**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of medical records, review of medical staff bylaws, rules and regulations, and staff interview it was determined the facility failed to ensure medical staff enforced responsibilities of the medical staff for one (#1) of four patients reviewed. Findings included: Review of the medical staff rules and regulations, pages 13 - 14, section titled Discharge Summary, stated a complete discharge summary shall be electronically dictated on all medical records of patients hospitalized over 48 hours with outcome of hospitalization , disposition of case and provisions for follow-up care. Final diagnosis shall be recorded within the discharge summary. On page 16, section titled Record Completion, stated the medical record should be completed within thirty (30) days following discharge. Review of the medical record for patient #1 revealed the patient was admitted to the facility on [DATE] and expired on [DATE]. Review of the record revealed the physician assessed the patient on 10/30/2021 with documentation which included an overall prognosis as guarded with a diagnosis which included bilateral pneumonia possible aspiration. Review of the note did not reflect the outcome of hospitalization or disposition of the case. Interview with the Vice President of Quality and Patient Safety on 12/15/2021 at 1:40 pm confirmed the above findings.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of the medical records, review of policy and procedures and staff interview it was determined the facility failed to ensure nursing staff evaluated the patient's medication history according to facility policy for one (#1) of four patients sampled. Findings included: Review of the policy and procedure titled, Medication Reconciliation, #302-MM-103, on page 2, Admission Reconciliation, Medication History stated the nurse will collect the list of medications as known or reported by the patient or caregiver and file in the Meditech system. The nurse will confirm or reaffirm the medication history with the patient or information provider and document the source of information. If the nurse is unable to complete the medication list, he/she will indicate this by highlighting unknown info as a flag for on coming shift. Review of the medical record for patient #1 revealed the patient was admitted on [DATE]. The nursing and physician assessments revealed the patient had altered cognitive function and was oriented to person only. Review of the admission medication reconciliation revealed the RN (Registered Nurse) reconciled the patient's medications on 10/21/2021 at 6:49 pm. The review revealed no evidence for the source of information. Review of the nursing and physician progress notes revealed the patient had a health care surrogate involved in the patient's plan of care. There was no evidence the patient's health care surrogate was the source of information for the patient's current medication history. Interview with the Vice President of Quality and Patient Safety and the Director of Pharmacy on 12/14/2021 at 3:50 pm confirmed the above findings.
Based on medical record review, policy review and staff interview it was determined the facility failed to ensure the type or technique of restraint used was the least restrictive intervention to protect the patient from harm for one (#5) of ten patients sampled. Findings included: Review of the medical record for patient #5 revealed the patient presented to the facility Emergency Department (ED) on 12/4/2020 for complaints of chest pain. Upon evaluation the physician determined the patient had major depression with suicidal and homicidal ideation and was admitted . Review of the record revealed the psychiatrist was consulted and evaluated the patient on 12/4/2020 at 12:30 pm. Review of the record revealed the patient was admitted under the Baker Act for further treatment and placed in a Careview room (Careview monitors patients 24/7 via camera). Review of the nursing note, dated 12/6/2020 at 10:05 am, revealed at approximately 8:50 am the patient was observed heading toward the elevators and was able to make his way down to the lobby before being apprehended by police and security. The patient was returned to his room, was apologetic and stated, I was just bored, I wanted to see what I could get away with. The nurse documented the patient was placed in two point soft wrist restraints and was informed of the reasoning and criteria for restraints to be removed. The nurse documented at approximately 9:00 am the patient removed the restraints and was found in the bathroom. The patient was returned to bed and the restraints reapplied. The nurse documented the patient was at risk for self harm and was under the Baker Act. Review of the nursing note, dated 12/6/2020 at 6:50 pm, revealed the patient continued to remove and replace the restraints at will. The nurse documented the patient did not appear to be harmful