HospitalInspections.org

Based on review of patients' records, review of policies and procedures and family and staff interviews the hospital failed to have an organized nursing service.

Findings include:

Nursing service failed to have a well-organized service, when the nursing failed to:

1) Ensure the person hired to be the Chief Nursing Officer (CNO A) received proper orientation or training for the CNO position. (Reference A 0386)

2) Provide an adequate number of certified nursing assistant (CNA) staff to meet the needs of patients. (Reference A 0392)

3) Supervise the care rendered to 2 of 5 sampled patients to ensure prevention of pressure ulcers and weight loss; Ensure 2 of 2 patients are weighed pre and post dialysis treatment; Monitor 4 of 4 high risk patients every 15 minutes per physician orders to prevent injuries; Ensure 1 of 15 patients was toileted to prevent incontinence; and Ensure direct care staff monitors and documents hygiene, activity, safety, nutrition, and sleep/rest status of patients. (Reference A 0395)


4) Develop, review, and revise the plan of care to meet the needs of 5 of 5 patients in a total of 15 sampled patients

The cumulative effects of these systemic failures, created an unorganized nursing service that did not meet the needs of patients dependent on their care.

Based on record review, policy review, and staff interview, the facility failed to ensure restraints are removed at the earliest possible time when restraints were used to prevent injuries due to fall potential in 5 of 5 patient's out of 15 sampled patients (Pt #2, #6, #7, #9, and #12).

Findings include:

The following examples are per Surveyor #03383:

Per review of restraints policy the morning of 12/30/09:

Lakeview ' s Use of Restraints - Medical Policy indicates the following:
" It is the policy of Lakeview Specialty Hospital and Rehab that each patient has the right to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff. All patients will be provided with a copy of their rights, including the right to be free from restraint, as part of the admissions process.
A restraint can only be used if needed to improve the patient ' s well-being and less restrictive interventions have been determined ineffective to protect the patient from harm. Any restraint must be initiated by staff trained in approved techniques and discontinued at the earliest possible time.
The philosophy that serves as a foundation for the regulation of restraint use at Lakeview is that use of restraint represents an exceptional event. Subsequently, each event is thoroughly assessed and orders for restraint are issued by the physician. The facility may not use restraints based solely on the request of the patient ' s legal surrogate. "
Restraint procedures:
" Medical restraints will only be used when clinically necessary to improve the patient ' s well-being and when other less restrictive measures have been determined ineffective to protect the patient from harm. Accordingly, staff will complete an assessment to attempt determination of the cause of the behavior to either clarify possible less invasive preventative measures or to verify that restraint is the only effective intervention option to maintain patient safety and the risk of restraint use is less than the risk of not using restraint.
The medical record will also reflect evidence of consideration of each patient ' s medical or psychological needs/limitations prior to the physician ' s designation of the permissible restrictive procedures including use of restraints.
The use of restraints will be integrated into the patient ' s modified plan of care. The modified plan of care will reflect assessment for the need of the restraint, its goal, and related interventions for decreasing use of restraint.
Medical restraints must be discontinued as quickly as possible. All members of the interdisciplinary team will monitor the patient ' s status and ability to effectively use less invasive alternatives and report related progress to the patient ' s physician. The physician will complete their own assessment of the patient ' s status and, if indicated, order the initiation of a trial reduction, including parameters for safe supervision of the patient. The physician will monitor success with these trials and determine when the restraint can be most quickly and safely discontinued. "
This policy and procedure was not followed for Pt #2 as evidenced by:
Per medical record review:

Per History and Physical:
Pt #2 was admitted to the facility on 11/5/09 with a diagnosis of status post (s/p) cardiopulmonary arrest, suicide attempt, COPD, and ischemic heart disease, CAD, impaired gait, and anxiety. The patient ended up in cardiac arrest after policed used a taser to subdue him. Pt #2 suffered anoxic brain injury and was admitted to Lakeview for continued care and management for deficits resulting from anoxic brain injury. Pt #2 is alert and oriented to person only; and has markedly diminished short-term memory.

The following progress notes indicate Pt #2 is attempting to stand while wearing a pelvic restraint on the following days:

11/6/09 at 11:00 AM: "1:1 supervision provided for safety. Has generalized weakness requiring assist of one for transfers and ambulation."

7:30 PM: " Patient taken off 1:1 supervision and put on 15 minute checks, pelvic in wheelchair, chair and bed alarm obtained. Patient attempted to stand up in wheel chair with pelvic in place. Redirected to sit down in w/c by staff. Patient kept near nurses station.

11/8/09 at 2:00 PM: "At times, patient attempting to get out of w/c by self."

Additional dates include:11/6/09 at 11:00 AM and 7:30 PM; 11/8/09 at 2:00 PM, 11/10/09 at 6:00 PM; 11/11/09 at 3:00 PM; 11/12/09 at 4:30 PM (Doesn't want to sit in w/c); 11/15/09 at 7:00 PM (patient is able to maneuver out of pelvic; 11/17/09 at 2:30 AM and 6:00 PM; 11/21/09 at 11:30 AM; 11/22/09 at 2:45 PM: Pt fought not to be restrained - wrist and mitt restraints applied with 3 staff; and at 10:40 PM; 11/23/09 at 1:45 AM: "standing up behind his chair with pelvic restraint still attached." 2:40: "Pt found in the bathroom pouring soap into a cup"; 11/26/09 at 3:00 PM; 12/4/09 at 7:00 PM; 12/5/09 at 5:50 PM, 12/6/09 at 6:00 PM: "Patient found with a bottled water with perineal cleanser and wipe in the bottle. Another patient stated that he was sucking on it"; 12/7/09 at 6:10 PM; and 12/8/09 at 1:30 AM.

The interdisciplinary team failed to develop a plan to address problems with Pt #2 standing up in his wheel chair with his pelvic restraint still attached to the wheel chair and the wheel chair dangling in the air. Progress notes fail to show less restrictive alternative methods were attempted (Reference V0396).

Physician Orders for Safety Intervention sheets show restraints were ordered on the following days:

On 11/10/09, 11/11/09, 11/12/09, 11/16/09, 11/17/09, 11/18/09, 11/19/09, 11/20/09, 11/21/09, 11/23/09 and at 11:00 - 11:10 AM: pelvic restraint for 24 hours due to climbing out of bed/chair- when unsafe to transfer/ambulate without assistance; and 15 minute checks due to being a fall risk and wandering. Safety interventions include Wander Guard, chair alarm and bed alarm; low bed, mat on floor, and video monitoring.

On 11/14/09 at 10:00 AM; 11/15/09 at 11:00 AM: pelvic restraint for 24 hours due to climbing out of bed/chair- when unsafe to transfer/ambulate without assistance; and 15 minute checks due to being a fall risk and wandering. Safety interventions include chair alarm and bed alarm; low bed, mat on floor, and video monitoring.

On 11/22/09 at 11:00 AM: left and right hand finger control mitts, left and right upper soft limb restraints, pelvic restraint for 24 hours due to climbing out of bed/chair- when unsafe to transfer/ambulate without assistance; and 15 minute checks due to being a fall risk and wandering. Safety interventions include Wander Guard, chair alarm and bed alarm; low bed, mat on floor, and video monitoring.

On 11/24/09, 11/25/09, 11/26/09, and 11/30/09, at 11:00 AM: left and right upper soft limb restraints, pelvic restraint for 24 hours due to climbing out of bed/chair- when unsafe to transfer/ambulate without assistance; and 15 minute checks due to being a fall risk and wandering. Safety interventions include Wander Guard, chair alarm and bed alarm; low bed, mat on floor, and video monitoring.

On 11/27/09 at 9:00 AM; 11/28/09, 11/29/09, 12/2/09 at 11:00 AM: left and right upper soft limb restraints, pelvic restraint for 24 hours due to climbing out of bed/chair- when unsafe to transfer/ambulate without assistance; and 15 minute checks due to being a fall risk and wandering. Safety interventions include seat belt (self-releasing), Wander guard, chair alarm and bed alarm; low bed, mat on floor, and video monitoring.

On 12/1/09 at 11:00 AM: left and right hand finger control mitts, left and right upper soft limb restraints, pelvic restraint for 24 hours due to climbing out of bed/chair- when unsafe to transfer/ambulate without assistance; and 15 minute checks due to being a fall risk and wandering. Safety interventions include alarmed seat belt, Wander Guard, chair alarm and bed alarm; low bed, mat on floor, and video monitoring.

