HospitalInspections.org

Based on record review and interview the facility failed to ensure the documentation of quality medical care (wounds present, turn and repositioning, wound treatment, skin assessments, eating, grooming, bathing, dressing, toileting, transferring, and Foley catheter care) provided to patients. In 8 out of 10 records reviewed (Patients #1, 4, 5, 6, 7, 8, 9 & 10).

Findings include:

The facility policy titled "Rehabilitation Hospital of Wisconsin Wound Care Decision Tree" was reviewed on 2/6/18 at 1:30 PM. This document revealed under "OPEN WOUND" "Incontinence related to skin breakdown 1. Minimize skin exposure to urine and stool. 2. Apply barrier cream bid and prn. 3. Leave skin open to air at night." Under "Abrasion, Skin Tear or Shallow Ulcer. 1. Cleanse with soap and water or saline. 2. Apply Steri-strips if able. 3. Cover with mepilex (dressing) and change every 3 days and prn."

The facility policy titled "WOUND PREVENTION, CARE AND DOCUMENTATION" no. POC 7.86 last reviewed 1/30/17 was reviewed on 2/6/18 at 1:30 PM. This document revealed under "D. Risk Assessment and Skin Breakdown Prevention Protocols" #4. "Establish a regular turning schedule every 2 hours, or more often as appropriate, when patient is in bed."

The facility policy titled "ASSESSMENT AND REASSESSMENT-NURSING" no POC 7.15 last reviewed 1/30/17 was reviewed on 2/6/28 at 1:30 PM. This document revealed under "POLICY" "A Registered Nurse completes an assessment of each patient admitted and reassesses the patient as needed in order to determine the appropriate care, treatment and services to meet the needs of the patient." IV. "Each patient is re-assessed by a Registered Nurse daily, or more often as needed. B. Reassessment is an ongoing process that continues throughout the rehabilitation program. Goals and direction may be altered to reflect changes in patient status." "V. CNA's (Certified Nurses Aide) will document on every patient every shift using the CNA Documentation form. The CNA Documentation form is to be reviewed every shift by the patient's nurse to verify completion."

The facility nursing charting aide entitled "Required documentation" was reviewed on 2/6/18 at 1:30 PM. This document revealed "1st shift 0700-1500 (7:00 AM-3:00 PM)/2nd shift 1500-2300 (3:00 PM-11:00 PM) and 12 hr (hour) shift 0700-1900/(1900-0700) (7:00 AM-7:00 PM/(7:00 PM-7:00 AM)" require "Full system assessment". "3rd shift 2300-0700 (11:00 PM-7:00 AM)" and "Any 4 hour shift 1500-1900/1900-2300 (3:00 PM-7:00 PM/7:00 PM-11:00 PM etc" require "Focused system assessment: Focused system assessment will minimally include any interventions for skin care, safety, precautions (i.e.-isolation, aspiration, etc), pain, devices, system assessment as needed per medical status, shift note.

The facility policy titled "CARE AND MAINTENANCE OF MIDLINE AND PERIPHERALLY INSERTED CENTRAL CATHETERS" was reviewed on 2/6/18 at 1:45 PM. This document stated under "POLICY" item C. "Peripherally inserted central catheters are flushed with 10 ml (milliliters) of normal saline twice a day and after each use." There was no instruction on policy that directs charting expectations of site assessment and care. In interview Chief Clinical Offer B stated they follow Lippincott standards for all things not listed on policies. Lippincott standards revealed in July 2005 Volume 35 Issue 7 page 28 article entitled "Documenting Peripheral IV Therapy", "Throughout I.V. therapy, document the patient's tolerance of the therapy, site appearance, site care, and reinforcement of patient and family teaching. Assess the site and change dressings and equipment as directed by facility policy and current clinical practice guidelines."

Patient #1 inpatient stay 6/6/17-6/26/17:

Patient #1's medical record was reviewed on 2/6/17 at 11:15 AM. Patient #1 was admitted 6/6/17 from acute care hospital after a fall in garage and had a past medical history of a motor vehicle accident 20 years ago with resulting vertebrae injuries. "Nursing Shift Assessment" reviewed for this inpatient stay (6/6/17-6/26/17) revealed no documented "Skin Assessment" on 6/9 11:00 PM-7:00 AM, 6/10 11:00 PM-7:00 AM, 6/11 7:00 PM-11:00 PM, 6/12 7:00 PM-7:00 AM, 6/14 3:00 PM-7:00 PM, 6/15 11:30 PM-6:00 AM, 6/17 6:30 PM-11:00 PM and 6/21 11:30 PM-6:00 AM.

