HospitalInspections.org

Based on document review and interview, the facility failed to meet the Condition of Participation for Nursing Services by failing to assess a patient's allergy status prior to giving medication and failing to assess/document pertinent patient status and update the plan of care, resulting in the potential for poor outcomes for all 54 patients at the facility. Findings include:


---(See A 396) The facility failed to update plans of care for 3 (#7, #12, #13) of 9 patients out of a total sample of 13.

---(See A 405) The facility failed to administer morphine medication under accepted standards of practice for 1 ( #13) of 1 patient allergic to morphine and failed to ensure medications were transcribed per facility policy for 1 (#12) of 13 patients, resulting in the potential for poor patient outcomes.

Based on observation, document review, and interview the facility failed to ensure nursing staff maintained an updated plan of care (POC) for 3 of 9 patients (#13, #7, #12) out of a total sample of 13, resulting in the potential for ineffective care. Findings include:

On 4/21/16 at approximately 0930, review of patient #13's medical record revealed that the patient was admitted for extended intravenous antibiotic therapy, hemodialysis, and rehabilitation. She had developed various pain multiple times a day (from 3/28/16 - 4/16/16) after the 3/24/16 admission date. The patient was treated with Tylenol 650 milligrams (mg) or Norco 7.5 mg oral pain medications up to every four (4) to six (6) hours for mild to severe pain with relief. On 4/16/16 the patient had continual "severe" and "diffuse pain" without relief, per interviews with Nurse N and Physician P, on 4/21/16 at approximately 1100 and 1200, respectively.

On 4/16/16 at 2250, the patient was medicated with Morphine 2 mg intravenous for severe pain per the Medication Administration Record (MAR). Review of the patient's care plan revealed no POC to address pain. The medical record documented an allergy to Morphine in the MAR and the History & Physical. Interview with the Chief Clinical Officer, on 4/21/15 at approximately 1300 verified that neither the Nursing POC or Interdisciplinary Team Care Conference dated 4/14/16 addressed the patient's pain.

On 4/21/16 at approximately 1400, review of the facility policy & procedure titled, "Assessment/Reassessment/Care Planning, revision date 1/16" documented, "C. Plan of Care... 4. The plan of care is updated when:... b) the patient's condition changes, c) when current therapies prove ineffective..." This had not been done.


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On 4/20/16 at 1000 patient #7 was observed during a wound care observation that was performed by Wound Care nurse E. The patient was observed with an undated gauze dressing covering the site of his suprapubic catheter (S/P) (surgically created opening between abdomen and the bladder that is used to drain urine). There was a large amount of dark reddish-brown particles noted sticking to the walls of the tubing that connected to the drainage bag. There was approximately 300 cubic centimeters (cc's) observed in the drainage collection bag that was dark reddish-brown in appearance. The catheter was not anchored or secured to prevent the potential for accidental dislodgment. The catheter moved freely with the patient's change in positioning by staff.

Staff E was observed as she removed the gauze dressing from the patient's (SP) site. The insertion site was dark pinkish-red. There was a moderate amount of yellow-pink tinged drainage on the old dressing. Staff E explained they were applying Medihoney (topical treatment to promote wound healing) and the area had improved. When asked if the patient's (S/P) should have be secured, Staff E stated, "Yes." Staff E then proceeded to tape the tubing of the (S/P) to the patient's thigh. Staff E was asked if there was a date on the tubing or the drainage bag to reflect if the catheter or drainage bag had been changed since the patient's admission. Staff E was observed as she looked for dates. Staff E then stated, "No. I don't see a date."

On 4/20/16 at 1040, review of patient #7's medical record revealed that the patient was admitted with diagnoses that included respiratory failure and impaired skin integrity. A review of the patient's care plans revealed there were no care plans for the care and maintenance for the patient's suprapubic catheter. Additionally, there were no nursing notes that addressed the condition of the patient's suprapubic catheter.

On 4/20/16 at 1130 during an interview and record review when asked how often (S/P) catheters and/or urinary drainage bags were changed, Chief Clinical Officer B stated, "They are not unless the (S/P) gets plugged. (S/P) are closed systems we don't change the catheter or the bag." When asked why there were no care plans for the patient's (S/P) catheter, Staff B stated, "There should be one."

