollen and reddened.

On 11/14/18 at approximately 1110 Staff M and Staff K were asked about the skin damage on Patient #1's nose and both reported that Patient #1 had pulled his NG tube out several times. When asked how this happened, Staff K stated, "He moves himself against the railing (bed rail) and pulls on his tubes even with his hands restrained." When asked if he had ever pulled out his tracheotomy tube (breathing tube), Staff K said that Patient #1 had done so "a few times." Staff K was asked if Patient #1 had ever pulled out his PICC line, and said, "a few times." Staff K was asked if Patient #1 had wrist restraints on each time he had dislodged or pulled out his tubing. Staff K reported that Patient #1 had been properly restrained each time, but he was able to reach the tubings and pull them out inspite of this. When asked why additional interventions were not added to keep Patient #1 safe, Staff K stated, "We're not allowed to use more than one restraint or to use chemical restraints, so all we could do is to increase the frequency of his monitoring rounds (staff observations) to every one hour." When he was asked if hourly rounding prevented patient #1 from having additional line and tube pulling incidents, Staff K reported that it hadn't. Staff K reported that if it was his decision, Patient #1 would have had a sitter (one to one staff monitoring), but management hadn't approved it.

On 11/15/18 at approximately 1000, Patient #1's clinical record and Adverse Event Reports were reviewed with the Quality Management Director, Staff B, and the following was revealed:

Patient #1 was a 33 year old developmentally delayed male with a history of Cerebral Palsy, Brain Tumor, and Seizures. Patient #1 was originally admitted to the facility on 8/3/18 and was subsequently transferred to an acute care facility for tension pneumothorax (hole in the airway causing air to enter into thoracic cavity) and bleeding from his tracheotomy site.

Patient #1 was readmitted to the facility on 8/15/18 on mechanical ventilation (breathing machine connected to his tracheotomy) with a tracheotomy and a PEG tube. Re-admission diagnoses included Blood Loss Anemia, Respiratory Failure, Ventilator Dependent, Status Post Tension Pneumothorax (perforation of lungs or airway leading to air accummulation in the thoracic cavity). There were no adverse events provided for the first admission. It was not determined during survey whether the bleeding from Patient #1's tracheotomy site and subsequent anemia due to blood loss or his tension pneumothorax were related to the patient possibly dislodging his tracheotomy tube during his previous admission. A Physician's Admission History and Physical Examination dated 8/16/18 at 1227 noted that Patient #1 had a PEG tube in place on readmission, and was readmitted after a transfer to acute care for bleeding from the tracheotomy site, blood loss anemia and tension pneumothorax.

Review of provided Adverse Event Reports for Patient #1 revealed he had 11 incidents for dislodged tubes and lines during his admission from 8/15/18 through 11/14/18. There were five tracheotomy decannulations (breathing tube pulled out of tracheotomy), three PICC (intravenous line leading to a main vein to the heart) line dislodgements, and three NG (nasogastric feeding tube) tube displacements. There was no documentation of an incident regarding a PEG tube displacement and no documentation was provided to explain why the PEG was no longer in place and why there was an infected wound at the site. An adverse event report dated 9/27/18 noted that Patient #1 "had taken his gown off and put his pillows and blankets on the floor." There was no documentation that Patient #1's restraints were reviewed after this incident or that new interventions were discussed to prevent line/tube dislodgement. Patient #5 decannulated (pulled out his tracheostomy tube) five times after this disrobing incident.

Review of Nursing Care plans for Patient #1 revealed there was no care plan specific for risk of decannulation or line/tube dislodgement despite 11 incidents where the tracheotomy tube, the PICC line or the NG tube were dislodged or pulled completely out. There was no nursing assessment of his risk for decannulation or line/tube dislodgement. The Respiratory Therapy decannulation risk assessment score remained below 16 (no risk) of decannulation after 5 documented decannulation events. Nursing interventions were not updated after events, no investigation (root cause analysis) was conducted and no staff interviews were done after these events to determine if the decannulations and line/tube dislodgements were due to staff mishandling, malpositioning, restraint device misapplication, the quality and performance of the restraint device itself, or the ability of the patient to pull lines and tubes despite the restraint. There was no documentation of identification of caregivers assigned to Patient #1 at the time of these events.

