HospitalInspections.org

Based on record review and interview the hospital failed to ensure the patient's right to formulate an advance directive by failing to provide requested information about advance directives to 1 of 5 patients in a total sample of 5 (#2). Findings:

Review of the hospital's Advance Directives policy "RI 1241.ALX" reflected "If the patient does not have an advance directive, the patient will be offered further information, with referral to the Social Worker as indicated....... Information related to discussions of advance directives will be documented in the medical record"

Review of the hospital's Advance Directive Acknowledgement Form signed on 4/6/11 by patient #2's family representative reflected she wished to speak to someone or receive further information about a living will/advanced directive or surrogate-decision maker. Further review reflected S8, Registered Nurse (RN), witnessed the documented request and signature on the Advance Directive Acknowledgement Form.

Continued review of the form revealed that if a patient/family representative answered "yes" to the above question then the section "Comments: Called/Requested: Date; Time and Signed" should be completed. Review of the comment section reflected the section was blank.

Interview on 12/15/11 at 10:40 a.m., with S1, Administrator/Director of Nursing (DON), revealed that when a patient/family representative check "yes" concerning their wish to speak to someone or receive further information about a living will/advanced directive, then the person who witnessed the signing of the form was responsible for assuring that the Comment section was completed and that someone who can provide the information to the person was notified of the person's wish.

S1 further stated that normally the Chaplain would speak to the patient/family representative, and the information concerning the advance directive should be in the nurses notes or progress notes.

Interview with S3, Chaplain, on 12/15/11 at 10:52 a.m. revealed she was the Chaplain for the hospital and that whenever she received a call from the nurse concerning a patient/family representative's desire to speak to someone about an advance directive, she would discuss the advance directive information with them and document it in the patient's record.

Review of the record revealed there was no documented evidence to reflect that information concerning the advance directive was given to patient #2's family representative.

Further interview with S3, Chaplain at the above time confirmed there was no documented evidence to reflect she had talked to the family regarding an advance directive.

Based on record review and interview the registered nurse failed to ensure the evaluation of care on an ongoing basis in accordance with accepted standards of nursing practice by failing to ensure a patient was accurately assessed and/or treated for wounds for 1 of 5 patients in a total sample of 5 (#2). Findings:

Review of the clinical record for Patient #2 reflected the patient was admitted to the hospital on 4/5/2011 with diagnoses to include Post Traumatic Pulmonary Insufficiency following trauma and surgery, End Stage Renal Disease (ESRD), Diabetes Mellitus II and Hemiplegia affecting unspecified side as late effect of cerebrovascular disease. Further review of diagnoses reflected the patient was diagnosed with Bacteremia, Disseminated Candidiasis and Infection due to Central Venous Catheter after admission to the hospital.

Review of the Admission Assessment dated 4/5/11 at 4:16 p.m. reflected a section for Skin Integrity. Review of the section reflected a picture of a body with instructions to "Mark wounds, incisions, discolorations and erythema lesions, bruises and scars noted on picture and describe below:" Review of documentation completed by S4, RN, revealed the patient had "dryness of the [right] and [left] feet and toes. Wound Care nurse-referral for sacral wound".

Review of the picture revealed there was a circle around the patient's sacral area, and the patient's right and left feet were circled. There was no description of the areas noted on the admission assessment.

Review of the hospital's "PHOTOGRAPHIC WOUND DOCUMENTATION" sheets and wound care notes reflected an assessment on 4/6/11. Documentation on the "Wound Care Notes" reflected the patients right and left heels were "boggy" and skin was intact. It was also noted that there was excoriation of the peri-rectal area and the sacral area was clear. Further review reflected a scab to the left lower leg and top of right foot.

There were no further photographic documentation and/or wound care notes of the skin noted until 4/20/11.

Review of the hospital's photographic and/or wound care notes dated 4/20/11 revealed documentation to reflect the patient had a dark brown scar on the right lower leg. Further review of the hospital's picture revealed there were 4 darkened areas noted on the right lower leg and one pink area noted.

There was no documented evidence of an assessment of these areas noted on the hospital's photographic wound documentation sheet or the wound care notes.

