HospitalInspections.org

Based on record review and interview, the facility failed to ensure the Patient's Rights for Patient #1 during a 9-week admission.

Findings were

Patient #1's admission consent paperwork was signed on 5/20/2021 by the son and reflected, "reason patient is unable to sign: incompetent."

Patient #1's record did not contain court documents to evidence the patient's incompetence that the son claimed.

Patient #1's record did not contain Debridement consents for documented debridement procedures dated 5/19/2021, 6/02/2021, 6/16/2021, and 6/30/2021.

Patient #1's record did not reflect patient or family involvement with the Care Plan process.

The facility's patient handbook did not contain the information on how complaints can be reported to the State of Texas including phone number, e-mail, and address.

During interviews on 8/06/2021, Personnel #1 and #2 reviewed the record and confirmed the findings.

During an interview on 8/06/2021 ending at 3:01 PM, Personnel #5 confirmed his presence during the wound debridement, stated the patient verbalized consent and they both signed consent for debridement procedures. Personnel #5 stated he did not know where the paperwork went.

The November 2019, revised "Medical Staff Rules and Regulations required, "...a specific consent that informs the patient of the nature of, and the risks inherent to, any invasive treatment should be obtained. Consents for in-house special procedures, including wound debridement...should be obtained..."

The facility's April 2021, reviewed "Interdisciplinary Treatment Planning" policy required, "patient treatment planning process that promotes an interdisciplinary team concept as well as utilizes input and goals from the patient (or family as appropriate)."

The August 2019, revised, "Patient Rights and Responsibilities" policy required, "the patient will be provided a copy of the patient handbook which will be reviewed with the patient/support person by the nurse...In a case of an incompetent adult patient, the patient's legal representative shall be provided the patient rights and responsibilities..."

Based on record review and interview, the medical staff failed to ensure accountability for the medical care provided for each patient throughout the stay, in that, documentation reflected Patient #1 was not seen (rounding)

by a physician daily;

by any provider on 7/05/2021 and 7/06/2021;

by the Wound Care Physician for the last month of his stay;

as well as

the History & Physical and Infectious Disease consult were not timely;

the Discharge Summary lacked patient specific issues; AND

the LIP (License Independent Practitioners) Progress notes were inconsistent.

Findings were

Patient #1 had no documented attending physician rounding on 7/29/2021 through 7/22/2021; 7/20/2021 through 7/05/2021; and 6/30/2021 through 6/25/2021.

Patient #1 had no provider notes for 7/05/2021 and 7/06/2021.

Patient #1 had no Wound Care Physician notes 7/29/2021 through 7/01/2021.

Patient #1's History and Physical was not completed within 24 hours of admission.

Patient #1's Discharge Summary did not contain significant patient specific issues including the recent, acute respiratory distress; continued, left heel pressure wound; and the hospital acquired - bilateral great and 5th toe wounds.

Patient #1's documented progress notes by the LIP reflected inconsistencies including:
Stage IV Decubitus on 7/28/2021, 7/22/2021 versus
Stage III Decubitus on 7/23/2021, 7/18/2021
7/19/2021 Patient's family recently made the patient DNR status (actually the patient was DNR status since 5/18/2021 admission)
No mention of the patient's Left Heel pressure wound since 6/15/2021 although the left heel wound care and pictures continue throughout the admission.

During an interview on 8/06/2021 ending at 9::45 AM, Personnel #1 and #2 reviewed the record and confirmed the medical staff documentation issues.

The 2/11/2020 revised, "Hospital Chart Completion" policy required, "...to ensure that the medical records...Fully and accurately reflect a patient's care and are completed...New employees/clinicians/professional staff shall receive orientation and training on the chart completion policies and their responsibilities and meeting the requirements of the policies...Missing signatures cannot be excluded when counting incomplete and/or delinquent medical records...All telephone orders must be authenticated within...96 hours...Discharge summary...the following information must be included in all discharge summaries: the reason for hospitalization; significant finding; procedures performed and treatments rendered; the condition of the patient at the time of discharge; and instructions to the patient and family...Transcribed progress notes...The Physician shall always make a written progress note entry indicating that 'a progress note was dictated on this date'...Documentation integrity; late entries and corrections...All entry should be made on the day of the occurrence or care episode; if information is recalled after word, the late entry should be made as soon as possible after the day of the occurrence/care...The entry(s) should be signed and dated and timed..."

