HospitalInspections.org

Based on document review, staff interviews and observations the hospital's Administrative Staff failed to ensure Nursing Staff performed assessments and provided cares in accordance with facility policy for 3 of 11 patients observed. (Patient #11, Patient #6 and Patient #8).

I. Review of Policy UPHDM174, titled GLOBAL NURSING DOCUMENTATION dated 12/17 revealed in part, "Shift Assessment-Head-to-toe physical assessment including daily cares/safety and appropriate screenings ...The shift assessment is completed at least once every 12 hour shift and/or any change of nurse. (Exception- Skilled Nursing Patient assessments are completed daily)...An admission assessment is completed by a Registered Nurse at the time of admission and documented within 8 hours of admission."

During observation on 4/19/18 at 9:50 AM, of Patient #11, an 81 year old revealed large amounts of built up skin and debris between their toes on both feet that was thick enough to prevent the toes from touching.

Review of Patient #11's medical record identified an admission date of 4/14/2018. The medical record failed to contain any skin assessment for Patient #11's to include assessment of Patient #11's feet until 4/19/2018. Approximately 5 days after addmission.

Review of Document titled Bathing: Bed Bath, adapted from Perry and Potter Clinical Nursing Skills & Techniques 9th edition, dated 4/2017 revealed in part, " ...Before or during the bath, assess the patient's skin condition. Note the presence of dryness, which is indicated by flaking, scaling, and cracking ...Cleanse the foot and between the toes ... Dry the toes and feet completely ..."

During an observation on 4/19/2018 at 9:50 AM, Patient #11, an 81 year old had large amounts of build up between their toes on both feet that was thick enough to prevent their toes from touching one another. There had been no foot care since admission on 4/14/2018. RN (Registered Nurse) F cleaned Patient #11"s feet for approximately 7 minutes each foot, removing copious amounts of debris from between Patient #11's toes, requiring the use of a bath towel to catch the skin and debris. After cleaning between the toes was accomplished, the patient's toes touched each other.

During an interview on 4/19/2018 at 9:50 PM, Nursing Supervisor B was asked if the nurses do foot care. Nursing Supervisor B's response was the order was only to wrap Patient #11"s legs, therefore no foot care had been provided for Patient #11.

II. Review of Mosby's Skills Online Resource titled TR (Trans Radial) Band Guidelines, provided by the hospital dictates in part, " ... Assess insertion site and pulses and vital signs as listed below: Q (every)15 min x 4, Q 30 min x 2, Q 60 min x 4, then per unit standard or as ordered by a physician AND Document Findings: a. Presence of blood flow distally using pulse Ox on thumb distal to puncture site ... Observe and compare color and temperature of the affected extremity ... Vital signs..."

Review of procedure titled TR (Trans Radial) BAND Guidelines followed by the hospital revealed in part, "... Assess Observe for pain or swelling of affected wrist ... Palpate radial pulse distal to the band ... A pulse oximeter must be applied to the thumb or index finger while the band is in place to assess the integrity of the extremity. Removal: For diagnostic cases the TR band should be left on for 60 minutes post procedure ... Once it is time to remove the TR band the operator should withdraw half of the air in the pillow slowly, observing for any bleeding. Observe site for a couple of minutes ... If there is no bleeding, slowly withdraw the other half of the air in the pillow. The injection port balloon should be flat. Observe site for a couple of minutes ..."

Review of Patient #6's medical chart identified on 4/17/2018 after angiography was completed at 10:30 AM a TR Band (a device that holds pressure and allows easy visual access of the insertion area) was placed on Patient #6's wrist. Patient #6's chart revealed documentation of assessments performed at 11:00 AM, 12:00 PM, 12:30 PM, 1:00 PM, 1:20 PM, 1:45 PM and 2:09 PM and 2:59 PM. The assessments and documentation failed to follow the policy and procedure for assessing pulses and vitals signs Q-15 minutes x 4 between 11:00 AM and 12:00 PM and Q-60 minutes x 4 from 1:00 PM to 4:00 PM. The documentation also lacked neurological notation.

Documentation revealed the facility staff failed to follow procedures for observations, assessment and removal of the TR Band post angiography for Patient #6:
10:30 AM - 8 ml (milliliters) of pressure was instilled initially;
1:20 PM - 2ml released to equal 6 ml;
1:45 PM - 2ml released to equal 4 ml;
2:09 PM - 2ml released to equal 2 ml;
2:49 PM -2ml released and TR Band removed.

During an interview with Registered Nurse (RN) E on 4/18/2018 at 2:00 PM revealed RN E stated that she does assessments every 15 minutes once the patient comes to the floor to check for circulation and documents it in the patient's chart. While RN E was showing the location of flow sheets in the electronic health record, the electronic health record lacked 15 minute assessments as identified by RN E.

During an observation of RN E on 4/18/2018 at 2:00 PM: RN E pulled 2 ml of air out of a vascular pressure device called a Trans Radial (TR) Band. RN E failed to assess the neurological function of Patient #6's right hand or use a pulse oximeter to assess for a pulse as directed by policy and procedure.

During the interview with RN E on 4/18/2018 at 2:00PM, when asked about the lack of 15 minute checks RN E stated that she would chart at the end of her shift for any of the times in her shift that she missed, reporting that she would have memory of every 15 minute assessment. There were a total of 7 instances that 15 minute checks were not documented for circulation and neurological function in Patient #6's chart.

Review of Job/Position Description ... Registered Nurse, effective date 4-10-2017 revealed in part, "Description of Position: ...Promptly completes documentation to assure an accurate legal record of patient's care ...adheres to policies and procedures and safety guidelines".

III. Review of ADDENDUM TO SKILLS DETAILED IN "FUNDAMENTAL OF NURSING" 6TH EDITION Authored by Patricia Potter and Anne Perry ... revised 11/6/2006 revealed in part, "Stat Lock Foley Stabilization Device Removal Technique ... Lift the edge of the Stat Lock anchor pad using 3-4 alcohol pads. Then continue to stroke the undersurface of the Stat Lock with alcohol to dissolve the adhesive pad away from the skin. DO NOT PULL OR FORCE THE PAD TO REMOVE. This may result in tearing of the skin."

Review of Procedure document titled Urinary Catheter: Indwelling (Foley) Catheter Removal, referenced from Elsevier Performance Manager 9th edition Edited 2018 revealed in part, " ...Procedure ... pull the catheter slowly and gently while wrapping the now- contaminated catheter in a waterproof pad ...Cleanse the perineum with soap and water or organization-approved wipes ...Unhook the collection bag and drainage tubing from the bed, Empty, measure, and record the urine present in the drainage bag. Discard supplies, remove gloves and perform hand hygiene ..."

During an observation on 4/19/2018 at 9:30 AM, CCRN (Critical Care Registered Nurse) C in ICU (Intensive Care Unit) had an order to discontinue Patient #8's urinary catheter. Before removal of the Stat Lock securing device on the inner thigh, CCRN C told the patient, "I am going to pull this off like what my son calls Nursy style", CCRN C counted to three and swiftly ripped the entire Stat lock off of the patient's inner thigh. The patient winced and grimaced during this procedure. CCRN C then performed pericares on the patient by using a disposable cloth to wipe the area around the urethra and downward between the labia three times without using a new disposable cloth or changing the area of the cloth used for each wipe. CCRN C then removed the saline from the catheter bulb port and removed the catheter.