HospitalInspections.org

Based on document review and interview, nursing services failed to complete daily patient hygiene and daily linen change per policy for 4 of 10 medical records reviewed. (P1, P3, P6 & P7); failed to initiate wound care/treatment for wound discovered on initial skin assessment for 1 of 10 MRs reviewed (P7); failed to assess wound dressing every 4 hours per policy for 2 of 10 MRs reviewed (P2, P3); failed to assess patient pain level every 4 hours per policy for 3 of 10 patient medical records reviewed (P3, P6, P10); and failed to re-assess pain 30-60 minutes after interventions per policy for 2 of 10 patient MRs reviewed. (P7, P10)

Findings Include:
1. Policy titled Inpatient Nursing Unit Standards of Care, no policy #, indicated Hygiene: Daily Bath all patients, CHG (chlorhexidine) bath daily for central lines; linen change daily and PRN (as needed). Pain: Q (every) 4 hours or presence of any S/S (signs/symptoms) discomfort. Following any alleviation intervention. Incisions/Dressings, Drains: Q4 hours. Skin: On admit, during bedside change of shift, and Q shift.

2. Policy titled Pain Management and Narcotic Usage, no policy #, last revised 3/2024, indicated after the medication is administered, follow-up of its effectiveness should be assessed and documented within 30-60 minutes. Procedure 6. Chart narcotic, when given, why, route, use pain scale prior to giving, and then chart the response to pain medication with pain scale within 30-60 minutes.

3. Policy titled Skin Assessment/Braden Scale Guidelines/Pressure Ulcer/Injury, Policy # 11998.3, last revised 9/1/2021, indicated Policy: On admission, nurse should assess patient and document assessment. Nurse should also complete skin assessment every shift throughout hospital stay. I. At Time of Admission - Interventions addressing care should be developed by the nursing staff and incorporated into the patient's plan of care, as appropriate.

4. Policy procedure titled Clinical Nursing Skills & Techniques (10th. Ed.), no procedure #. no revision date, indicated 5. Assess the location of the stoma, the type of stoma, and the characteristics of the patient's abdomen to determine the best type of pouching system. Consider the abdominal contour and the presence of scars or incisions.

5. P1 Medical Record (MR) review completed on 4/30/2024 indicated:
a. Patient was admitted on 3/27/2024 with chief complaint of mechanical fall.
b. MR lacked documentation of patient daily bathing and daily linen change completed on 3/28/2024 and 3/29/2024.
c. Patient was discharged home on 3/31/2024.

6. P2 MR review completed on 4/30/2024 indicated:
a. Patient was admitted on 3/27/2024 with pain to the back post lateral fusion procedure.
b. MR lacked documentation of nursing assessing PICO (wound care system that provides suction) dressing, according to policy, every 4 hours, from 1959 hours on 3/28/2024 through 0739 hours on 3/29/2024.
c. Patient was discharged home on 4/4/2024.

7. P3 MR review completed on 4/30/2024 indicated:
a. Patient History and Physical dated 3/27/2024 at 1844 hours indicated patient was admitted on 3/27/2024 with chief complaint of abdominal pain.
b. MR lacked documentation of inguinal hernia dressing and site assessment completed every 4 hours, per policy, from 1959 hours on 3/28/2024 through 0739 hours on 3/29/2024.
c. MR lacked pain assessment every 4 hours, per policy, from 0859 hours on 3/30/2024 through 2001 hours on 3/30/2024.
d. MR lacked documentation of midline abdominal wound dressing and site assessment completed every 4 hours per policy, from 1913 hours on 4/11/2024 through 1634 hours on 4/12/2024.
e. MR lacked documentation of colostomy site dressing and site assessment completed every 4 hours, per policy, from 0424 hours on 4/13/2024 through 1148 hours on 4/13/2024, and from 1148 hours on 4/13/2024 through 2203 hours on 4/13/2024.
f. MR lacked documentation of daily patient bathing and linen change 3/28/2024, 3/29/2024, 3/31/2024 and 4/1/2024.
g. Patient was discharged home on 4/16/2024 in stable condition.

8. P6 MR review completed on 4/30/2024 indicated:
a. Patient was admitted on 3/28/2024 with chief complaint of dyspnea.
b. MR lacked documentation of pain assessment every 4 hours, per policy, on from 0800 hours on 4/1/2024 until 2000 hours on 4/1/2024.
c. MR lacked documentation of daily patient bathing and linen change on 4/1/2024.
d. Patient was discharged home on 4/3/2024.

9. P7 MR review completed on 4/30/2024 indicated:
a. Patient was admitted on 3/28/2024 with chief complaint of left knee pain.
b. Initial nursing assessment dated 3/28/2024 indicated a wound was found on patient left knee; no further documentation/description or interventions were noted. No further documentation until assessment on 3/31/2024.
b. MR indicated pain intervention was administered on 3/28/2024 at approximately 2131 hours, pain was not reassessed within 30-60 minutes per policy; pain was reassessed on 3/29/2024 at 0032 hours.
c. MR lacked documentation of daily patient bathing and linen change on 3/30/2024.
d. MR indicated pain intervention was administered on 4/1/2024 at approximately 0830 hours, pain was not reassessed within 30-60 minutes per policy; pain was reassessed on 4/1/2024 at 1200 hours.
e. Patient was discharged home on 4/1/2024.

10. P10 MR indicated:
a. Patient was admitted on 4/23/2024 with chief complaint of right flank pain.
b. MR lacked documentation of pain assessment from 2004 hours on 4/23/2024 through 0700 hours on 4/24/2024.
c. MR lacked documentation of daily patient bathing and daily linen change on 4/24/2024.
d. Patient was administered pain intervention on 4/28/2024 at approximately 0421 hours, MR indicated intervention was not reassessed in 30-60 minutes per policy, pain was reassessed at 0424 hours on 4/28/2024.
e. P10 is currently inpatient on SIPS unit.

11. In interview on 4/30/2024 at approximately 1500 hours with A4 (Accreditation Coordinator), he/she confirmed MR findings of lack of pain management and reassessment documentation, lack of hygiene and linen change, lack of dressing and wound assessments and interventions as appropriate for MRs reviewed (P1, P2, P3, P6, P7, and P10).