On 6/18/17 two skin integrity impairments were documented one on coccyx and one on right buttock. The physician was notified and treatment to the areas was started. There was no documented turn and repositioning every two hours related to open areas by registered nurse or CNA after the skin integrity impairments were discovered. From 6/18/17 (day wounds found) until 6/26/17 (day discharged from facility and readmitted to acute hospital) three shifts on "Nursing Shift Assessments" completed documented "No Wound" (6/21,6/23 & 6/24).

There was no documented charting (left blank) on "CNA Documentation" form during this inpatient stay for the following shifts: 6/7 11:00 PM-7:00 AM, 6/9 7:00 AM-11:00 PM, 6/12 3:00 PM-11:00 PM, 6/18 7:00 AM-11:00 PM, 6/19 3:00 PM-11:00 PM, 6/23 7:00 AM-3:00 PM, & 6/25 7:00 AM-3:00 PM.

Patient #1 inpatient stay 6/28/17-7/19/17:

There was no documented evidence of "Nursing Shift Assessments" and/or CNA (Certified Nursing Aides) that documented scheduled turning and repositioning every 2 hours. "Nursing Shift Assessment" from day of admission until 7/7/17 at 7:00 AM documented two wounds (neck incision and right buttock) while Patient #1 was admitted on 6/28/17 with a total of six wounds documented. There was no documented skin assessments in "Nursing Shift Assessments" for six shifts (6/29 7:00 PM-11:00 PM, 7/4/ 7:00 PM-11:00 PM, 7/5 7:00 PM-11:00 PM, 7/11 7:00 PM-11:00 PM, 7/11 11:00 PM-7:00 PM & 7/12 11:00 PM-7:00 AM).

There was no documented charting on "CNA Documentation" form during this inpatient stay for the following shifts: 6/28 7:00 AM-3:00 PM, 7/2 3:00 PM-11:00 PM, 7/8 3:00 PM-11:00 PM (indwelling catheter), 7/12 3:00 PM-11:00 PM,

Patient #1 inpatient stay 7/25/17-8/16/17:

"Admission Body Assessment" completed on admission 7/25/17, by two registered nurses, right knee incision 19 cm with 28 staples, left heel "unstageable" pressure ulcer 2 cm x 2.5 cm, lumbar spine incision 9 cm long, sacral pressure stage 3-0.5 cm x 2.5 cm, coccygeal pressure stage 3-3 cm x 2 cm, and right buttock pressure ulcer stage 1-1 cm x 1 cm.

There was no documented evidence of "Nursing Shift Assessments" and/or CNA (Certified Nursing Aides) that documented scheduled turning and repositioning every 2 hours during this stay. There was no documented skin assessments in "Nursing Shift Assessments" in eight shifts (7/25 7:00 PM-11:00 PM, 7/27 6:30 PM-11:55 PM, 7/30 11:00 PM-7:00 AM, 8/8 6:30 PM-11:00 PM, 8/8 12:00 PM-6:30 PM, 8/11 3:00 PM-7:00 PM, 8/13 7:00 PM-11:00 PM & 8/13 11:00 PM-7:00 AM). There was no documented assessment on "Nursing Shift Assessment" of central line site assessment or care of in eight shifts (8/6 6:30 AM-7:00 PM, 8/8 6:30 AM-11:00 AM, 8/8 12:00 PM-6:30 PM, 8/11 3:00 PM-7:00 PM, 8/12 7:00 AM-7:00 PM, 8/13 7:00 PM-11:00 PM, 8/14 7:00 PM-7:00 AM & 8/15 7:00 PM-7:00 AM).

