HospitalInspections.org

Based on record review and interview the facility failed to:


A. maintain a current care plan and include the patient /medical power of attorney/family in the care planning process in 1 of 1 patients (pt). (Cross reference findings at A 0130 Patient Rights: Participation in Care Planning)

B. provide care in a safe setting by failing to maintain skin assessment , skin integrity, failed to notify both the family and physician of the skin brake down and failed to care plan nursing intervention for the skin break down for 1 of 1 patient identified (pt #2).(Cross reference findings at A 0144 Patient Rights:Care in a Safe Setting)

C. evaluate the need for restraint and failed to identify and implement the least restrictive form of restraint and failed to discontinue the restraint at the earliest possible time in 1 of 1 ventilator supported patient identified (pt #2. (Cross reference to findings at A 0154 Use of Restraints and Seclusion)

Based on document review and interview the facility failed to involve all departments in Quality Assessment Process Improvement as evidenced by 12 department identified.

On 8/7/2012 at 1:30 PM the Quality Assessment Process Improvement for the hospital was reviewed and the following departments were identified with no contributing documentation to the Quality assessment committee and no documentation presented for review to the Governing Body.
- Laboratory
- Radiology
- Housekeeping
- Laundry
- Nuclear medicine
- Respiratory therapy
- Physical Therapy
- Occupational Therapy
- Speech Therapy
- materials Management
- Social services/Case management
- Dietary

An interview with the Chief Nursing Officer on 8/8/2012 at 3:00 PM confirmed the above mentioned departments had no data for review in the Quality Committee review logs. Although some departments were keeping data nothing had been submitted for review and no process improvement had been identified for the above mentioned departments.

Based on document review and interview the facility failed to maintain a current care plan and include the patient /medical power of attorney/family in the care planning process in 1 of 1 patients.

On 8/8/2012 in the conference room the patient's medical record (MR) was reviewed for evidence of the care planning process. The MR revealed the patient was admitted on 4/11/20122 and an initial care plan that was initiated 4/12/2012. Although interdisciplinary team conferences were documented as held on 4/16/2012, 5/3/2012, 5/17/2012 the patient's care plan was not updated weekly to reflect changes in condition or treatment. The patient was discharged to an acute care facility on 5/28/2012. The patient was in the extended care hospital 49 days.

On 8/7/2012 at 3:00 PM in the conference room the policy Interdisciplinary Documentation Model effective date 9/1/20122 revealed Interdisciplinary Patient Plan (s) of Care 2. a. Initiated on admission and reviewed/revised a minimum of every week in association with team conferences and as needed.

A telephone interview with the medical power of attorney on 8/7/2012 at 2:00 PM revealed either he or his sister visited the patient daily while she was in the hospital and he did not know about the care planning process.

A telephone interview with the patient's daughter on 8/8/2012 at 10:00 AM revealed she had numerous conversations with the staff about the care her mother was receiving but was never made aware of the care planning process.

Based on documentation review and interview the facility failed to provide care in a safe setting by failing to maintain skin assessment , skin integrity, failed to notify both the family and physician of the skin break down and failed to care plan nursing intervention for the skin break down for 1 of 1 patient identified.

During the day of 8/8/2012 the medical record for patient #2 was reviewed and the following was revealed.:
-The patient was admitted on 4/11/2012. A review of admission pictures of patient #2 skin revealed only very slight pink discoloration to her peri- anal, however the peri-anal skin area was pictured upon discharge reflecting patient #2 was discharge with a bright red denuded skin over the sacrum and entire peri-anal are.
-There was no personal patient hygiene records located within the chart.
-The was no routine skin assessment located in the nursing notes that reflected when the patient's skin became denuded .
- There was no nursing documentation that the patient's doctor and family were notified of the skin breakdown.
-There was no care planning to reflect the skin break down.
-There was no change in the Braden scale assessment to reflect the patient's increase in incontinence, increased moisture to the skin or the skin breakdown.
-There was no intervention documented for the skin breakdown.