to self but the nurse feared he may become violent if given the opportunity. Review of the record revealed the restraints remained on until 12/7/2020 at 6:00 am. Review of the facility policy, Suicide Screening and Precautions, stated the RN (Registered Nurse) will determine the appropriate interventions and implement immediately upon identification based on assessed risk. The policy stated for patients at high risk interventions would include 1:1 patient safety attendant and staff member would accompany the patient to the bathroom and maintain line-of-sight at all times. The policy further stated after reassessing a patient and determining that the patient is at a decreased risk for suicide the RN will collaborate with the physician regarding patient condition and will adjust the interventions based on risk level. An interview was conducted with the Interim Vice President of Quality on 12/09/2020 at 10:25 am at which time the above findings were reviewed and confirmed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on Policy and Procedures, medical record reviews, and staff interviews it was determined that the facility failed to ensure the involvement of the designated representative in developing and implementing the plan of care for one (#1) of five patients sampled. Findings included: Review of the facility policy, Fall Prevention Plan, revealed in section (IV) Post Fall Management, (5) Notification of fall: (d) patient's emergency contact, if the patient consents to notification. If the patient is unable to consent, notifications should occur. Review of the medical record revealed the patient was admitted on [DATE]. Review of the nursing assessment revealed the patient was alert and oriented to name only and unable to make informed decisions. Review of the nursing documentation, dated 08/15/2020 at 7:35 AM, revealed the patient was found on the floor. Review of the record revealed no evidence the patient's family was notified of the patient's possible unwitnessed fall, the assessment or treatment provided, or any changes to the patient's plan of care. On 08/25/2020 at 10:14 AM a review of the medical record with the RN Sepsis Coordinator confirmed the above findings.
Based on Policy and Procedure, medical record reviews, and staff interviews. The facility failed to ensure the register nurse supervised and evaluated the nursing care for one of five patients sampled. Findings included: Review of the policy, Standards of Practice, stated (D) Weights, 3) Daily - patients should be weighed at the same time each day. A patient's weight must be documented daily for any of the following situation: (g) patients receiving tube feedings. Review of Patient #1's medical record showed on 07/25/2020 (admission) the estimated weight of 100 kg (kilograms) documented. Review of Physician orders on 08/14/2020 revealed an order to initiate tube feedings. Further review of the record on 08/24/2020, the patient's documented weight was 80.9 kg. There was no documentation on how weight was obtained. Review of the record revealed no evidence of any additional weight measurements. On 08/25/2020 at 10:14 AM the medical record for patient #1 was reviewed with the Register Nurse Sepsis Coordinator and confirmed the above finding.
Based on review of policy and procedures, review of agency nursing personnel files, and staff interview it was determined the facility failed to ensure the director of nursing service provided for evaluation of agency nursing personnel clinical activities for two (B, C) of five personnel files reviewed. Findings included: Review of the facility policy, Performance Evaluation, #HR.LD.007, stated the scope of the policy included the nursing staff obtained from the facility contracted agency. The policy stated a formal performance evaluation would be conducted, at a minimum, on an annual basis. Review of the personnel file for RN (Registered Nurse) B revealed the RN was an agency nurse that had provided clinical services at the facility since August 2017. Review of the last evaluation of the clinical activities performed by RN B revealed the evaluation was completed on 10/7/2019 by a separately licensed facility. There was no evidence an evaluation of the nurses clinical activities was conducted by the facility employee nursing staff. Review of the personnel file for RN (Registered Nurse) C revealed the RN was an agency nurse that had provided clinical services at the facility since February 2017. Review of the last evaluation of the clinical activities performed by RN C revealed the evaluation was partially completed on 9/10/2019 by the contracted agency. There was no evidence an evaluation of the nurses clinical activities was conducted by the facility employee nursing staff. An interview was conducted with the facility HR (Human Resources) Business Partner and the Director of Quality on 8/25/2020 at 10:30 am at which time the above findings were confirmed.
