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Based on interview and record review, the facility failed to implement and update care plans for three of 10 sampled patients (Patient 1, Patient 2, and Patient 5).

This failure had the potential for patient care needs and goals to go unmet, with potential and actual negative health outcomes.

Findings:

A review of a facility policy titled, "Patient Care Planning," rev 11/16/23, indicated individualized plans of care are developed in order to meet patient care goals, including the implementation and maintenance of the medical treatment plan and keeping the patient comfortable and safe during the hospital stay. The care planning process includes patient assessment, goal setting, intervention, referrals to other health care professionals, evaluations of patient response to treatment, and revision of care and treatment in order to meet the patient's needs. Patient needs are determined through the patient assessment process; the registered nurse will complete the initial patient assessment and determine the patient's needs in relation to their diagnosis and treatment plan. Nursing staff document and review the nursing care plan daily and make changes as needed throughout the patient's hospital stay.

A review of a facility policy titled, "Suggested Wound care Algorithm Stage 1 Pressure Ulcer," (according to the National Pressure Injury Advisory Panel, a pressure injury is localized damage to the skin and underlying soft tissue, usually over a bony prominence) undated, provided interventions of keeping the skin clean and dry, using a draw sheet to lift or turn patients, inspecting skin every 4 to 8 hours, repositioning the patient every hour while in a chair or every two hours while in bed, encouraging the patient to get out of bed, encouraging fluid or nutrition within physician orders, keeping the bed free of foreign material and wrinkles, positioning the head of bed as low as possible within physician orders, using skin barrier cream.

Review of the facility's policy and procedure, "Skin Integrity Management," dated 8/23/23, indicated the purpose was to provide nursing staff guidelines for skin integrity management including maintenance and treatment of skin conditions. Specific interventions are made based on patient assessment, risk assessment, skin condition and identification of specific skin findings. The role of the nurse is to assess the patient for skin integrity risks and implement preventative measures. When the patients skin is compromised, the role of the nurse is to perform a complete wound assessment, photo document the wound, obtain initial orders and implement basic wound care. Notify the provider (physician or nurse practitioner) and communicate when the wound condition changes.
The policy indicated licensed nurses may initiate and direct the implementations of nursing interventions to prevent skin injury or skin breakdown as part of routine patient care. Interventions may include but are not limited to routine positioning, pressure off-loading measures, float heels with pillows under calf, routine skin checks each shift, and foam protective dressings to areas at risk for skin injury (pressure points).

Review of the facility's policy and procedure, "Patient Care Planning," dated 11/16/23, indicated an individualized plan of care for each patient is developed by the registered nurse to meet the following goals: implement and maintain the medical treatment, keep the patient safe and comfortable, complete education and have discharge plan. The care planning process includes patient assessment, goal setting, intervention, evaluation of patient response to treatment and revision of care and treatment to meet the patient's needs. Nursing staff documents and reviews the nursing car plan daily and makes changes as needed per the patient's needs.

1. Review of Patient 1's record, "History and Physical," dated 2/27/2025, Family Nurse Practitioner (FNP) A indicated Patient 1 was admitted to the facility on 2/27/25 with diagnoses that included severe dementia, high blood pressure and urinary retention (unable to urinate) requiring a Foley catheter (tube placed into the bladder to drain the urine). Patient 1 was confused. Patient 1 had warm dry intact skin with no rashes or lesions.

Review of Patient 1's nursing record, "Patient Progress Notes," dated 3/28/2025 at 1:21 am, Registered Nurse (RN) G indicated Patient 1 had intact skin.

Review of Patient 1's care plan record, "Problem Activity," dated 2/28/2025, indicated Patient 1 was at risk for impaired skin integrity (skin breakdown). The intervention was to monitor the skin and encourage a good diet. The goal of the interventions was to prevent any skin breakdown.

Review of Patient 1's record, "Patient Progress Note," dated 3/10/25 at 10:24 am, Wound Care Nurse (WCN) indicated Patient 1 had red, blanchable skin (skin temporarily turns white when you press on it and returns to normal skin color when pressure is released; normal circulation) to the sacral area (tail bone area).

Review of Patient 1's care plan record, "Problem Activity," dated 3/10/2025, indicated there was no nursing diagnosis or interventions added to the care plan to prevent further damage to the skin on Patient 1's sacral area when the skin was red.

Review of Patient 1's nursing record, "Patient Progress Notes," dated 3/14/25 at 1:43 am, RN F indicated Patient 1's sacral area had an open blister.

