HospitalInspections.org

Based on interview and document review, the facility failed to include notification of patient and/or family in its Patient Rights Interdisciplinary Care Policy. The facility failed to document the patient and/or family was notified to participate in the interdisciplinary care team meeting for 1 patient (#1) of 10 patients (#1-#10) patient medical records reviewed.

This deficient practice had the likelihood to affect all patients of the hospital.


Findings included:

On 2/8/2021 at 11:00 AM in the conference room, an interview was conducted with case manager, staff #6, who confirmed the family and patient (Pt/pt) were notified for participation in the Interdisciplinary Case Management meetings. The staff member further confirmed this evidence of documentation would be located on the IAA (Interdisciplinary Admission Assessment) form. The identification and review of the IAA form, in pt #1's medical record dated 1/15/2021, was facilitated with the assistance of the Director of Nurses (DON), staff #2. The DON confirmed no evidence of documentation was identified on the IAA form indicating that neither the patient nor the family had been informed of the time of the Interdisciplinary Care Team (IDT) would meet (Thursdays) and what method of inclusion the family could expect. (Telephone conference call).

A review of the next scheduled IDT (Thursday) meeting should have occurred on 1/21/2021. A review of Pt #1's medical record identified no IDT form dated 1/21/2021. The following week of 1/28/2021 was reviewed. Signatures identified on the form indicating participation; Registered pharmacist, Physical Therapist, Occupational Therapist Speech Language Pathologist included case manager, social worker, Registered Dietitian and Respiratory Therapist. There was no documentation indicating that nursing, wound care, the patient and/or family had participated.

Copies of policies provided by the facility, none of which contained identification numbers were reviewed and identified below:


Patient Rights and Responsibilities, effective date 9/1/2011 reviewed 2015, 2017 and 2020, pages 1 and 2.
Interdisciplinary Treatment Plan, effective date 9/1/2011 and reviewed 2014, and 2017, pages 6 of 6.
Interdisciplinary Documentation Model, effective date 9/1/2011, reviewed 2015 and 2017, pages 4 of 4.

The above policies failed to include the patient and/or family as part of the team. The above policies refer to educating the patient family after the "team" has identified a patient problem and a treatment approach has been determined. EX. Interdisciplinary Documentation Model pages 1-4. On page #3,
4. Interdisciplinary Team Conference Progress Report:
Used at each Interdisciplinary Team Conference Meeting.
Utilized to document attendance at the team meeting and a summary of the discussion among team members, including patient progress toward stated goals and barriers to discharge.
Used to identify the team focus of discharge planning.
Used to provide an overview of the plans of care and the activity in regards to the patient pan of care.

5. Interdisciplinary Patient Education:
a. Patient/Family education provided by the Interdisciplinary team is documented within the appropriate section of the "Interdisciplinary Patient/Family Teaching record".
b. This record serves as an interdisciplinary record of the following manner:
i. As a plan regarding education topics that may need to be provided to the patient/family.
ii. As a communication tool regarding the topics of information provided to the patient/family and the response of the patient/family to the provided information.

In none of the policies provided by the facility was the patient/family included to be present. There was no policy provision instructing communication with the patient/family at or during the interdisciplinary team meeting. The patient/family was not present to make their desires known or have input into the planning process.

On 2/4/2021 written communication from the family of pt #1 was received and the documentation included, "The family was not allowed to visit do to COVID restrictions. The family spoke with the patient by phone, often. The patient reported to the family she was starving and the staff was only feeding her ice cream. She also complained that she was constantly thirsty and not getting enough to drink." A review of medical records found no mention of pt. #1's hunger or thirst. An interview with the Registered Dietician confired she had never had pt #1 tell her she was not getting enough to eat or drink.

The family of pt #1 had many complaints. The Interdisciplinary Team was unaware of any complaint. The case manager revealed personal communication with the family via facility cell phone texts but the case manager was not present for the IDT meeting and the text messages were not transcribed into pt #1 medical record. The failure to transcribe the text messages were confirmed by the case manager staff #6.

The facility could not provide documentation that the IDT had communicated with the family, sought out input from the family or provided explanation for the disciplinary teams care planning choices.

Based on record review and interview, the hospitals nursing department failed to properly identify pressure related skin/tissue damage, failed to document the correct identification of the pressure related wound and failed to record measurements after the skin surface broke and a pressure wound developed in 1 patient (#1) of 10 patients (#1-#10) reviewed.

This deficient practice had the likelihood to effect all patients of the extended care hospital.


Findings included:

On 2/8/2021, a review of patient (Pt/pt) #1's medical record (MR) was conducted with the assistance of the Director of Nursing, staff #2. The initial admission nursing assessment dated 1/15/2021 at 7:16 PM recorded in a hand written nurses note from the admitting nurse, "Skin is intact"... "Pt. has no bed sores or redness to bottom".

