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Based on observation, interview, medical record review and review of the facility's policies, it was determined the facility failed to deliver nursing services in accordance with physician orders (A-0392). The facility failed to ensure registered nurses evaluated nasogastric tube placement of patients (A-0395). The facility failed to ensure the nursing staff kept nursing care plans current (A-0396). The facility failed to ensure nursing staff followed the facility's policy for verbal orders (A-0407). The cumulative effect of these systemic practices resulted in the facility's inability to ensure the patients nursing needs would be met.

Based on medical record review, policy review and interview, the facility failed to ensure one patient (Patient #3) received a meal tray with restrictions as ordered by a physician. The facility failed to ensure nurses provided nasogastric tube flushes as ordered by a physician for one (Patient #3) of 16 medical records reviewed. This had the potential to affect all of the facility's patients who have a gastrostomy tube. The facility's active census at the time of the survey was 71 patients.

Findings include:

The medical record review for Patient #3 was completed on 4/3/14. The patient was admitted to the facility on 3/28/14 with a diagnosis of acute respiratory distress syndrome (ARDS, a life-threatening lung condition that prevents enough oxygen from getting to the lungs and into the blood) and dysphagia (difficulty swallowing). Patient #3 had a tracheostomy and required mechanical ventilation. Patient #3's admission orders written on 3/29/14 stated Patient #3 was to be nil per os (NPO, nothing by mouth). A physician ordered Honey Thickened Liquids until seen by speech therapy on 3/29/14. The time was not entered on the order.

A facility report showed Patient #3 received one meal tray during Patient #3's admission. The tray was delivered to Patient #3 on 3/29/14 from the host facility. The report showed the patient received apple juice (honey consistency), Beef and macaroni casserole, brownie, coffee (honey consistency), dry creamer packet, Italian salad dressing packet, maple glazed carrots, margarine cup, and a regular diet kit (napkins, straws, salt and pepper).

On 4/3/14 at 9:25 AM, Staff B was interviewed. Staff B reported Staff B delivered a tray to Patient #3 which included beefaroni, cooked carrots and some dessert, maybe a pudding. Staff B was unable to recall the beverages which were delivered on the tray. Staff B reported asking Staff C if the tray was supposed to be delivered to Patient #3 and Staff C reported yes. Staff B reported Patient #3 did not require assistance with opening items on the tray. Staff B reported Patient #3 might have asked one time if Patient #3 was supposed to have the tray. Staff B reported Patient #3 ate less than 10% of the tray.

On 4/3/14 at approximately 3:00 PM, the facility's Physician Orders policy #O02-G, last revised on 10/01/13 was reviewed. The policy stated a licensed nurse will contact the physician if an order is in any way incomplete or questionable. The policy stated orders will be carried out appropriately by facility staff.

On 4/3/14 at 10:37 AM, the facility's Diet Orders and Diet Changes policy #6.32 issued on 06/21/02 was reviewed. The policy stated any dietary regimen served to a patient is ordered by the attending physician. Any change or modification of that order is made by the physician. The dietician or approved designee should be consulted when a question arises concerning interpretation of a diet order or problems involved in the calculation, preparation and/or serving of modified diets.

The medical record did not contain evidence a dietician was contacted regarding Patient #3 on 3/29/14.

2. The medical record of Patient #3 contained an order on 3/28/14 for water flushes 200ml every six hours per the nasogastric tube. The 24 Hour Patient Record and Plan of Care for Patient #3 on 3/29/14 had evidence of the Patient #3 being administered 400 milliliters water flush at 4:00 AM. The 24 Hour Patient Record and Plan of Care for Patient #3 on 3/30/14 at 4:20 AM had evidence of Patient #3 receiving a 661 milliliters water flush. The 24 Hour Patient Record and Plan of Care for Patient #3 on 3/31/14 at 6:00 PM and 4:45 AM had evidence of Patient #3 receiving a 250 milliliters water flush.

On 4/3/14 at approximately 3:00 PM, the facility's Physician Orders policy #O02-G, last revised on 10/01/13 was reviewed. The policy stated a licensed nurse will contact the physician if an order is in any way incomplete or questionable. The policy stated orders will be carried out appropriately by facility staff.