Based on record review and interview, with the Director of Plant Operations, the facility failed to maintain the transfer switch gear. Findings included: During facility record review with the Director of Plant Operations, it was revealed that during the scheduled maintenance by the facility's vendor on 09/05/2018, it was documented that transfer switch ATS-EQB control panel had been recommended to be replaced in the near future. It was also documented that transfer switch ATS-9(EA) caused major damage to equipment years ago when bypassed and had never been repaired. An interview was conducted with the Director of Plant Operations concurrent with observations and confirmed the findings. per NFPA 101 (2012 Edition) 4.5.8 per NFPA 99 (2012 Edition) 6.4.4.1.1.3 per NFPA 110 (2010 Edition) 8.3.5
Based on medical record review and staff interview it was determined the facility failed to ensure the nursing staff provided care and services to meet the needs for one (Patient #2) of four sampled patients. Findings included: The History and Physical dated 1/22/19 at 11:32 p.m. was signed by the attending physician. The document indicated Patient #2 was being admitted for generalized weakness, dizziness, and complaints of fever, chills, and a sensation of fainting for about the past week and a half. The note included Patient #2 experienced significant orthostatic hypotension (drop in blood pressure associated with changes in position). The note included Patient #2 had a past medical history that included dementia and bipolar disorder. The Nurses Notes dated 1/23/19 at 12:50 and signed by the Registered Nurse (RN) assigned to the care of Patient #2, documented Patient #2 had an unwitnessed fall earlier in the morning. The note described Patient #2 as being found agitated and requesting to go to the bathroom. The note documented the author left the patient unattended in order to get equipment to measure the patient's blood pressure prior to having the patient stand up. The nurse found the patient on the floor when she returned. The report of the x-ray of the right shoulder dated 1/23/19 at 11:28 a.m. was signed by the radiologist. The findings included a questionable mild dislocation of the right shoulder and suggested clinical correlation to confirm the finding. There was no evidence of an acute fracture. The Vice President of Quality and Patient Safety confirmed the finding the nurse failed to ensure the patient's safety by leaving Patient #2 unattended when the patient indicated an urgent need to use the bathroom.
Based on document review and staff interviews, it was determined the facility failed to ensure compliance with infection control procedures, protocols, and manufacturer instructions for preventative maintenance of surgical instrument sterilizers. The facility performs approximately 7,000 annual surgeries and has eight steam sterilizers. Findings included: A review of the facility sterilizer's manufacturers instructions for use (IFU's), showed the facility had 4 Amsco Century Medium Steam Sterilizer's, model #V148H and 4 Amsco Century Small Steam Sterilizer's, model #V116. The facility had a total of 8 surgical instrument steam sterilizers. 7.1.1 Clean Chamber Drain Strainer Important: The chamber drain strainer must be cleaned at least once a day preferably in the morning before running the first cycle. 1. Remove the drain strainer from the drain in the bottom of the chamber. 2. Remove any obvious debris from the strainer. If necessary, clear the screen in the strainer using a brush, wire or similar tool. 3. Once it has been cleared of obvious debris, reverse flush the strainer under running water. 4. Replace the strainer in the chamber drain 8.3 Weekly Maintenance Procedure: Flush Chamber Drain 1. Flush chamber drain as follows whenever the line becomes clogged: 2. Turn off steam supply valve. Wait until jacket pressure is zero. Wait until chamber has cooled to room temperature. 3. Remove chamber drain strainer (Figure 8-1). Clean strainer using procedures given SECTION 8.2.2, if necessary. 4. Pour a solution of 60 mL (1/4 cup) of Liquid-Jet 2 Instrument Detergent (Contact your local STERIS representative), and 500 mL (1 pint) of hot water into the drain... Should the detergents in Step 3 be unavailable, you may use a hot solution of 15 mL (1 tablespoon) of trisodium phosphate to 500 mL (1 pint) of hot water. 5. Open door and place strainer back in drains On 03/13/19 at 1:00 p.m., a tour was conducted of the Sterile Processing Department (SPD), accompanied by the VP of Quality & Safety and Director of Surgical Services. While on tour, an interview was conducted with a Certified Surgical Technologist (CST). The CST was asked for the daily and weekly sterilizer maintenance logs for cleaning and flushing of the sterilizer drain. The CST stated he did not have a log and stated that he thought the STERIS Technician performed that maintenance every 3 to 4 months. On 03/13/19 at 3:30 p.m., an interview with the Director of Surgical Services confirmed the facility did not have a log documenting required daily cleaning of the sterilizer chamber drain strainer and weekly flushing of the chamber drain, per the manufacturer's instructions for use (IFU's).
