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Based on record review and interview the facility failed to provide necessary care and services for one (1) of twenty-two (22) patients in the survey sample. (Patient #17)

The findings included:

Patient #17 was admitted to the hospital on 6/8/12, with a diagnosis of Pneumonia, Diabetes and Bladder Cancer, with an ileal conduit (A way to route urine through intestinal tissue. Tubes (stints) are put in place of detached intestine, which is then sewed to a hole in the abdominal wall where a collection device is fixed.).

A physician's order on 6/8/12 for Patient #17 stated, "Consult, wound care: for recommendations and on treatment, for evaluation of the drains of the ileoconduit". The Registered Nurses failed to clean and change the ileal conduit until Patient #17's wife lodged a complaint that stated Patient #17's needs were not being met ( I.e. care for the patient's ileal ostomy and changing the ostomy bag). The first documented care to Patient's #17's ileal conduit was performed on 6/20/12, twelve (12) days after the patient had been admitted to the facility.

Interview with Wound Consult LPN #21, on 8/23/12, at 3:45 p.m., stated that the Wound Consult was answered on 6/9/12. The Registered Nurse was informed by Wound Consult LPN #21, that the care of the ileal conduit was the responsibility of the Registered Nurses. The Registered Nurses failed to ensure that Patient #17 received necessary care and services by failing to ensure his/her ileal ostomy bag was changed in a timely manner.

Based on record review and interviews the facility failed to modify the care plans for two of four restrained patients included in the survey sample. (Patients #13 and #16)

The findings included:


Review of Patient #13's medical record revealed the patient was placed in restraints on June 27, 2012. Review of Patient #13's care plan did not include revisions or modifications, which reflected restraints or the behaviors that required the restraints.

Review of Patient #16's medical record revealed the patient was placed in restraints on July 21, 2012. Review of Patient #16's care plan did not reflect the patient had been restrained. A revision to the care plan dated August 2, 2012 addressed the patient's dementia, but did not include the behaviors of pulling at lines and tubes or that the patient required restraints.

An interview and review of the finding was conducted on August 23, 2012 at 8:37 a.m. with Staff #3. Staff #3 reviewed the care plans for Patients #13 and Patient #16. Staff #3 reported the care plans had not been revised to include restraints or interventions utilized prior to the use of restraints.

Based on record review and interview the facility failed to obtain an order for two restrained patients (Patients #13 and #16) in a sample of four restraint patients.

The findings included:

1. Review of Patient #13's restraint documentation revealed gaps in nursing restraint documentation on:
? June 28, 2012- the nursing documentation ceased to assess related to restraints at 10:00 a.m. with the notation that "family in to visit request mitts off." The physician's order for restraint had been written on June 27, 2012 at 10:33 a.m. for twenty-four hours. The next physician order for restraining Patient #13 was documented on June 29, 2012 at 7:08 a.m.;
? July 3, 2012 after 10:00 a.m. until July 4, 2012 at 5:35 p.m. -The physician's order for restraint had been written at 10:42 a.m. on July 2, 2012 and was no longer valid after 10:42 a.m. on July 3, 2012. The following physician's restraint order was documented at 5:35 p.m. on July 4, 2012. The nursing notes did not document Patient #13's family had been on the unit, or had made request for the patient's restraints to be removed during visiting.
? July 6, 2012 from 5:47 p.m. until 8:15 p.m. -The physician's order for restraints included directions to assess the patient every two (2) hours.
? July 7 and July 8 2012 did not have documentation of Patient #13 being assessed for restraints or a physician's order for restraints. The next physician's order for restraint was dated July 9, 2012 at 7:52 p.m. The nursing documentation did not reveal a change in behaviors or occurrence of Patient #13 self-decannulating.
? July 12, 2012 from 5:49 a.m. until 9:03 a.m. -The physician's order dated July 11 at 11:00 p.m. covered the twenty-four hour period until July 12, 2012 at 11:00 p.m. The physician's order directed nursing staff to assess the patient every two hours.
? July 13, 2012 did not reveal certified nursing assistant (CNA) charting after 00:16 a.m. and did not reveal any documentation of restraint assessment under nursing documentation. The review did not reveal a physician's order for restraints for July 12 or 13, 2012. The next physician's order for Patient #13's restraints was documented at 6:11 p.m. on July 14, 2012.

