HospitalInspections.org

Based on review of Hospital Patient Handbook, Visitor's Log, medical records (MR) and interview with administrative staff, it was determined the hospital failed to inform the patient and families/ caregiver when patients are placed on visitation restrictions for 1 of 1 record reviewed.

This affected MR # 2 and had the potential to negative affect all patients served by the hospital.

Findings include:

Hospital Patient Handbook

Administrative Policy and Procedure
Visitation Rights if All Patients - General Guidelines.
Revised Date: 7-2012

Procedure

...

13. For the purpose the visiting hours are scheduled from 3:00 PM to 5:30 PM Monday to Friday and 3:00 PM to 6:00 PM Saturday and Sunday.

***

Administrative Policy and Procedure
Patient Rights/ Visitation Rights for All Patients " Clinically Necessary Limitation or Restrictions"
Revised Date: 2- 2013

Policy: All patients have the right to receive visitors. BHC encourages visitation as part of each patient's plan of care. ...

Definitions:

Clinical Limitation - Specific times are set for visitors to come to the hospital to see a patient. No other time may be used to visit unless approved by the Medical Director, DON (Director of Nurses)/ ADON (Assistant Director of Nurses), or supervision RN (Registered Nurse).

Procedure:

...

9. Visitation may have reasonable restrictions for the following reasons. The patient, patient legal representative and/ or support person will be notified of the following restrictions.

- Infections Control issues.
- Visitation interferes with care of other patients.
- Hospital aware that there is an existing court order restricting contact.
- Visitor engaged in disruptive, threatening or violent behavior of any kind.
- Patient may be undergoing care interventions.
- Visitor presence causes the patient to have non-therapeutic response or the patient attempts to engage the visitor in a non- therapeutic event.
- Specific situations may be identified by the medical director/ or treatment team members that would require restrictions of certain visitors and/ or visitation time until a therapeutic intervention/s is in place.

...

Restrictions will be care planned by treatment team members, with input from patient and patient's legal representative. ..


1. MR # 2 was admitted to the hospital on 11/30/15 with the diagnoses including Dementia with Behavioral Disturbance and Alzheimer's Disease.

Review of the Visitors Log 12/8/15 revealed patient's family signed in at 4:15 PM. Review of the Nurse Progress Note 12/8/15 revealed there was no documentation whether the family was able to visit the patient.

Review of the Visitors Log 12/26/15 revealed patient's family signed in at 3:00 PM. Review of the Nurse Progress Note 12/26/15 revealed there was no documentation whether the family was able to visit the patient.

Review of the Visitors Log 12/30/15 revealed patient's family signed in at 3:30 PM. Review of the Nurse Progress Note 12/30/15 revealed there was no documentation whether the family was able to visit the patient.

Review of the Case Management Progress Notes/ Treatment Team Meetings dated 12/11/15, 12/14/15, 12/18/15 and 12/29/15 revealed documentation the patient's family attended the team meeting. There were no documentation the patient's family was encouraged to visit patient.

Review of the Nurses Progress Notes dated 12/11/15, 12/14/15, 12/18/15 and 12/29/15 revealed there were no documentation the patient's family visited the patient.

An interview was conducted on 3/29/16 at 2:30 PM with Employee identifier (EI) # 1, Administrator who confirmed the above mentioned findings.

An interview was conducted on 3/29/15 at 6:16 PM and 3/30/16 at 11:30 AM with MR# 2's spouse. The spouse stated that MR # 2 was moved to the patient room with an adjacent nurses' observation room with a window (1 Registered Nurse (RN) to 1 patient ratio) and the spouse asked the RN on duty if she/ he could visit the patient. The RN contacted his/ her manager and informed the decision was "no", since patient was asleep. The spouse stated she/he was not going to bother the patient, she/ he just wanted to see MR # 2.

Based on observation, review of the facility's policy and procedure, Lippincott Manual of Nursing Practice, and medical records, and interview it was determined the facility failed to ensure:

1. The patient received all medications and assessments were provided to the patient as ordered by the physician.
2. Physician's orders were obtained for the care of the patient's foley catheter.
3. The staff documented the assessment of urine output for patient with a foley catheter.
4. The staff documented wound care and skin assessments per policy.


This affected Medical Record (MR) # 5, 1 of 10 records reviewed, and had the potential to negatively affect all patients served by this facility.