The November 2019, revised "Medical Staff Rules and Regulations required, "complete admission history and physical examination shall be written or dictated within twenty-four hours of the patient's admission...Progress Notes...Pertinent progress notes shall be recorded at the time of observation, sufficient to permit continuity of care and transferability. Whenever possible, each of the patient's clinical problems should be clearly identified in the progress notes and correlated with specific orders, as well as, results of tests and treatments...Consultations Reports...show evidence of a review of the patients record by the consultant, pertinent findings on examination of the patient, and the consultant's opinion and recommendations...consults...no later than 48 hours after the order for consultation has been given..."

Based on record review and interview, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient, in that,

Patient #1 nursing care documentation was incomplete including care plans, catheter care, and wound care.

Findings were

Patient #1 was admitted on 5/18/2021 with multiple severe wounds, wound vac, indwelling catheter, antibiotic therapy, Diabetes, Alzheimer's Dementia, Hypertension, Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease, osteomyelitis (left toe and sacrum), and severe malnutrition.

Patient #1's indwelling catheter care was not documented daily throughout the 9-week stay.

Patient #1 had wound debridement procedures on 6/30/2021, 6/16/2021, 6/02/2021, and 5/19/2021. There were no documented wound debridement consents found in the record.

Patient #1's "Wound Care Evaluation" (3 page forms) were not filled out/left Blank for the required information (Wound Type, Tissue Layer, Location, Wound Number, Undermining/Tunneling measurements, Comments, Signature, Title, Initials). Pain assessment is not completed for each dated picture/evaluation session. There is no indication the wounds were dressed after pictures were completed.

Patient #1 gained (hospital-acquired) additional pressure injuries to Bilateral Great toes, 5th toes and the Right heel.

Patient #1's wound care treatment was not documented for:

Bilateral Heels and sacral: 7/29/2021, 7/28/2021, 7/17/2021 and 7/14/2021. Treatment Orders reflected Daily and PRN.

Right Heel: 7/12/2021, 7/07/2021, 7/06/2021, and 7/05/2021. Treatment orders reflected Daily and PRN (as needed).

Sacral and Left Heel: 7/12/2021, and 7/05/2021. Treatment orders reflected three times weekly and PRN.

The facility's report reflected the bilateral great toes and 5th toes injury discovered on 6/07/2021 by Personnel #5.

Patient #1 had no wound care orders or wound care documentation for the bilateral great toes and 5th toes injury.

Patient #1's wound care records did not document discovery of the bilateral great toes and 5th toes injury.

Personnel #1's record did not document weekly pictures of the bilateral toes injuries.

During an interview on 8/05/2021 ending at 1:55 PM, Personnel #1 reviewed the record and confirmed the indwelling catheter care findings. Personnel #2 confirmed consent would be expected to be signed for wound debridement. Personnel #2 stated she did not find debridement consents.

During an interview on 8/06/2021 9:07 AM, Personnel #1 and #2 confirmed the wound care documentation findings.

During an interview on 8/06/2021 ending at 3:01 PM, Personnel #5 confirmed his presence during the wound debridement, and stated the patient verbalized consent and they both signed consent for debridement procedures. Personnel #5 confirmed the 6/07/2021 discovery of the bilateral great toes and 5th toes injury and not documenting in the patient's record.

The October 2021 reviewed were no photographs policy required to provide photographic record of wound status and progress or decline...Evaluation of wound care management...Patient admitted with disruption of skin...will have photographic documentation of the involved areas...photographic documentation is performed within 24 hours of wound care consult and weekly until the area is resolved...If the patient is unable to give consent, alternative consent may be obtained as per hospital policy...Delays regarding photographing of wounds are documented in the medical record...Subsequent orders are obtained only if integrity of the site becomes compromised...Photographs are identified with only to date, a patient's medical record number, and wound site..."

The April 2021, reviewed "assessment and re-assessment of skin integrity, Braden score, and wounds" required, "weekly skin/wound assessment by a member of the wound care team...Re-assessment daily and with identification of any significant change in patient condition...Accurate data for determining appropriate interdisciplinary skin/wound care management...Documentation of skin destruction is recorded...Skin care Management orders...wound care team will monitor and record on the wound care evaluation form, skin care management issues weekly and when providing patient care...Any significant change in the patient's skin integrity requires re-assessment by a member of the wound care team..."