12/5/09, 12/6/09, and 12/7/09 at 8:00 AM: pelvic restraint for 24 hours due to climbing out of bed/chair- when unsafe to transfer/ambulate without assistance; and 15 minute checks due to being a fall risk and wandering. Safety interventions include alarmed seat belt, Wander Guard, chair alarm and bed alarm; low bed, mat on floor, and video monitoring; and Arm ' s length - having near proximity (an arm ' s length) to the patient for wandering pelvic restraint for 24 hours due to climbing out of bed/chair- when unsafe to transfer/ambulate without assistance; and 15 minute checks due to being a fall risk and wandering. Safety interventions include alarmed seat belt, Wander Guard, chair alarm and bed alarm; low bed, mat on floor, and video monitoring on 12/5/09 and 12/6/09 at 8:00 AM.

Physical restraint Monitoring - Hospital form has a section that lists alternatives tried for reducing restraint usage. Listed on this form for alternatives is 1:1 conversation, distraction/activities/OT, change of environment, 1:1/family supervision, TV monitored rooms, self-removing seat belt, low bed/floor mat, bed or chair alarm, removable safety device, repositioning, bladder/bowel training, PRN meds for pain/anxiety, Wander Guard, abdominal binder, and other.

The next section shows the patient's response to restraint. Listed under this section is asleep, quiet, combative, disoriented, and other.

Examples were identified in 4 patient records that show not all of the alternatives listed were exhausted and patient response does not always indicate combativeness, or disorientation to justify keeping the patient restrained. Examples include:

Physical Restraint Monitoring form dated 11/30/09 shows staff used finger control mitts and a pelvic restraint for Pt #2. Alternatives listed that were tried include TV monitored room, low bed/mat, repositioning, bladder/bowel program, and PRN meds for pain and anxiety. Response to restraint shows Pt #2 is asleep and quiet. Pt #2 was not monitored every hour or every 2 hours for Safety Assessment and Comfort Measures from 8:00 AM to 6:00 PM. No other alternatives, i.e., distraction/activities/OT, change of environment, or 1:1/family supervision were tried.

On 12/2/09, Physical Restraint Monitoring form shows Pt #2 was in a pelvic restraint. Alternatives listed that were tried are TV monitored room, low bed/mat, repositioning, bed and chair alarm, bladder/bowel program, PRN meds for pain and anxiety, and Wander Guard. Response to restraint shows Pt #2 is asleep and quiet for most of the day except at 6:00 PM and 7:00 PM it shows Pt #2 was combative and disoriented. This is 2 hours out of the entire day. No other alternatives were tried.

On 12/3/09, Physical Restraint Monitoring form shows Pt #2 was in a pelvic restraint. Alternatives listed that were tried from include 1:1 conversation, TV monitored room, low bed/mat, repositioning, bed alarm, bladder/bowel program, PRN meds for pain and anxiety, and Wander Guard. Response to restraint shows Pt #2 is asleep and quiet for most of the day except at 8:00 PM and 11:00 PM it shows Pt #2 was combative and disoriented. Hourly and every 2 hour Safety Assessment and Comfort Measures documentation was not done from 8:00 AM to 2:00 PM. No other alternatives were tried.

Additional examples for Pt #2 include 12/4/09, 12/5/09, 12/6/09, 12/7/09, and 12/8/09.

Physical Restraint Monitoring forms indicate patients should be released from restraints every shift. Pt #2 was not trialed out of restraints at all on 12/2/09 and 12/5/09; released once at 12:00 PM on 11/30/09, 12/3/09 and 12/6/09, released twice on 12/4/09 at 8:00 PM and 10:00 PM. (Note: Only have Physical Restraint Monitoring forms from 11/30/09 to 12/8/09).

2) Physical Restraint Monitoring form dated 11/4/09 shows Pt #7 has marked agitation, disorientation, and is a marked fall potential. Pt #7 was placed in a pelvic restraint and is on 1:1. Alternatives listed that were tried include 1:1 conversation, 1:1/family supervision, TV monitored room, low bed/mat, repositioning, bed alarm, and bladder/bowel program. Patient response lists Pt #7 as either asleep or quiet for the entire day. No other alternatives were tried to reduce use of pelvic restraint, especially when Pt #7 had 1:1 supervision.

Physical Restraint Monitoring form dated 11/17/09 shows Pt #7 is confused and is a marked fall potential. Pt #7 was placed in a pelvic restraint. Alternatives listed that were tried include 1:1 conversation, TV monitored room and low bed/mat. Patient response lists Pt #7 as either asleep or quiet for the entire day. No other alternatives were tried to remove pelvic restraint.

Physical Restraint Monitoring form dated 11/18/09 shows Pt #7 is confused and is a marked fall potential. Pt #7 was placed in a pelvic restraint and soft limb restraint. Alternatives listed that were tried include 1:1 conversation, TV monitored room, low bed/mat, and repositioning. Patient response lists Pt #7 as either asleep or quiet. Safety Assessment & Comfort Measures section shows staff did not monitor Pt #7 every hour or every 2 hours from 8:00 AM to 6:00 PM. No other alternatives were tried to reduce use of pelvic and soft limb restraints.

Additional examples of similar finding occurred on the following dates: 11/5/09, 11/9/09, 11/10/09, 11/11/09, 11/12/09, 11/16/09, 11/19/09, 11/20/09, 11/21/09, 11/22/09, 11/23/09, 11/24/09, 11/25/09, 11/26/09 (Safety Assessment & Comfort Measures section shows staff did not monitor Pt #7 every hour or every 2 hours from 8:00 AM to 11:00 PM, 11/27/09, 11/28/09, 11/29/09, 11/30/09, and 12/3/09 through 12/10/09.

Physical Restraint Monitoring forms indicate patients should be released from restraints every shift. Pt #7 was not trialed out of restraints while up in chair on the dates listed above.

3) A review of Pt #9's Physical Restraint Monitoring form on 1/4/10 dated 12/29/09 to 1/3/09 revealed the form dated 1/3/10 shows Pt #9 is confused and is a marked fall potential. Pt #9 was placed in a geri chair with a pelvic restraint and 4 side rails are used when in bed. Finger control mitts was also used on 12/29/09, 12/30/09, 12/31/09, 1/1/10, and 1/2/10, Alternatives listed that were tried include TV monitored room, low bed/mat, repositioning, and bowel/bladder training. Patient response lists Pt #9 as either asleep or quiet. No other alternatives were tried to reduce use of pelvic when up in geri chair. and soft limb restraints. Similar examples occurred on 12/29/09, 12/30/09, 12/31/09, 1/1/10, 1/2/10, and 1/3/10.

4) Physical Restraint Monitoring form dated 10/28/09 through 11/5/09 shows Pt #6 has confusion, disorientation, and is a marked fall potential. Pt #6 was placed in a pelvic restraint and is on 1:1 supervision. Alternatives listed that were tried include 1:1 conversation, 1:1/family supervision, TV monitored room, low bed/mat, repositioning, bladder/bowel program, and abdominal binder. Patient response lists Pt #6 as either asleep or quiet for the entire day on 11/7/09, 11/8/09, from 12:00 AM to 7:00 AM on 11/10/09, and 11/15/09. No other alternatives were tried to reduce use of pelvic restraint. Safety Assessment & Comfort Measures section shows staff did not monitor Pt #12 every hour or every 2 hours on 11/12/09 and 11/13/09 from 8:00 AM to 11:00 PM.

5) Physical Restraint Monitoring form dated 11/5/09 shows Pt #12 was placed in a pelvic with 1:1 supervision from 11/5/09 to 11/15/09. Alternatives listed that were trialed include 1:1 conversation with patient, 1:1/family supervision, repositioning, and abdominal binder. Patient response lists Pt #12 as either asleep or quiet. Safety Assessment & Comfort Measures section shows staff did not monitor Pt #12 every hour or every 2 hours from 7:00 AM to 6:00 PM.

Administrator D and Dr. N confirmed during exit conference on 1/4/10 between 2:45 PM and 3:30 PM that documentation fails to show alternatives tried to reduce restraint usage.

Based on personnel file review and staff interview, the hospital failed to ensure the person hired to be the Chief Nursing Officer (CNO A) received proper orientation or training for the CNO position.