Further review of the wound care notes dated 4/20/11 reflected "Toes on [right] ft - great toe ?PVD - closed blister bluish discoloration - [no] drainage noted. Paint [with] betadine [every] 24 [hours]. There was documentation of measurements of the blister.

Continued review of the hospital's photographic wound documentation sheet dated 4/20/11 revealed a picture of Patient #2's sacral and peri-rectal area. Review of the picture reflected multiple open reddened, scarred and pink areas in the sacral and peri-rectal area.

Documentation on the photographic wound documentation sheet reflected "excoriation" to the sacral and peri-rectal. Review of the Wound Care Notes dated 4/20/11 revealed "Sacral [and] Perineal area - excoriation noted-pink tissue......". There was no documentation of the opened reddened and/or scarred areas.

During an interview with S2, Wound Care Nurse on 12/15/11 at approximately 9:56 a.m. she revealed the Admission Assessment did not reflect an accurate assessment of the patient's skin condition on admit. S2, Wound Care Nurse further stated the patient's wound changes on the sacral and perineal area were caused by diarrhea and not by pressure, therefore, she did not call it pressure sores but referred to the wound changes as "excoriated".

Interview with S1, Administrator/DON on 12/15/11 at approximately 10:40 a.m. revealed the admission assessment nurse should have documented "more clearer the description of the patient's toes, feet and sacral area on admission." S1 confirmed there was no accurate description of the patient's skin noted on admission.

Further interview with S1, Administrator/DON on 12/15/11 at approximately 11:15 a.m. revealed through review of Patient #2's nurse's notes, the nurses were not consistent in addressing the patient's wounds during the patient's hospital stay.

Based on record review and interview the hospital failed to ensure the nursing care plan was developed and/or kept current by failing to ensure care plans were developed for infections and/or actual impairment of a patient's skin for 1 of 5 patients records reviewed in a total of sample of 5 (#2). Findings:

Review of the clinical record for patient #2 reflected the patient was admitted to the hospital on 4/5/2011 with diagnoses to include Post Traumatic Pulmonary Insufficiency following trauma and surgery, End Stage Renal Disease (ESRD), Diabetes Mellitus II and Hemiplegia affecting unspecified side as late effect of cerebrovascular disease. Further review of diagnoses reflected the patient was diagnosed with Bacteremia, Disseminated Candidiasis and Infection due to Central Venous Catheter after admission to the hospital.

Review of patient #2's care plan dated 4/6/11 revealed a care plan for an actual problem with infection related to the patient's surgical incision and a high risk of infection related to the patient's "Foley" and right central line.

Further review of the patient's care plan reflected there was no documented evidence of progression toward goals or new goals related to infections after the patient was diagnosed with Bacteremia, Disseminated Candidiasis and Infection due to Central Venous Catheter.

Continued review of the patient's care plan revealed a care plan for skin integrity dated 4/6/11. It was noted that the patient had a problem with "Skin integrity risk score <=16(wound care consult)". Interventions included turning schedule, wound care evaluation/treatment and education. This care plan was also noted to be signed by S2, Wound Care Nurse on 4/12/11.

Review of Patient #2's Photographic Wound Documentation and/or Wound Care Notes reflected the patient had actual impairment of skin to the left leg, top of right foot and excoriation to the peri-rectal area which was noted on 4/6/11. Further review of the documents reflected patient #2 had actual impairment of skin noted to the sacral and peri-rectal area on 4/20/11. However, review of the care plan reflected a problem with "excoriation" was not noted until 4/27/11.

There was no documented evidence to reflect the patient was care planned for the actual skin impairment noted to the skin.

Interview with S2, Wound Care Nurse on 12/15/11 at approximately 8:45 a.m. confirmed the care plan did not address the patient's actual skin impairment to the leg or sacral area. S2 stated that nurses were responsible for ensuring the care plans were completed and/or updated as needed.

Interview on 12/15/11 at approximately 11:00 a.m. with S1, Administrator/DON revealed the continuity of care was not evident in review of the record. S1 confirmed the care plan was not revised and/or updated as needed.