Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 531311	(X3) Date Survey Completed 11/17/2011
Name of Provider or Supplier Crook County Hospital	Street Address, City, State 713 Oak Street, Sundance, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag

Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)

C0295

NURSING SERVICES
CFR(s): 485.635(d)(1)

A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient's needs and the specialized qualifications and competence of the staff available.

This STANDARD is not met as evidenced by:
Based on medical record review and interviews with visitors and staff, the facility failed to provide nursing services that met the needs of 4 of 22 sample patients (#4, #10, #18, #22) reviewed. The findings were: 1. Review of the medical record for patient #18 revealed the patient was admitted to the hospital on 7/27/11 from long term care; the admitting diagnoses included dementia and severe agitation. Interview with the social services director on 11/16/11 at 6:10 PM revealed the patient's extreme, agitated behavior started a few days prior to 7/27/11 after daily doses of Seroquel were added to his/her medication regime. Review of the nursing admission assessment showed the patient was confused and disoriented, required assistance with activities of daily living, did not have pressure ulcers, had a shuffling gait, and had no problems with urination. Review of the physician admission orders showed the following medications were ordered daily: Zyprexa 5 mg, Plavix 75 mg, Isosorbide mononitrate, Bystolic 5 mg, Seroquel XL 50 mg, Zoloft 50 mg and intravenous or intramuscular injections of Haldol 10 mg with Benadryl 25 mg every six hours as needed. Review of the medication administration record showed the following medications were ordered and administered: On 7/27/11 Haldol and Benadryl prior to the 8 PM transfer to the hospital and again at 10:50 PM. On 7/28/11 Haldol and Benadryl at 1:45 AM and 9 PM. On 7/29/11 Haldol and Benadryl at 4:40 AM, 12:30 PM and 1 PM. On 7/29/11 Haldol and Benadryl at 8 PM. On 7/30/11 Haldol and Benadryl at 2 AM, 10:15 AM, and 6 PM. On 7/31/11 Haldol and Benadryl 8 AM. On 8/1/11 Haldol and Benadryl at 8 and 2 PM. On 8/2/11 Haldol and Benadryl at 8 AM and 2:20 PM. On 8/3/11 Haldol at 6 AM and 12 PM. On 8/5/11 Haldol 5 mg at 4 AM. On 8/6/11 Haldol 5 mg at 3:12 PM and 8:15 PM. On 8/7, 8/8, and 8/9/11 the patient received Haldol 5 mg at least once each day. According to the 7/27/11 to 8/9/31 nurses' notes and medication administration records, the Haldol injections were administered intravenously until 8/1/11 when the route of administration was changed to intramuscular. Further review of the nurses' notes showed a urinary catheter was inserted on 7/30/11 at 10:20 AM due to urinary retention, and the patient developed a stage II pressure sore on the coccyx on 8/6/11. Review of the 8/5/11 nursing summary showed the patient's condition had declined and s/he required total care for all activities of daily living except feeding and that required assistance. Review of the 8/7/11 nurse's notes showed the patient continued to have periods of agitation, ambulated with "much difficulty", and later fell out of bed. The following concerns were identified regarding the care the patient received: a. Interview with the patient's friend on 11/15/11 at 1:30 PM revealed his/her concern regarding the patient's progressive decline that increased at each visit. S/he stated s/he was concerned about the medications the patient received. The visitor also stated s/he had taken her concerns to the administrator, but no changes were made. b. Review of the plan of care showed no interventions for monitoring psychotropic drug use, decline in activities of daily living, nutritional and hydration needs, urinary catheter care, and preventive skin care. c. Review of the medical record and interview with the CNO on 11/17/11 at 1:45 PM, revealed no evidence of monitoring for the effects of psychotropic medication use and adverse effects (anticholinergic) of frequent benadryl use. The CNO further stated this monitoring should have been done. d. Review of the medical record and interview with RN #6 on 11/16/11 at 5:35 PM revealed the necessary ongoing skin assessments, care and monitoring to prevent the development of the pressure sores were not implemented because as the patient got weaker and weaker, s/he was resistant to care and did not want to leave the recliner. e. According to the medical record, a nutritional evaluation was completed by the dietary manager on 8/5/11, but an additional assessment of nutritional needs by a registered dietitian was not done. Review of the food consumption records showed sometimes the patient only ate a few bites; however, the records were incomplete and documentation for each meal was lacking. f. Review of the manufacturer's packaged insert information for Haldol showed the following information was included in the warning: "Haldol injection is not approved for intravenous administration. If Haldol injection is administered intravenously, electrocardiogram monitor..." for changes in heart pattern and arrhthymias. Review of the medical record and interviews with RN #6 on 11/16/11 at 11:20 AM and with the CNO on 11/17/11 at 1:45 PM revealed staff failed to do this monitoring. g. Interview with social worker and discharge planner on 11/16/11 at 6:10 PM revealed the patient was discharged from the hospital on 8/9/11 and returned to the long term care unit where s/he began to physically and mentally improve after the Haldol injections were discontinued. 