Findings include:

A review of personnel files on 12/9/09 beginning at 8:55 AM revealed that CNO A was hired on 7/28/08 as a Patient Care Manager (PCM). Orientation and training in CNO A's personnel file shows orientation for PCM. CNO A was promoted to CNO position on 2/1/09. No formal orientation or training was found in CNO A personnel file to confirm training for CNO position. CNO A confirmed this finding on 12/9/09 at 1:15 PM. CNO A indicated that she spent 1 week with the previous CNO; however, this is not reflected in CNO A's personnel file.

Lack of formal training may contribute to system failures found within the nursing services Condition of Participation. (Reference A 0385, A 0392, A 0396, and A 0154).

Based on policies and procedures review, staffing review, payroll sheet review, patient census review, job description review, and staff interview, the hospital failed to provide an adequate number of certified nursing assistant (CNA) staff to meet the needs of patients. The hospital failed to ensure the hospital provides enough certified nursing assistants to perform tasks as specified by the CNA job description. (Please reference A0154, A0385, and A0395 for specific examples associated with staffing failures).

Findings include:
Per interview with Chief Nursing Officer (CNO) A on 12/9/09 at 11:35 AM:
CNO A indicated the hospital is broken into two units; Hospital East where most behavioral patients are admitted; and Hospital South is where medically compromised patients are admitted. A total of 20 patients can be admitted to Hospital East; and a total of 19 patients can be admitted to Hospital South. A staffing matrix was developed by CNO A based on prior experience as well as some input from the former CNO. The staffing matrix is used to determine staffing for the hospital. Staffing for nurses, including registered nurses (RNs) and licensed practical nurse (LPNs) on the day (7:00 AM - 3:00 PM) shift is six patients to one staff (6:1) on days, 8:1 on the evening shift (3:00 PM - 11:00 PM), and ten patients to one nurse (10:1) on the night shift (11:00 PM - 7:00 AM). The hospital is staffed with eight certified nursing assistants (CNA) on the day shift, eight CNAs on the evening shift, and five CNAs on the night shift. Three CNAs typically work on Hospital South, while five CNA ' s work on Hospital East. CNO A indicated problems with CNA staffing on third/night shift.

Data reviewed and used to determine staffing: Patient Census sheets, Hospital Daily Staffing Sheets, staff Time Card Reports, grid provided by Administrator D, and Hospital Daily Staffing Sheets for Hospital East and Hospital West.

Two months of Patient Census sheets from 10/1/09 through 11/30/09 shows patient names, the number of patients on Hospital East and Hospital South, patients requiring 1:1 intense supervision (IS) and the length of time required, 15 minute checks, total hours needed for 1:1 IS, patient admissions and discharges, and patient transfers to another acute care hospital.

Per Staffing Matrix:

Hospital East
0-6 patients, need 1 Nurse and 3 CNAs
7-12 patients need 2 Nurses and 3 CNAs
13-16 patients need 2 Nurses and 4 CNAs
17-20 patients need 3 Nurses and 4 CNAs

Hospital East AM/PM shift

*Staffing ratio is sufficient to accommodate 2 intense supervision (IS) patients; for >2, add 1 CNA for every 1 IS

*Add 1 RN/LPN for >2 anticipated admissions on a shift to a maximum of 3 total RN/LPN
0-7 patients, need 1 Nurse and 3 CNAs
8-14 patients, need 2 Nurses and 3 CNAs
15-20 patients, need 2 Nurses and 4 CNAs

Hospital East Night (Noc) Shift

*Staffing ratio is sufficient to accommodate 3 IS patients; for >3, add 1 CNA for every 1 IS

Hospital South:
0-6 patients, 1 Nurse and 2 CNAs
7-12 patients, 2 Nurses and 2 CNAs
13-19 patients, 3 Nurses and 3 CNAs

Hospital South AM/PM shift

*Staffing ratio is sufficient to accommodate 1 IS patient; for >1, add 1 CNA for every 1 IS

*Add 1 RN/LPN for >2 anticipated admissions on a shift to a maximum of 3 total RN/LPN
0-6 patients, 1 Nurse and 2 CNAs
7-14 patients, 2 Nurse and 2 CNAs
15-19 patients, 3 Nurses and 3 CNAs
Hospital South Noc Shift

*Staffing ratio is sufficient to accommodate 1 IS patient; for >1, add 1 CNA for

Per Staffing Policy:

Critical Staff Protocol Policy under Staffing Minimums, Staffing Reassignments, and Training indicates " each unit within Lakeview Specialty Hospital & Rehab is responsible for identifying their staffing needs based on patient census, acuity and milieu, and directives by governing regulations. Lakeview Specialty Hospital & Rehab requires that changes in need be communicated to the Administration for inclusion as an amendment to Lakeview ' s Emergency Operations Plan (EOP) and the Hospital incident Command System (HICS). In situations where patient safety is compromised due to staffing levels dropping below established minimums it is incumbent upon the unit Director to communicate the need as soon as possible.
i. Alter working hours of any employee to meet demands of the community.
ii. The reassignment of experienced and trained staff from the other areas of the facility will be implemented in keeping with the Staff Utilization Policy, #17.1007.
iii. In situations where it is necessary to hold over into the next shift due to staffing shortages and/or call-ins, the facility will implement the Shift Hold Over Policy, #17.309.
iv. Lakeview recognizes the importance of matching staff skills with patient/resident needs to ensure continuum of care. As staff hold over and reassignments become necessary Lakeview will implement the Matching Staff Skill to Patient/Resident Care Needs Policy, #17.1005.
v. In severe staffing shortages it may be necessary to implement the reassignment of non-direct care employees into direct care roles. Whenever possible consideration should be made to match employees ' prior work experiences with patient needs. In many cases previous front line employees may be filling roles of techs, social workers, therapists, clinicians, housekeepers, and back-office support workers. "
Policy: Staffing - Shift Hold Over indicates " Lakeview Specialty Hospital & Rehab must provide a safe environment and a high level of care for residents/patients at all times, therefore, all facilities will require direct care employees to remain on the care areas until appropriate personnel arrive to relieve the staff. "

The hospital failed to follow their staffing policies as evidenced by the following:

Per Job Descriptions:

Job Description & Performance Evaluation for Certified Nursing Assistant (CNA) shows key CNA responsibilities include: " Tends to the patients immediate needs for safety, education, health/hygiene, and comfort in ways that foster independent functioning on the part of the patient (i.e. activities of daily living/ADL ' s, mealtime, bathing, laundry, community access, recreational activities, and vocational skills) in accordance with competencies. " Section E of Performance Standards indicates CNA " Check special precautions during the beginning of each shift. Performs safety checks at scheduled times and documents observations. " Standard #3 indicates 15% also indicates, " Completes daily CNA documentation on assigned patients, including 1:1 ' s.

Based on staffing submitted to Surveyor #03383 on 12/23/09 by Administrator D and reviewed on 12/28/09, 12/29/09, and 12/30/09:

Surveyor #03383 placed RN, LPN, and CNA staffing on a grid using staff time sheets from 10/1/09 to 11/30/09 and requested Administrator D and Chief Nursing Officer (CNO) A review staffing and confirm whether it is correct on 12/19/09. Administrator D created his own staffing grids and returned staffing grids to Surveyor #03383 on 12/23/09. Surveyor #03383 compared staffing grids submitted and confirmed findings with Administrator D and CNO A the morning of 1/4/2010.