Based on medical record review and policy review, the facility failed to ensure nursing staff documented an assessment of the placement a nasogastric tube for one patient (Patient #3) of 16 medical records reviewed. This has the potential to affect all of the facilities patients who require a nasogastric tube.

Findings include:

The medical record review for Patient #3 was completed on 4/3/14. The 24 Hour Patient Record and Plan of Care for the 7:00 AM to 7:00 PM 3/30/14 shift did not contain evidence the nursing staff assessed Patient #3's nasogastric tube exit level site. The 24 Hour Patient Record and Plan of Care for the 7:00 AM to 7:00 PM on 3/31/14 shift did not contain evidence the nursing staff assessed Patient #3's nasogastric tube exit level site. The 24 Hour Patient Record and Plan of Care for the 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM on 4/1/14 shifts did not contain evidence the nursing staff assessed Patient #3's nasogastric tube exit level site.

On 4/2/14 at 11:20 AM, the facility's Gastric/Duodenal Tube Guidelines policy #G01-N last revised on 07/01/13 was reviewed. The policy stated to check for tube positioning and patency prior to all instillation's/irrigations. For small bore tubes and other tubes orally or nasally placed, validate consistent level at lip or nares line. The policy stated tubes that are nasally and orally inserted are the tubes most at risk for dislodgement and thus aspiration. A properly placed tube does not ensure that aspiration will not occur. Critically ill patients can have delayed gastric emptying and can aspirate even with properly placed tubes. Aspiration is more related to delayed gastric emptying. This is a common problem in the critically ill. The policy stated the current thinking about tube placement:
-X-ray (KUB) is the gold standard for initial placement
-For oral and nasal tubes the most important verification is measuring the level at the
nares or lip line.

Based on medical record and policy review, the facility failed to ensure nursing care plans for one patient with a diagnosis of dysphagia (Patient #3) of 16 medical records reviewed contained interventions for dysphagia. The facility failed to ensure nurses documented the diet of one patient (Patient #3) of 16 medical records reviewed as ordered by a physician in the medical record. This had the potential to affect all of the facility's 71 active patient.

Findings include:

1. The medical record review for Patient #3 was completed on 4/3/14. The patient arrived to the facility on 3/28/14 at 6:15 PM with a diagnosis of acute respiratory distress syndrome (ARDS, a life-threatening lung condition that prevents enough oxygen from getting to the lungs and into the blood) and dysphagia (difficulty swallowing). Patient #3 had a tracheostomy and required mechanical ventilation. Patient #3's 24 Hour Patient Record and Plan of Care sheets from 3/28/14 through 4/1/14 did not contain interventions for the swallowing difficulty of the patient.

2. The 24 Hour Patient Record and Plan of Care for Patient #3 on 3/28/14 listed the patient as a mechanical soft diet. The medical record contained an order for Patient #3 to be NPO on 3/28/14.

3. The 24 Hour Patient Record and Plan of Care for Patient #3 on 4/1/14 did not have a mark in the NPO box to indicate Patient #3 was NPO. The last diet order in the medical record written on 3/30/14 at 10:05 PM stated Patient #3 was to be NPO until seen by speech therapy.

4. On 4/2/14 at 11:20 AM, the facility's Nursing Care Plan policy #N02-N last revised on 10/2013 was reviewed. The policy stated the care plan along with relevant internal and external bundles and standard assessment formats have been incorporated into the 24 Hour Patient Record and Plan of Care. The policy stated elements of care planning include assessment, problem identification, intervention, evaluation and communication. The nurse will implement and document approaches related to key nursing care issues.

Based on medical record review and policy review, the facility failed to ensure verbal orders were documented according to the facility's policy for one (Patient #1) of 16 medical records reviewed. This had the potential to affect all of the facility's patients. The facility had 71 active patients at the time of the survey.