2. According to the history and physical dated 10/22/11, patient #10 was admitted for chest pain resulting from a fall that morning. Review of the 10/22/11 fall risk assessment showed the patient was at high risk for additional falls. Review of nursing documentation timed at 4 AM on 10/28/11 showed the patient was found face down on the floor with his/her legs entangled in the reliner. The notes documented that the patient was "carefully untangled from around foot of recliner, et [and] rolled to back. 2-man assist into bed...cont [continues] to be lethargic et unable to answer questions. Arouses to verbal stimuli briefly et [and] returns to sleep...mumbles that [s/he] fell, but no other words spoken...4 cm bruised, swollen bump noted to [left] forehead...abrasion above left eye. 0.5 cm laceration below [left] eye..." The following deficient practice was identified: a. There was no evidence the patient was assessed and the extent of his/her injuries determined prior to being moved. b. Despite the evidence of head injuries, neurological checks were not completed appropriately. They were obtained at 4 and 6 AM but "sleeping" was written in at 5 AM even though, according to the nursing notes at 5 AM, the patient was "Heard calling out et [and] moaning...appears more alert..." and was given a narcotic for complaints of chest pain. Review of the facility's policies and procedures entitled "Neurological Vital Signs" and "Altered Level of Consciousness Protocol" revealed neither addressed the frequency for performing neurological checks. On 11/16/11 at 6:10 PM the CNO confirmed the neurological checks should have been completed at 5 AM. c. There was no documentation that the physician was immediately notified of the acute care patient's fall and subsequent injuries; therefore, no orders for treatment were obtained 3. According to the medical record, patient #22 was admitted to swing bed status on 10/21/11 for rehabilitation after surgical repair of a fractured hip. Review of the "Admission Nursing Assessment & History" revealed it was incomplete. The immunization status was blank, the skin assessment failed to describe the patient's incision, abrasions to the right hand and forearm were listed but not indicated on the physical outline, and the pain assessment was inaccurate as the patient's highest pain level of 6/10 (0 to 10 scale with 10 the worst pain) in the last 24 hours was neither continuous nor breakthrough pain, nor was it described as both. The nursing assessment completed on the afternoon or evening (PM was circled) of 10/21/11 documented that the patient's entire left heel was discolored and "purplish", but the skin was intact. The following concerns were noted: a. Even though the patient's discolored left heel was documented on 10/21/11, there was no evidence treatment was initiated until 10/27/11, and on 10/28/11 the physical therapist recommended "Skin-Prep" applied to both heels twice daily. Review of the physician's progress note dated 10/31/11 showed "...will treat it like a pressure sore." No other orders were given. b. Review of the MARs showed nursing applied "Skin-Prep" to both heels three times per day as a "nursing order" from 10/27/11 through 11/9/11. c. Review of the "Pain Monitoring Flow Sheet" showed the patient was not always assessed before or after pain medication was administered. Although the patient was medicated from 10/22/11, monitoring was not initiated until 10/23/11 and was then performed only one of the three times the patient received a narcotic. Evidence of pain monitoring was lacking from 12:15 PM on 10/23/11 to 10/27/11 at 8:15 AM. During that time period, the patient was medicated ten times. Monitoring from 10/27 through the patient's discharge on 11/9/11 remained sporadic and did not coincide with all the times the patient was medicated. Furthermore, on 11/8/11 the patient's pain was documented as 4/10; the patient was medicated, but the untimed reassessment showed it was ineffective. However, no other treatment for pain relief was initiated. d. During an interview on 11/16/11 at 5:10 PM, the social worker stated she had been informed by a family member that the patient had been in the facility for a week, but his/her dressing had not been changed. Detailed review of the nursing documentation provided no evidence the dressing on the patient's incision was removed and the incision assessed until 10/28/11. 4. Review of the medical record for patient #4 showed the 11/7/11 physician's orders included checking the patient's blood pressure four times daily and administering the following blood pressure medications; hydrochlorothiazide 25 mg daily, Norvasc 10 mg daily, and Coreg twice a day. On 11/9/11 the physician increased the dose of Coreg to 25 mg twice a day and ordered the pulse to be checked with the blood pressure four times a day. On 11/11 /11 an additional blood pressure medication, lisinopril 10 mg daily, was added to the patient's medication regime. On 11/12/11 the lisinopril was increased to 20 mg daily; then on 11/13/11 it was increased to 30 mg daily. However, a review of the vital signs documented in the medical record showed the patient's blood pressure and pulse were checked only one to three times a day on 11/8, 11/9, 11/11, 11/12, 11/13 and 11/14/11. Interview with RN #10 on 11/15/11 at 8:55 AM revealed staff failed to obtain the vital signs four times a day because this physician's order was not consistent with the usual routine for the unit which was to check the vital signs weekly. 5. On 11/16/11 at 3:00 PM the CNO stated staff were to perform a complete assessment on every acute care patient every shift (twice daily) and as needed. A complete assessment of every swing bed patient was to be conducted weekly and as needed. Care plans for both acute and swing bed patients were to be updated with every assessment.