A review of Assessment, Wound/Skin/Risk approved 09/01/2012 revealed under Skin Assessment/Reassessment A.4. Reassessment a. Floor staff to monitor and record skin condition on a daily basis. c. Any significant change in the patients condition related to skin care management gives rise for assessment. d. All patients admitted to the facility will have a skin assessment completed by the wound care team weekly.

A review of the weekly skin assessments revealed the documentation read no wounds or the skin assessment documentation was left blank.

An interview with the patient's daughter on 8/8/2012 at 10:00 revealed patient #2 did not receive peri care when it was requested. The daughter reported the RN told her "they would let her "Poop" in her diaper then change her"

On 8/8/2012 at 2:00 PM an interview with the Chief Nurse Officer revealed the investigation of this complaint determined the patient had diarrhea and the RN determined the patient had begun to have a loose stool and chose to wait until patient #2 was finished to clean her" However there was no documentation in the nurses notes to reflect the patient had diarrhea. There was no documentation of nursing intervention to determine the cause of the diarrhea or the duration of the diarrhea. There was no treatment noted in the nurses note for this change in condition.

Based on documentation review and interview the facility failed to evaluate the need for restraint, failed to identify and implement the leased restrictive form of restraint, and failed to discontinue the restraint at the earliest possible time in 1 of 1 ventilator supported patient identified. (pt #2)

On 8/8/2012 at 1:00 PM the restraint policy was reviewed and revealed in Appendix A Procedures for placing patients in restraints the RN determines if alternative interventions had failed and documents behaviors that support reason for restraints and interventions used and why they failed on the restraint plan of care flow sheet.

On 8/8/2012 at 1:00 PM the Restraint assessment flow sheets were reviewed and revealed the following:
- Date 5/23/2012 No alternative to restraints was documented as attempted for 24 hours. No behavior documented. Potential risk to pull at lines or tubes documented.
- Date 5/24/2012 No alternative to restraints was documented as attempted for 24 hours. No behavior documented only potential to pull at lines or tubes documented.
- Date not identified No alternative to restraint documented as attempted for 24 hours. No behavior documented only potential to pull at lines or tubes.
- Date not identified No alternative to restraint documented as attempted for 24 hours. No behavior documented only potential to pull at lines or tubes documented.
- Date not identified No alternative to restraint documented as attempted for 24 hours. No behavior documented only potential to pull at lines or tubes documented.
- Date 5/27/2012 documented "close observation" attempted no results documented. No behavior documented only potential to pull at lines or tubes documented.
- Date 5/28/2012 No alternative documented for 13 hours. "close observation" documented for every two hours for 6 hours but no results the close observation failed. No behavior documented only the potential to pull at lines or tubes documented.

Further review of Appendix A, "The RN will determine if possible to include the family in decision to restrain".

A telephone interview on 8/7/2012 at 2:00 PM with the Medical Power of Attorney (MPOA) revealed when asked by the hospital if they could restrain Patient #2 the Medical power of attorney told them "No" they did not want her restrained. The MPOA stated each time he came to visit patient #2 had hand mittens on.

A telephone interview on 8/8/2012 at 10:00 AM with the daughter of patient #2 revealed each time she visited patient #2 was in hand mittens and she took them off while she was visiting.

Further review of Appendix A revealed, "The Medical Doctor (MD) must in-person evaluate the patient on the next calendar day. If need for restraint continues a new order is written. Each order is for one calendar day. If the MD does not perform an in-person evaluation before the order expires the restraint must be removed.

An interview with staff RN #12 on 8/9/2012 at 10:00 AM revealed: The night shift fills out the restraint form for the doctor to sign when he comes around the next morning. The MD only signs the form he does not fill in the date or time. He does not evaluate the patient for the need for restraint. When staff #2 was questioned in regards to who determines what type of retrain is used staff #12 replied "they always try to use soft wrist restraints when asked about mittens she said yes we use them also". The nursing staff determine what restrain they want. They fill in the form and the MD signs the form the next day when he makes his rounds. The form is filled in to reflect a 24 time frame however the MD may not make rounds until after 24 hours has lapsed.

Further review of the nurses restraint assessment flow sheets revealed wrist restraint are identified as the restraint of choice from 5/23/12 until 5/26/2012. On 5/27/2012 wrist and mittens are documented as used.

