HospitalInspections.org

Based on review of clinical records, hospital policies, and staff interviews, the hospital failed to ensure that a registered nurse properly supervised and evaluated the nursing care for each patient, including not completing and/or accurately documenting assessments, not documenting patient repositioning, and not updating the treatment plan.

Findings were:

Review of the clinical record for patient #1 revealed that patient assessments and interventions were not completed, were incomplete, or were inaccurate; patient education was not documented for contact isolation precautions; and the treatment plan was not updated with a change in the patient ' s condition. Cross refer: CFR 482.23(b)(3)

Based on review of clinical records, hospital policies, and staff interviews, the hospital failed to ensure that a registered nurse properly supervised and evaluated the nursing care for each patient, including not completing and/or accurately documenting assessments, not documenting patient repositioning, and not updating the treatment plan.

Findings were:

Review of hospital policy entitled " Assessment / Reassessment, Policy #A20:02:04, effective date 4/99, revision date 6/7/00, stated, in part, " Reassessment A. During the patient ' s stay, each discipline will perform regular reassessments ... The reassessment data is used to reevaluate and revise the treatment plan and discharge plan ...B. Reassessment i. A nurse will reassess each patient according to the patient needs and each shift change. ii. Reassessment is performed every shift and documented on the Nurses Notes and Graphics. "

Review of the clinical record for patient #1 revealed no documented evidence of an RN assessment for 2 shifts during the patient ' s stay, including the following:
10-6-11 7 am to 7 pm
10-10-11 7 am to 7 pm

Review of hospital policy entitled " Wound Care Policy - 402.04 " Positioning " effective date 8/30/93, last revised 7/28/07, stated, in part, " A. Personal Care i. Patients will be turned every two hours, with small shifts more frequently. "

Review of the clinical record for patient #1 revealed no documented evidence or incomplete documentation to reflect that the patient was turned, sitting in a chair or bed, or up out of bed, or repositioned for the following shifts:

10-5-11, 7 am - 7 pm
10-6-11, 7 pm - 7 am
10-9-11, 7 am - 7 pm
10-10-11, 7 am - 7 pm
10-11-11, 7 am - 7 pm
10-11-11, 7 pm- 7 am

Review of the clinical record for patient #1 revealed no documented evidence or incomplete documentation of an integumentary assessment on the daily nursing assessment form by the registered nurse for the following shifts:

10-6-11, 7 am - 7 pm
10-6-11, 7 pm - 7 am
10-9-11, 7 am - 7 pm
10-9-11, 7 pm - 7 am
10-10-11, 7 am - 7 pm
10-11-11, 7 am - 7 pm
10-11-11, 7 pm - 7 am

Review of hospital policy titled " Wound Assessment by Staff and Wound Care Team (WCT), " policy #202.01, effective date: July 2002, last reviewed May, 2011 stated, in part, " Procedure: ...4. Any new wounds, (nosocomial or acquired) need to be entered on the Wound Assessment Sheet. The Wound Care Team will be responsible for checking the Wound Identification Sheet. Identified patients will be assessed and proper treatment initiated by the Wound Care Team ...Documentation should include: 1. Date of the assessment. 2. Location of the wound ...3. Type of wound: Pressure, diabetic. 4. Stage for pressure ulcers only ...b. Stage II: Partial thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents clinical as an abrasion, blister or shallow crater. "

Review of the clinical record for patient #1 revealed no documentation of a buttocks pressure ulcer on admission. On 10-12-11 at 0900, the nurse documented a progress note stating, " new blisters to buttock open, wound care here, cleaned and applied xeroderm to buttocks, turned to R side. " On the nursing graphic sheet dated 10-12-11, the nurse documented " (4) new blisters to buttocks. " There was no documented evidence that the pressure ulcer was discovered until it was classified at Stage 2 with 4 blisters.

Review of the clinical record for patient #1 revealed no " Wound Assessment Sheet " form completed as required by policy.

Review of hospital policy entitled, " Assessment/Reassessment " effective date 4/99, last revision date 6/7/00, stated, in part, " During the patient ' s stay, each discipline will perform regular reassessments ...the reassessment data is used to reevaluate and revise the treatment plan and discharge plan. "

Review of the clinical record for patient #1 revealed that a Stage 2 pressure ulcer was discovered on 10-12-11. Review of the nursing section of the " Interdisciplinary Team Conference Report " on 10-13-11 revealed a " zero " symbol for " Change in Condition " indicating incorrectly that there was no change in condition. Review of the " Wound Care " section of the same report on 10-13-11 revealed no documentation of the Stage 2 buttocks pressure ulcer (4 blisters) identified on 10-12-11.

Review of hospital policy entitled, " Patient/Caregiver Education " effective date 4/1/99, last revision date 1/17/03 stated, in part, " Patients as consumers have the right to be fully informed as to the nature of their illness and options for treatment ...Each patient has the right to maximize their health status and requires specific information to prevent disease and to improve and maintain that status ...all training performed will be documented on the Patient/Caregiver Education Log. "

Review of the clinical record for patient #1 revealed that he was admitted to the hospital on 10-3-11 on contact isolation for Methicillin-resistant Staph Aureus (MRSA). The record also indicated that the patient ' s wife visited the patient on several occasions. Review of the Educational Needs form revealed a table with 21 entries of education provided for the patient; however there was no documented evidence that the patient or visitors received education or instruction related to contact isolation, isolation procedures, MRSA, or preventing the spread of infection. The checkbox for " Isolation Precautions " was left unchecked.