Based on record review and interviews it was determined the facility failed to ensure a consent was in place prior to the initiation of hemodialysis treatments for one [#4] of ten sampled medical records reviewed . Findings included, A review of patient #4's medical record specifically the physician's hemodialysis orders dated 10/24/17, hemodialysis treatment flow sheets and patient consent forms did not reveal a patient consent for hemodialysis. On 10/31/2017 at 3:00 p.m. an interview with the VP of Quality/Patient Safety during the record review confirmed the above finding.
Based on record reviews, policy review and interview it was determined the facility failed to ensure restraints were released and repositioned every two hours for 1 (#2) of 10 sampled records reviewed. Findings included, A review of Patient #2's medical record revealed physician's orders for soft wrist restraints for patient safety due to pulling at and dislodging tubes. A review of the restraint documentation dated 10/29/17 showed the restraints were released and repositioned every two hours until 11:51 a.m. There was no documentation of the restraints being released and repositioned again until 8:00 p.m. The record documented the restraints released and repositioned at 8:00 p.m. and 10:00 p.m. There was no further documentation until 10/30/17 at 1:59 a.m. a four hour time span. A review of the facility policy titled Patient Restraint/Seclusion stated a RN will assess the patient at least every two hours for signs of injury associated with restraint....needs for range of motion, exercise of limbs and systematic release of restrained limbs are being met. On 10/31/2017 at 3:00 p.m. an interview with the VP of Quality/Patient Safety during record review confirmed restraint documentation should show every two hours assessments and confirmed the above findings did not follow policy.
Based on observation, record review and interviews it was determined the facility failed to have sufficient patient care staff to ensure patient care needs were met. Findings included, On 10/30/2017 at 10:00 a.m. accompanied by the VP of Quality/Patient Safety a tour of the 4 North patient care unit was conduced. At the time of the tour the unit had thirty-seven patients. It was staffed with seven registered nurses and two patient care technicians. An interview with the charge nurse stated all patients required turning and repositioning and assistance with feeding. However there is not enough staff to accomplish. Interview with an Agency Nurse at 10:40 a.m. stated I am just starting my scheduled 9:00 a.m. medication pass. The Charge Nurse stated medications have 1 hour before or 1 hour after scheduled time. The medications are considered late and the policy states to notify the patient's physician. Interview with current patients [patient #4 and #5] revealed it takes over an hour to have the call light answered and then the staff says they don't have time to get me up. Both patients stated it did not matter day or night, they get the same response from staff can't get you up don't have time. Patient #4 stated his bed has been changed twice, because I had a bowel movement in the bed, I just couldn't hold it any longer. The patient staff refused to get him up stating didn't have time. Interview on 10/31/2017 at 2:00 p.m. with the Nursing Supervisor revealed we had a recent influx of patients over the weekend and staffing was not what it should be even though we have pulled in agency staffing. The VP of Quality/Patient Safety confirmed the above findings.