Findings include:

1. The medical record review for Patient #1 was completed on 4/3/14. The patient arrived to the facility on 3/28/14 at 6:15 PM with a diagnosis of acute respiratory distress syndrome (ARDS, a life-threatening lung condition that prevents enough oxygen from getting to the lungs and into the blood) and dysphagia (difficulty swallowing). Patient #3 had a tracheostomy and required mechanical ventilation. A physician ordered Honey Thickened Liquids until seen by speech therapy on 3/29/14. The time was not entered on the order. On 3/29/14 at 8:00 AM, a nurse received a verbal order and documented the order as "Ambien 5 milligrams QHS prn - insomnia". The order did not contain a route for administration. On 3/30/14 a nurse documented a verbal order for Ativan 1 mg intravenously X 1 now and Dilaudid 0.5 milligrams intravenously every 4 hours prn pain. The order did not contain the time the ordered was received by the nurse.

On 4/3/14 at approximately 3:00 PM, the facility's Physician Orders policy #O02-G last revised on 10/01/13 was reviewed. The policy stated "All written orders are to be dated and timed". The policy stated a complete medication order consists of the name of the medication, the dose of the medication, the frequency of administration and the route of administration.

Based on observation, review of facility policies and staff interview, the facility failed to complete tracheostomy care, endotracheal suctioning and labeling of medications per facility policy. This affected two patients (Patient #14 and #15) of 16 medical records reviewed and had the potential to affect all patients cared for who have tracheostomies.
Findings include:
1.) An observation of tracheostomy (trach) care and suctioning for patient # 14 was completed on 04/03/14 at 10:30 AM. Staff member K completed this procedure by opening the tracheostomy kit and pouring in sterile water. It was noted at this time the bottle of sterile water had been previously opened but had no date of when it was opened. Interview with Staff K at this time indicated the bottle should have been dated. A review of the facility policy #L01-P last revised on 12/2003, titled labeling of medications indicates all solutions including irrigation solutions should be labeled with the opened date and time. The policy further indicates that any item found unlabeled is immediately discarded.
Prior to trach care staff member K applied clean gloves, opened up the supplies then applied a pair of blue gloves over the clear ones and proceeded to remove the inner cannula of the trach and inserted the new disposable cannula. New sterile gloves were applied over the dirty gloves prior to suctioning the trach. Staff K suctioned down the trach then realized the suction machine was off and reached over with their sterile hand and turned on the machine then returned to suction with the now dirty gloves. The sterile gloves were then removed; the blue gloves remained on from the previous inner cannula change and were used to clean around the trach tube with 4 X 4's soaked in sterile water and hydrogen peroxide and wiped with sterile water. The trach ties were changed with these gloves and a new drain sponge was applied.
The facility policy #S07-R issued on 03/13/06, titled suctioning by respiratory therapy was reviewed on 04/03/14 at 3:30 PM. This policy indicates that sterile hand and technique must be used while suctioning the tracheostomy. The policy titled tracheostomy care #T02-R last revised on 01/01/13 was reviewed on 04/03/14 at 11:00 AM indicating during trach care you must change your gloves after removing the inner cannula and prior to placing the drainage sponge underneath the flange of the tracheostomy tube. These findings were verified with Staff A and Staff O on 04/03/14 at 3:30 PM.

2.) An observation tracheostomy (trach) care for patient # 15 was completed on 04/03/14 at 2:30 PM. Staff P applied clean gloves, opened a new bottle of sterile water, opened the trach kit and placed a sterile field down on the over bed table. A new inner cannula was opened and placed on this sterile field. The disposable inner cannula was removed and placed on the sterile field and the new cannula was put in. Staff P then cleansed around the trach with sterile water and peroxide with gauze and Q-tips that were in the kit. A new dry drain sponge was applied under the flange of the trach all with the same gloves. Staff P then changed their gloves and proceeded to date the open bottle of sterile water. The facility policy #T02-R last revised on 01/01/13, titled Tracheostomy Care, indicates after trach care (changing the inner cannula and cleaning around the trach site) the gloves must be changed prior to placing the clean drainage sponge. These findings were verified with staff A and O on 04/03/14 at 3:30 PM.