HospitalInspections.org

I. Based on medical record and policy review, job description review and staff interview, it was determined that the registered nurse (RN) failed to supervise and evaluate the nursing care for 3 of 5 patients (Patient #'s 1, 2 and 3) in the sample with wounds. Findings include:

The hospital job description for the "Registered Nurse" stated, "...the Registered Nurse (RN) maintains the delivery of quality of care by assuring the nursing care plan is followed...Initiates an on-going systematic assessment of the physical...needs of the patient/family through...observation, and physical examination...Performs a complete head-to-toe assessment of each assigned patient per shift using proper documentation tools...Performs wound care in accordance with policy, utilizing proper documentation tools..."

The hospital policy entitled "Nursing Care Plan" stated, "...The key issues that Nursing has primary responsibility...include...Wound prevention and management..."

The hospital policy entitled "Wound Assessment" stated, "All patients admitted to the hospital will have a skin assessment on admission and daily thereafter. Patients admitted for wound care will have a comprehensive assessment of the wound on admission and weekly thereafter. The assessment of a wound will include at a minimum location, size, tunneling, undermining, drainage, odor, color and surrounding tissue...Photographs of the wound will be taken on admission...on discharge...Measurement should include length, width, and depth of the wound..."

A. Patient #1 - right heel pressure ulcer

4/11/12 at 4:00 PM - Admission "Nurses Progress/Narrative Notes"
- Skin intact

4/11 - 5/9/12 - "24 Hour Patient Record & Plan of Care"
- included turning and repositioning Patient #1 every two hours
- documentation failed to provide evidence that staff turned and/or repositioned Patient #1 every two hours according to the plan of care
- documentation failed to provide evidence to support staff assessed/observed a change in Patient #1's right heel until a deep tissue injury was discovered on 4/25/12

Review of wound assessment documentation by Wound Care Nurse A revealed the following assessments of the right heel:

- 4/25/12: identified a right heel pressure ulcer - deep tissue injury; wound bed described as black-purple discolored area; color photograph of right heel supported wound description

- 5/1/12: described wound bed as black discolored area; color photograph of right heel supported wound description

- 5/7/12: described wound bed as black, dark red discoloration; color photograph supported wound description

Review of "Wound Documentation" revealed assigned nursing staff assessed Patient #1's right heel wound bed to be "Pale" in color on 4/27, 4/29, 4/30, 5/2, 5/3 and 5/4/12. Based on color photographs of the right heel and right heel wound assessments performed by Wound Care Nurse A, the nurses' assessments of a "Pale" right heel wound bed were determined to be inaccurate.

The Chief Nursing Officer confirmed these findings on 6/21/12 between 10:50 and 11:00 AM.

Review of the "Nurses Progress/Narrative Notes" documentation revealed Patient #1 was discharged to home on 5/10/12 at 3:40 PM. There was no evidence in the medical record on the day of discharge to support:

- an assessment of the right heel wound by either the assigned nurse and/or Wound Care Nurse A
- that a wound photograph was obtained as per policy

On 6/21/12 from 11:09 - 12:04 PM, the Chief Nursing Officer reviewed Patient #1's medical record and confirmed these findings.

B. Patient #2 - Wounds on the sacrum (lower back), top of the right foot, right medial foot, right heel and right shin

Review of the wound assessment documentation revealed no evidence of the following:

a. A comprehensive wound assessment completed on admission, 5/25/12. The first comprehensive wound assessment was completed 6 days after admission, on 5/31/12.

This finding was confirmed with Wound Care Nurse A on 6/21/12 at 11:35 AM.

b. That the wound depth was assessed during the weekly comprehensive wound assessments dated 5/31, 6/7 and 6/14/12.

These findings were confirmed with Wound Care Nurse A on 6/21/12 at 11:40 AM. Wound Care Nurse A reported that the wound depth was assessed every week, however, he would not document the wound depth if it was less than or equal to one millimeter.

C. Patient #3 - Left buttock wound

Review of the wound assessment documentation revealed no evidence that the wound depth was assessed during the weekly comprehensive wound assessments on 6/6 and 6/13/12.

This finding was confirmed with Wound Care Nurse A on 6/21/12 at 11:15 AM.