Findings include:

Policy and Procedure Wound Care:

Policy: These recommended guidelines are for identifying those patients at risk for compromised skin and for implementing preventative measures and treatment protocols. The LPN (Licensed Practical Nurse) or RN (Registered Nurse) will notify the physician for specific wound treatment upon admission or on day of wound development.

Procedure:
...b. The Weekly Wound Progress Note must be initiated by the nurse. The date of onset and location must be documented. This will be completed weekly and PRN (as needed).

f. Weekly documentation is to be recorded on a Weekly Wound Progress Note...

3. Wound Measurement- When documenting the size of all wounds, the nurse should include length, width, depth and tunneling or undermining (if present) in centimeters (CM)..."


Lippincott Manual of Nursing Practice 10th Edition:
Chapter 21 page 780

General Procedures and treatment Modalities:
"catherization:... amount and appearance of urine."


1. MR # 5 was admitted to the facility on 12/22/15 with diagnoses including Alzheimer's Disease and Major Neurocognitive Disorder with Behaviors.

Review of the 12/22/15 Initial Skin Assessment revealed the patient had lacerations on both arms and a foley catheter. There were no descriptions found of the patient's wound drainage or measurements or the patient's urine output (color, clarity, odor, or amount).

Review of the 12/22/15 Physician's Admission Orders revealed no orders for the care of the patient's Foley Catheter.

Review of the Non-Ulcer Weekly Progress Note (WPN) dated 12/23/15
revealed no documentation of the patient's right forearm wound only the dressing covering the wound.

Review of the 12/27/15 WPN for right forearm revealed the measurements of 50 centimeters (cm) times (X) 15 cm. There was no wound depth documented.

Review of the 1/6/16 WPN for right forearm revealed documentation of the wound as 2.54 cm X 0.64 cm, partially open, partially scabbed over, and no drainage. There was no wound depth documented.

Review of the 1/11/16 WPN revealed the documentation open wound to right forearm to include: 3 cm X 1.7 cm with purulent moderate amount of drainage. Verbal Order for Levaquin 500 mg (milligram) daily for 7 days. There was no wound depth documented.

The open wound to the right forearm was not measured until 12/27/15, 5 days after admission to the facility.

There was no wound depth documented during the patient's admission from 12/22/15 to 1/12/16.

Further review of the MR revealed no documentation of the wound to the patient's left arm as identified on admission.

In an interview conducted on 3/30/16 at 2:30 PM with Employee Identifier (EI) # 3, Director of Nurses (DON), verified the staff failed to assess the patient's wounds.

Review of the 12/22/15 3:15 PM Psychiatric Nursing Assessment (PNA) revealed no documentation the had a patient foley catheter.

Further review of the Skilled Nurse documentation on 12/22/15, 12/23/15, and 12/24/15 revealed no description of the patient's urine output.

Review of the 12/25/15 Nurses Progress Notes (NPN) revealed the documentation, "patient has foley amber in color..."

Review of the 12/26/16 NPN revealed the documentation to include, "...restless and confused...Foley catheter intact and patent with cloudy yellow urine..."

The surveyor asked if the patient was treated for the amber/ cloudy urine.

The surveyor asked for the facilities policy for foley catheter, none was provided.

In an interview conducted on 3/30/16 at 2:30 PM with Employee Identifier (EI) # 3, Director of Nursing (DON) verified there was no physician's order for the foley catheter, then stated the patient was admitted on antibiotics for the infection, and the course of treatment was completed after admission.

Review of the 12/22/15 Admit Medication Form revealed no antibiotic therapy on admission.

Review of the 12/22/15 Admission Orders revealed the physician's order for a Dietary Consult.

Review of the 1/7/16 Physician's Order revealed another order for a Dietary Consult.

Review of the 1/7/16 NPN revealed documentation the dietician referred the dietary consult to the Speech Therapist (ST). The ST assessed the patient on 1/7/16.

There was no physician's order for the ST evaluation found.

In an interview conducted on 3/30/16 at 2:30 PM with EI # 3, the above findings were verified.

Review of the 12/29/16 Physician's order revealed the now order for Potassium (KCL) 40 milliequivalent (mEq) now. Review of the Medication Administration Record (MAR) revealed no documentation the medication was given to the patient.