Hospital Daily Staffing Sheets for first, second, and third shift were reviewed on 12/30/09 and compared to staffing grids submitted by Administrator D along with Hospital East and Hospital South Patient Census sheets. Patient Census sheets reveal the number of patients admitted on specific days; and also the number of patients requiring 1:1 supervision and patients requiring 15 minute checks. A review of staffing information from 11/1/09 to 11/13/09 revealed the following:

1. Hospital East Patient Census form shows patient census on 11/1/09 was 16 patients. Pt #6 and Pt #7 were on 1:1 supervision for 24 hours; Pt #8 is on 15 minute checks, and Pt #9 is on 1:1 supervision with meals. Staffing grid provided by Administrator D shows 4 CNAs worked the day shift (7:00 AM to 3:00 PM). Two CNA or Resident Assistance (RA) staff must be assigned to supervise Pt #6 and Pt #7. Another CNA or RA is responsible for monitoring Pt #8 every 15 minutes. This leaves 1 CNA to provide care for 12 patients. Care according to CNA job description include: ADL ' s, mealtime, bathing, laundry, community access, recreational activities, and vocational skills. Third shift shows one CNA to care for all 16 patients, including the Pt #6 and #7 on 1:1 supervision and 15 minute checks. CNA staffing on the third shift (11:00 PM - 7:00 AM) shows one CNA (CNA W) to care for all 16 patients, including two 1:1 supervision patients #6 and #7.
Similar problems were identified with CNA staffing on Hospital East that put patients at risk of not receiving basic cares like toileting, repositioning, incontinence care, bathing, and assistance with dressing, transfers, feeding, or any other care the patient requires as evidenced by:
2. Patient Census is 16 on 11/13/09. Pt #9 was on 1:1 supervision for 7.5 hours with meals; Pt #7 was on 1:1 supervision for three hours with meals; Pt #8, #13, #14, and #15 are on 15 minute checks. Two CNAs (FF and GG) worked the night shift (11:00 PM - 7:00 AM). If one CNA provides 1:1 supervision to Pt #9, this leaves one CNA to provide care for the 15 remaining patients, including the four patients (#8, #13, #14, and #15) requiring 15 minute checks.
3. Patient Census is 17 on 11/13/09. Pt #11 was moved to Hospital East from Hospital South at 7:00 PM and requires 1:1 supervision for 24 hours; Pt #9 was on 1:1 supervision for 7.5 hours with meals; Pt #7 was on 1:1 supervision for three hours with meals; Pt #8, #13, #14, and #15 are on 15 minute checks. Three CNAs (Y, KK, and LL) worked the night shift (11:00 PM - 7:00 AM). One CNA providing 1:1 supervision to Pt # 11 leaves two CNAs to provide care for 16 remaining patients, including the 4 patients (#8, #13, #14, and #15) requiring checks every 15 minutes.
4. Patient Census on 11/2/09 is 15. Pt # 7 was on 1:1 supervision for 24 hours; Pt #9 was on 1:1 supervision for six hours with meals; Pt #8 was on 1:1 supervision for three hours with meals. Two CNAs (FF and GG) worked the night shift (11:00 PM - 7:00 AM). According to the staffing matrix, 3 CNAs should be working the night shift with a patient census of 15.
5. Hospital South Patient Census form shows patient census on 11/1/09 was 9 patients. Pt #10 and Pt #11 were on 1:1 supervision for 24 hours. Staffing grid provided by Administrator D shows 2 CNAs (CNA T and CNA U) worked on the day shift (7:00 AM to 3:00 PM). This leaves 7 patients without a CNA to care for them or two Pt's (#10 or Pt #11) without 1:1 supervision on the day shift. CNA staffing on the third shift (11:00 PM - 7:00 AM) shows one CNA (CNA V) was the only CNA present to care for all 9 patients, including two patients (#10 and #11) requiring 1:1 supervision.
Similar problems were identified with CNA staffing on the following days on Hospital South that put patients at risk of not receiving basic cares such as toileting, repositioning, incontinence care, bathing, assistance with dressing, transfers, feeding, or any other care the patient requires, as evidenced by:
6. Patient Census is 10 on 11/3/09. Pt #6, #10, Pt #11, and #12 were on 1:1 supervision for 24 hours. One CNA (FF) worked on the day shift (7:00 AM - 3:00 PM) and 1 CNA (Y) worked on the night shift (11:00 PM - 7:00 AM). This leaves 3 patients without 1:1 supervision and 6 patients without a CNA to perform toileting, repositioning, incontinence care, bathing, assistance with dressing, transfers, feeding, or any other care the patient requires.
7. Patient Census is 11 on 11/8/09. Pt #6, #10, and Pt #11 were on 1:1 supervision for 24 hours. One CNA (GG) worked on the night shift (11:00 PM - 7:00 AM). Ten patients did not have the benefit of CNA care, including two patients requiring 24 hour 1:1 supervision.
8. Patient Census is 9 on 11/4/09. Pt #6, #10, and Pt #11 were on 1:1 supervision for 24 hours. One CNA (BB) and one Resident Assistant (RA) worked on the day shift (7:00 AM - 3:00 PM) and 2 CNAs (V and W) worked on the night shift (11:00 PM - 7:00 AM). This leaves 2 patients without 1:1 supervision and 6 patients without a CNA to perform toileting, repositioning, incontinence care, bathing, assistance with dressing, transfers, feeding, or any other care the patient requires.
9. Patient Census is 14 on 11/13/09. Pt #5, #6, #10, and Pt #11 were on 1:1 supervision for 24 hours. Three CNA's (U, HH, II) worked the day shift (7:00 AM - 3:00 PM) and 3 CNAs (V, GG, JJ) worked on the night shift (11:00 PM - 7:00 AM). This leaves 1 patient without 1:1 supervision and 10 patients without a CNA to perform toileting, repositioning, incontinence care, bathing, assistance with dressing, transfers, feeding, or any other care the patient requires.
10. Patient Census is 10 on 11/6/09. Pt #6, #10, and Pt #11 were on 1:1 supervision for 24 hours. One CNA (W) and one Resident Assistant (RA) MM worked on the night shift (11:00 PM - 7:00 AM) leaving 8 patients without CNA care, including a patient requiring 1:1 supervision.
11. Patient Census is 11 on 11/10/09. Pt #6, #10, and Pt #11 were on 1:1 supervision for 24 hours. Two CNAs (GG and NN) worked on the night shift (11:00 PM - 7:00 AM). Ten patients did not have the benefit of CNA care, including one patient requiring 24 hour 1:1 supervision.
12. Patient Census is 10 on 11/2/09. Pt #10 and Pt #11 were on 1:1 supervision for 24 hours; Pt #12 was on 1:1 supervision for eight hours; Pt #6 was on 1:1 supervision for 5.5 hours. Two CNAs (Y and FF) worked the night shift (11:00 PM - 7:00 AM). This leaves 8 patients requiring basic CNA care.
Staffing grids were reviewed with Administrator D on 1/4/10 from 10:34 AM until 11:40 AM and staff findings were confirmed with CNO A on 1/4/10 at 3:22 PM.

Based on record review and staff interview conducted by Surveyor #03383, the registered nurse failed to supervise the care rendered to 2 of 5 sampled patients to ensure prevention of pressure ulcer and weight loss (Pt #1). Staff failed to ensure 2 of 2 patients (Pt #3 and #5) out of a total sample of 15 sampled patients are weighed pre and post dialysis treatment. Staff failed to monitor 4 of 4 patients (Pt #1, #2, #7, and #8) every 15 minutes per physician orders out of a total sample of 15 sampled patients; and staff failed to ensure 1 of 15 patients (Pt #2) was toileted to prevent incontinence; and failed to ensure direct care staff monitors Nursing Standards Flowsheet to ensure staff monitors and documents hygiene, activity, safety, nutrition, and sleep/rest status of patients.

Per medical record review conducted the morning of 12/21/09, 12/22/09 and 12/23/09:

1) The Initial Nursing Admission Assessment shows Pt #1 was admitted to Lakeview on 10/23/09 from a Madison area hospital. Initial Nursing Assessment indicates Pt #1 is a high risk for skin breakdown (score <17: "15"), is on tube feedings and has swallowing difficulties. Skin diagram shows midline abdominal dehiscence with no other pressure ulcers noted. Pt #1's admission is weight 160 lbs and height is 6 ft. Pt #1 was transferred to a local area hospital on 11/8/09 due to fever and leukocytosis.

Pressure Ulcers:
A wound assessment conducted at hospital in Burlington on 11/9/09 reveals Pt #1 " has non-stageable pressure ulcer to coccyx that is at least a Stage III. Foam dressing put over ulcer to soften eschar and will need non-excisional debridement of slough and eschar. Pressure ulcers to heels and plantar foot are dried and blisters are stage II pressure ulcers. Skin intact. Patient has ileostomy and Lakeview was leaving appliance off and stool was leaking over the skin cause extreme skin irritation and denudement. Skin very wet. Evidently Lakeview was having trouble keeping wafer on and so they left it off and stool was constantly on the skin causing it to become very wet, raw, and denuded."

Wound assessment measurements at the Burlington Hospital on 11/9/09 show the following:
11/9/09
Coccyx pressure ulcer is 7.50 cm in length, 7.00 cm in width, 0.10 cm depth with 80% necrotic tissue eschar and 20% necrotic tissue slough. Unable to stage due to necrotic tissue. Serosanguineous drainage with faint odor.