On 4/19/16 at 1600 a review of #12's closed clinical record documented the following:

According to the History and Physical (H&P) dated 09/05/15 the patient was a 72 year old male admitted to the facility on 09/04/2015 following his hospitalization at a local community hospital for a subdural hematoma (a pool of blood between the brain and the outermost covering).

A review of "Nurse Wound Team" skin assessment notes and color photographs documented the following:

On 09/05/15, "Skin not intact...Partial thickness skin loss (involving epidermis and or dermis) measuring 6 x 5 centimeters (cm) to bilateral buttocks. Granulation tissue less than 75 (%) percent bright beefy red...no dressing (skin protectant)."

On 09/11/15, "Skin not intact...Full thickness skin loss(involving damage or necrosis of subcutaneous tissue) measuring 6 x 5 (cm) bloody drainage...no dressing."

There were no care plans for the patient's impaired skin integrity to direct the staff with individualized interventions to promote wound healing for the patient's skin condition.

On 4/20/16 at 1130 during an interview and record review when asked who was responsible for developing an actual skin impairment care plan for patient #12, Chief Clinical Officer B stated, "The nurses are."

On 4/21/16 at approximately 1400, review of the facility policy & procedure titled, "Assessment/Reassessment/Care Planning, revision date 1/16" documented, "C. Plan of Care... 4. The plan of care is updated when: ..b) the patient's condition changes, c) when current therapies prove ineffective..."

Based on record review and interview, the facility failed to administer Morphine medication under accepted standards of practice for 1 (#13) of 1 patient allergic to Morphine and failed to ensure medications were transcribed per facility policy for 1 (#12) of 13 patients, resulting in the potential for poor patient outcomes. Findings include:

On 4/21/16 at approximately 0930, review of patient #13's medical record revealed that the patient was admitted for extended intravenous antibiotic therapy, hemodialysis, and rehabilitation. She had developed various pain multiple times a day (from 3/28/16 - 4/16/16) after the 3/24/16 admission date. The patient was treated with Tylenol 650 milligrams (mg) or Norco 7.5 mg oral pain medications up to every four (4) to six (6) hours for mild to severe pain with relief. On 4/16/16 the patient had continual "severe" and "diffuse pain" without relief, per interviews with Nurse N and Physician P, on 4/21/16 at approximately 1100 and 1200, respectively.

The medical record documented an order on 4/16/16 at 1330 for "Morphine 4 mg IVP (intravenous push) prn (as needed) q (every) 4 hours for break thru (sic) pain." On 4/16/16 at 2250, the patient was medicated with Morphine 2 mg intravenous push for pain per the Medication Administration Record (MAR) --"HO (house officer) aware." The medical record documented an allergy to Morphine in the MAR and the History & Physical.

On 4/21/16 at approximately 1100, phone interview with Nurse M revealed that she did not check for allergies before administering the Morphine. She stated, "I was giving it for Nurse N (Licensed Practical Nurses (LPN) do not give IV push meds), he is good about checking meds." Phone interview with the LPN Staff N taking care of the patient, on 4/21/16 at approximately 1040, revealed that after the patient had received the pain medication he went by the room at approximately 23:15 and noted the oxygen sat alarm going off at 89%. He stated that the patient was unresponsive and a code blue was called. The patient was pronounced deceased at 0039 on 4/17/16.

On 4/21/16 at approximately 1330, review of the facility policy and procedure titled, "Administration of Medications, review date 1/2016" documented, ...."D. The healthcare professional administering the medication....will verify that there are no contraindications for administering the medication. Patient allergies must be checked on either the MAR or in the Kardex prior to administering any medications..."


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Additionally, review of patient #12's clinical record on 4/20/15 at 1400 documented the following:

According to the History and Physical (H&P) dated 09/05/15 the patient was a 72 year old male admitted to the facility on 09/04/2015 following his hospitalization at a local community hospital for a subdural hematoma (a pool of blood between the brain and the outermost covering).