II. Based on medical record and policy review, job description review and staff interview, it was determined that the RN failed to ensure discharge instructions for 1 of 1 discharged patients in the sample (Patient #1) were complete. Findings include:

Review of the job description entitled "Registered Nurse" stated, "...the Registered Nurse (RN)...Provides discharge instructions..."

The hospital policy entitled "Discharge, Discharge Planning and Instruction Form" stated, "...ensures that each patient is referred to the proper environment to maintain safety and continuity of care...To provide documentation of instructions given to a patient before dismissal...Each patient going...home...will receive written and verbal discharge instructions...discharge instructions will be documented according to procedure...If the Case Manager is not on duty, the charge nurse will...Re-check all required forms for accuracy and completion...The nurse will complete the Discharge Instruction Form...Procedure...is to be completed on all patients who are going...home...patient's nurse will document patient instruction for...wound care...write additional discharge instructions as appropriate...This may include treatment routines and equipment/supplies sent with the patient or instructed to purchase..."

A. Patient #1
Review of "Physician's Orders" dated 5/1/12, included a wound care order to apply skin prep to the right heel and cover with an ABD (gauze) dressing every other day.

Review of the "Interdisciplinary Patient Discharge Instructions..." dated 5/10/12 revealed that Patient #1 was to be discharged to home with a relative. Nursing staff failed to ensure that the discharge instructions included:

- wound condition (draining)
- skin condition (pressure ulcer)
- dressing type and location of dressing (wound care orders/supplies provided to patient)
- name of individual to whom oral instructions were provided for wound care, pressure ulcer and signs and symptoms of infection
- when next scheduled doses of medication were due
- if prescriptions were provided to the patient/family

On 6/21/12 at 11:09 AM, the Chief Nursing Officer reviewed the medical record and confirmed these findings. The Chief Nursing Officer reported that it was the expectation that nursing staff provide complete instructions to the patient and/or family at the time of discharge to ensure continuity of care.

III. Based on medical record review, document review, policy review and staff interview, it was determined that for 2 of 5 patients in the sample (Patient #'s 2 and 3), the RN failed to adhere to physician's orders. Findings include:

The hospital job description entitled "Registered Nurse" stated, "...Assures that medication...administration is correct...Administers medications as ordered..."

The hospital policy entitled "Medication Administration" stated, "...Obtain B/P (blood pressure) prior to administering anti-hypertensives and document..."

The hospital food and nutrition policy entitled "Patient Services" stated, "...Nourishment between meals shall be provided as required by the diet prescription..."

A. Patient #2
Review of physician orders dated 5/31/12, revealed an order for the right foot and leg open areas to be cleansed with sterile water and treated with Silvadene (a topical, local anti-infective medication) twice a day.

Review of the "Wound Documentation" sheets revealed that staff failed to perform the ordered treatments twice daily for the following:

1. Top of the right foot wound:
6/1, 6/3, 6/4, 6/5, 6/6, 6/7, 6/9, 6/10, 6/11, 6/15 and 6/18/12

2. Right heel wound:
6/1, 6/4, 6/5, 6/6, 6/9, 6/10, 6/11, 6/15 and 6/18/12

3. Right shin wound:
6/1, 6/4, 6/5, 6/6, 6/7, 6/9, 6/10, 6/11, 6/15 and 6/18/12

Wound Care Nurse A reviewed the medical record documentation on 6/21/12 at 11:30 AM and confirmed that wound treatments had not been completed as ordered.

B. Patient #3
1. Medical record review revealed a physician order written on 6/5/12 for Metoprolol (used to treat high blood pressure) to be administered every 8 hours; Hold for a heart rate of less than 60 or a systolic blood pressure reading of less than 100.

a. Review of medication administration records and vital sign documentation revealed that between 6/5 and 6/21/12, there was no evidence that Patient #3's heart rate and systolic blood pressure were checked prior to the administration of the following doses of Metoprolol:

6/10/12 at 4:00 PM
6/11/12 at 4:00 PM
6/12/12 at 4:00 PM
6/14/12 at 4:00 PM
6/16/12 at 4:00 PM

Interview with the Chief Nursing Officer on 6/21/12 between 10:50 and 11:00 AM confirmed these findings.

b. Review of the medication administration record revealed no evidence that the Metoprolol was administered on 6/24/12 at 12:00 AM.

