HospitalInspections.org

Based on review of documentation and interview with staff, it was determined the facility failed to to follow its own policy and procedures regarding patient grievances.

Findings included:
Review of the medical record of patient #1 revealed a hand written physician progress note by the attending physician on 11/27/10 documenting the concerns of the family of patient #1. The note documented that they believed that the decubitus ulcers which occurred to patient #1 were preventable. This note also contained the comment: "they want to complain to administration about PT/OT & nursing." There was no documentation found by or provided to the surveyor indicating that this documented concern by the family of patient #1 had been reported to the nurse manager.

A review of facility policy # H-PC 05-007 entitled: "Patient Complaint/Grievance Process," with a revised date of 12/2008, stated on page 1, "Purpose: The purpose of this policy is to: 1: Provide a standardized form to document complaints and grievances received by the hospital. 2: Provide a process to review, investigate, and resolve a patient's/patient representative's complaint within a reasonable time frame."

In an interview on 11/02/11 at 11:35am with staff member # 11, it was confirmed that the Patient Complaint/Grievance Process standardized form was in an electronic format. Additionally staff member # 11 confirmed that if a physician receives a complaint, he/she is to report the complaint to the Nurse Manager and that the Nurse Manager then inputs the complaint information into the facility computer system. It was also confirmed by Staff member #11 in the same interview that there was not a facility complaint/grievance form available for review by the surveyor or that there was any other documentation available indicating that the facility was aware of the family's concerns.

Based on review of documentation and interview with staff, it was determined the facility failed to modify the patient's care plan.

Findings included:
The facility failed to modify the care plan of patient #1. A review of the medical record of patient #1 reflected restraint orders dated 11/20/10 through 12/15/10. The initial nursing restraint assessment found was dated 12/04/10 at 10:40am. There was no documentation found or provided to the surveyor that the nursing care plan had been kept current prior to 12/04/10. The nursing staff failed to document the safety issues that resulted in the need for ongoing restraints, the desired measurable outcome-oriented goals, interventions, ongoing evaluations, and patient/family-education.

A review of facility policy # H-PC 05-010 entitled: "Use of Physical or Chemical Restraints," with a revised date of 11/2009 stated on pages 4-5, "II. Non-emergency Use of Restraints: Physical... C. Documentation: 2: Modify the care plan electronically... or in writing to include: a: the safety issue that resulted in the need for restraints... b. Desired measurable outcome-oriented goals. c. Interventions...d. Ongoing evaluations...e. Patient/Family-education..."

In an interview with staff members #10, #11 and #12 on 11/02/2011 at approximately 12:15pm it was confirmed that the nursing care plans for patient #1 had not been updated to include the safety issues that necessitated the need for restraints.

Based on review of documentation and interview with staff, it was determined the facility failed to maintain current personnel files as 4 of 5 files were found to be incomplete.

Findings included:
A review of 4 of 5 personnel files, revealed that the facility's form which demonstrated competency in restraints was either missing or incomplete. In the personnel files for staff members #5 and #6, a review of a document entitled, "Kindred Hospital Tuesday Clinical Core Classroom Competencies," was found to be incomplete. In the column, "Return Demonstration Pass/Fail/NA," the entire column was blank. In the personnel files for staff members #3 and #7, the staff members did not have a "return demonstration form" in their files.

A review of facility policy # H-PC 05-010 entitled: "Use of Physical or Chemical Restraints," with a revised date of 11/2009 stated on pages 15-16 that "VI. Quality Assurance/Performance Improvement, Training and Competency...B. Training and Competency...1. Staff (employees...) having direct patient care responsibilities/contact shall be trained in: b. the proper use of restraints...2. Training is to be provided during initial orientation and competency reassessment is to be conducted annually."

In an interview with staff members #10 and # 11 on 11/02/11 at approximately 9:00am it was confirmed that the personnel files for staff members #3, #5, #6 and #7 were missing documentation of restraint competencies.

Based on a review of documentation and interview with staff, it was determined the nursing staff assigned to patient #1 failed to supervise and evaluate the nursing care provided, as there was not documentation that patient #1 was consistently repositioned every two hours in accordance with the facility's own policy for patients with impaired skin integrity.

Findings included:
Patient #1 was not consistently repositioned every two hours and experienced skin breakdown resulting in the formation of decubitus ulcers. A review of the medical record of patient #1 reflected the following:

1) A review of the medical record of patient #1 revealed an order on 09/29/10 at 16:35 to "reposition, q2h (every 2 hours), (0, 2, 4, ...22), start 09/29/10 1800." Further review revealed another order to "reposition bed-bound patients ASAP (as soon as possible), q2h (every 2 hours), (0, 2, 4, ...22), start 11/01/10 8:28."

2) A review of the medical record of patient #1 revealed an admission date of 9/29/10. The Registered Nurse charted the following for the skin assessment "Integumentary assessment: General skin appearance: pink, warm, dry, thin/transparent, poor turgor, intact." The nursing notes dated 10/01/10 at 20:19 reflected patient #1 received wound care for a sacrococcygeal pressure ulcer. Further review revealed, nurse's notes dated 10/05/10 at 15:35 a "weekly wound assessment-pressure ulcer: sacrococcygeal ...wound onset type: community acquired."