Review of Patient 1's record, "Order Chronology," dated 3/14/2025, indicated Patient 1 had no new orders to treat the open blister on the sacral area.

Review of Patient 1's care plan record, "Problem Activity," dated 3/14/2025, indicated no nursing diagnosis or interventions were added to the care plan to prevent further damage to the skin on Patient 1's sacral area.

Review of Patient 1's record, "Order Chronology," dated 3/17-3/22/2025 and 3/24/2025 indicated Patient 1 had no new orders to treat the open blister on the sacral area.

Review of Patient 1's care plan record, "Problem Activity," dated 3/17-3/22/2025 and 3/24/2025 indicated no nursing diagnosis or interventions were added to the care plan to prevent further damage to the skin on Patient 1's sacral area.

Review of Patient 1's record, "Wound Care Note," dated 3/25/2025 at 9:22 am, WCN indicated Patient 1 had an unstageable deep tissue injury (also refers as unstageable pressure injury to a wound where the full extent of tissue damage is obscured by slough or eschar preventing staging) on the sacral area.

Review of Patient 1's record, "Wound Care," dated 3/25/2025 at 5:29 pm, Medical Doctor (MD) A (wound care doctor) indicated Patient 1 had an unstageable deep tissue injury on the sacral area and small wound to the perianal area. MD A indicated the cause of the sacral wound was pressure. MD A recommended to keep pressure of the sacral wound, dietary consult, low air loss mattress, reposition per facility protocol, physical therapy consult for offloading (prevent pressure), vitamin C 500 mg by mouth twice daily, zinc sulfate 220 mg by mouth once daily for 14 days.

Review of Patient 1's care plan record, "Problem Activity," dated 3/25/2025 indicated no nursing diagnosis or interventions were added to the care plan to prevent further damage to the skin on Patient 1's sacral area as mentioned above from the ordering physician MD A.

Review of Patient 1's record, "Wound Care Note," dated 3/28/2025 at 3:00 pm, WCN indicated Patient 1's sacral wound had increased in size and redness. WCN indicated Patient 1 had been up in wheelchair for most of the day yesterday. Wound measurements were; length 6.0 cm; width 6.5 cm; depth not measurable. WCN recommended when up in a wheel chair or Geri chair (medical reclining chair designed to provide comfortable and supportive seating for individuals with limit mobility that can recline and has a tray table).

Review of Patient 1's nursing records, "Patient Progress Notes," dated 2/27/2025-3/28/2025 indicated Patient 1 was confused and tried to climb out of bed on different occasions. Patient 1 would be placed in a Geri chair at the nurse's station frequently for safety.

During an interview on 6/19/2025 at 1:30 pm with Certified Nursing Assistant (CNA), CNA stated Patient 1 would sit up in the Geri chair during the day by the nurse's station. CNA stated the Geri chair would recline and Patient 1 would sleep in the chair at times while in the nurses' station.

During an interviw on 6/19/2025 at 10:45 am with RN H, stated the nurse was expected to review the care plans everyday and added interventions depending on the pateint's needs and assessment. RN H stated if a patient had a new wound the nurse should informed the wound care nurse, documented what the wound looked like in the chart and updated the care plan with a nursing diagnosis and interventions. RN H stated the wound care nurse would be verbally informed or texted when a patient needed a wound conult and then the wound care nurse would place the order in the computer. RN H stated if the wound care nurse was not available she would enter the wound consult order in the computer, measured and photographed the wound. RN H stated the facility process that if a patient had a blister on the sacral area, nursing staff should have ordered a wound consult, documented in the chart and updated the care plan with a nursing diagnosis and interventions.

During a phone interview on 6/20/2025 at 3:25 pm with MD A, MD A stated the most important interventions the nursing staff should implement to prevent skin breakdown would be to monitor the skin frequently, reduce pressure and reduce sheering. MD A stated each facility had there own policies and the nursing staff should follow them to prevent skin breakdown. MD A stated his role that he had to do assessment of the patients at the facility every 1-2 weeks and as needed. MD A stated the facility had their own policies indicating how frequently the wound care nurse should follow up with the patients and the wound care nurse should follow the facility policy.

Review of Patient 1's nursing record, "Patient Progress Notes," dated 2/27-3/28/2025, indicated there was no documentation by the nursing staff that Patient 1 had a cushion/pillow to reduce pressure to his sacral area while up in the Geri chair or was repositioned/stood up every 1 hour while in the Geri chair. This was according to their facility policy and procedure to implement.