During interviews with the nursing staff and the family, both confirm only mittens were used to restrain patient #2 during the 49 days she was a patient in the extended care facility.

Based on document review and interview the facility failed to analyze data and implement process improvement in the dietary department.

On 8/7/2012 at 2:30 PM a review of the food temperature logs collected by staff #7 revealed food temperatures for 9/10 meals served were outside required Test tray evaluation temperature log parameters.

A review of the pre printed Test tray Evaluation temperature log collection form revealed the following expected temperatures:
- soup 160-170 degrees
- meat 140-150 degrees
- Entree 140-150 degrees
- starch 140-150 degrees
- vegetable 140-150 degrees
-dessert 36-45 degrees
- cold beverage 36-45 degrees
- hot beverage 170-180 degrees

Instruction for the use of the form includes the following:
- 6. Develop action plan for identified problems.

A review of the dietary serving temperatures revealed the following
- 10/28/2011
soup vegetable 115 degrees
meat chicken 104 degrees
starch rice 112 degrees
vegetable corn 112 degrees
dessert fruit mix 64 degrees
All items recorded as too warm are noted as such the chicken is noted as bland and cold. Overall evaluation -Good.

- 11/1/2011 lunch
soup tomato 110 degrees
entree roast beef 86 degrees
starch Mac & cheese 98 degrees
vegetable green bean 110 degrees
cold beverage iced tea 115 degrees
All food items that were too warm are noted as such in the comments. Overall evaluation-Fair.

- 12/31/2011 lunch
soup mushroom gravy 115 degrees
meat chicken 120 degrees
entree spaghetti 115 degrees
starch green beans no temp recorded
vegetable carrots 115 degrees
cold beverage iced tea 115 degrees
All food item that were too warm are noted as such in the comments. Overall evaluation-Good.

1/13/2012 lunch
soup tomato 120 degrees
entree baked chicken 120 degrees
starch Spanish rice 120 degrees
vegetable corn 120 degrees
All food items that were too warm are noted as such in comments. Overall evaluation-Fair

2/7/2012 lunch
soup tomato 110 degrees
entree roast beef 115 degrees
starch mac & cheese 115 degrees
vegetable 115 degrees
No comments are listed in the comments section other than a wrong portion size for the soup. Overall evaluation-Fair

There was no data for March

4/17/20122 lunch
soup 110 degrees
meat 110 degrees
starch mac & cheese 115 degrees
vegetable 110 degrees

Comments were note legible. Overall evaluation-Good

5/14/2012 lunch vegetable carrots 138 degrees

no comments. Overall evaluation-Good

6/25/2012 Breakfast
meat (eggs) 120 degrees
Hot coffee 140 degrees
No comments. Overall evaluation-Good

7/9/2012 Breakfast all temperatures within acceptable limits. Overall evaluation-Good

8/8/2012 lunch
soup 105 degrees
entree chicken 114 degrees
starch mashed potato 110 degrees
vegetable green beans 120 degrees
cold beverage iced tea 150 degrees
no comments recorded. Overall evaluation-Good

On 8/7/2012 at 2:30 PM in the conference room RD/LD staff #7 was interviewed and asked what did she do when food temperatures were wrong? Staff #7 replied "I notify the contracted kitchen". When asked what did they do with the information she replied "they tell me they will note it"

A review of the quality assurance and process improvement (QAPI) for the dietary department revealed no data from the dietary department was submitted to the QAPI committee for review. There was no action documented for the improvement of the incorrect food temperatures for meals served to patients.

During an interview the Chief Nurse Officer confirmed the temperatures were not within the food temperature log parameters and confirmed the RD/LD had not brought the information forward to the QAPI committee.

Based on record review the facility failed to keep current care plans for 3 of 3 patient care plans reviewed.