Left heel: 3.20 cm length; 2.00 cm width; Stage II; brown in color

Left foot: 2.10 cm length; 1.50 cm width; Stage II; brown in color

Right heel: 2.00 cm length; 1.80 cm width; Stage II; brown in color

Abdomen: excoriation, erythema in color, poorly defined.

Unstageable coccyx pressure ulcer was debrided on 11/16/09 while Pt #1 was at a local area hospital in Burlington. Once debrided, coccyx pressure ulcer was determined to be a Staged IV on 11/16/09. Pt #1 developed the above pressure ulcers while admitted to Lakeview.

Pt #1 was transferred back to Lakeview on 11/16/09. Wound measurements on discharge from hospital in Burlinton on 11/16/09 after debridement was completed and day of discharge was as follows:

Coccyx pressure ulcer is 7.00 cm length, 9.00 cm width, 3.00 cm depth with necrotic tissue eschar and necrotic tissue slough. Stage IV.

Left heel: 3.20 cm length; 2.00 cm width; Stage II; brown in color

Left foot: 2.10 cm length; 1.50 cm width; Stage II; brown in color

Right heel: 2.00 cm length; 1.80 cm width; Stage II; brown in color

Abdomen: Peristomal skin continues to improve and only has one area to right of stoma that is slightly denuded.

Pt #1 was transferred back to the original transferring hospital in Madison on 12/1/09 from Lakeview due to pressure ulcers. Physician progress note and Wound Care note completed on 12/1/09 indicates the following: " He has a stage IV ulcer over the sacrum and coccyx. The wound has 60-75% healthy viable tissue, but is without granulation. There is necrotic connective tissue. This was debrided today by myself using a scissor and pickup. There is exposed muscle and fascia, but not viable or palpable bone. Periwound skin is free of rash and erythema, induration. No purulence. There is a stage ll ulcer on the left heel that with also without infection and superfical. There is a resolving blister without fluid over the right heel. Abdomen is excoriated from chemical burn due to leaking ileostomy. This extends 30cm from side to side. The abdominal wound is healed with a long vertical crease causing appliance leaks. The area is without infection. Painful. Crusted skin with stomahesive powder and nosting prep. The patient was noted to have significant irritation of his abdominal wall due to the patient dismantling his ostomy bag frequently.
Impression: stage IV pressure ulcer of the sacrum, stage II ulcers of the bilateral heels, peristomal excoriation due to chemical damage for leaking ileostomy

SMH measurement of pressure ulcers completed by Wound Ostomy Nurse K on 12/2/09:
Right heel: 0.2 cm L x 0.2 cm W. Unable to determined depth due to black scab. Area is defined, skin is blanchable around wound site. Unable to determine staging at this time. Continue use of Prevalon boot.
Left heel: 2.1 cm L x 1.7 cm W x 0.1 cm D. Has deep tissue injury at base of wound. Stage II for the open area. Wound bed has pink granulation tissue. Skin is blanchable. Edges defined except by the deep tissue area. No drainage noted. Has some callused skin around the wound. Use dimethicone oint to this area. Continue use of Prevalon boot.
Left bunion great toe: 1.3 cm L x 1.7 cm W x 0.1 D. Area is defined, partial thickness, blanchable, no drng, no odor, base has pink granulation tissue. Stage II. Continue Prevalon boot.
Abdomen around ostomy site is reddened and warm to touch, but blanchable. Will try a different appliance to prevent leakage onto skin.
Coccyx wound: Stage IV. Measures 8.5 cm L x 6.5 cm W x 4 cm deep, with undermining as follows:
12 O'clock - 3.0 cm
3 O'clock - 3.0 cm
6 O'clock - 3.5 cm
7 O'clock - 1 cm
9 O'clock - 1.5 cm
Wound drainage thick yellow, odorous liquid. Edges of wound have some pink granulation tissue, Base with some pink granulation tissue and areas of yellow eschar. Edge of wound is defined. No tunneling noted.

Lakeview Wound Care Documentation sheets show right butt pressure ulcer documentation began on 10/28/09 and measured 2 cm length, 1.2 cm width, and 0.1 cm depth. On 11/4/09 right butt pressure ulcer is 8.0 cm length, 5.8 cm width, and 0.1 cm depth. Stage II left buttock pressure ulcer documentation began on 11/4/09 and measures 3.0 length, 1.8 width, and 0.1 depth. Stage II left foot medial ball began on 10/30/09 and measures 2.3 cm length, 1.2 width, and 0.1 cm depth. On 11/4/09 left foot is 100% eschar and unstageable. Right heel is not mentioned.

Documentation above shows pressure ulcers developed and worsened at Lakeview on from 10/28/09 to discharge on 12/1/09.

2) Pt #5's medical record was reviewed the morning of 12/21/09, 12/22/09 and 12/23/09 and revealed the following: Pt #5 was admitted to Lakeview on 11/11/09 for wound care and dialysis according to Initial Nursing Assessment completed on 11/11/09; Pt #5 was transferred to a local area hospital in Burlington on 11/28/09 due to leukocytosis, hypotension, and lethargy; and readmitted to Lakeview on 12/4/09.

Pt #5's Nursing Admission Assessment completed on 11/11/09 shows Pt #5 is a high risk for skin breakdown (score <17: "15") It also shows Pt #5 has a Stage II sacral pressure ulcer measuring 6 cm length, 4 cm width, 0.2 cm depth . No other pressure ulcers are identified on full body diagram. Pt #5 was transferred to a local hospital in Burlington on 11/28/09, 17 days later, and a wound assessment performed by Wound Care Nurse P revealed the following:

On 11/29/09, the next day after transfer to the local hospital in Burlington on 11/28/09, A Comprehensive Wound Assessment performed by RN R at 12:27 AM shows Pt #5 had a sacral pressure ulcer measuring 5.00 cm in length, and 4.00 cm in width. Sacral ulcer is described as a possible Stage III with unstageable necrotic tissue and slough, black around edges and darkening around skin around it. Sacral wound documentation entered by RN Q on 11/29/09 at 9:00 AM, by RN S at 4:33 PM and Wound Care RN P on 11/30/09 at 1:15 PM, and by RN P on 12/3/09 at 3:04 PM (day prior to discharge back to Lakeview) indicates sacral ulcer was unchanged.

Pt #5 was transferred back to a local hospital in Burlington on 12/22/09 and Wound Care RN P documented on 12/22/09 at 11:17 AM: "Pt with pressure ulcers that were present on admission. Non-excisional debridement of slough from sacral ulcer. Able to see small areas of red wound bed in base after debridement. This ulcer is unstageable due to the slough but it is at least a Stage III. The ulcer right hip is pink tissue mixed with thin slough. Also to lateral right thigh she has an ulcer covered with dry adherent eschar. It is also at least a

Stage III." Measurements of pressure ulcers:

Sacrum: 9.50 length; 5.50 width; 1.30 depth. necrotic tissue, 100% slough, unable to stage.

Right Hip: 3.00 cm length; 0.50 width. 40 % Granulated tissue, 60 % Necrotic tissue, Stage III.

Lateral Right Thigh: 5.50 cm length, 1.20 cm width. 100% necrotic eschar tissue. Unable to stage.

On 12/23/09 at 4:00 PM per Wound Care RN P: "Sacral ulcer with less slough. Able to see more granular buds. Less erythema around ulcer. In center of ulcer is white boggy tissue that appears to be bone sheath, so ulcer is a Stage IV now that wound is debrided. Still with slough present but not able to sharply debride."

Pt #5 started with a Stage II sacral ulcer measuring 6 cm length, 4 cm width, 0.2 cm depth on admission to Lakeview on 11/11/09 that worsened to a Stage IV sacral ulcer by 12/22/09. Pt #5 also developed new stage III pressure ulcer on right hip measuring 3.00 cm length; 0.50 width, and an unstageable pressure ulcer on lateral right thigh measuring 3.00 cm length; 0.50 width that is believed to be at least Stage III.