Based on record review, policy and interview it was determined the facility failed to ensure medications were given appropriately to ensure the effectiveness of the medication for one (#7) of ten sampled records and failed to ensure Hemodialysis was administered per physician prescribed prescription for one (#4) of ten sampled records. Findings included, 1. A review of Patient #7's medical record revealed a physician order for Calcium Acetate [PhosLo 667 mg (milligram) tablet, two tabs by mouth three times a day with meals. A review of the medication administration record [MAR] showed the medication was profiled as three times a day with meals at 8:00 a.m., 12:00 p.m. and 5:00 p.m. An interview on 10/31/2017 at 3:00 p.m. with the Director of Food Services stated tray service to 4 North was at 8:00 a.m., 1:00 p.m. and 6:00 p.m. A review of the MAR indicated the following: 09/22/2017 Calcium Acetate was given at 12:23 PM and 6:04 PM 09/23/2017 Calcium Acetate was given at 8:09 AM, 12:52 PM and 4:56 PM-not given with meal 09/24/2017 Calcium Acetate was given at 9:19 AM-not given with meal, 1:27 PM and 4:41 PM-not given with meal 09/25/2017 Calcium Acetate was given at 8:15 AM, 2:51 PM-not given with meal and 10:15 PM-not given -patient not available-no documentation if the patient received a dinner time meal. 09/26/2017 Calcium Acetate was given at 8:43 AM, 2:00 PM-tray late and 4:33 PM-not given with meal 09/27/2017 Calcium Acetate was given at 8:56 AM, 2:22 PM-not given with meal and 5:15 PM-not given-patient not available-no documentation if patient received a dinner time meal. 09/28/2017 Calcium Acetate was given at 8:42 AM, 1:35 PM the patient was discharged prior to meal service. Documentation confirmed the patient did not receive then phosphate binder with meals for 6 out of 19 scheduled doses. Phosphate binders need to be taken with food to effectively bind with phosphate. An interview on 10/31/2017 at 3:10 p.m. with the VP of Quality/Patient Safety confirmed the findings. 2. A review of Patient #4 Hemodialysis physician orders revealed Hemodialysis was ordered for three times per week on [MWF] Monday, Wednesday and Friday via AV Fistula, Duration 3 hours, blood flow rate [BFR] 400, dialysis flow rate [DFR] 600, Potassium [K] bath: 3K and Calcium [Ca] Bath of 2.5 Ca. A review of the treatment flow sheets documented hemodialysis treatments was given on TTS [Tuesday, Thursday, Saturday]. There was no documentation why hemodialysis not given on physician prescribed days. Continued review of the treatment flow sheets documented the following: On 10/24/2017 the BFR was at 350-no documentation why the BFR ran below the physician prescribed BFR of 400. On 10/26/2017 the BFR fluctuated between 350 and 300-no documentation why the BFR ran below the physician prescribed BFR of 400. Potassium Bath [K] was set at 2K-no documentation why the potassium bath was below the physician prescribed 3K bath. On 10/28/2017 the BFR was at 300-no documentation why the BFR ran below the physician prescribed BFR of 400. Calcium Bath [Ca] was set at 2Ca-no documentation why the calcium bath was below the physician prescribed 2.5Ca bath. On 10/30/2017 the BFR was 350-no documentation why the BFR ran below the physician prescribed BFR of 400. Potassium Bath [K] was set at 2K-no documentation why potassium bath was below the physician prescribed 3K bath. An interview on 10/31/2017 at 3:10 p.m. with the VP of Quality/Patient Safety confirmed the findings.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of medical records, staff interview and review of facility policy and procedures it was determined the facility failed to ensure medications were controlled and documented according to standards of practice for three (#3, #11, #12) of thirteen patient records sampled. Findings included: Review of the facility policy Medication Management stated the patient's electronic medication administration (eMAR) record shall be a record of medications administered and to be administered to an individual patient over a twenty-four hour period. Departments providing diagnostic or treatment services may document medication administration in eMAR. 1. Review of the medical record for patient #3 revealed the patient was admitted to the facility on [DATE] for a surgical procedure. Review of the physician's operative report revealed Monsel's Solution was administered. Review of the intra-operative documentation and the eMAR revealed no documentation of the medication or the amount of the medication used. Interviews were conducted with two RN's (Registered Nurses) on 1/10/2017 at approximately 1:30 p.m. that were present at the time of the procedure on 8/12/2016. The RNs stated 10 ml (milliliters) of the medication was drawn up in a syringe but they could not confirm the total amount used. 2. Review of the OR (Operating Room) Pyxis medication summary for Monsel's paste was reviewed. Two (#11, #12) patient's medical records reviewed. The sampled patient's had Monsel's paste removed under their name. Review of patient #11's medical record revealed the patient was admitted to the facility on [DATE] for a surgical procedure. Review of the intra-operative documentation and the patient's eMAR revealed no documentation the medication was administered. Review of the Pyxis summary revealed no evidence the medication was wasted due to non-use. Review of patient #12's medical record revealed the patient was admitted to the facility on [DATE] for a surgical procedure. Review of the intra-operative documentation and the patient's eMAR revealed no documentation the medication was administered. Review of the Pyxis summary revealed no evidence the medication was wasted due to non-use. Interview and review of the medical records with the Vice President of Quality and the Director of Surgical Services on 1/10/2017 at approximately 3:15 p.m. confirmed the findings.