An interview conducted on August 22, 2012 at 5:10 p.m., with Staff #10 revealed Patient #13 was "able to wiggle off (the) mittens." Staff #10 reviewed the CNA restraint documentation. Staff #10 reported Patient #13's family would request that the mittens be removed during their visit with the patient. Staff #10 reported the family "always" told nursing when they were leaving so Patient #13's mitten restraints could be placed on the patient's hands. Staff #10 reported Patient #13 after he/she pulled his/her tracheal tube out was in restraints, unless the family was present. Staff #10 reviewed his/her documentation and stated, "I remember her (Patient #13) going back in restraints, but I didn't chart that. I'm not sure why, but I know she went back in restraints."

An interview conducted on August 23, 2012 at 9:14 a.m., with Staff #12 revealed Patient #13 had been in restraints on July 3, 2012. Staff #12 reported the previous physician's order for restraint had ran out, but the patient remained in restraints until the new order was obtained. Staff #12 confirmed Patient #13 was restrained for approximately thirty-one (31) hours without a physicians' order.

An interview was conducted on the "High Observation" unit August 23, 2012 at 11:26 a.m., with Staff #15. Staff #15 reported physician's orders for restraints were only good for twenty-four hours. Staff #15 reported the nurse has to be aware of the time to ensure a new order is obtained. Staff #15 reported if the nurse becomes busy caring for a crisis a restraint order may run out.

An interview and review of the finding was conducted on August 23, 2012 at 8:37 a.m. with Staff #3. Staff #3 confirmed the findings "seemed to suggest the patient was restrained at times without a physician's order or the nursing failed to document changes in behavior, which prompted the reapplication of restraints." Staff #3 confirmed that for Patient #13 the nursing documentation for the every two hour assessment was documented at the end of the shift or at intervals greater than every two hours. Staff #3 reported if the nurse waited to the end of the shift to document the assessment, there was a possibility the physician's order might have ran out, while the patient was in restraints.

2. Review of Patient #16's medical record revealed gaps in restraint documentation. Nursing documentation revealed Patient #16 had dementia and as a result was continually pulling at lines and tubes.

Review of Patient #16's restraint documentation revealed:
? July 23, 2012 nursing staff stopped restraint assessments at 6:00 a.m. The physician's order dated July 22, 2012 at 7:18 a.m. stopped at 7:18 a.m. on July 23, 2012. The next documented restraint order was at 6:49 p.m. on July 23, 2012.
? July 24, 2012 nursing restraint assessments stopped at 6:39 p.m. and restarted with an 8:00 p.m. assessment, which had been documented at 4:51 a.m. on July 25, 2012. The physician's order for Patient #16's restraints had not been obtained until 11:25 p.m. by telephone order on July 24, 2012. Nursing staff documented an assessment at 8:00 p.m. three hours before a new order for restraints had been obtained.
? No physician's orders for restraints were located for the dates of July 26 and July 27, 2012. The medical record did not contain restraint assessments and the nurse's note offered no additional details related to changes in behavior from previous documentation of the patient pulling at lines and tubes. The next physician's order for restraints was dated July 28, 2012 at 2:17 p.m.

A telephone interview was conducted on August 23, 2012 at 1:26 p.m. with Staff #17. Staff #17 reported the computer prompts nursing staff to document every two hours when a patient has a restraint order. Staff #17 reported if the physician's order runs out then the prompting stops.

An interview and review of the finding was conducted on August 23, 2012 at 8:37 a.m. with Staff #3. Staff #3 confirmed the findings "seemed to suggest the patient was restrained at times without a physician's order or the nursing failed to document changes in behavior, which prompted the reapplication of restraints." Staff #3 stated, "Getting some staff to document at the point of care is a work in progress." Staff #3 reported if the nurse waited to the end of the shift to document the assessment, there was a possibility the physician's order might have ran out, while the patient was in restraints.

Review of the facility's policy titled "Use of Physical or Chemical Restraints" read, "3. Restraints use requires an order by a physician or licensed independent practitioner (LIP) responsible for the patient's care and authorized to order restraint use. They may never be ordered as a standing or PRN (as needed) order ... 5. The health and mental status for any patient in restraints will be monitored and addressed to preserve the patient's dignity, including response to restraint use."

Patient #17 was admitted to the hospital on 6/8/12, with a diagnosis of Pneumonia, Diabetes and Bladder Cancer, with an Ileal Conduit (A way to route urine through intestinal tissue. Tubes (stints) are put in place of detached intestine, which is then sewed to a hole in the abdominal wall where a collection device is fixed.).