Nutrition:

3) The Initial Nursing Assessment completed on 10/23/09 indicates Pt #1 weighed 160 lbs and height is 6 feet. Madison area hospital Progress notes dated 12/22/09 show Pt #1's weight on 10/19/09 is 170 lb 10.2 oz, 10/20/09 is 168 lb 14 oz, 10/21/09 is 168 lbs 14 oz, and 12/22/09 is 168 lb 10.4 oz. Weights are relatively consistent with a minimal amount of weight loss. When Chief Nursing Officer A was asked the morning of 12/10/09 who weighed Pt #1 on admission to Lakeview on 10/23/09 and which scale was used, Staff A indicated that she had no idea. Pt #1 was transferred and admitted to the local hospital in Burlington from Lakeview 11/8/09 to 11/16/09 (8 days). The hospital in Burlington shows Pt #1's admission weight is 150.3 lbs. on 11/8/09. Based on discharge weight from Madison area hospital on 10/22/09 and admission weight on 11/8/09, Pt #1 lost approximately 18 lbs in 16 days.

A Nutrition Services Assessment performed by the dietician on 10/23/09 at 1:55 PM indicates Pt #1's weight is 160 lbs and ideal body weight is 178 lbs. Body Mass Index (BMI) is 21.7 and albumin was 3.5 (normal range: 3.5 to 5.0 g/dL). The dietician indicated the weight was taken from the nursing assessment when questioned about it the morning of 12/10/09. Nutren 1.5 at 65 cc/hour at 180 cc 6 times/day for 2340 Kcals/day for 94 grams/day and 1209 cc/day (plus 1080 cc with flushes). Dietary Nutrition Care Plan dated 10/23/09 indicates Pt #1's nutritional status will be assessed every week or as needed. Progress note written on 10/26/09 at 8:40 shows nursing indicates Pt #1 does not have intolerance to tube feeding. No weight is mentioned. Nutrition note entered on 11/5/09 at 8:32 AM (10 days later) indicates Pt #1's weight is stable at 158 lbs. Pt #1's family spoke with the dietician and informed the dietician that Pt #1 used to weigh between 180-200 lbs. The dietitian indicated to Surveyor #03383 the morning of 12/10/09 that she used 160 lbs to calculate the caloric needs for Pt #1. Lab test results show Albumin was 2.5 g/dL on 10/28/09 and 10/29/09; and 11/6/09 was 2.8 g/dL. Albumin is a good indicator to show if Pt #1 is receiving adequate nutrition. Albumin level dropped after Pt #1 was admitted to Lakeview.

Pre and Post Dialysis Weights:

4) A review of dialysis treatment records and progress report records the afternoon of 12/23/09 revealed pre and post weights were not always obtained for the following patients receiving dialysis treatments:

Pre and post weights were ordered for Pt #5 on hemodialysis days (Monday, Wednesday, and Friday). The following weights were not done as ordered: No post weights documented on 11/11/09, 11/13/09, and 11/27/09. Pt #5 was transferred to local area hospital in Burlington on 11/28/09 with hypotension and lethargy.
Pre and post weights were ordered for Pt #3 on hemodialysis days (Monday, Wednesday, and Friday). No weight was documented for Pt #3 on 12/9/09 and no post weight on 12/4/09 for Pt #3.
Pt. Monitoring:
5) A review of 15 Minute Checks sheets the evening of 1/4/10 revealed the following patients were not monitored every 15 minutes per physician orders:
Pt #1: A review of 15 Minute Check sheets show 15 minute checks were not completed on Pt #1 on 11/17/09 from 7:00 PM through 11:00 PM; 11/24/09 from 4:30 PM to 6:00 PM, and 6:15 PM through 11:00 PM; 11/25/09 from 7:00 AM through 11:00 PM; and 11/26/09 from 7:00 AM through 3:35 PM.
Pt #2: A review of 15 Minute Check sheets show 15 minute checks were not completed on Pt #7 on 12/1/09 from 3:00 PM to 7:00 PM; 12/4/09 from 8:45 PM to 11:15 PM; and 12/8/09 from 2:30 PM to 7:00 PM.
Pt #7: A review of 15 Minute Check sheets show 15 minute checks were not completed on Pt #7 on 11/11/09 from 3:30 PM to 11:00 PM; on 11/12/09 from 2:00 PM to 3:00 PM; 11/18/09 from 11:00 PM to 7:00 AM; 11/19/09 from 3:34 PM to7:00 PM and 3:15 to 3:45 PM; 11/23/09 from 10:30 AM to 11:00 PM; on 11/27/09 from 10:15 PM to 11:00 PM; and 11/30/09 from 3:15 PM to 7:00 PM
Pt #8: A review of 15 Minute Check sheets show 15 minute checks were not completed on Pt #8 on 10/22/09 from 1:45 AM to 7:00 AM; 10/25/09 from 9:00 PM to 11:00 PM; 10/26/09 from 3:00 PM to 11:00 PM; 10/28/09 from 3:00 PM to 11:00 PM; 10/29/09 from 9:30 AM to 3:00 PM; 11/3/09 from 7:00 PM to 11:00 PM; 11/5/09 from 7:00 PM to 11:45 PM; 11/12/09 from 11:15 AM to 3:00 PM; 11/11/09 from 3:30 PM to 11:00 PM; 11/17/09 from 7:00 AM to 3:00 PM; 11/19/09 from 3:15 PM to 7:00 PM; 11/23/09 from 10:00 AM to 11:00 PM; and 11/30/09 from 3:15 PM to 7:00 PM.
Pt. Incontinence:
6) A very strong urine smell was detected during a tour of Hospital East and Hospital South the morning of 12/8/09 by Surveyor #03383. Quality Manager (QM) B and Staff OO were present and confirmed urine smell. Pt #2 was observed standing up with his wheel chair attached with a pelvic restraint in the hallway of Hospital East. Pt #2 smelled of urine. Surveyor #03383 asked about a toileting program and was told that patients on a toileting program would have a form posted in their room. Bladder Flow Sheet found on the door in Pt #2's room shows only 3 entries: 11/10/09 at 12:35 PM: "N/A"; 11/13/09 at 7:45 AM: "1 garment in toilet"; and 11/24/09 at 12:00 PM: "large amount voided."
Nursing Standards Flowsheet is missing staff initials for hygiene, activity, safety, nutrition, and sleep/rest for PM shift on 11/6/09 and 11/7/09; day shift on 11/8/09, 11/20/09, 11/22/09, 11/29/09, 12/3/09, for days and PM shift on 12/7/09; night shift (NOC) on 11/9/09; evening shift (PM) on 11/16/09; NOC, days, and PM shift on 11/17/09.

Per Nursing Progress Notes:
Progress notes show Pt #2 was admitted on 11/5/09 with a Foley that was discontinued on admission. Bladder scans and straight cath was done after discontinuing the Foley catheter. Pt #2 eventually became continent of bowel and bladder on 11/19/09. The following progress notes show continence:

"11/19/09 at 3:00 AM: Pt #2 is able to express need to use the BR.

11/20/09 at 9:00 AM: Pt #2 continent at time of bowel and bladder.

11/21/09 at 9:30 AM: Pt continent of bowel and bladder.

11/22/09 at 2:25 PM: Pt taken to BR."(bathroom)

Staff began documenting incontinence again on 11/26/09 as indicated by the following progress notes:

11/26/09 at 3:00 PM: incontinent of a large amount of urine. Urine soaked onto floor. Pt ' s clothing and pelvic changed.

11/27/09 at 11:00 AM: Pt incontinent of urine.

11/28/09 at 10:15 AM: Pt incontinent. 3 staff to change him. Mitts and wrist restraints applied.

12/5/09 at 8:30 AM: Pt became impulsive after episode of incontinence.

12/6/09 at 4:45 PM: Incontinent of urine

The progress notes fail to show Pt #1 was on a regular toileting schedule to prevent incontinence.

Based on record review, policy review, and staff interview conducted by Surveyor #03383, the registered nurse failed to develop, review, and revise the plan of care to meet the needs of 5 of 5 patients in a total of 15 sampled patients (Pt #1, #2, #3, #4, and #5).

Per policy and procedure review conducted the morning of 12/23/09:

Policy entitled, "Interdisciplinary Care Planning - Hospital" indicates: "A collaborative, interdisciplinary approach to provide medical/rehabilitative services consistent with professional licensure laws, regulations, and certifications is used to coordinate and plan care to meet patient/client care goals and achieve optimal outcomes."

Procedure:
1. Based on assessment of the patient's/residents physical, cognitive, emotional, and social status, a written treatment plan is developed that identifies the patient's/resident's medical/rehabilitation needs.