The Centers for Disease Control and Prevention web article entitled, "Prevention of MRSA Infections in Healthcare Settings " stated, in part, " Patient education is a critical component of MRSA case management. Healthcare professionals should educate patients and visitors on methods to avoid MRSA transmission to close contacts. " (http://www.cdc.gov/mrsa/prevent/healthcare.html)

In an interview with staff #3, Director of Infection Control, she stated that the hospital should provide education to a patient and visitors about contact isolation for Methicillin-resistant Staph Aureus. The chief nursing officer, staff #1 stated that since most patients transferred from another hospital, they assume the patient and visitors would understand about isolation and procedures however he also acknowledged that education should be conducted for each patient and visitor in the hospital.

Review of the hospital policy entitled, " Fall Risk Identification & Prevention Program " Policy # K20:03:12, effective date 3/1/99, latest revision 5/24/05, stated, in part, " 8. Nursing or therapy staff can implement changes from a lower to higher risk level at any time. Changes from a higher to a lower risk level can be recommended at any time after consultation between nursing and therapy staff. "

Review of the clinical record for patient #1 revealed the Fall Risk/Safety Observations graphic was inconsistently and inaccurately completed by the assessing nurse over the course of the patient ' s stay, resulting in an inaccurate fall risk assessment. Review of the fall risk graphic on the daily nursing assessment indicated a scoring system based on patient risk factors, with a higher score indicating a higher level of risk. The resulting score designated the patient as a low, moderate, or high fall risk. Inconsistent areas scored included the patient ' s previous history of falls, failing to rank/include the patient ' s amputated leg, and the number of medications in certain classes that the patient was taking.

On 10-3-11, the nurse failed to score the patient ' s amputated leg, which scored the patient at a moderate risk for falls.

On 10-4-11, the nurse failed to rank the patient ' s amputated leg, which scored the patient at a moderate risk for falls.

On 10-5-11, the nurse failed to rank the patient ' s amputated leg, and failed to document that the patient had multiple falls >2 times in the past six months (which was scored on 10-3-11 and 10-4-11), which scored the patient at moderate risk

On 10-6-11, the nurse documented that the patient had no history of falling in the past six months.

On 10-6-11, a second fall risk failed to document that the patient had multiple falls >2 times, and failed to document that the patient was on three or more of the medications indicated on the form (antihypertensives, diuretics, narcotics, psychotropics, sedatives/hypnotics).

On 10-7-11, the nurse failed to document that the patient had multiple falls >2 times in the past six months.

On 10-8-11, the nurse failed to document that the patient had multiple falls >2 times I in the past six months.

On 10-9-11, the nurse increased the ranking for fall risk from medium risk interventions to high risk interventions.

On 10-10-11, the nurse failed to document that the patient had multiple falls >2 times in the past six months, and decreased the ranking for fall risk from high risk interventions to medium risk interventions. There was no documented evidence of a consultation between nursing and therapy staff as required by policy to lower the patient ' s fall risk.

On 10-11-11, the nurse failed to rank the patient ' s amputated leg. This resulted in a decreased ranking for fall risk from medium risk to low risk interventions for falls. There was no documented evidence of a consultation between nursing and therapy staff as required by policy to lower the patient ' s fall risk.

On 10-12-11, the nurse failed to rank the patient ' s amputated limb, the nurse failed to document that the patient had multiple falls >2 times, and failed to document that the patient was on three or more of the medications indicated on the form (antihypertensives, diuretics, narcotics, psychotropics, sedatives/hypnotics).

The above was confirmed in an interview with staff #1, chief clinical coordinator, on 6/21/12.

Based on a review of clinical records and staff interview, the hospital failed to ensure discharge summary inclusion in the clinical record.

Findings were:

Review of the clinical record for patient #1 revealed no documented evidence of a discharge summary.

In an interview on 6/21/12 with staff #3, the Director of Medical records, she confirmed that there was no discharge summary for patient #1.

Based on a review of clinical records and staff interviews, the hospital failed to ensure that education occurred for a patient and visitors on isolation precautions for methicillin-resistant staph aureus.

Findings were:

Review of hospital policy entitled, " Patient/Caregiver Education " effective date 4/1/99, last revision date 1/17/03 stated, in part, " Patients as consumers have the right to be fully informed as to the nature of their illness and options for treatment ...Each patient has the right to maximize their health status and requires specific information to prevent disease and to improve and maintain that status ...all training performed will be documented on the Patient/Caregiver Education Log. "

Review of the clinical record for patient #1 revealed that he was admitted to the hospital on 10-3-11 on contact isolation for Methicillin-resistant Staph Aureus (MRSA). The record also indicated that the patient ' s wife visited the patient on several occasions. Review of the Educational Needs form revealed a table with 21 entries of education provided for the patient; however there was no documented evidence that the patient or visitors received education or instruction related to contact isolation, isolation procedures, MRSA, or preventing the spread of infection. The checkbox for " Isolation Precautions " was left unchecked.

The Centers for Disease Control and Prevention web article entitled, "Prevention of MRSA Infections in Healthcare Settings " states, in part, " Patient education is a critical component of MRSA case management. Healthcare professionals should educate patients and visitors on methods to avoid MRSA transmission to close contacts " (http://www.cdc.gov/mrsa/prevent/healthcare.html).

In an interview with staff #3, Director of Infection Control, she stated that the hospital should provide education to patients and visitors about contact isolation for Methicillin-resistant Staph Aureus. The chief nursing officer, staff #1 stated that since most patients transferred from another hospital, they assume the patient and visitors would understand about isolation and procedures however he also acknowledged that education should be conducted for each patient and visitor in the hospital.

The above was confirmed in an interview on 6/21/12 with staff #1, Chief Clinical Coordinator.