HospitalInspections.org

Based on document review and interview, the facility failed to ensure evaluation of care provided for 8 of 10 patients closed medical records (MRs) reviewed (patients 1, 3, 4, 6, 7, 8, 9 and 10's).

Findings include:

1. Review of facility policy, E.5.08 Turn Teams and Hourly Purposeful Rounding, last revision 11/2017, indicated each shift the Charge Nurse will identify 3 members of the turn team and schedule the rounding for every 2 hours, on either even or odd hours, to reposition patients who are unable to reposition themselves. The 3 person team is used to prevent: patient injury, skin shearing or breakdown dislodgement of lines/tubes and employee injury.

2. Patient 1, 3, 4, 6, 7, 8, 9 and 10's MR lacked documentation of turning patient completed every 2 hours during admission.
Patient 1's MR indicated 12/20/2019, PT (physical therapy) progress note, dependent (assist) 2 (person) bed turn. Patient 1's MR lacked documentation of turning patient every 2 hours, including but not limited to 12/23/2019, at 1500 (hours), B (back), next position change 1900 (hours) R (Right). 12/20/2019, 1900 (hours) B, 2000 (hours) B and 2200 (hours) R.
Patient 3's MR indicated on 11/20/2019, dependent helper does all the work. MR lacked documentation of turning patient every 2 hours including but not limited to 11/20/2019, B, 1100 (hours) next position change R at 1900 hours.
Patient 4's MR indicated on 12/23/2019, dependent helper does all the effort. MR lacked documentation of turning patient every 2 hours including but not limited to 12/23/2019, 1700 (hours) L (left), 1900 (hours) L and 2100 (hours) B.
Patient 6's MR indicated on 12/14/2019, substantial/Maximal assistance-helper does more than half the effort. MR lacked documentation of turning patient every 2 hours including but not limited to, 12/14/2019, at 1900 (hours) B, position blank through 0600 (hours) of 12/15/2019 .
Patient 7's MR indicated 12/03/2019, substantial/Maximal assistance-helper does more than half the effort. MR lacked documentation of turning patient every 2 hours including but not limited to 12/03/2019, 0900 hours, C (chair), 1100 (hours) C, 1200 (hours) C, 1300 (hours,) C, 1400 (hours) C, 1500 (hours), B. 12/04/2019, position blank from 0200 (hours), through 0600 (hours).
Patient 8's MR indicated 11/10/2019, substantial/Maximal assistance- helper does more than half the effort. MR lacked documentation of turning patient every 2 hours including but not limited to 11/10/2019, blank regarding position from 0700 (hours) until 11/11/2019 at 0600 (hours).
Patient 9's MR indicated 11/24/2019, substantial/Maximal assistance- helper does more than half the effort. MR lacked documentation of turning patient every 2 hours including but not limited to 11/24/2019, blank regarding position from 0700, until patient on L (left) at 1900 (hours).
Patient 10's MR indicated 12/03/2019, substantial/Maximal assistance-helper does more than half the effort. MR lacked documentation of turning patient every 2 hours including but not limited to 12/03/2019, at 0800 (hours) R position unchanged until 1100 (hours) L.

3. Patient 1, 3, 4, 6, 7, 8 and 9's MR indicated orders for tube feeding. MR lacked documentation of tube feedings per order during admission.
Patient 1's MR indicated 12/02/2019, change TF (tube feed) to Vital ... Began at 40 mls (milliliters) an hour and advance as tolerated... MR lacked documentation of tube feeding on 12/18/2019 from 0700 hours until midnight.
Patient 3's MR indicated 10/31/2019, change TF to Promote. Begin at 40 mls an hour with 25 mls an hour FWF (free water flush). Advance TF to 80 mls an hour as tolerated. MR lacked documentation tube feeding including but not limited to, tube feeding on 11/03/2019 from 0700 hours to 1900 hours.
Patient 4's MR indicated 11/14/19, Tube feeding, Glucerna 1.5 at 30 ml with 20 ml of FWF. MR lacked documentation of tube feeding including but not limited to 12/05/2019, from 0700 (hours) through 1900 (hours).
Patient 6's MR indicated 11/26/2019, change TF to Glucerna 1.5, and began at 25 mls an hour... MR lacked documentation of tube feeding including but not limited to 11/27/2019, 0700 (hours) through 1900 (hours).
Patient 7's MR indicated 11/07/2019, TF change to Vital ... @ 75 mls an hour as tolerated... MR lacked documentation of tube feeding including but not limited to 11/09/2019, from 0700 (hours) through 1900 hours.
Patient 8's MR indicated 11/08/2019, TF to Glucerna 1.5 at 65 mls an hour ... MR lacked documentation of tube feeding including but not limited to 11/10/2019 from 1900 (hours) until 11/11/2019 at 0600 (hours).
Patient 9's MR indicated 11/26/2019, TF to 75 mls an hour... MR lacked documentation of tube feeding including but not limited to 11/24/2019, from 1900 until 0700 of 11/25/2019.