The initial skin assessment, documented by the wound care nurse was dated 1/16/2021. A form with "Admit Sacrum" documented was provided in the medical record. A photograph visually identified an area of bright pink tissue on pt #1's sacrum. There were no measurements documented. The photograph was a picture of a bright pink area of tissue across the sacrum, near the center of this pink area was a distinct circular outline of tissues with a darker pink color and a center point that was even darker. There was no documented description of the visualized tissue. Therefore there was no accurate description of the size of the altered tissue, which by coloration indicated tissue damage.

An initial skin assessment form was found in the pt's MR with a black and white outline of the anatomical man. The photo offered front, back and side views for marking the location of skin related issues. No location was marked on the anatomical man. The comments on the page were documented as, "Sacrum protective (sic) applied instructed to turn on side often". No further description or location was identified on the "Initial Skin Assessment" form.

Identified on the "Wound Care Treatment Record" dated 1/16/2021, "Initial skin assessment completed. Pictures taken, no culture obtained at this time. Pt on regular mattress, LALM (Low air loss mattress) ordered".

On 2/8/2021 an interview with the Director of Wound Care Services, staff #17, verbally described pt #1's bright pink skin irritation on the sacrum as "evidence of shearing". The photograph was reviewed. The surveyor commented to staff #17, on the content of the picture, and what appeared to be a border around a wound of shallow depth. Staff #17 again stated the picture was shearing.

By definition, taken from "Advances in Skin and Wound Care 2004, Volume 17,issue 5, page 222: Friction and shear are mechanical forces contributing to Pressure Ulcer (PU) formation. Friction and shear are 2 separate forces. The tissues injury may look like a superficial skin insult. Friction and shear work together to create tissue ischemia and ulcer development."

"Shear is a mechanical force that acts on an area of skin in a direct parallel to the body surface. Think of pulling the bone of the pelvis in one direction and the skin in the opposite direction. This insult and compromise creates ischemia, leads to cellular death and tissue necrosis. Shear and friction go hand in hand and rarely occur without the other."


Interview with Staff Wound Nurse #18 also described the broken area of skin on the sacrum as shearing. The surveyor remarked to staff #18 that the edges of the wound were well marked with a pale yellow center. The staff Nurse #18 again stated the area was only shearing and not a wound. When asked why measurements ere not recorded, staff #18 stated, "That's not how we do it here."

Further reference for staging a pressure ulcer: www.hopkinsmedicine.org. John Hopkins Medical Center;

"Stage I, Intact skin with non-blanchable redness of a localized area, usually over a bony prominence.
Stage II Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open ruptured serum filled blister."

Further review of the nurses notes dated 1/31/2021 the evening nurse documented "Patient is incontinent of bowel and is diapered" 2/3/2021 the date of discharge the RN staff #20 documented, 7:00 AM "excoriation noted to perineal area, wound care following". At 11:30 AM "Pt states she needs to have a BM (Bowel Movement) Pt is diapered". "Diapering" an adult with fecal incontinence would hold fecal matter close to the perineal area and increases the risk of skin breakdown secondary to the fecal contamination.

Reference: Wound Management and Prevention: Volume 53, Issue 12 December 2007.
"Incontinence-associated dermatitis, a clinical manifestation of moisture-associated skin damage is a common consideration in patients with fecal and or urinary incontinence. Among hospitalized patients the prevalence rate has been found to be as high as 27%. Exposure to skin surface irritants may be a predicate and the condition, in turn, may factor in pressure ulcer risk because skin integrity in compromised. ..."

Pt #1 was discharge on 2/4/2021. On 2/4/2021, review of the Home Health Care admitting nurses assessment for pt #1 documented, "Pressure Ulcer Sacral region stage II. Present on admission. Size: Length 5.3 Centimeters (CM). width 2.3 CM and depth 0.2 CM. The dressing ordered was Cleanse with normal saline, pat dry, apply allginate with silver to wound bed and cover with Mepilex dressing."

Although the facility nursing staff refused to acknowledge the presence of a wound. The photograph provided by the facility, and the Home Health Care Nurses notes documented evidence of a stage II pressure ulcer.

Based on record review and interview, the hospital's nursing staff failed to care plan fecal incontinence for 1 pt (#1) of 10 patients (#1 - #10) reviewed.

This deficient practice had the likelihood to effect all patients of the hospital.


Findings included:


On 2/8/2021 in the conference room the medical record (MR) for PT #1 was reviewed with the assistance of the Director of Nursing. The MR of pt #1 revealed the patient was incontinent of fecal matter and had developed changes in her skin in the area of the sacrum. A review of the nurses notes indicated that adult diapers were in use secondary to pt #1's fecal/bowel incontinence.