2. The medical/rehabilitation plan incorporates, at least:
a. The patient's/resident's personal goals for medical/rehabilitation;
b. Medical/rehabilitation goals and objectives related to activities of daily living, learning, and working;
c. Measures and time frames for achievement of medical/rehabilitation goals and objectives; and
d. Factors that may influence use of services or goal achievement.

10. The patient/client is reassessed on an ongoing basis and provides for recognizing progress towards goals and objectives and allows for revision of goals and objectives as needed.

The hospital failed to follow their policies and procedures as evidenced by:

Per medical records reviews review:

1) Pt #1's medical record was reviewed the morning of 12/8/09, 12/10/09, and 12/15/09 and revealed the following: Pt #1 was admitted to Lakeview on 10/23/09 with a diagnosis of anoxic brain injury secondary to cardiac arrest with 30 minutes resuscitation efforts (CPR), Status post (S/P)colectomy and proximal ileostomy secondary to complicated Hartmann takedown with anastomotic bleed, ileostomy, peritonitis with fungal infection, Methicillin-Resistant Staphylococcus Aureus (MRSA) pneumonia, lateral wall myocardial infarction, Profound hypoxic encephalopathy, diabetes, anemia, hyperkalemia, hypoalbuminemia, hyperglycemia, acute pancreatitis, necrotic gallbladder, status post cholecystostomy tube placement and removal, acute metabolic encephalopathy, respiratory failure, S/P intubation with tracheostomy, and dysphagia.

Initial Nursing Assessment completed on 10/23/09 indicates Pt #1 is a high risk for skin breakdown (score <17: "15") and a high risk for falls (score >25: "65"). Pt #1 is on tube feedings and has swallowing difficulties. Pt #1 is confused, has MRSA infection and skin diagram shows midline abdominal dehiscence. The two most pertinent problems identified to be initiated immediately on the Interdisciplinary Plan is fall risk and risk for self-harm related to tube and line pulling. Skin is not identified as a problem, alteration in nutrition and potential for weight loss or weight gain (weight 160 lbs, height 6 ft) due to swallowing difficulties is not identified as a problem, and infection is not identified as a problem. Pt #1's Initial Nursing Care Plan dated 10/23/09 reveals additional assessments of systems without identifying problems and developing measurable goals. Pt #1 was transferred and admitted to a local area hospital in Burlington on 11/8/09 due to febrile episodes and leukocytosis.

Pt#1 was readmitted to Lakeview on 11/16/09 after spending 8 days at a local area hospital in Burlington. Initial Nursing Assessment completed on 10/23/09 indicates Pt #1 is a high risk for skin breakdown (score <17: "11") and a high risk for falls (score >25: "70"). Pt #1 now weighs 139.3 lbs. Pt #1 now has a Stage IV sacral pressure ulcer measuring 7 .0 cm by 6.5 cm by 2.5 cm. The most pertinent problems identified to be initiated immediately on the Interdisciplinary Plan is impaired mobility, self-care deficit, and decubitus ulcer Stage IV sacrum. Alteration in nutrition and weight loss (weight 139.3 lbs from 160 lbs, height 6 ft) is not identified as a problem. Pt #1's Initial Nursing Care Plan dated 11/16/09 reveals additional assessments of systems without identifying problems and developing measurable goals. Interdisciplinary Plan of Care dated 11/24/09 Nursing Goals lacks measurable long-term and short-term goals.


2) Pt #5's medical record was reviewed the morning of 12/21/09, 12/22/09 and 12/23/09 and revealed the following: Pt #5 was admitted to Lakeview on 11/11/09 for wound care and dialysis according to Initial Nursing Assessment completed on 11/11/09; transferred to a local area hospital in Burlington on 11/28/09 due to leukocytosis, hypotension, and lethargy; and readmitted to Lakeview on 12/4/09. History & Physical shows Pt #5 has a history of encephalopathy, end stage renal disease, history of clostridium difficile (C-Diff), malnutrition, hypertension, alcoholic liver disease, cardiomyopathy with congestive heart failure (CHF), hypothyroidism, chronic pleural effusions, gout, and sacral decubitus ulcer.

Pt #5's Nursing Admission Assessment completed on 11/11/09 shows Pt #5 is a high risk for skin breakdown (score <17: "15") and a high risk for falls (score >25: "85"). It also shows Pt #5 has +2 pitting edema bilateral extremities, is a nutritional risk due to tube feedings, is confused and has a Stage II sacral pressure ulcer measuring 6 cm by 4 cm by 0.2 cm. The two most pertinent problems listed on 11/11/09 nursing assessment is altered thought process and impaired skin integrity.

The Initial Nursing Care Plan dated 11/12/09 lacks measurable goals and interventions. Interdisciplinary Plan of Care dated 11/18/09 and 11/24/09 Nursing Goals section include does not list long-term or short-term goals, barriers to obtaining goals, or equipment needed for discharge. The Nursing Goals section is blank. Wound care area is also blank. The care plan does do not list problems with hypotension during dialysis treatment or the potential for fluid volume issues due to end stage renal disease requiring hemodialysis. Nutrition is not addressed on the care plan despite ordered tube feedings and malnutrition diagnosis.

Pt #5 was readmitted to Lakeview on 12/4/09 after spending 6 days at a local area hospital in Burlington for leukocytosis, hypotension, and lethargy. Pt #5's Nursing Admission Assessment completed on 11/11/09 shows Pt #5 is a high risk for skin breakdown ("10" score <17) and a high risk for falls ("135" score >25). It also shows Pt #5 is experiences pain in all joints and coccyx; has generalized edema and dizziness, is incontinent, is at nutritional risk due to tube feedings, is lethargic and has a Stage IV sacral pressure ulcer. Problems listed on 12/4/09 nursing assessment is altered mobility weakness and unsteady gait, and altered skin Stage IV wound coccyx related to malnutrition and anemia. The Initial Nursing Care Plan dated 12/4/09 lacks measurable goals and interventions to address problems identified on the Nursing Admission Assessment.

Pt #5's Interdisciplinary Plan of Care dated 12/9/09 lists one short-term goal ((STG) and long term goal (LTG); however goal is not measurable (STG: "breakdown to heal" LTG: "open area to heal") Interdisciplinary Plan of Care dated 12/17/09 Nursing Goals section does not list long-term or short-term goals. Interdisciplinary Plan of Care dated 12/9/09 and 12/17/09 fails to address barriers to obtaining goals or equipment needed for discharge. The Nursing Goals section is blank. Wound care area is also blank. The care plan does do not list problems with hypotension during dialysis treatment or the potential for fluid volume issues due to end stage renal disease requiring hemodialysis. Nutrition is not addressed on the care plan despite ordered tube feedings and malnutrition diagnosis.

3) Pt #2 was observed by Surveyor #03383 and QI Manager B on 12/8/09 at approximately 11:30 AM standing up in his wheelchair while he had seatbelt and pelvic restraints applied. Pt #2 had a strong smell of urine. No staff were observed keeping an eye on Pt #2 at the time. QI Manager B intervened by coaxing Pt #2 to sit down and requested the certified nursing assistant (CNA) responsible for caring for Pt. #2 to clean him up.

A review of Pt #'2's medical record the morning of 12/21/09, 12/22/09 and 12/23/09 revealed the following: Pt #2's Nursing Admission Assessment completed on 11/5/09 identifies Pt #2 as a fall risk, having safety needs and suffering from impaired thought process. Interdisciplinary Plan of Care dated 11/12/09; 11/19/09, 11/25/09, and 12/3/09 do not show nurse involvement. The Nursing/Medical Condition section, which includes bowel and bladder, skin, safety awareness, cognition, pain, psychological, and other is blank. The Nursing Goals section includes long-term and short-term goals, barriers to obtaining goals, and equipment needed for discharge. The Nursing Goals area is blank. Wound care area is also blank. Physical restraints were used daily and chemical restraints were used occasionally on Pt #2 without a plan to show other ways of reducing restraint usage. (Reference A154). Even though documentation in the progress notes on 11/6/09 shows Pt #2 standing while restrained in his wheel chair with a pelvic restraint, and continued to stand up with wheel chair attached throughout his stay, the interdisciplinary failed to reassess Pt #2 and develop a new strategy or plan of action. The plan of care also failed to address incontinence.

