HospitalInspections.org

Based on review of policies and procedures and patient rights' handouts and interviews with hospital staff, the hospital failed to ensure patients and/or their representatives are provided written information notifying them of their right to make decisions concerning the patient's care.

Findings:

1. The hospital's Patient Rights' policy, LM-RI-H-0021 with an effective date of 01/01/2009, documented, "...6. The patient has a right to designate a decision-maker in the event that that (sic) the patient is incapable of understanding a proposed treatment or procedure or is unable to communicate his/her whishes (sic - wishes) regarding care..."

2. The "Patient Information Guide" provided to patients only documented the patient, "as long as they are considered capable of making sound decisions, or choices" (also documented - "the patient is of their sound mind") had rights to make treatment choice or refuse treatment.

3. This findings was reviewed and confirmed with Staff B and C on 03/06/2015.

Based on review of policies and procedures and interviews with hospital staff, the hospital failed to develop a policy that clearly defined the steps the hospital would take to protect all patients during the investigation when an allegation of patient abuse or harassment had been alleged against a staff.

Findings:

1. The hospital's policy, entitled "Suspected Abuse" with an effective date of 01/01/2009, documents, "...1.1.2 If the alleged perpetrator is a staff member, that person shall be removed from caring for the patient in question..."

2. The policy does not specify how they will protect other patients from being abused or harassed from the alleged staff while the investigation is being conducted.

3. The policy was reviewed and verified with Staff B on the afternoon of 03/06/2015. At that time, Staff B stated that the staff would be relieved of patient duty for the rest of the shift and would be placed on administrative leave if the investigation was still ongoing at the time the staff was next scheduled to work and would remain so until the investigation was completed and reviewed.

Based on review of hospital documents, medical records, and meeting minutes and interviews with staff, the hospital failed to ensure the quality assessment and performance improvement (QAPI) program included adequate monitoring, analysis and development of actions plans to remediate or at least reduce the development of Stage III pressure ulcers.

Findings:

1. The surveyor reviewed the QAPI meeting minutes for 2014 and 2015.

2. The meeting minutes documented the hospital had two patients that developed hospital acquired Stage III pressure ulcers during 2014.
a. The meeting minutes did not contain analysis with a plan of corrective action to remediate or at least reduce this patient care issue.
b. The meeting minutes did not contain documentation of tracking/monitoring patients who had Stage I and Stage II pressure areas.

3. The surveyor reviewed seven current patient medical records. In five (Records #9, 10, 12, 13, and 16) of the seven medical records, nursing notes documented the patient had developed a new pressure area since admission.

On the morning of 03/12/2015, the surveyor's observation of Patient #10 skin's integrity, showed the previously documented pressure areas had progress from intact skin to open wounds. This was verified with Staff B and C who were present for the observations.

4. On 03/06/2015 and 03/12/2015 Staff E stated that if a Stage III pressure wound was not identified, wound care only documented the initial pressure area, but did not chart follow-up visits/assessments, including charting when Stage I or Stage II pressure areas/wounds are resolved.

Based on hospital documents and medical record review, and interviews with hospital staff, the hospital failed to ensure the registered nurse (RN) accurately assessed, planned, supervised and reassessed/evaluated the nursing needs and care for each patient.

The nurse, when skin issues occurred, failed to provide evaluations and interventions to remediate or reduce the development of open pressure ulcers. This occurred in one (Patient #10) of five current patient medical records reviewed who had skin issues/problems identified.

Findings:

1. Patient #1 -
a. The initial nursing assessment on 02/18/2015 at 1605 documented a skin ulcer around the tracheostomy site as the only skin interruption/problem. No description of the trach area ulcer was documentation.
b. On 02/20/2015, the wound care nurse documented the neck/trach site as a pressure/erosion ulcer at Stage III with dimensions of 1.4 centimeters (cm) by 1.6 cm by 0.2 cm with 20% slough. Treatment was prescribed and performed. The wound nurse also document the patient's sacrum had redness (no size documented).
c. On 02/26 through 02/28/2015, in addition to the skin ulcer on the neck/trach area, nursing notes documented skin problems on the patient's buttocks (no description or location recorded) and a barrier cream was applied.
d. For the period of 03/01 through 03/09/2015, nursing notes did not document any wounds/skin alterations. (No exact date of when the trach wound resolved was charted by nursing or the wound care nurse.)
e. On 03/10/2015 and 03/11/2015 nursing notes document the patient had sacral redness times two (again no exact location or description with dimensions were charted).
f. On 03/11/2015, the wound care nurse showed the surveyor a photo taken of the patient's posterior that showed inflamed dark red skin on both internal buttocks. No dimensions were documented on the photo.
e. On 03/12/2015 at 1115, the surveyor observed the Patient #10's skin integrity. The patient had dark red pressure areas on the interior aspects of both buttocks, around the sacral area. The patient was not touch by the surveyor and the staff present so no exact measurements were obtained. However, the pressure areas were approximately 12 cm long, by 2.5 cm at the widest point. Inside the lower portion of the intact skin pressure areas, were open wounds. This was verified at the time by Staff B and C, who were present at the time of the observation.

2. On 03/06/2015, Staff B and E told the surveyor that wound care saw all patients in the hospital throughout their stays.

3. On 03/06/2015 and 03/12/2015 Staff E stated that if a Stage III pressure wound was not identified, wound care only documented the initial pressure area, but did not chart follow-up visits/assessments, including charting when Stage I or Stage II pressure areas/wounds are resolved.

Based on review of medical records and hospital documents and interviews with hospital staff, the hospital failed to ensure medical records were complete and entries were dated and times. This occurred in eight (Records # 9, 10, 11, 12, 13, 14, 15, and 16) of eight medical records of current patient that were reviewed.

Findings:

1. Skin alterations:
a. For five of five (Records #9, 10, 12, 13, and 16) current patient medical records review where hospital acquired skin alterations, including skin tears and pressure areas, were identified by nursing assessment notes, the nursing assessment did not contain complete description of the skin alteration/pressure areas with exact location and dimensions.

b. On 03/06/2015, Staff B and E told the surveyor that wound care saw all patients. On 03/06/2015 and 03/12/2015 Staff E stated that if a Stage III pressure wound was not identified, wound care only documented the initial pressure area and does not chart follow-up visits/assessments, including charting when Stage I or Stage II pressure areas/wounds are resolved.

2. Physical therapy notes are not contained in all medical records, including closed medical records reviewed. This finding was reviewed and confirmed with Staff B at the time of review.

3. Staff B told the surveyors that the hospital also had a restorative aide that saw all patients that did not have physical or occupations therapy services to provide at least range of motion to patients. The medical records did not contain any notes of care provided by the restorative aide. Staff B brought documentation to show the surveyor the restorative aide's activities and patient care. Staff B told the surveyor that the restorative aide documentation was not included in the medical record.

4. For Records #9, 10, 11, 12, 13, 14, and 15, the physicians do not consistently record the date and time telephone orders and dictated reports were signed. This was reviewed with Staff B at the time of medical records reviewed.

5. Nursing notes did not always document when a patient refused a bath. This findings was reviewed with Staff B and C on 03/11/2015 Examples include, but not limited to:
a. Patient #10 - Three of three times baths were not charted as provided;
b. Patient #14 - Four of four times baths were not charted as provided.