Based on record review and staff interview, the Registered Nurse failed to supervise and evaluate care to ensure a complete and appropriate assessment of the response to a nursing intervention for one (#5) of ten sampled patients was performed. Findings included: Patient #5's record revealed nursing documentation dated 1/25/16 at 5:02 a.m. noted the patient's blood pressure was 200/105. The Medication Administration Record documented the RN administered Vasotec 1.25 milligrams intravenously in accordance with the physician's orders. The documentation revealed the blood pressure was rechecked one minute later at 5:03 a.m. with no change. The blood pressure was not rechecked until 6:59 a.m., nearly two hours later. An interview and record review was conducted with the nurse manager of the nursing unit on 2/2/15 at the time of the record review. She confirmed the finding patient #5's response to the intravenous blood pressure medication was not assessed in a timely manner.
Based on medical record review, staff interview, and review of facility policy and procedures it was determined the facility was not in compliance with 42 CFR 489.24. The facility failed to provide a complete medical screening exam for one patient (#5) of twenty patients sampled (see A2406).
Based on medical record review, staff interview, and review of policy and procedure it was determined the facility failed to ensure an appropriate medical screening examination was provided to determine whether or not an emergency medical condition existed for one (#5) of twenty patients sampled. Findings include: Review of the medical record for patient #5 revealed the patient arrived at the facility's ED (Emergency Department) on 6/25/2014 at 2:43 pm. The patient's complaint was abdominal pain that started approximately 2 hours prior to arrival. Nursing triage documentation revealed the patient was 32 weeks gestation and was seen by her Obstetrician in the morning with no problems noted. The patient was noted to be a unaccompanied walk in. At 4:58 pm the ED physician performed a medical screening exam. Physician documentation revealed the patient was 32 weeks gestation presenting with 2 hours of constant mild abdominal pressure. The patient denied flank pain, vomiting, diarrhea, dysuria, vaginal bleeding, discharge, odor, or rash. The symptoms were noted to be very mild and the patient had not had any prenatal complications. Physician physical exam revealed the abdomen was soft, non-tender, no guarding, no rebound, and the gravid uterus was non-tender. Review of the ED course revealed physician documentation stated the patient looked well and had no pain on exam. Documentation revealed the patient had concern that she may be having contractions. Physician documentation stated he did not suspect the patient was having contractions and was safe to drive to labor and delivery at a nearby facility to be evaluated on a tocometer (an instrument for measuring and recording uterine contractions). Nursing documentation revealed FHT (Fetal Heart Tones) at 5:11 pm were 130's, strong and regular. Review of the physician documentation revealed no evidence the patient's obstetrician was notified and no other testing was performed. The physician's primary impression was third trimester abdominal pain and the patient was discharged at 5:13 pm. Review of the discharge instructions stated the patient was to drive directly to labor and delivery at another local acute care hospital to be evaluated for pre-term uterine contractions. Nursing documentation revealed at 5:13 pm the patient was discharged from the ED. Review of the physician documentation revealed no evidence the physician notified the other local acute care hospital of the patient's instructions to go to labor and delivery for evaluation of uterine contractions. Review of the facility policy #302-RI-124, EMTALA - Florida Medical Screening Examination and Stabilization , effective 2/23/2012, states 4(e)(ii) Pregnant Women: the medical records should show evidence that the screening examination includes, at a minimum, on-going evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, and status of membranes (i.e., ruptured, leaking and intact), to