During an interview on 6/19/2025 at 1:30 pm with WCN, stated she would make rounds on a patient every one to two weeks and as needed depending on the severity of the wound. WCN stated she assessed Patient 1's wound on 3/10/2025 and did not reassess Patient 1's wound again until 3/25/2025. WCN agreed she should have reassessed Patient 1's wound before 3/25/2025. WCN stated she was not informed by the bedside nurse there was a change in Patient 1's sacral wound until 3/25/2025. WCN confirmed the nursing staff did not implement preventive interventions to prevent skin breakdown in the care plan on admission or updated the care plan when nursing staff identified skin breakdown to Patient 1's sacral area. WCN confirmed that their facilty's policy to update and implement care plans were not followed.

During an interview on 6/19/2025 at 1:45 pm with Director of Nursing (DON), stated Patient 1 liked to be up in the Geri chair by the nurse's station. DON confirmed the nursing staff did not implement preventative interventions to prevent skin breakdown on admission or after new pressure injuries were identified. DON confirmed the nursing staff did not make a nursing diagnosis with interventions related to Patient 1's pressure injuries and did not follow the facility's presure injury and care plan polices.


2. Review of Patient 2's record, "History and Physical," dated 2/26/2025, indicated Patient 2 was admitted to the facility with deconditioning, chronic pain, high blood pressure and diabetes. Patient 2 had no pressure injuries to her skin.

Review of Patient 2's nursing record, "Progress Note," dated 2/26/2025, indicated Patient 2 had clean dry intact skin.

A concurrent interview and record review on 6/26/2025 at 2:30 pm with DON, nursing "Progress Notes," dated 3/3-3/25/2025 were reviewed. The nursing "Progress Notes," indicated Patient 2 had redness to her sacral area and was at risk for skin breakdown. DON confirmed the nursing staff were charting redness to Patient 2's sacral area and was at risk for skin breakdown.

Review of Patient 2's record, "Wound Care," MD A indicated Patient 1 had a stage 2 pressure injury (damage to the skin and underlying tissue typically caused by prolonged pressure of friction) of the left buttocks.

A concurrent interview and record review on 6/26/2025 at 2:30 pm with DON, Patient 2's nursing care plans dated 3/3-3/25/2025 were reviewed. The nursing care plans indicated nursing staff did not update Patient 2's nursing care plans with interventions suggested on the facility policy to prevent further skin breakdown. DON confirmed the care plans were not updated per facility policies. DON confirmed the nursing staff were expected to update the care plans as indicated in the facility policies.


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3. A record review of Patient 5's record indicated she was admitted on 1/3/25 at 5:05 pm with diagnoses that included deconditioning (decline in physical function and strength resulting from a period of inactivity or reduced physical activity), dementia (a general term for a progressive decline in thinking, behavioral and social skills that affects a person's ability to function), coronary artery disease (reduced blood flow to the heart muscle due to build-up of plaque in the arteries of the heart), atrial fibrillation (disorder of the heart that effects its ability to pump normally), and for rehabilitation following femoral neck fracture, closed reduction with percutaneous pinning (surgery to repair her right hip).

A review of Patient 5's care plans dated 1/3/25 6:31 pm, by RN B, indicated that a care plan was initiated for the potential impairment of skin integrity.

A review of Patient 5's care plans dated 1/3/25 10:26 pm, indicated RN B updated the care plan for the potential impairment of skin integrity with two interventions: monitoring for skin breakdown, and keeping the (surgical site) dressing clean and intact.

A review of Patient 5's record found no entries by either day or night shift nurses on 1/4/25 addressing Patient 5's care plans.

A review of Patient 5's progress notes dated 1/5/25 at 9 am, indicated RN D documented redness to the sacral area. (a generalized term for area on the buttocks between the hip bones and above the coccyx, or tailbone)

A review of Patient 5's care plans dated 1/5/25 11:19 am, indicated RN D did not update the care plan for potential impairment of skin integrity and no interventions were documented.

A review of Patient 5's care plans dated 1/5/25 8 pm, indicated RN E did not update the care plan for potential impairment of skin integrity and no interventions were documented.

A review of Patient 5's record found no entry by day shift nurses on 1/6/25 addressing Patient 5's care plans.

A review of Patient 5's orders dated 1/6/25 2:52 pm, indicated FNP B ordered in low air loss mattress, heel protectors and knee pillow when turning, turning every two hours, and zinc oxide ointment 40% one topical application twice a day.