A physician's order on 6/8/12 for Patient #17 stated, "Consult, wound care: for recommendations and on treatment, for evaluation of the drains of the ileoconduit ". The Registered Nurses failed to follow the physician's orders. Nursing staff failed to clean and care for Patient #17's ileal conduit until Patient #17's wife lodged a complaint that stated Patient #17's needs were not being met.

Interview with Wound Consult LPN #21, on 8/23/12, at 3:45 p.m., stated that the Wound Consult was answered on 6/9/12. The Registered Nurse was informed by Wound Consult LPN #21, that the care of the ileal conduit was the responsibility of the Registered Nurses. No care plan was developed for the care of the ileal conduit until 6/21/12, thirteen days after admission to the hospital.






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Based on record review and interviews the facility's nursing staff failed to:

1. Perform an initial nursing assessment for one (1) of twenty-two (22) patients in the survey sample (Patient #14) and
2. Follow physician's orders for two (2) of twenty-two (22) patients in the survey sample (Patients #10 and #17)

The findings included:

1. Review of Patient #14's medical record revealed he/she had been admitted on July 13, 2012. The medical record did not have a comprehensive nursing admission assessment. The "Nursing admission assessment" included only the date and time of the admission, the attending physician, a list of belongings, hospital unit information, the name of the transferring hospital and who accompanied the patient to the unit.

An interview was conducted on August 23, 2012 at 4:22 p.m., with Staff #1. Staff #1 reviewed Patient #14's medical record confirmed the incompleteness of the initial nursing assessment. Staff #1 reported the nurse that performed the incomplete assessment was on duty.

An interview conducted on August 24, 2012 at 11:00 a.m., with Staff #24. Staff #24 reviewed Patient #14's medical record and confirmed his/her electronic identification as the nurse who performed the electronic initial "Nursing admission assessment." Staff #24 confirmed the initial nursing assessment was incomplete. Staff #24 stated, " When a patient comes in after 6 p.m. then the RN (Registered Nurse) makes an initial notes that shows the patient was welcomed to the unit. The supervisor asked me to do that and I did. The nurse coming on should have complotted the assessment, but there was no follow through." Staff #24 verified the evening/night shift nurse responsible for Patient #14's care was a Licensed Practical Nurse (LPN) who could not perform an initial assessment. Staff #24 reported the nurse should have reminded the nursing supervisor the initial assessment needed to be completed.

An interview was conducted on August 24, 2012 at 11:48 a.m., with Staff #1. Staff #1 was informed of the findings. Staff #1 acknowledged Patient #14 was in the facility for approximately 27 days without an initial nursing assessment.

2. Review of Patient #10's medical record on August 21, 2012 at 10:41 a.m., revealed a physician's order dated August 2, 2012 for "Occult blood stool/lab perform: collect specimen: Site stool." Review of the laboratory reports did not provide the results of the test. Review of the nursing documentation reflected a prompter to collect the specimen.

Review of certified nursing assistant (CNA) documentation of intake and output and nursing documentation revealed Patient #10 had documented bowel movements on August 3, 4, 5, 6, and 8, 2012. As of the review date (August 21, 2012) the physician's order for Patient #10's Occult blood labs had not been completed. The nursing notes did not reveal documentation the physician had been notified that his/her order had not been performed.

An interview was conducted on August 24, 2012 at 11:48 a.m., with Staff #1. Staff #1 was informed of the findings. Staff #1 acknowledged the order had not been completed within the nineteen days prior to the survey and remained not carried out as of August 24, 2012. Staff #1 reported he/she was not aware if the physician had been made aware that the order had not been performed. Staff #1 confirmed Patient #10 had documented bowel movements. Staff #1 reported nursing staff failed to collect a specimen and follow the physician's order.