There was no documented charting on "CNA Documentation" form during this inpatient stay for the following shifts: 7/29 3:00 PM-11:00 PM, 7/30 3:00 PM-11:00 PM, 8/2 3:00 PM-11:00 PM, 8/5 7:00 AM-3:00 PM, 8/6 7:00 AM-3:00 PM, 8/9 3:00 PM-11:00 PM,

Patient #1 inpatient stay 8/21/17-9/22/17:

"Admission Body Assessment" completed on admission 8/21/17, by two registered nurses, documented left heel stage two pressure ulcer, and a midline posterior incision. On 9/3/17 a stage 2 distal intergluteal cleft area 1 cm x 0.25 cm and a stage two area on right buttock 1 cm x 1 cm.

There was no documented evidence of "Nursing Shift Assessments" and/or CNA (Certified Nursing Aides) that documented scheduled turning and repositioning every 2 hours during this stay. There was no documented skin assessments in "Nursing Shift Assessments" in fourteen shifts (8/21 6:30 PM-11:59 PM, 8/27 7:00 PM-7:00 AM, 8/28 7:00 PM-11:00 PM, 8/29 6:30 PM-11:59 PM, 9/6 7:00 PM-11:00 PM, 9/8 7:00 PM-11:00 PM, 9/9 7:00 PM-11:00 PM, 9/9 11:00 PM-11:00 PM, 9/10 6:30 PM-7:00 AM, 9/11 6:30 PM-11:00 PM, 9/11 11:00 PM-7:00 AM, 9/12 6:30 PM-11:00 PM, 9/16 3:00 PM-7:00 PM, 9/19 7:00 PM-11:00 PM, & 9/20 7:00 PM-11:00 PM). There was no documented assessment on "Nursing Shift Assessments" of central line site assessment or care of in twenty two shifts (8/21 6:30 PM-11:59 PM, 8/22 7:00 PM-7:00 AM, 8/28 7:00 PM-11:00 PM, 8/29 6:30 PM-11:59 PM, 9/2 6:30 PM-7:00 AM, 9/4 6:30 PM-7:00 AM, 9/6 7:00 PM-11:00 PM, 9/8 7:00 PM-11:00 PM, 9/9 7:00 PM-11:00 PM, 9/9 11:00 PM-7:00 AM, 9/11 6:30 PM-011:00 PM, 9/12 6:30 PM-11:00 PM, 9/13 7:00 AM-7:00 PM, 9/13 7:00 PM-7:00 AM, 9/14 7:00 PM-7:00 AM, 9/15 7:00 PM-7:00 AM, 9/16 3:00 PM-7:00 PM, 9/16 7:00 PM-7:00 AM, 9/17 7:00 PM-7:00 AM, 9/19 7:00 PM-11:00 PM, 9/20 7:00 PM-11:00 PM, & 9/20 11:00 PM-7:00 AM).

There was no documented charting on "CNA Documentation" form during this inpatient stay for the following shifts: 8/21 7:00 AM-11:00 PM, 8/23 7:00 AM-3:00 PM, 8/24 all three shifts (indwelling catheter), 8/25 3:00 PM-11:00 PM, 8/27 all three shifts, 8/28 all three shifts, 8/29 all three shifts, 8/31 3:00 PM-11:00 PM, 9/1 7:00 AM-11:00 PM, 9/2 3:00 PM-11:00 PM, 9/7 11:00 PM-7:00 AM,9/8 7:00 AM-3:00 PM, 9/10 11:00 PM-7:00 AM, 9/12 7:00 AM-3:00 PM, 9/13 11:00 PM-3:00 PM, 9/15 7:00 AM-3:00 PM, 9/16 7:00 AM-3:00 PM, & 9/17 7:00 AM-11:00 PM.

An interview was conducted with Director of Quality A and Chief Clinical Officer B at the time of above chart reviews. Director of Quality A stated "If there is a doctor's order for turn and repositioning we do a sheet that documents the time and positioning. But everyone gets hourly rounding." When shown "Nursing Shift Assessment" "hourly rounding" is documented under patient safety and addresses call light in reach, brakes locked, bed height, ID band on etc. does not account for turning and repositioning in patient's that either are at a high risk for breakdown or have breakdown present. Director of Quality A stated "I see what you mean and you are right." In regards to missing documentation for skin assessments and intravenous line assessments Director of Quality A stated "It's not there and it should be."