A review of Patient 5's care plans dated 1/6/25 8 pm, indicated RN E did not update the care plan for potential impairment of skin integrity to reflect Patient 5's pressure injury nor reflect the orders created 1/6/25 at 2:52 pm, and no interventions were documented.

A review of Patient 5's record found no entry by day shift nurses on 1/7/25 addressing Patient 5's care plans.

A review of Patient 5's care plans dated 1/7/25 8 pm, indicated RN E did not update the care plan for potential impairment of skin integrity and no interventions were documented.

A review of Patient 5's wound care note dated 1/6/25 2:53 pm, indicated WCN A performed an initial assessment of Patient 5's right hip surgical incision, and buttock. WCN A documented this as a stage 1 pressure injury (stage 1 indicates the injury is in initial stages of progression, with intact skin surface). WCN A documented Patient 5 was to be placed on a low air loss mattress (a medical grade mattress designed to prevent/treat pressure injuries).

A review of Patient 5's medical progress note by Medical Doctor (MD) A, dated 1/7/25, indicated Patient 5 had a stage 1 pressure injury to the buttock, duration of one day, measuring 0.5 centimeters (cm, a unit of measure) in length and width, and ordered treatment with zinc oxide (a topical ointment) twice daily.

During a concurrent interview and record review, on 6/26/25 at 3 pm, the DON reviewed Patient 5's care plans from 1/3/25 to 1/12/25. DON stated that, after developing the initial care plan, the nursing staff needed to improve documentation as interventions and changes that affect care were not addressed "like they should be."

During a follow-up concurrent interview and record review on care planning on 7/1/25 at 11:45 am, the DON stated that the expectation was for nurses to write their interventions.

Based on interview and record review, the facility failed to ensure that psychotherapeutic medications (drugs that affect the brain and nervous system to treat mental health disorders) were not administered without first obtaining informed consent from the patients and/or their representatives for two of 10 sampled patients. (Patient 1 and Patient 8)

This deficient practice prevented Patients 1 and 8 and/or their representatives from understanding the potential risks, benefits, and alternatives to the psychotherapeutic medications given and violated their right to make informed decisions about their treatment and care.

Findings:

A review of facility Policy and Procedure (P&P) titled, "Psychotherapeutic Medication: Use and Consent," dated 4/5/19, indicated facility staff were directed to verify documentation of informed consent was present in the patient's health record "before initiating the administration of psychotherapeutic drugs." The P&P indicated documentation of informed consent was reflected by a signed 'Consent to Receive Psychotherapeutic Medications' form.

A review of "Patient Rights," dated 1/2022, (provided to patients in their admission packet) indicated, "You have the right to:"
5. "Make decisions regarding medical care, and receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse a course of treatment."

A review of "Consent to Receive Psychotropic (affecting the brain and nervous system) Medications," dated 11/1/22, indicated a voluntary patient was not to be treated with antipsychotic medications (used to treat psychotic disorders and stabilize mood) until "such person has been informed of his or her right to accept or refuse such medications and has consented to the administration of such medications." Signing the consent indicated the patient (or authorized signer) acknowledged having had an opportunity to read and ask questions about the medication, their questions had been answered to their satisfaction, and they gave consent to the use of the medication as prescribed.
The consent form indicated the patient must be provided the following with "sufficient information by the provider" prescribing the medication:
1. The nature of the patient's mental condition,
2. The reason for taking the medication, including the likelihood of improvement or not, and that consent may be withdrawn at any time,
3. Reasonable alternative treatments available,
4. The type of medication (antidepressant, antianxiety, antipsychotic, or stimulant) prescribed, how often (daily, twice daily) and how long (weeks, months) it would be given, the amount, the method (pill or injected into a vein), and
5. Probable commonly known side effects and any side effects likely to occur with the particular patient.
The document also contained signature lines for licensed nurse "Witness" and "House Supervisor Review."

1. Review of Patient 1's record, "History and Physical," dated 2/27/25, indicated Patient 1 was admitted to the facility on 2/27/25 with diagnoses that included severe dementia (confusion), high blood pressure and urinary retention (unable to urinate) requiring a Foley catheter (tube placed into the bladder to drain the urine).

Review of Patient 1's record, "Order Chronology," dated 2/28/25 at 9:25 am, indicated the Family Nurse Practitioner (FNP) A ordered Haldol (psychotropic medication used to treat various mental health conditions) 5 milligrams (mg) by mouth daily for Patient 1.