document whether or not the woman is in labor. A woman experiencing contractions is in true labor unless a physician, certified nurse-midwife or other QMP (Qualified Medical Personnel) acting within his or her scope of practice as defined by the hospital's medical staff bylaws and State practice acts, certifies that after a reasonable time of observation, the woman is in false labor. Review of the medical record for patient #5 revealed the patient was triaged at 4:23 pm, a medical screening exam performed at 4:58 pm, and the patient was discharged at 5:13 pm. The fetal heart tones were noted at 5:11 pm to be 130's, strong, and regular. There was no evidence the medical screening exam included the minimum examination of a pregnant woman to include on-going evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, or status of membranes. Interview with the VP of Quality and Risk, the ED Director, and the CMO on 7/01/2014 at 12:00 pm confirmed the above information.
Based on record review, staff interview, and review of facility policy and procedures it was determined the facility failed to have a registered nurse supervised, evaluated and documented the nursing care, interventions and patient response for one (#1) of eight patients sampled. This does not ensure patient goals are met. Findings include: Review of the medical record for patient #1 revealed the patient presented to the facility's emergency department on 4/2/2012 with complaints of abdominal pain, nausea, vomiting, and constipation. The patient was admitted for treatment of a small bowel obstruction. On 4/4/2012 the patient underwent a colectomy with colostomy. Documentation revealed the patient had no alteration in skin with the exception of the surgical incision and colostomy. On 4/5/2012 at 7:40 a.m., post operative day 1, the patient was noted to be alert, neurological function was within defined parameters and the patient was noted to be sitting up in the chair. Review of the nursing documentation revealed the patient remained sitting in the chair until 4/7/2012 at 10:30 a.m. At this time nursing documentation revealed the patient was assisted to bed with the aid of a walker. On 4/7/2012 at 8:40 p.m. nursing documented the patient's coccyx was red and purple and had a blister. A mediplex dressing was applied. Review of the nursing documentation revealed the patient developed a stage 2 pressure ulcer. It was determined the pressure ulcer was hospital acquired. Review of the facility's policy, Skin Breakdown-Prevention/Management , effective 10/2004 states 7 (a)(ii) upon identification of a Stage II, III or IV pressure ulcer acquired during the patient's hospitalization wound photographs will be utilized. Review of the record revealed lack of documentation of wound care and treatments and revealed no photographs of the identified pressure ulcer. On 4/8/2012 at 7:40 a.m. nursing documentation revealed the patient's coccyx was red with an intact blister present. The skin was noted to be open to air and no documentation of a mediplex dressing in place or of being removed. On 4/8/2012 at 10:37 a.m. nursing documented the patient had a pressure ulcer to the coccyx, non-open, purple with red outline to outer edge with opened blister to right buttock, measurement of 10 cm X 10 cm (centimeters) was documented. Nursing documented wound care to the coccyx area on 4/8/2012 at 12:00 p.m. On 4/9/2012 at 11:49 a.m. the pressure ulcer was measured and documented as 12 cm in length with a blister. There was no documentation of the width, no documentation of wound care or dressing application at that time. At 8:05 p.m. nursing documented a mediplex dressing was in place. Review of the nursing documentation revealed lack of documentation of specific wound treatments and adequate wound description. Review of the facility's policy, Skin Breakdown-Prevention/Management , effective 10/2004. The policy states (4) document specific wound treatments. Review of the nursing documentation revealed the facility failed to ensure nursing documented specific wound treatments. Interview with the risk manager on 11/8/2012 at 1:00 p.m. confirmed the above findings.
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