Pt #2's Nursing Admission Assessment completed on 11/5/09 identifies Pt #2 as a fall risk, having safety needs and suffering from impaired thought process. Interdisciplinary Plan of Care dated 11/12/09; 11/19/09, 11/25/09, and 12/3/09 do not show nurse involvement. The Nursing/Medical Condition section, which includes bowel and bladder, skin, safety awareness, cognition, pain, psychological, and other is blank. The Nursing Goals section includes long-term and short-term goals, barriers to obtaining goals, and equipment needed for discharge. The Nursing Goals area is blank. Wound care area is also blank. Physical restraints were used daily and chemical restraints were used occasionally on Pt #2 without a plan to show other ways of reducing restraint usage. (Reference A154).

4) Pt #3 was observed during a tour the morning of 12/8/09 at approximately 12:45 PM by Surveyor #03383 and QI Manager B leaning forward in his geri chair as if trying to stand up. QI Manager B was questioned about Pt #3's status and QI Manager B requested staff assist Pt #3. A review of Pt #3 medical record the morning of 12/8/09, 12/10/09, and 12/15/09 revealed Pt #3 was admitted to Lakeview on 12/1/09 with chronic Stage III sacral ulcer, chronic respiratory failure with tracheostomy, colonization with pseudomonas.

Nursing Admission Assessment completed on 12/1/09 identifies Pt #3 as a risk for skin breakdown ("15" score <17) and a risk for falls ("40" score >25). Pt #3 experiences sharp pain intermittent in his left shoulder and coccyx when lying in one position too long; has expiratory wheezing; and has a Stage III pressure ulcer on coccyx measuring 2.0 cm by 1.8 cm. The Nursing Admission Assessment lists the most pertinent problems identified to begin immediately on the Interdisciplinary Plan of Care is altered breathing pattern and impaired skin integrity. Pain and fall risk is not listed as a problem. Pt #3 also receives dialysis three times per week for end stage renal disease.

The Initial Nursing Care Plan dated 12/1/09 lacks measurable goals and interventions to address problems identified on the Nursing Admission Assessment. The Interdisciplinary Plan of Care dated 12/9/09 indicates a short-term goal: "open area sacral healing" and long-term goal: "open area to heal sacral" The short-term and long-term goal is not measurable. The Interdisciplinary Plan of Care does not address fall risk/safety, pain, or infection or list interventions.

5) A review of Pt #4 medical record the morning of 12/8/09, 12/10/09, and 12/15/09 revealed Pt #4 was admitted to Lakeview on 4/16/09 for rehab and cognitive therapy. Diagnosis includes traumatic brain injury, paraplegia, and end stage renal disease requiring dialysis three days/week. Pt #4's Nursing Admission Assessment completed on 11/5/09 identifies Pt #4 as a fall risk. Pt #4 is described as confused, irritable, belligerent, and impulsive. Pt #4 has a g-tube and Foley catheter; and open areas on left ankle, left buttock, and right knee, according to full body diagram. The Nursing Admission Assessment lists the most pertinent problems identified to begin immediately on the Interdisciplinary Plan of Care is cognitive rehabilitation, behavioral management, and strengthening. Open areas, nutrition, and any problems associated with end stage renal disease and dialysis are not identified as problems that should be added to the Interdisciplinary Plan of Care.

Pt #4's Initial Nursing Care Plan dated 4/16/09 lacks measurable goals and interventions to address problems identified on the Nursing Admission Assessment. Interdisciplinary Plan of Care dated 11/27/09 indicates Pt #4 has ongoing problems with late effect intracranial injury, pressure ulcers, and paraplegia. The care plan does not show nurse involvement. The Nursing/Medical Condition section, which includes bowel and bladder, skin, safety awareness, cognition, pain, psychological, and other is blank. The Nursing Goals section includes long-term and short-term goals, barriers to obtaining goals, and equipment needed for discharge. The entire Nursing Goals area is blank. Wound care area is also blank. Respiratory, nutrition, and rehabilitation therapy areas are also blank.

The above findings were confirmed with Administrator D and Chief Nursing Officer on the afternoon of 12/10/09 and the afternoon of 12/23/09.

Based on record review and staff interview, the dietitian failed to conduct more frequent monitoring of 2 of 2 (Pt #1 and #5) nutritionally compromised patients in a total sample of 15 patients.

Findings include:

A Nutrition Services Assessment performed by the dietician on 10/23/09 at 1:55 PM indicates Pt #1's weight is 160 lbs and ideal body weight is 178 lbs. and albumin was 3.5 (normal range: 3.5 to 5.0 g/dL). The dietician (RD) indicated weight was taken from the nursing assessment when questioned about it the morning of 12/10/09. A review of a Madison area hospital's Progress notes show Pt #1's weight on 10/19/09 is 170 lb 10.2 oz, 10/20/09 is 168 lb 14 oz, 10/21/09 is 168 lbs 14 oz, and 12/22/09 is 168 lb 10.4 oz. Weights are relatively consistent with an approximate 1 lb weight loss. Surveyor #03383 questioned accuracy of scale used at Lakeview and RD C and Chief Nursing Officer A confirmed that there were problems with the scale during the exit conference on 1/4/10 between 2:45 PM and 3:30 PM. Pt #1 was placed on Nutren 1.5 at 65 cc/hour at 180 cc 6 times/day for 2340 Kcals/day for 94 grams/day and 1209 cc/day (plus 1080 cc with flushes).

Dietary Nutrition Care Plan dated 10/23/09 indicates Pt #1's nutritional status will be assessed every week or as needed. Progress note written on 10/26/09 at 8:40 AM shows nursing indicates Pt #1 does not have intolerance to tube feeding. No weight is mentioned. Nutrition note entered on 11/5/09 at 8:32 AM indicates Pt #1's weight is stable at 158 lbs. The note shows Pt #1's family spoke with the dietician and informed the dietician that Pt #1 used to weigh between 180-200 lbs. The dietitian indicated to Surveyor #03383 the morning of 12/10/09 that she used 160 lbs to calculate the caloric needs for Pt #1. Lab test results show Albumin was 2.5 g/dL on 10/28/09 and 10/29/09; and 11/6/09 was 2.8 g/dL. Albumin is a good indicator to show if Pt #1 is receiving adequate nutrition. Albumin level dropped after Pt #1 was admitted to Lakeview on 10/23/09 from 3.5 to 2.8 on 10/28/09. Pt #1 was transferred to a local area hospital in Burlington on 11/8/09 and the admission record shows Pt #1's admission weight is 150.3 lbs. on 11/8/09. Based on discharge weight from a Madison area hospital on 10/22/09 (168.10 lbs) and weight on admission to a local area hospital in Burlington on 11/8/09, Pt #1 lost approximately 18 lbs in 16 days.

2) Pt #5 was admitted to Lakeview on 11/11/09 with a diagnosis of encephalopathy, end stage renal disease, history of clostridium difficile (C-Diff), malnutrition, hypertension, alcoholic liver disease, cardiomyopathy with congestive heart failure (CHF), hypothyroidism, chronic pleural effusions, gout, and sacral decubitus ulcer. Pt #5 receives hemodialysis 3 times per week on Mondays, Wednesdays, and Fridays. A nutritional assessment was conducted by dietitian (RD) C on 11/11/09 and indicates Pt #5 is 63 inches (5'3") in height and weighs 121.6 lbs. Pt #5 is also on tube feedings and albumin is low at 2.4 on 11/12/09. Pt #5 was placed on Juven and Beveprotein 2x/day with increased water flushes initially and then switched to Nepro. The Nutritional Care Plan completed by RD C on 11/12/09 indicates RD C will assess Pt #5's nutritional status as needed.
RD C entered the next progress note on 11/16/09 and had a concern with staff not obtaining weights because the last weight found was in flowsheets dated 11/13/09. Pt #5's weight was 117.8 pre hemodialysis. Pt #5 has lost approximately 4 lbs since admission. The next note entered in the progress notes by RD C is dated 11/27/09 (11 days later). RD C indicates Pt #5 is now down to 115 lbs pre hemodialysis. Tube feeding was withheld the night prior due to emesis.

Pt #5 was transferred to a local area hospital in Burlington on 11/28/09 with hypotension, lethargy, and leukocytosis. Pt #5 lost approximately 6 lbs since admission to Lakeview on 11/11/09. RD C failed to aggressively monitor Pt #5 who is nutritionally-compromised.