On 11/15/18 at approximately 1100 Staff B was asked about this and stated, "He was able to wiggle down to where he could reach his tubes and lines with his restraint on." There was no documentation to support this statement and no documentation of planned interventions to address this. When asked about this, Staff B stated, "We can't do much more if he already has wrist restraints. I discussed whether we could have a sitter for him (one to one staff observation) but the previous Nursing Director wouldn't allow it."

On 11/15/18 at approximately 1130 review of the Respiratory Therapy "Decannulation Risk Assessments" on Patient #1's Respiratory Therapy Flow records with Staff B revealed there was no risk scoring for behaviors that posed a risk for decannulation (prior pulled lines, inability to comprehend, non-compliance, attempts to grab or pull at lines) and that Patient #1's agitation and impaired cognition were not correctly scored (Patient #1 was incorrectly scored as alert and oriented). When asked about this, Staff B stated, "There's no behavior component in this decannulation risk assessment tool." Staff B noted that there was no nursing assessment tool or documentation for assessing a patient's risk of decannulating or pulling out lines or tubes, and noted that one should be developed.

On 11/15/18 at approximately 1200 the Director of Respiratory Therapy Staff I was interviewed and reported that there was no behavior component on the Respiratory Therapy Decannulation Risk Assessment tool (form) because behaviors that pose a risk for decannulation or line dislodgement would be a Nursing assessment. Staff I stated, "This is a (corporation) wide assessment tool. The tool needs to be fixed."

There was no policy provided regarding risk assessment and interventions to prevent self decannulation and line dislodgement.

On 11/15/18 at approximately 1445, Patient #3's clinical record was reviewed with the Director of Quality Management Staff B and revealed the following information:

Patient #3's had a cardiopulmonary arrest after an accidental decannulation of her tracheotomy tube and subsequently expired.

Patient #3 was a 72 year old female who was admitted to the facility on 7/23/18 and expired in the facility on 8/14/18. Admission diagnoses included Interferential Hemorrhage (brain bleed) with Left Frontal Craniotomy and Drain Placement, Metabolic Encephalon, Right Side Empress (unable to move right side of body), Respiratory Failure with Ventilator Dependence, Tracheotomy and Percutaneous Endoscopic Gastrostomy (PEG). Patient #3 was admitted into the facility with a left soft wrist restraint in place and a flaccid (limp) right hand and arm.

A Code Status form, dated 7/23/18 at 2300 revealed Patient #3's responsible party (family) wanted full resuscitative measures to be initiated in the event of cardiac, pulmonary or cardiopulmonary arrest.

Review of Patient #3's care plans revealed there was no individualized care plan with targeted interventions for preventing unintended decannulation or line/tube dislodgement until 8/12/18 (two days before she deannulated and expired and nearly three weeks after admission) despite daily documentation of attempts to grab and pull at lines and tubes every time her left wrist soft restraint was loosened, and despite a prior incident on 8/5/18 when Patient #3 pulled her PEG tube out while her left wrist was restrained.

An "At Risk for Injury" Nursing Care plan dated 8/12/18 contained the following interventions to prevent accidents. The interventions noted to prevent line/tube lodgement or decannulation were all dated as assigned on 8/12/18 and included:
1. "perform frequent rounds on patient to monitor for safety (no time intervals specified)",
2. "notify Physician of continued risk that requires restraint of patient"
3. "assess restraint for proper appplication every two hours"
4. "wrap IVs (intravenous access devices) with gauze to prevent patient from disrupting or disconnecting lines-tubes" (no documentation this was done),
5. "position and secure tubing out of patient reach" (no documentation this was done or evaluated after incidents),
6. "consider using occlusive dressings, kling wrap or stockinette, skin sleeves, abdominal binder, mesh panties (no documentation that this was done)."

Review of Respiratory Therapy (RT) Flowsheets revealed Patient #3 was weaned from the mechanical ventilator and was receiving oxygen connected to her tracheostomy via a tubing at the time she expired. Her RT decannulation risk score throughout her admission, including on the day she expired was assessed as "no risk" of decannulation.

There was no documentation to indicate that Patient #3's tubing was protected with kling wrap, dressings, stockinette, an abdominal binder or mesh panties at any time during her admission, despite daily documentation of attempts to pull on lines and tubings and one instance when she pulled her PEG tube out.

