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Based on interview, record review, and policy review, the facility failed to ensure that patient wounds were assessed and documented according to policy for two patients (#4 and #9) of two patients whose medical records were reviewed for wound assessment and documentation. This had the potential to lead to unidentified or worsening patient wounds, which could affect all patients in the hospital. There were six patients with wounds at the time of the survey. The patient census was 22.

Findings included:

1. Record review of the facility's policy titled, "Skin Safe Pressure Ulcer Prevention Program," revised 02/13, showed directions for staff to perform and document a comprehensive skin assessment on every patient upon admission and every shift.

2. Record review of Patient #4's medical record showed:
- Photographs of seven wounds at the time of the patient's admission on 05/23/14;
- Documentation of seven wounds (one on the bottom of each foot, one on the front of each ankle, one on the inner portion of the left shin, one on the right inner buttock, and one on the skin over the tailbone) on the patient's admission assessment dated 05/23/14;
- Patient Handoff Summary (Kardex - provides current and up to date needs, care and treatments for the patient) showed seven wounds with corresponding treatments;
- Nurse documentation of a wound on the bottom of the right foot for seven out of 14 shifts from 05/29/14 through 06/04/14;
- Nurse documentation of a wound on the left shin for four out of 14 shifts from 05/29/14 through 06/04/14;
- Nurse documentation of reddened buttocks for three out of 14 shifts from 05/29/14 through 06/04/14; and
- No nurse documentation was found for the remaining four wounds for any of the 14 shifts from 05/29/14 through 06/04/14.

During an interview on 06/04/14 at 1:35 PM, Staff H, Licensed Practical Nurse, who was Patient #4's nurse on 06/04/14, stated that the patient still had five wounds and two additional areas of skin breakdown, but was unable to answer why there was no documentation of the additional wounds in the patient's record.

During an interview on 06/05/14 at 11:40 AM, Patient #4 verified that he still had seven wounds.

During an interview on 06/04/14 at 1:35 PM, Staff A, Chief Clinical Officer, stated that Patient #4 had five wounds on admission and two areas of skin breakdown. Staff A stated that she was only able to find nursing documentation for two of the wounds (documentation of three wounds were found by surveyor). Staff A stated that even though patient records did not contain documentation for all patient wounds, she was sure that all patients' wounds and skin breakdown were being assessed and cared for by nursing staff.

3. Record review of Patient #9's nursing documentation showed:
- The patient had fallen on 05/31/14.
- The patient had abrasions on the right forehead, left wrist and right forearm from the fall.
- There were no nursing assessments of the abrasions on 06/01/14 and 06/02/14.

Based on interview and record review, the facility failed to ensure that patients' nursing care plans were developed and kept current for two current patients (#5 and #9) of four current patients whose medical records were reviewed, and two discharged patients (#10 and #11) of two discharged patients whose medical records were reviewed. This had the potential to affect all patients by failing to ensure that patients' physical and psychological needs were addressed for optimal patient outcomes. The facility census was 22.

Findings included:

1. During an interview on 06/04/14 at approximately 10:30 AM, Staff A, Chief Clinical Officer, stated that:
- The facility did not have a policy on nursing care plans.
- The interdisciplinary plan of care in the medical record contained patient goals.
- The Patient Handoff Summary (Kardex) contained nursing interventions for specific patient needs and was a component of the nursing care plan.
- The Kardex became a permanent part of the medical record upon patient discharge.

2. Record review of Patient #5's medical record showed a diagnosis of urinary retention with physician order to perform urinary catheterization (tube inserted into the bladder to drain urine) as needed.

Record review of Patient #5's Kardex showed no nursing interventions for urinary retention.

During an interview on 06/03/14 at approximately 2:30 PM, Staff D, Licensed Practical Nurse (LPN), confirmed that Patient #5's Kardex did not include interventions for urinary retention.

3. Record review of Patient #9's medical record showed:
- Nurses notes that the patient had fallen on 05/31/14;
- Nurses notes the patient had abrasions on the right forehead, left wrist and right forearm from the fall; and
- No interventions for the abrasions on the patient's Kardex.

During an interview on 06/04/14 at 9:00 AM, Patient #9 stated that she did not know what staff were doing for her abrasions.

4. During an interview on 06/04/14 at 9:15 AM, Staff H, LPN, stated that if the physician did not order treatments, there was no reason to add nursing interventions to the Kardex.

5. Record review of Patient #10's discharged medical record showed no Kardex in the record.

6. Record review of Patient #11's discharged medical record showed no Kardex in the record.

7. During an interview on 06/05/14 at 9:25 AM, Staff U, Medical Records Director, and Staff V, Registered Nurse (RN), stated that Kardexes were not part of the permanent record and were removed from the patient records and shredded when patients were discharged.



















29047

Based on interview, record review, and policy review, the facility failed to ensure that one non-employed (agency) licensed nursing staff (Staff O) of one non-employed licensed nursing staff education file reviewed, was oriented to the hospital and their specific work areas. This had the potential to lead to medical errors and affect all patients. There were 33 licensed agency staff who have worked at the facility over the previous six months. The facility census was 22.

Findings included:

1. Record review of the facility's policy titled, "Competency Verification of Caregivers," dated 02/14, showed that the clinical department manager/designee would review and approve the scope of practice/job description and competencies for agency personnel prior to patient care activities, and a file would be maintained on each of those individuals.

Record review of the facility's policy titled, "Hospital Wide Education Plan," revised 02/12, showed the following:
- Department Directors/Managers are responsible for the implementation and documentation of department-specific orientation and competency testing.
- Department Directors/Managers are responsible to ensure completion of sign-in sheet, skills checklist, and program evaluations, which are forwarded to the Educator.
- Agency personnel will complete a hospital-wide orientation and department specific orientation which includes computer training, clinical competencies, equipment usage competence, and chain of command reporting.

2. Record review on 06/04/14 at 4:50 PM of the education file for Staff O, Agency Registered Nurse (RN), along with concurrent interview of Staff A, Chief Clinical Officer (CCO), showed no hospital-wide or department specific orientation or competencies. Staff A was unable to state what department specific competencies were and was unsure who was responsible for the orientation of agency staff.

During an interview on 06/04/14 at 4:30 PM, Staff O, Agency RN, stated that she worked her first shift at the facility on 05/29/14 and that her current shift was her second shift at the facility. Staff O stated that no one had oriented her to the facility, and no one had followed or observed her during her shifts to ensure that she completed patient care in a competent manner or according to facility policies or procedures.

3. During an interview on 06/04/14 at 4:50 PM, Staff R, Clinical Educator, stated that agency staff have not been through department specific orientation or competencies.

4. Record review of Agency Staffing Rosters showed 33 agency staff (RNs and Licensed Practical Nurses) had worked at the facility between 12/01/13 and 05/31/14.