The Chief Nursing Officer confirmed this finding on 6/21/12 between 10:50 and 11:00 AM.

2. Physician's orders dated 6/7/12 contained orders for the following nutritional supplements:
- Juven one packet twice a day at lunch and dinner
- Prostat 30 milliliters once a day

Review of Patient #3's "Enteral Nutrition Record" revealed no evidence that the nutritional supplements were administered as ordered on the following dates:

a. Juven - 6/14, 6/16, 6/17, 6/19 and 6/20/12
b. Prostat - 6/17/12

The Chief Nursing Officer confirmed these findings on 6/21/12 at 11:05 AM. In addition, the Chief Nursing Officer reported that the RN was responsible for the administration of nutritional supplements.

3. Physician's orders dated 6/16/12 contained orders for Enlive (a nutritional supplement) twice a day.

a. Review of Patient #3's "Enteral Nutrition Record" revealed no evidence that the Enlive was administered twice a day as ordered on 6/17, 6/18, 6/19 and 6/20/12.

The Chief Nursing Officer confirmed this finding on 6/21/12 at 11:05 AM.

Based on medical record review, policy review and staff interview, it was determined that for 1 of 5 patients (Patient #2) in the sample, staff failed to administer medications according to hospital policy. Findings include:

The hospital policy entitled "Orders, Physician" stated, "...All patient medication...must have a physician's order...A complete medication order consist of...Frequency of administration..."

The hospital policy entitled "Drug Orders" stated, "...In order for a drug order to be valid it must include the following elements...the frequency with which the drug is to be administered..."

A. Patient #2
"Physician's Orders" dated 5/26/12, revealed an order for Santyl ointment (used to remove dead tissue) to be applied to the sacrum (lower back), but no frequency was specified.

Review of the "Wound Documentation" sheets on 6/20/12 revealed that staff had documented the daily application of Santyl ointment to the sacral wound on 5/27, 5/28, 5/29, 5/30, 5/31, 6/1, 6/2, 6/3, 6/5, 6/6, 6/7, 6/8, 6/9, 6/10, 6/12, 6/13, 6/14, 6/15, 6/16, 6/17, 6/18, 6/19 and 6/20/12.

During a review of the medical record on 6/21/12 at 11:30 AM, Wound Care Nurse A confirmed that the physician's order for the Santyl ointment did not specify a frequency. In addition, Wound Care Nurse A confirmed that the Santyl ointment was administered on the noted dates without a complete medication order.

Based on closed medical record review, document review and staff interview, it was determined that the medical record for 1 of 1 (Patient #1) discharged patients in the sample, failed to contain an ordered consultative evaluation. Findings include:

The document entitled "Rules and Regulations of the Medical Staff..." stated, "...Consultations...shall show evidence of a review of the patient's record by the consultant...in the progress notes within 72 hours of the consultation being ordered..."

A. Patient #1
Review of "Physician's Orders" dated 5/1/12 at 6:45 AM, included an order for a cardiology consult to evaluate Patient #1 for a LifeVest (device worn outside the body that, if a life-threatening rhythm was detected, the device alerts the patient prior to delivering a treatment shock).

Review of the "Report of Consultation" revealed that the consult was requested by the hospital on 5/1/12 at 7:30 AM. However, review of the medical record failed to provide evidence that the cardiology consultation was completed as ordered.

The Chief Nursing Officer reviewed Patient #1's medical record on 5/21/12 at 11:09 AM and confirmed this finding.

Based on closed medical record review and staff interview, it was determined that the medical record for 1 of 1 (Patient #1) discharged patients in the sample, failed to contain a final diagnosis within 30 days of discharge. Findings include:

The Health Information Management policy entitled "Medical Record Analysis" stated, "...The discharge summary shall be completed...within 30 days of discharge..."

Review of the "Nurses Progress/Narrative Notes" documentation revealed Patient #1 was discharged from the hospital on 5/10/12 at 3:40 PM.

The "Discharge Summary" which included the discharge diagnosis, was dictated by Physician A on 6/13/12 at 5:58 PM (34 days later).

Director of Quality Management A reviewed Patient #1's medical record on 6/20/12 at 1:55 PM and confirmed that the medical record, which included the patient's final diagnosis, was not completed within 30 days of discharge.