Patient #4's medical record was reviewed on 2/6/18 at 1:55 PM. Patient #4 was admitted on 12/1/17 and discharged on 12/10/17. There was no documented charting on "CNA Documentation" form for the following shifts: 12/2 7:00 AM-3:00 PM, 12/3 7:00 AM-3:00 PM, 12/5 11:00 PM-7:00 AM, & 12/6 11:00 PM- 7:00 AM.

Patient #5's medical record was reviewed on 2/6/28 at 12:20 PM. Patient #5 was admitted on 1/23/18 and was still an inpatient at the time of survey. There was no documented charting on "CNA Documentation" form for the following shifts: 1/24 11:00 PM-7:00 AM, 1/27 3:00 PM-11:00 PM, 1/30 3:00 PM-11:00 PM, 2/3 11:00 PM-7:00 AM, & 2/4 7:00 AM-3:00 PM.

Patient #6's medical record was reviewed on 2/6/18 at 1:30 PM. Patient #6 was admitted on 12/14/17 after an acute care hospital stay for a subarachnoid hemorrhage and discharged on 1/23/18 to a long term facility. There was no documented charting on "CNA Documentation" form for the following shifts: 12/22 11:00 PM- 7:00 AM, 12/24 7:00 AM-3:00 PM, 1/3 3:00 PM-11:00 PM, 1/8 3:00 PM-11:00 PM, 1/11 11:00 PM-7:00 AM, 1/15 7:00 AM-3:00 PM, 1/18 11:00 PM-7:00 AM, & 1/19 11:00 PM-7:00 AM.

Patient #7's medical record was reviewed on 2/6/28 at 3:00 PM. Patient #7 was admitted on 12/14/17 and discharged on 1/6/18 after an inpatient stay at an acute care hospital for a C 1-2 laminectomy for occipital headache and neck pain. There was no documented charting on "CNA Documentation" form for the following shifts: 12/15 3:00 PM-11:00 PM, 12/16 3:00 PM-11:00 PM, 12/22 3:00 PM-7:00 AM, 12/23 7:00 AM-3:00 PM, 12/24 7:00 AM-11:00 PM, 12/29 7:00 AM-11:00 PM, & 1/6 11:00 PM-7:00 AM.

Patient #8's medical record was reviewed on 2/6/18 at 3:25 PM. Patient #8 was admitted on 12/21/17 and discharged on 1/16/18. There was no documented charting on "CNA Documentation" form for the following shifts: 12/22 11:00 PM- 7:00 AM, 12/28 3:00 PM-11:00 PM, 12/29 3:00 PM-7:00 AM, 1/2 3:00 PM-11:00 PM, 1/10 11:00 PM-7:00 AM, 1/11 11:00 PM-7:00 AM, 1/15 11:00 PM-7:00 AM, 1/16 3:00 PM-7:00 AM,

Patient #9's medical record was reviewed on 2/6/18 at 3:20 PM. Patient #9 was admitted on 12/1/17 and discharged 12/18/17. There was no documented charting on "CNA Documentation" form for the following shifts: 12/10 11:00 PM- 7:00 AM, 12/15 7:00 AM-11:00 PM, & 12/18 3:00 PM-7:00 AM.

Patient #10's medical record was reviewed on 2/6/18 at 3:35 PM. Patient #10 was admitted on 1/18/18 and discharged on 1/27/18 after a fall at home and an acute hospitalization for a hip fracture. There was no documented charting on "CNA Documentation" form for the following shifts: 1/19 11:00 PM-7:00 AM, 1/23 11:00 PM-7:00 AM, 1/24 11:00 PM-7:00 AM, & 1/27 3:00 PM-7:00 AM.

An interview was conducted with Director of Quality A and Chief Clinical Officer B at the time of chart reviews. In regards to missing CNA documentation Director of Quality A stated "a lot of times on the day shift the OT (occupational therapy) performs the ADL's (activities of daily living). When questioned if that shouldn't be charted by CNA's on what items were done with OT Director of Quality A stated "yes they should document which ones they did and which ones OT did". When it was pointed out that there are whole shifts that have no documented signatures for any cares Director of Quality A stated "it is expected that all shifts and all areas are to be documented on."