According to www.webmd.com/ Fecal occult blood test is performed by "For this test, you put tiny samples of your stool on a special card or cloth and send it to a lab. The lab uses chemicals to find blood that you can't see with the naked"

According to www.medicinenet.com "...bleeding from the gastrointestinal tract can be too slow to cause either rectal bleeding or melena. In these patients bleeding is occult (not visible to the naked eyes). The blood is found only by testing the stool for blood (fecal occult blood testing) in the laboratory. Occult bleeding has many of the same causes as rectal bleeding and may result in the same symptoms as rectal bleeding. It is often associated with anemia that is due to loss of iron along with the blood. "

Based on record review and interview nursing staff failed to develop and revise care plans for five (5) of twenty-two (22) patients in the survey sample. (Patients #10, #11, #13, #14, and #16)

The findings included:

Review view of Patient #10's initial nursing assessment revealed the patient was admitted to the facility on June 18, 2012 with a wound. Patient #10 was hospitalized on July 5, 2012 and re-admitted to the facility on July 9, 2012. Therapy services updated Patient #10's care plan related to the July 9, 2012 re-admission. The care plan did not reflect an update or revisions by nursing staff. Patient #10's current wound was not addressed within the care plan. Patient #10 had a physician's order dated July 9, 2012 for "[Product name] to Left buttock wound."


Review of Patient #11's medical records revealed the patient was admitted to the facility on August 3, 2012 with a sacral wound. The initial nursing care plan listed "Potential impaired skin related to Braden score." Patient #11's care plan did not address the patient's actual sacral pressure ulcer.

The Braden Scale for Predicting Pressure Sore Risk Background: This tool can be used to identify patients at-risk for pressure ulcers. The Braden Scale was developed by Barbara Braden and Nancy Bergstrom in 1988 and has since been used widely in the general adult patient population. The scale consists of six subscales and the total scores range from 6-23. A lower Braden score indicates higher levels of risk for pressure ulcer development. Generally, a score of 18 or less indicates at-risk status. Reference:http://www.bradenscale.com/images/bradenscale.pdf.

Review of Patient #13's medical record revealed the patient was placed in restraints on June 27, 2012. Review of Patient #13's care plan did not include revisions or modifications, which reflected restraints or the behaviors that required the restraints.

Review of Patient #14's medical record revealed the patient was admitted on July 13, 2012 and nursing staff failed to initiate an initial care plan. Patient #14 had been admitted to the facility for continues antibiotic therapy for a bacterial endocarditis [defined as: "The endocardium is the inner lining of the heart muscle, which also covers the heart valves. When the endocardium becomes damaged, bacteria from the blood stream can become lodged on the heart valves or heart lining. The resulting infection is known as endocarditis."] Nursing failed to address the patients infection, antibiotic treatment and PICC (Peripherally inserted central catheters ) line in the care plan. Nursing notes documented on July 13, 2012 the patient had pain and was receiving anti-coagulant therapy, but did not care plan the issues. Patient #14's care plan was not revised after the interdisciplinary team identified him/her as a fall risk on July 16, 2012. Nursing documented Patient #14 left the facility on more than one occasion and eloped on August 10, 2012 with a PICC line in place. The nursing staff had not addressed Patient #14's leaving the facility or developed intervention for the patient's safety.

According to vascular access management at http://picclinenursing.com/picc_indications.html "Peripherally inserted central catheters are used to obtain central venous access in patients undergoing treatment in acute care facilities, home health agencies and skilled nursing care in a variety of settings. PICC lines are reliable alternatives to other central venous catheters and have lower risks of complication..."

Review of Patient #16's medical record revealed the patient was placed in restraints on July 21, 2012. Review of Patient #16's care plan did not reflect the patient had been restrained. A revision to the care plan dated August 2, 2012 addressed the patient's dementia, but did not include the behaviors of pulling at lines and tubes or that the patient required restraints.

An interview was conducted on August 23, 2012 at 2:49 p.m., with Staff #20. Staff #20 stated, "The care planned for a patient with potential skin impairment has a different focus then actual breakdown. The interventions needed when a patient has an actual wound are focused on measures for healing." Staff #20 reported the care plan for a patient with actual skin impairment should reflect the patient's needs and progress towards healing the wound.

An interview and review of the finding was conducted on August 23, 2012 at 8:37 a.m. with Staff #3. Staff #3 reviewed the care plans for Patients #10, #11, #13, #14, and #16. Staff #3 reported the care plan for Patient #10 did not reflect his/her skin status and should have been updated on re-admission to the facility on July 9, 2012. Staff #3 acknowledged Patient #11 should have had a care plan that reflected an actual wound as well as the prevention of further skin impairment. Staff #3 confirmed Patient #14 did not have an initial nursing care plan or a revised care plan to reflect the patient and his/her concerns. Staff #3 reported the care plans for Patient #13 and Patient #16 had not been revised to include restraints, the patient's behaviors associated with the need for restraints or interventions utilized prior to the use of restraints.