HospitalInspections.org

Based on document review and interview, the Registered Nurse failed to supervise the care of providing patient incontinence care, ensure a patient was assisted with repositioning/turning every two hours, pain level assessments/reassessments were completed per physician orders and/or facility policy for 1 of 10 medical records reviewed. (Patient #1)

Findings include:

1. Facility policy titled "Pain Management" last reviewed/revised on 10/1/23 indicated the following: "POLICY: Pain assessment and pain management is an essential part of rehabilitation care of patients and is a priority in the hospital setting. PROCEDURE: 8. Re-assessment after initiating treatment: a. Pain will be assessed prior to pain interventions. b. Pain will be re-assessed approximately 30-60 minutes following a pharmacologic pain intervention, including the patient's perception of relief, improved functional status, etc.

2. Facility policy titled "Pressure Injury Prevention" last reviewed/revised 4/1/23 indicated the following: "Prevention: All patients admitted will be considered at risk for the development of pressure injuries. Mobility deficit: Patients that are bed bound or with limited activity should be repositioned at least every two hours. Moisture/Incontinence: All patients will be cleaned as soon as possible after soiling."

3. Facility policy titled "Guidelines and Protocols: Inpatient Rehabilitation Hospitals" last reviewed/revised 10/1/23 indicated the following: "Purpose: To outline clinical routines, guidelines and protocols of patient care. Policy...outlines basic tasks and designates the minimum frequency with which these tasks must be performed to maintain quality care. Hygiene: Bed linen changed, every other day and PRN (as needed). Draw sheets, incontinent pads, gown changed, daily and PRN. Peri-care every 12 hours and PRN.

4. Review of patient #1's medical record indicated the following:
The patient was admitted on 11/30/23 at 6:36 p.m. and discharged on 12/18/23 at 11:45 a.m. The patient had diagnoses that included but were not limited to cerebral infarction due to thrombosis of unspecified middle cerebral artery and displaced bimalleolar fracture of left lower leg.

(A.) A physician order dated 11/30/23 at 6:40 p.m. indicated to cleanse the patient with bath wipes after incontinence and/or as needed for soiling/saturation with a start date of 11/30/23 at 6:40 p.m. and end date of 12/18/23 at 2:05 p.m.

A physician order dated 11/30/23 at 6:40 p.m. indicated to assess the patient's pain every four hours with a start date of 11/30/23 at 8:00 p.m. and an end date of 12/18/23 at 2:05 p.m.

A physician order dated 11/30/23 at 6:40 p.m. indicated to turn the patient every two hours to start on 11/30/23 at 8:00 p.m. and was discontinued on 12/18/23 at 2:05 p.m.

(B.) A review of intake and output flowsheets indicated Patient #1 had episodes of urine incontinence on 12/3/23 at 7:00 p.m., 12/4/23 at 12:48 a.m. and 3:03 a.m., 12/9/23 at 7:00 a.m. and 12/10/23 at 10:00 a.m. The medical record lacked documentation of linen changes, incontinence care being provided to the patient and/or patient refusal of linen changes/incontinence care.

(C.) The medical record lacked documentation of a pain level assessment on the following dates and times:

On 12/1/23 at 1:03 a.m. and 9:30 a.m.
On 12/2/23 at 1:26 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m.
On 12/3/23 at 5:37 p.m.
On 12/4/23 at 3:00 a.m., 7:00 a.m. and 4:03 p.m.
On 12/5/23 at 4:25 a.m. and 6:25 p.m.,
On 12/6/23 at 6:47 p.m.
On 12/7/23 at 1:00 a.m., 1:43 p.m. and 5:43 p.m.
On 12/8/23 at 6:31 a.m.
On 12/9/23 at 12:34 a.m., 4:34 a.m., 8:34 a.m. and 12:34 p.m.
On 12/10/23 at 1:00 a.m., 9:26 a.m., 1:26 p.m. and 7:13 p.m.
On 12/11/23 at 1:02 p.m. and 6:43 p.m.
On 12/12/23 at 12:10 a.m.
On 12/13/23 at 9:14 a.m. and 7:01 p.m.
On 12/14/23 at 1:17 a.m., 9:38 a.m. and 6:36 p.m.
On 12/15/23 at 8:52 a.m.
On 12/16/23 at 6:08 p.m.
On 12/17/23 at 1:17 p.m.

(D.) A review of Patient #1's Medication Administration Record indicated medications were administered that included but were not limited to the following:

On 12/1/23 at 5:24 a.m., Tylenol 650 milligrams 1 tablet by mouth. The medical record lacked documentation of a pain level reassessment 60 minutes after a pain intervention at 6:24 p.m.

On 12/1/23 at 9:26 p.m., Tylenol 1300 milligrams by mouth. The medical record lacked documentation of a pain level reassessment 60 minutes after a pain intervention at 10:26 p.m.

On 12/8/23 at 9:03 a.m., Norco 5/325 milligrams 1 tablet by mouth. The medical record lacked documentation of a pain level reassessment 60 minutes after a pain intervention at 10:03 a.m.

On 12/11/23 at 2:43 p.m., Norco 5/325 milligrams 1 tablet by mouth. The medical record lacked documentation of a pain level reassessment 60 minutes after a pain intervention at 3:43 p.m.

On 12/12/23 at 9:28 a.m., Norco 5/325 milligrams 1 tablet by mouth. The medical record lacked documentation of a pain level reassessment 60 minutes after a pain intervention at 10:28 a.m.

On 12/13/23 at 11:05 a.m., Norco 5/325 milligrams 1 tablet by mouth. The medical record lacked documentation of a pain level reassessment 60 minutes after a pain intervention at 12:05 p.m.

(E.) The medical record lacked documentation of patient repositioning/turning every two hours and/or patient refusing repositioning/turning every two hours for the following dates and times:

On 11/30/23 at 10:00 p.m., 12/1/23 at 8:00 p.m., 9:00 p.m., 10:00 p.m., 11:00 p.m., 12/2/23 at 2:00 a.m. and 5:00 a.m.

The patient was documented as being in the supine position on 12/1/23 at 12:00 a.m., 1:00 a.m., 2:00 a.m., 3:00 a.m., 4:00 a.m., 6:00 a.m., 7:00 a.m., 12/2/23 at 12:00 a.m., 1:00 a.m., 3:00 a.m., 4:00 a.m., 6:00 p.m., 7:00 p.m., 8:00 p.m., 9:00 p.m., 10:00 p.m., 11:00 p.m., 12/5/23 at 6:00 a.m., 7:00 a.m., 8:00 a.m., 9:00 a.m. and 10:00 a.m.

The patient was documented as being in the sitting position on 12/2/23 at 9:00 a.m., 11:00 a.m., 12:00 p.m. and 1:00 p.m.

The patient was documented as being in the semi-fowler's position on 12/3/23 at 10:00 p.m., 11:00 p.m., 12/4/23 at 12:00 a.m., 1:00 a.m., 2:00 a.m., 3:00 a.m., 4:00 a.m., 4:59 a.m., 12/5/23 at 12:00 a.m., 1:00 a.m., 2:00 a.m., 3:00 a.m. and 4:00 a.m.

(F.) A review of a physical therapy evaluation note dated 12/2/23 at 8:30 a.m., indicated that Patient #1 required total assistance/dependent and moderate verbal cues related to bed mobility.

A review of physical therapy weekly progress note dated 12/5/23 at 6:39 a.m., indicated that Patient #1 was a moderate assist for bed mobility.

5. During an interview with A3 (Chief Nursing Officer) on 1/23/24 at approximately 4:45 p.m., he/she verified the medical record information for patient #1.