The 2/11/2020 revised, "Hospital Chart Completion" policy required, "...to ensure that the medical records...Fully and accurately reflect a patient's care and are completed...New employees/clinicians/professional staff shall receive orientation and training on the chart completion policies and their responsibilities and meeting the requirements of the policies..."

Based on record review and interview, the facility failed to develop and keep current a PLAN OF CARE which addresses the patient's goals and care to be provided to meet the patient's specific needs, in that,

the plan of care was not developed and up to date including all disciplines and physician for Patient #1's 9-week inpatient stay or sent to the patient's next facility at transfer for continuum of care.

Findings were

There was no care plan or Education started upon admission.

Patient #1 was admitted on 5/18/2021 with multiple severe wounds, wound vac, indwelling catheter, antibiotic therapy, Diabetes, Alzheimer's Dementia, Hypertension, Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease, osteomyelitis (left toe and sacrum), and severe malnutrition.

The patient specific issues were not addressed on the patient's CARE PLAN and Education.

There was no documentation of patient/family or Physician involvement in the care plan process throughout the 9-week stay.

The Patient/Family Education Record did not begin until 5/24/2021 and only addressed wound care/vac changes.

The Patient/Family Education was not updated at the time patient issues (6/07/2021 bilateral toe wounds, and 7/24/2021 acute respiratory issue).

The Care Plan Document (Weekly Interdisciplinary Team Conference Report) was not updated at the time of patient issues (6/07/2021 bilateral toe wounds, 7/24/2021 acute respiratory issue, and change from DNR status).

The Care Plan did not begin until 5/24/2021 and only addressed wound care/vac changes.

The Care Plan was not completed/filled out weekly. Whole required sections were left blank.

The 5/24/2021 Care Plan:

for Nursing: Code status, Foley questions, Education needs, Education provided, Short Term Goals were BLANK;

all of Respiratory was BLANK;

all of Wound Care was BLANK;

all of Nutrition was BLANK;

for Physical Therapy: Discharge Recommendations, DME Recommendations were BLANK;

for Occupational Therapy: Discharge Recommendations, DME Recommendations were BLANK;

for Social Services/Case Management: Patient/Family involvement in Plan of Care, Referrals were BLANK;

for Signatures: Case Manager, Dietician, HIM Coder, Wound Care, Respiratory, Patient, Physician were BLANK.

The 5/31/2021 Care Plan was similar with blank areas for Nursing, Wound Care, Occupational Therapy, Social Services/Case Management and Signatures. All of Physical Therapy and Nutrition are BLANK.

The 6/07/2021 Care Plan was similar with blank areas for Nursing, Wound Care, Physical Therapy, Occupational Therapy, Social Services/Case Management and Signatures. All of Nutrition is BLANK.

The 6/14/2021 Care Plan was similar with blank areas for Nursing, Wound Care, Physical Therapy, Occupational Therapy, Social Services/Case Management and Signatures. All of Nutrition is BLANK.

The 6/21/2021 Care Plan was similar with blank areas for Nursing, Physical Therapy, and Occupational Therapy. All of Respiratory, Wound Care, Speech Therapy, Social Services/Case Management, Nutrition and Signatures are BLANK.

The 6/29/2021, 7/05/2021, 7/12/2021, and 7/19/2021 Care Plan were similar or almost completely blank.

There was no Care Plan paperwork for 7/26/2021 prior to the 7/29/2021 discharge.

The care plan was not kept current, completed, and sent to the patient's next facility at transfer.

During an interview on 8/05/2021 ending 1:55 PM, Personnel #1 reviewed the documentation and confirmed the findings.

The facility's April 2021, reviewed "Interdisciplinary Treatment Planning" policy required, "patient treatment planning process that promotes an interdisciplinary team concept as well as utilizes input and goals from the patient (or family as appropriate). To enhance the communication and understanding of patient care management by all disciplines...performed in a coordinated interdisciplinary manner by all patient care managers/disciplines upon admission and continued throughout the patient's hospitalization. The plan shall be provided to the discharge continuum for facilitation of ongoing care management...as the patient's needs or changes in current planned care are identified...reviewed and revised a minimum of weekly before and/or during team conference and as change in patient condition warrants..."