An Adverse Event Report for Patient #3 dated 8/5/18 at 1538 documented that the Respiratory Therapist entered Patient #3's room to do rounds and noticed that Patient #3 had pulled her PEG tube completely out and had blood on her gown. The Event Investigation noted, "Patient had consistent periods of confusion and is at high risk for line dislodgement. Restraints were in place but patient was able to tug on them to loosen the fabric of the soft wrist restraint and then malposition body to reach the PEG tube." The Event Summary noted, "No further follow-up". A Care Plan with interventions to prevent decannulation or line/tube dislodgement was not created until six days later, on 8/12/18, and there was no documentation to indicate that all the interventions it contained were implemented.

An Adverse Event Report for Patient #3 dated 8/14/18 at 0309 noted that Patient #3 was found unresponsive with the tracheostomy tube decannulated. The patient was pulseless and a code blue was called (cardiopulmonary resuscitation). A Cardiopulmonary Resuscitation (CPR) Report form dated 8/14/18 documented the time of death as 0835 and the cause of death as, "Hypoxic Respiratory Arrest" (lack of oxygen due to stopped breathing).

On 11/15/18 at approximately 1540, Staff B was interviewed regarding Adverse Event root cause analysis and corrective measures implemented after these two incidents regarding Patient #3. Staff B reported that no investigation was done to determine whether the restraints were applied properly, whether the restraints themselves were faulty, whether the patient or the tubings were not properly positioned or who the assigned staff were at the time of the incidents. Staff B stated that there was no additional documentation to indicate that care planned devices were implemented to minimize patient access to the tracheostomy tube and oxygen tubing. Staff B was unable to provide documentation that staff were counseled or re-educated on interventions to prevent decannulation and line/tube dislodgement.

On 11/15/18 at approximately 1600, the Director of Respiratory Therapy was interviewed and stated that pulling on the oxygen tubing connected to the tracheostomy could cause decannulation of the tracheostomy tube.

On 11/14/18 at approximately 1230, Patient #6 was observed while Patient #6's assigned Staff Nurse R administered the patient's medications. Patient #6 was connected to mechanical ventilation (breathing machine) through an endotracheal tube (a plastic tube inserted into the trachea through the mouth to deliver oxygen to the lungs. - called also breathing tube). Patient #6 opened her eyes when addressed but appeared lethargic. Staff Nurse R reported that the patient was declining and not expected to survive much longer, and the Physician was attempting to contact the guardian to discuss changing the Patient's status to "Do Not Resuscitate" (no cardioplmonary resuscitation if her heart stops). Patient #6's lower lip had three brown scabbed areas which were draining bright red serosanguinous fluid. Patient #6's lips appeared cracked and dry. The largest scab was just to the left of the center of her lower lip and was approximately the size of a pencil eraser. Staff Nurse R suctioned bright red drainage from the patient's mouth with a suction cannister, and also mopped the blood off of Patient #6's lips and endotracheal tube with a gauze several times during the medication administration observation. Patient #6's left nostril was reddened and scabbed. When asked, Staff R said, "Her nostril has erosion from the nasogastric tube."

On 11/14/18 at approximately 1240, Staff R was asked about Patient #6's bleeding scabbed lips. Staff R stated that Respiratory and Nursing did mouth care approximately every four hours for patients on mechanical ventilation. When asked if Patient #6 had anything to treat Patient #6's dry cracked lips and bleeding lip sores, Staff R opened the patient's drawers and searched the patient's room and stated, I don't see anything. She should have ointment for her lips, but I can't find any in the room."

On 11/14/18 at approximately 1250 Patient #6's assigned Respiratory therapist (RT) Staff U was interviewed and stated she did mouth care twice a shift for Patient #6 and cleaned her lips with the mouth moisturizer included in the mouth care kit and changed the position of the endotracheal tube each time. Staff U stated that Nursing had ointments they could use for dry lips.

On 11/14/18 at appproximately 1300 an RT mouth care kit was inspected with the Director of Respiratory Therapy Staff I and the Director of Quality Management who were both interviewed at that time. The mouth care kit contained one small tube of single use water soluble mouth libricant. When asked if this would treat or prevent dry cracked lips, Staff I stated, "It's water soluble so it can be used to swab out the mouth. The water soluble mouth moisturizer in.our mouth care kits is not enough for dry cracked lips." Staff I stated that it was both Nursing and RT's responsibility to contact the physician to get an order for an ointment to treat dry cracked lips. Staff I stated that this should have been done as soon as either the RT or the Nurse noticed that Patient #6's lips were cracked and bleeding.