On 2/3/2021, the date of discharge, the RN staff #20 documented, 7:00 AM "excoriation noted to perineal area, wound care following". At 11:30 AM "Pt states she needs to have a BM (Bowel Movement) Pt is diapered".

A review of pt #1's nursing care plan found no problem was identified for fecal/bowel incontinence. The nursing staff documented use of adult diapers to contain the incontinent fecal matter. The adult diapers held the fecal matter against pt #1's skin between diaper changes.

No intervention was documented on the nursing care plan since no problem had been identified and commented. Neither the floor nurses nor the wound care nursing staff identified fecal/bowel incontinence as a problem with potential to contribute to skin breakdown.

Based on record review and interview, the hospital failed to insure complete timely nursing documentation of patient weights to facilitate the Registered Dietician's dietary calculations. The facility failed to insure the patient weights were correct and documented timely. The facility failed to insure staff were trained in a uniform method to determine the nutritional intake of patients, so that when the Registered Dietician calculated the nutritional intake and nutritional needs for each individual patient, the calculations would be adequate to meet the patients nutritional need for 1 Patient, #1 (Pt/pt) of 10 patients (#1 through #10) patients whose medical record was reviewed, from 1/15/2021 through 2/4/2021.

This deficient practice had the likelihood to effect all hospital patients.


Findings included:

On 2/8/2021 in the conference room, staff Registered Dietician (RD) #15 was interviewed. During the interview staff #15 was asked why her dietary consult was lacking the patient's weight (wt) for the date of 1/15/2021. She stated, "The wt was not documented on the chart for pt #1 when I reviewed and collected the information". Weeks 1/23 and 1/30 also had no wt recorded on the RD evaluation. Staff #15 stated, "A different RD had evaluated pt #1 on those days. If the wt was not recorded by the RD in her evaluation, then it is very likely the wt wasn't recorded the MR for those two weeks."

Staff #15 confirmed a RD visit occurred every 7 days after the initial. A second RD had submitted her dietary consultation and the wt for pt #1 was also missing. Staff #2 was asked why the MR for patient #1 had documented weight on the flow sheets when they were reviewed by the surveyor, but 2 registered dieticians on 2 different weeks had recorded that patient #1's wt was not available? Staff #2, the Director or Nursing (DON), who facilitated the medical record (MR) review for pt #1 indicated the weights were likely not recorded in the MR for pt #1 when the RD reviewed the MR.

During the interview with staff RD #15, it was brought to the attention of the RD that pt #1 had a poor appetite on most days. Staff #15 revealed she looked at the meal intake percentages that were documented on pt #1's flow sheet and calculated the nutritional value of intake based on that information.

During the interview, the DON was asked if the Certified Nurse Aides (CNA) had been educated on how to collect the percentage of food consumed, and if a consistent methodology had been created by the hospital, so each CNA looked at the pt's meal consumption the same. The DON stated "no". When asked how did the CNA determine how much each patient ate, the DON, stated, "They just kinda guess". The surveyor presented a scenario," If the patient ate their dessert and bread that could be considered 50% of the meal. The DON indicated, "Well yes I guess so."

The RD had documented pt #1 had sores in her mouth and had requested cool liquids and ice cream. The RD admitted she had not recorded or asked the CNA to record the cool liquids or ice cream when it was requested and served the pt #1. There was no documentation pt #1 had received ice cream or cool liquids.

Pt #1 was admitted with a wt of 145. The RD had documented intake for pt #1 was recorded as 50%-80%. A review of pt #1's MR indicated that during pt #1's stay 59 meals were served to her. Of those 59 meals 16 meals were recorded as an intake of 50% or better. That left 43 meals with a recorded intake of less than 50%. Also of those 43 meals, 13 meal intakes were not documentation with any intake consumed. With less than 50% consumed out of 43 meals it would be unlikely pt #1 would maintain her admission wt.

On 2/8/2021 the DON provided copies of pt #1's MR with recorded wt's of
1/15/2021 wt 145,
1/23/2021 wt 139.5 and
1/30 wt of 140.2 respectively. When the DON was asked why the wt's were not found when the RD's reviewed the MR she stated, "the wt's were taken, but weren't recorded when the RD reviewed the MR."

On 2/8/2021 The RD confirmed she had recommended Ensure Enlive to be provided twice a day for pt #1. Ensure Enlive provides 350 calories in each can. If pt #1 consumed 100% of 2 cans she would have consumed 700 calories. far less than the 2000 calorie diet the RD used as the base calorie count. Each can provided 40% of the recommended daily protein. Two cans wound provide 40% of the protein required.

The RD was asked if ensure products were the only supplements available for recommendation. She replied yes. Her choices were Ensure Enlive at 350 calories, Ensure Clear added another 150 Calories and Promod was a high protein supplement. She explained pt #1 had poor kidney function and Promod was not a valid option."