HospitalInspections.org

Based on interview and document review it was determined the facility staff failed to ensure an assessment and hourly rounds were provided per hospital policy for one (1) of one (1) patients, Patient #1.

The findings include:

A review of Patient #1"s medical record revealed the following: Patient #1 was a 66 year old admitted to the facility on 7/19/16 as a transfer from an acute hospital. On admission Patient #1 was diagnosed with 1. Bilateral full thickness cellulitis (decubitus ulcers) of the feet with possible left osteomyelitis [which left Patient #1 unable to ambulate], 2. End-stage renal disease (ESRD) [requiring peritoneal dialysis], 3. Anemia of chronic disease, 4. History of sepsis [continues on antibiotics], 5. Type 2 insulin-dependent diabetes mellitus, 6. Peripheral vascular disease with a history of hypertension (high blood pressure), arteriosclerotic cardiovascular disease, multiple previous surgeries for vascular anastomosis of both lower extremities.

The following events occurred on 8/8/16:
Staff Member #4 noted the following: At 1940 (7:40 P.M.) "Received Pt. awake and alert oriented & verbally responsive. Sitting up in bed with HOB (head of bed) elevated. No distress noted..."
The Hourly Rounding Log for Patient #1 noted rounds there were no hourly rounds noted since 8:00 P.M. and the next noted was at 2248 (10:48 P.M.) at which time Patient #1 was noted to be expired.
Vital signs were not recorded as taken from 8/7/16 8:00 A.M. until the patient expired on 8/8/16 at 10:48 P.M. (over 48 hours)

Staff Member #1 also stated, "The staff are supposed to do hourly rounds every hour from 6:00 A.M. to 10:00 P.M. then every 2 hours from 11:00 P.M. to 5:00 A.M. They did not do rounds after 8:00 P.M. until the nurse caring for [him/her] went in the room to give medications and drain the PD fluid, which was a little after 10:00 P.M. The nurse also did not conduct an assessment at the beginning of the shift, which is what we prefer to be done. [His/Her] vital signs were not done at the beginning of the shift because there was only one vital signs machine on the unit that was working. Vital signs should be done at the beginning of every shift."

Staff Member #4 was interviewed on 9/27/16 at 11:30 A.M. via telephone and stated, "I had an orientee with me on 8/8/16 and we made rounds with the nurse going off duty. We go from patient room to patient room to do rounds. After we finished the rounds I showed the nurse I was orienting where everything was.
There was nothing of special note about [him/her]. [He/She] was sitting up in bed with [his/her] legs straight out in front watching TV. I don't recall that [he/she] said anything. The door to [his/her] room was open during rounds. The CNA (Certified Nursing Assistant) was supposed to get vital signs. This was the CNA's first time on the floor by himself (with no mentor). I heard the dialysis nurse had closed the room door but I did not see that.
I had no need to go into [his/her] room. [He/She] could use the call bell to ask for anything they needed. I usually give [his/her] meds last when I do the exchange then I am not having to go in and out of the room. I went in [his/her] room to give [him/her] [his/her] medications and start the PD drain and found [him/her] sort of halfway on the BSC and unresponsive. There was blood all over the floor."

Based on document review and interview it was determined the facility staff failed to ensure the Nursing Plan of Care included a plan of care for peritoneal dialysis for one (1) of one (1) patients, Patient #1.

The findings include:


A review of Patient #1"s medical record revealed the following: Patient #1 was a 66 year old admitted to the facility on 7/19/16 as a transfer from an acute hospital. On admission Patient #1 was diagnosed with 1. Bilateral full thickness cellulitis (decubitus ulcers) of the feet with possible left osteomyelitis [which left Patient #1 unable to ambulate], 2. End-stage renal disease (ESRD) [requiring peritoneal dialysis (PD)], 3. Anemia of chronic disease, 4. History of sepsis [continues on antibiotics], 5. Type 2 insulin-dependent diabetes mellitus, 6. Peripheral vascular disease with a history of hypertension (high blood pressure), arteriosclerotic cardiovascular disease, multiple previous surgeries for vascular anastomosis of both lower extremities.

On 8/8/16 at 7:50 A.M. Patient #1 only returned 800 ml (milliliters) of peritoneal dialysis (PD) fluid, fibrigin noted in the the fluid. Physician notified and a one time order for 8000 units of heparin to be added to 2000 ml of PD fluid. Instill 1/4 of the bag (500 ml) if patient can tolerate give 1/2 of the bag (1000 ml) dwell for 1 hour and drain.

During the review of the medical record for Patient #1 a Nursing Plan of Care could not be located. Staff Member #1 looked through the medical record and stated, "I do not see one for PD. All of the chart should be there but there could have been something missed that is still on the floor."