On 11/15/18 at approximately 1500 Patient #6's clinical record was reviewed with Staff B and revealed the following information:

Patient #6 was a 68 year old female who was admitted into the facility on 11/1/18 with diagnoses which included Rectal Cancer with Metastasis, Seizure, Cerebral Vascular Accident and Surgical Removal of a cancerous left groin mass with diverting colostomy, Ascites (fluid build up in the abdominal cavity), and Anasarca (generalized swelling of the whole body). The patient was receiving multiple intravenous antibiotics for infection.

Review of Patient #6's Nursing Care Plans revealed a care plan entitled, "Infection or Risk for Infection", assigned on 11/7/18 (six days after admission) with an intervention, "Assess for breaks in the patient's first line of defense (open wounds and abrasions)." There was no documentation that the nostril or mouth wounds were noted or assessed or that the care plan was updated to reflect the alteration of skin integrity of the patient's left nostril and lower lip. There were no targeted interventions to prevent, treat or heal mouth or nostril wounds.

Review of Patient #6's Nursing Care Plans revealed a care plan entitled, "The Patient Has Altered Skin Integrity, assigned on 11/7/18 revealed the following intervention, "assess Patient skin every shift for pressure from medical devices." There was no documentation that the care plan was updated to include the the alteration of skin integrity of the patient's left nostril and lower lip.There were no targeted interventions to prevent, treat or heal mouth or nostril wounds.

There was no Nursing Care Plan for mouth or lip care.

On 11/15/18 at approximately 1520 the Director of Quality Management Staff B was interviewed and stated, "Even though Patient #6 is dying and is"Comfort Care Only", we should be keeping her as comfortable as possible."

On 11/15/18 at approximately 1525, review of the facility policy entitled "Oral Hygiene for Patients with Artificial Airway", revised 2/18, with Staff B revealed the following Statements: "Respiratory and Nursing staff will be responsible for patients who have an artificial airway. The following are reported to the nurse if observed during oral hygiene: Dry cracked swollen or blistered lips. Nursing Documentation will include...notification of physician of any changes and any physician orders given."

On 11/15/18 at approximately 1530, review of the facility policy entitled, "Skin Integrity Check", reised 1/22/15 revealed the follwoing statements, "Complete skin integrity checks will be done daily to ensure skin/wound problems asr assessed and treated in a timely manner."

There was no policy provided regarding nursing interventions for alterations in skin integrity for lips or nostrils.

On 11/15/18 at approximately 1500 review of the facility policy entitled, "Assessment and care Planning", revised 10/10/16 revealed the following notations:

"The plan of care is developed by a registered nurse within 24 hours of admission"
"The plan of care is updated when current therapies prove ineffective"

Based on record review and interview, the facility failed to ensure an annual nursing competency and an annual performance evaluation were completed for 1 (Staff X) of 6 nursing staff members out of a total of 10 personnel files reviewed, resulting in the potential for less than optimal patient outcomes for all patients assigned to Staff X.
Findings include:

On 11/14/18 at 1000 an interview and tour of the nursing unit was conducted with the Director of Nursing (DON). She explained she was the new DON and new to the facility. She said she was hired on 11/12/18. She explained she was currently in orientation for her role as the DON.

On 11/15/18 at approximately 1300 a review of personnel files was conducted, and the following was revealed:
Staff X was a full time Licensed Practical Nurse (LPN) who was currently employed by the facility. A form entitled "Core Competency/Demonstration" dated 7/14/17 was reviewed and documented Staff ... had been evaluated for competency.

However, there was no further evidence in Staff X's personnel file that documented Staff X was evaluated for nursing competency after 7/14/17.

Additionally, further review of Staff X's personnel file revealed a form entitled "Annual Performance" dated 5/18/18 that was not signed by the employee Staff X nor the manager.

A review of the nursing schedules dated 11/11/2018 through 11/15/2018 documented Staff X was currently scheduled to work the 1900-0700 nursing shift on 11/11/2018 and 11/14/2018.

An interview was conducted with the Director of Quality Management on 11/15/18 at 1600. She explained competencies and performance evaluations were conducted annually for all staff. She said we have a "skills fair for competencies." She said, "I will have them look again."

On 11/15/18 at 1630 the Director of Quality Management said, "We could not find the competency for Staff X." She said, I don't know why the Performance evaluation was not signed upon review or completion. She said, those are the only documents in her file.