3) The nurse ' s notes dated 10/14/10 at 19:47 (7:47pm) reflected, the LPN (Licensed Practical Nurse) charted, " skin etiology assessment- skin tear: L (left) scapula(s), skin tear description: flat- epidermal (skin) flap covers the dermis to 1mm of wound margin, dressing: no cover dressing, peri wound/dressing: erythema, comments: red scrape noted to left scapula by blister, pain assessment: signs/symptoms of pain: no signs/symptoms of pain exhibited. " The nurse ' s notes dated 10/28/10 at 10:50am reflected, the RN (Registered Nurse) charted, " skin tear: L (left) scapula (s), discharged 10/28/10 10:49am, skin etiology assessment- skin tear: L scapula (s), skin tear description: linear (appears as if incision has been made), pain management: signs/symptoms of pain: no signs/symptoms of pain exhibited. " The nurse ' s notes dated 11/02/10 at 15:55 (3:55pm) reflected, the wound care nurse charted " intact blister (not pressure related): L scapula (s), resurfaced/healed 11/02/10 15:54, skin etiology assessment- intact blister (not pressure related): L scapula (s), pain assessment: signs/symptoms of pain: no signs/symptoms of pain exhibited. "

4) The nursing notes dated 11/18/10 at 15:26 reflected a weekly wound care visit. The wound care nurse charted the following, "weekly wound assessment - pressure ulcer: sacrum, wound onset type: hospital acquired, wound length 2 cm (0.8 in), wound width (2 cm (0.8 in), wound depth .2 (0.1 in), stage: stage II, comments: old site rebroken down, pain management: signs/symptoms of pain: no signs/symptoms of pain exhibited."

5) The nurse's notes dated 11/28/10 at 07:16am, the RN (Registered Nurse) charted, " skin etiology assessment-skin tear: RL (right lower) back, skin tear description: flat-greater than 25% of epidermal flap lost, wound length 3 cm (1.2 in), wound width 2 cm (0.8 in), pain assessment: signs/symptoms of pain: no signs/symptoms of pain exhibited." On 12/08/10 at 10:14am, the wound care nurse charted the following, " skin tear: RL back, resurfaced/healed 12/08/10 at 10:12am, skin etiology assessment-skin tear: RL back, skin tear description: flat-100% of epidermal flap lost. "

6) On 12/09/10 at 1:08am, the RN (Registered Nurse) charted the following, "daily wound assessment- pressure ulcer: R (right) buttock, comments: redness noted around the right buttock stage 2 ulcer, pain assessment: signs/symptoms of pain: no signs/symptoms of pain exhibited." On 12/14/10 at 14:05 (2:05pm), the wound care nurse charted the following, "pressure ulcer: R buttock, resurfaced/ healed 12/14/10 14:02, wound onset type: hospital acquired, pain management: no signs/symptoms of pain exhibited."

A review of facility policy #H-WC 01-001 "Wound Prevention," which has a revised date of 06/2011 stated on page 1, "All patients will be assessed for risk of skin breakdown by nursing staff, at time of admission and routinely thereafter. Appropriate preventative interventions will be implemented. Rational: Patients with impaired ability to reposition and/or multiple co-morbidities... increase comfort and quality of life." The policy also reflected, "Procedure: Preventative interventions: A. Mechanical Load/Support Surface/Pressure Relieving Devices, i. Turn, when patient is unable to turn self, every two hours..."

In an interview with staff members #9 and #11 on 11/02/2011 at approximately 9:00am it was confirmed that there was no documentation that patient #1 had been consistently repositioned every two hours, it was also confirmed in the same interview that patient #1 had experienced skin breakdown and the formation of decubitus ulcers while at the facility.

Based on review of documentation and interview with staff, it was determined the facility failed to maintain an accurate system for identifying, reporting, investigating, and controlling infections as patient #1 was not on the facility nosocomial avoidable/nonavoidable wound list.

Findings included:
Patient #1 experienced skin breakdown resulting in the formation of decubitus ulcers.

1) A review of the medical record of patient #1 revealed an admission date of 9/29/2010. The Registered Nurse charted the following for the skin assessment "Integumentary assessment: General skin appearance: pink, warm, dry, thin/transparent, poor turgor, intact." The nursing notes dated 10/01/10 at 20:19 reflected patient #1 received wound care for a sacrococcygeal pressure ulcer. Further review revealed, nurse's notes dated 10/05/10 at 15:35 a "weekly wound assessment-pressure ulcer: sacrococcygeal ...wound onset type: community acquired." The nursing notes dated 11/18/10 at 15:26 hours reflected a weekly wound care visit. The wound care nurse charted the following, "weekly wound assessment - pressure ulcer: sacrum, wound onset type: hospital acquired, wound length 2 cm (0.8 in), wound width (2 cm (0.8 in), wound depth .2 (0.1 in), stage: stage II, comments: old site rebroken down, pain management: signs/symptoms of pain: no signs/symptoms of pain exhibited. "

2) On 12/09/10 at 1:08am, the RN (Registered Nurse) charted the following, "daily wound assessment- pressure ulcer: R (right) buttock, comments: redness noted around the right buttock stage 2 ulcer, pain assessment: signs/symptoms of pain: no signs/symptoms of pain exhibited." On 12/14/10 at 14:05 (2:05pm), the wound care nurse charted the following, "pressure ulcer: R buttock, resurfaced/ healed 12/14/10 14:02, wound onset type: hospital acquired, pain management: no signs/symptoms of pain exhibited. "

A review of the Infection Control Committee Minutes dated 01/20/11 revealed in the section, "Topic, # 9, Wound Care, " discussion/recommendations: "Wound Care Coordinator to start reporting on number of nosocomial wounds, wounds that were developed here, how many were non avoidable and how many were avoidable." The meeting minutes reflected the results for nosocomial wounds for October, 2010, 0 wounds, November, 2010, 7 wounds (3 non avoidable/ 4 avoidable), and December, 2010, 1 wound. A review of the results by individual patient name revealed that of the 7 patients listed in November and 1 patient in December, patient #1 was not found on the list.

In an interview on 11/02/11 at 11:35am with staff member #11, it was confirmed patient #1 was not on the Infection Control Committee wound List for November or December of 2010 for nosocomial avoidable/non avoidable wounds.