Review of Patient 1's record, "Medication Record," indicated Patient 1 was given Haldol 5 mg by mouth on 2/28/25 at 9:33 am and 3/1/25 at 11:36 am.

During an interview on 6/17/25 at 2:35 pm with Family Member (FM) 1, FM 1 indicated Patient 1's wife was Patient 1's responsible party and had legal responsibility to make medical decisions for Patient 1's health care decisions. FM 1 stated Patient 1 was started on Haldol the first night at the facility. FM 1 stated Patient 1's responsible party was not notified and did not want Patient 1 started on Haldol.

Review of Patient 1's records, "Progress Notes," dated 2/28/25, indicated there was no documentation made by FNP A indicating why Patient 1 was ordered Haldol or that Patient 1's wife was notified and consented for Haldol to be given to Patient 1.

Review of Patient 1's record, "Progress Note," dated 3/2/25 at 10:34 am, FNP A indicated Patient 1's family was questioning why Patient 1 was on Haldol.

During an interview on 6/18/25 at 11:30 am with Director of Nursing (DON), confirmed Patient 1's wife was Patient 1's responsible party. DON confirmed there was no documentation made by FNP A or nursing staff indicating Patient 1's wife was notified when Patient 1 was given Haldol. DON confirmed Patient 1's wife should have been notified before Haldol was ordered and given to Patient 1.


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2. A review of "History and Physical," dated 1/9/25, indicated Patient 8 was transferred from another facility following surgery for an "unstageable decubitus ulcer" (severe pressure injury) with necrosis (dead tissue) at the base of the spine/left buttock region. Patient 8 was admitted for treatment of "deconditioning" (decline in physical and/or mental abilities) and wound care. Patient 8 also had a history of diabetes (chronic high blood sugar), high blood pressure, dyskinesia (a disorder that causes involuntary, erratic muscle movements), "gravely disabled," and posttraumatic stress disorder (PTSD). The plan was to treat the wound, provide rehabilitation therapies, and continue Vraylar, an antipsychotic medication he was taking for PTSD prior to admission.

A review of "Medication Record," dated 1/9/25 to 6/26/25, indicated Patient 8 received Vraylar daily from 1/10/25 to 2/17/25, when the order was stopped.

A review of "Order Chronology" of active Pharmacy orders, dated 1/9/25 to 6/25/25, indicated FNP A ordered lurasidone hydrochloride (Latuda - an atypical antipsychotic medication that helps normalize brain activity and reduce depressive episodes), one 40-milligram (mg - a unit of measure) tablet to be taken at bedtime, for Patient 8 on 2/24/25. The record indicated Patient 8 was also taking several medications to control diabetes: insulin, Actos, Farxiga, and Metformin.

A review of Lexidrug (Trademark) (a drug information resource), indicated potential Latuda side effects included increased mortality (death) in elderly patients, suicidal thoughts and behaviors, drug-induced movement disorders (dyskinesia), blood cell abnormalities, high blood sugar, drowsiness, weight gain, temperature dysregulation (fluctuations), and potential drug-drug interactions with diabetes medications.

A review of "Medication Record," dated 1/9/25 to 6/26/25, indicated Patient 8 received Latuda 121 times from 2/24/25 to 6/25/25.

During an interview with the DON on 7/1/25 at 9:30 am, a copy of Patient 8's signed 'Consent to Receive Psychotherapeutic Medications' for Latuda was requested. DON stated she would attempt to locate it.

During a concurrent interview with Doctor of Pharmacy (PharmD) A and review of Patient 8's medical records on 7/1/25 at 10:40 am, PharmD A stated Patient 8 received his home medication Vraylar for PTSD for approximately one month following admission to the facility. PharmD A stated Patient 8 had severe hand tremors (dyskinesia) on admission that made it difficult to perform activities of daily living (eating, drinking, grooming, dressing, toileting). PharmD A stated the Interdisciplinary Team (IDT - a team of members from different disciplines who work together to set patient goals and make care decisions) discussed it and changed Vraylar to Latuda due to the possibility that Vraylar was causing Patient 8's significant tremors. PharmD A acknowledged that Latuda also had the potential to cause dyskinesia.

During an interview with DON on 7/1/25 at 12:15 pm, DON stated she could not find documentation in Patient 8's medical records of a signed 'Consent to Receive Psychotherapeutic Medications' for Latuda and acknowledged there should have been one per facility policy.