A review of the "Pre-Admission Screening" form (electronic referral) dated 09/04/15 from the referring local community hospital documented:
Admission Disposition: Accepted.
Skin: Multiple Bruises.
Special Considerations: Specialty Mattress. Pressure Redistribution Mattress.
Additional notes/Discussion: "...Glucose Monitoring: Diabetes Mellitus (DM) uncontrolled prior to admission.
Medications: See MAR (medication administration record)..."

A review of the physician's discharge summary dated 09/02/15 for patient #12's medication regime orders included: "Lantus (insulin) 20 units subcutaneous nightly.

A review of the patient's "Admission Medication Reconciliation and Insulin" forms dated 09/04/2015 at 2200 upon admission to the facility included "Glargine (Lantus Insulin) (long acting) injection. There was no dosage, route or frequency for the insulin transcribed on the Insulin order form.

A review of a "Nutritional Assessment" dated, 09/08/15 documented:
"Diet orders nothing by mouth (NPO) and was on enteral feedings via percutaneous gastrostomy tube (peg) at 50 milliliters (ml) per hour...Diet Plans...Patient with a range of blood sugars (BS) 89-400 recommend tighter glucose control...".

A review of the patient's blood glucose (BS) laboratory results documented the following:
09/05 at 1054 (BS) 227
09/05 at 1609 (BS) 206
09/06 at 0023 (BS) 188
09/06 at 0557 (BS) 202
09/06 at 1133 (BS) 262
09/06 at 1629 (BS) 230
09/06 at 2213 (BS) 293
09/07 at 0606 (BS) 82
09/07 at 1154 (BS) 409
09/07 at 1829 (BS) 304
09/08 at 0000 (BS) 281
09/08 at 0622 (BS) 345
09/08 at 1827 (BS) 256
09/08 at 2101 (BS) 343
09/09 at 0029 (BS) 171
09/09 at 0529 (BS) 275
09/09 at 1112 (BS) 404
09/09 at 1713 (BS) 365
09/10 at 0030 (BS) 423
09/10 at 0532 (BS) 256
09/10 at 1309 (BS) 220
09/10 at 1835 (BS) 285
09/10 at 2000 (BS) 249
09/11 at 0037 (BS) 189
09/11 at 0837 (BS) 431
09/11 at 1220 (BS) 469
09/11 at 1813 (BS) 466
09/12 at 0025 (BS) 302
09/12 at 0516 (BS) 219

A review of physician orders dated 09/04/15 through 09/12/2015 revealed there were no orders for the Lantus insulin to be administered, held or discontinued.

However, there was a one-time orders for Levemir (long acting insulin) 20 units to be administered on 09/10/15 at 0844, and 30 units to be given on 09/12/15 at 0930. There was no further documentation in the clinical record to explain why the patient's long acting insulin was not prescribed or scheduled as prescribed by the referring physician.

On 4/21/16 at 1330 during an interview and record review Staff B stated, "The admission nurse should have clarified the Insulin order when she contacted the physician. It's possible the 'Levemir' insulin was not formulary." However, Staff B offered no further explanation when queried regarding why there were no nursing notes or physician orders, to hold or discontinue the patient's long acting Insulin.

On 4/21/16 at 1345 at review of the facility's "Reconciling Medications Upon Admission, Transfer and Discharge EMAR or paper MAR" policy dated 2/2016, documented:
Procedure:
"I. B. Patients admitted from a short-term acute care hospital, skilled nursing, or other health care facility:
The nurse reviews the Discharge Medication Lists provided by the transferring facility, including the MAR or discharge summary and pre-admission home medication list (if any) completed by the transferring facility. When possible, validate the list with the patient or family as outlined in Section I-A above.
C. For all admission, document the medications on the Admissions Medication Reconciliation List and Order Form. For each medication, document the name, dose, route, frequency, and if known, the last time the medication was administered, and comments, if any, including level of compliance. Address any discrepancies between the medication history and the physician's admitting orders prior to administering any medications, either in person or by telephone order from the prescriber, according to hospital policy."