On 8/8/2012 in the conference room the patient's #2, #3, #4, medical record (MR) was reviewed for evidence of the care planning process. The MR revealed patient #2 was admitted on 4/11/2012 and an initial care plan that was initiated 4/12/2012. Although interdisciplinary team conferences were documented as held on 4/16/2012, 5/3/2012, 5/17/2012 the patient's care plan was not updated weekly to reflect changes in condition or treatment. The patient was discharged to an acute care facility on 5/28/2012. The patient was in the extended care hospital 49 days with no care plan update documented.

Patient #3 was admitted on 4/12/2012 and the initial care plan was dated 4/12/2012. The patient was discharged on 5/25/2012. No update was documented on the care plan after 4/12/2012. There was no documentation the patient or patient's representative participated in the care planning process. The patient was in the extended care facility 44 days with no care plan update documented.

Patient #4 was admitted 3/26/2012. The initial care plan was dated 3/26/2012. The patient was discharged on 5/30/2012. No update was documented on the care plan after 3/26/2012. There was no documentation the patient or patient representative participated in the care planning process. The patient was in the extended care facility 65 days with no care plan up date documented.

On 8/7/2012 at 3:00 PM in the conference room the policy Interdisciplinary Documentation Model effective date 9/1/20122 revealed Interdisciplinary Patient Plan (s) of Care 2.a. Initiated on admission and reviewed/revised a minimum of every week in association with team conferences and as needed.

A telephone interview with the medical power of attorney for patient #2, on 8/7/2012 at 2:00 PM revealed either he or his sister visited the patient daily while she was in the hospital and he did not know about the care planning process.

A telephone interview with the patient #2 daughter on 8/8/2012 at 10:00 AM revealed she had numerous conversations with the staff about the care her mother was receiving but was never made aware of the care planning process.

Based on document review and interview the facility failed to insure the medical record was complete in 6 of 6 medical records reviewed.

A chart review from 8/7/2012 through 8/9/2012 revealed the following:

Patient #2 was admitted 4/11/2012 and discharged 5/29/2012
-14 restraint orders without the type of restraint identified (4/27,28,29. 5/14,15,16 x 2, 17, 18, 19, 20, 23 x 2, & 28 of 2012)
-2 restraint orders not signed by the prescribing physician
-5 restraint orders with out date or time signed by the physician

Patient #3 was admitted 4/12/2012 and discharged 5/25/2012
-10 verbal orders not signed
-17 physician's orders not signed
-1 restraint order not signed
-25 restraint orders without the type of restraint identified
-19 restraint orders with no date and time by the MD
-6 restraint orders not signed by the RN
-1 consent not signed by the MD
-1 progress note not signed by the MD

Patient #4 was admitted 3/26/2012 and discharged 5/30/2012
-23 verbal orders not signed
-3 restraint orders not signed by the prescribing physician
-32 restraint orders without date or time signed by MD
-16 restraint orders not signed by an RN
-56 restraint orders without the type of restraint identified

Patient #5 was admitted 4/4/2012 and discharged 4/16/2012
-1 consult not signed by the MD
-2 progress notes signed by he MD
-3 restraint orders not signed by the prescribing physician
-1 wrong order signed by MD for behavioral restraint rather than restraint for safety.

Patient #6 was admitted 4/27/2012 and discharged 5/15/2012
-7 progress note not signed by the MD
-8 verbal orders not signed by the MD
-5 restraint orders not signed by the prescribing physician
-7 restrain orders without date or time signed by physician
-8 restraint orders without the type of restraint identified
-1 restraint order without an RN signature

Patient #7 was admitted 2/1/2012 and discharged 2/29/2012
-2 consents not signed by MD
-11 verbal orders not signed by the MD

An interview with staff RN #12 on 8/9/2012 at 10:00 AM revealed the restraint orders were filled out by the night shift, so the doctor could sign then whenever he made rounds the following day.

Based on document review and interview the facility failed to insure a discharge summary was available in 1 of 1 patient medical record reviewed.

On 8/9/2912 at 9:30 AM in the conference room the Medical Record for patient #2 was reviewed and no discharge summary was located in the record. Patient #2 was admitted on 4/11/2012 and discharged on 5/29/2012.

An interview with the Chief Nursing Officer confirmed the discharge summary was not available and the final disposition of patient #2 would be found in the nurses notes.