4. Review of facility policy, I.9.01 Initial Assessment/Reassessment of Wounds, reviewed date 01/2019, indicated wounds will be reassessed and photographed at least every 7 days by the Wound Care nurse and as needed by the RN or Wound Care nurse until the wound is resolved or the patient is discharged.

5. Patient 3, 4, 6, 7 and 8's MR lacked documentation of wound care assessments every 7 days during admission.
Patient 3's MR lacked every 7 day wound care assessment, including but not limited to assessment on right breast was documented on 11/8/2019, and again on 11/19/2019, (11 days later).
Patient 4's MR lacked every 7 day wound care assessment including but not limited to assessment on coccyx was documented on 11/15/2019, and again on 11/26/2019, (11 days later).
Patient 6's MR lacked every 7 day wound care assessment including but not limited to assessment on forehead 11/16/2019, and again on 11/26/2019 (10 days).
Patient 7's MR lacked every 7 day wound care assessment including but not limited to assessment on Peg (feeding tube), 11/05/2019, and again on 11/15/2019 (10 days). Assessment on bilateral breast 11/05/2019, no further documentation of wound care assessment.
Patient 8's MR lacked every 7 day wound care assessment, including but not limited to assessment on right upper abdomen (PEG tube site) was documented on 11/7/2019, and again on 11/19/2019 (12 days).

6. Patient 1, 3, 4, 6, 7, 8, and 9's MR lacked documentation of daily wound care as ordered during admission.
Patient 1's MR indicated, 11/22/2019, daily wound care order, coccyx daily and PRN (as needed) cleanse with saline, pat dry, apply santyl, moist gauze, and dressing and medfix tape. MR lacked documentation of wound care completion, including but not limited to on 12/05/2019. MR indicated, 12/10/2019, Coccyx/sacral wound, three times daily and as needed cleanse with saline, pat dry... MR lacked documentation of wound care completion including but not limited to on 12/12/2019 and 12/15/2019.
Patient 3's MR indicated order for, 11/08/2019, Right Breast every other day and PRN, cleanse with saline, pat dry, apply dressing. MR lacked documentation of wound care orders completed, including but not limited to every other day 11/14/2019 through 11/18/2019.
Patient 4's MR indicated 11/15//2019, cleanse with soap and water, pat dry and apply Rileys. MR lacked documentation of wound care orders completed, including but not limited to December 5, 11, 12, 13, 14, 16, 18, 20, and 21 of 2019.
Patient 6's MR indicated 11/28/2019, forehead incision, daily cleanse with saline, pat dry, leave open to air. MR lacked documentation of wound care orders completed, including but not limited to 12/04/2019 and 12/05/2019.
Patient 7's MR indicated 11/05/2019, under bilateral breasts, twice daily and PRN, cleanse with mild soap and water, pat dry, apply miconazole powder. MR lacked documentation of wound care orders completed, including but not limited to November, 08, 09, 10, 13, 14, 15, 16, 21, 22, 24, 25, of 2019. Wound healed noted on 11/26/2019.
Patient 8's MR indicated 11/06/2019, PEG tube site- clean with soap and water, pat dry, apply drain sponge and secure with tape. Change daily and PRN (as needed). MR lacked documentation of wound care orders completed, including but not limited to November, 08, 13, 16, 17, 20, 23 and 24 of 2019.
Patient 9's MR indicated 11/26/2019, lower abdomen every 3 days and PRN, cleanse with saline, and pat dry, apply bordered adhesive gauze. MR lacked documentation of wound care orders completed, including but not limited to, 12/15/2019.

7. Interview on 03/03/2020, at approximately 1225 hours, with N1 (Registered Nurse/Chief Clinical Officer) confirmed he/she reviewed medical records 1 through 10 and each had missing documentation as indicated above.

8. Interview on 03/03/2020, at approximately 1445 hours, with N5 (Certified Nurse Assistant), confirmed the following. N1 does not document or note which patient has been turned, their position or the time of positioning. N1 had just finished turning all 1300 patients that she could turn by himself/herself. N1 had not had assistance with 1300 patient turns. N1 informs the nurse and they document patient, position and time, in the patient's medical record. When asked, N1 stated he/she had placed patient 13 on their right side at 1200 hours.

9. Interview with 03/03/2020, at approximately 1451 hours, with N6 (Licensed Practical Nurse/Wound Care Nurse) confirmed N6 had not documented or noted any positioning today on patient 13 (current patient). N6 had been pulled from floor for an interdisciplinary meeting. N6 had 5 patients assigned to him/her today. N6 has a hard time remembering all patient positioning.

10. Interview on 03/03/2020, with N3 (Registered Nurse/Certified Wound Care Nurse) at approximately 1530 hours, confirmed the following. Patient 12's (current patient) MR indicated, 02/04/2020, order left great toe/foot, daily and PRN, clean with/saline, pat dry, apply Adaptic, cover with kerlix/coban. Dressing documentation should not have been as clear dry and intact as it was marked 02/08/2020 and 02/09/2020. There was no indication the dressing was changed on 02/08/2020 and 02/09/20.