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Based on medical record review, review of manufacturer's guidelines, staff interview, review of video footage, and review of facility policy, the facility failed to follow their policies and manufacturer's guidelines to ensure staff provided repositioning, bathing, changing of external urinary devices and appropriate pain assessments. (A395). The cumulative effects of these systemic practices resulted in the agency's inability to ensure patient care needs would be met.

Based on medical record review, review of manufacturer's guidelines, staff interview, review of video footage, and review of facility policy, the facility failed to follow their policies and manufacturer's guidelines to ensure staff provided repositioning, bathing, changing of external urinary devices and appropriate pain assessments. This affected Patient #2, Patient #5, Patient #11, Patient #14 and Patient #18 with the potential to affect all patients cared for in this facility. The facility's current census was 402.

Findings include:

1a) The medical record for Patient #18 was reviewed on 02/02/24. On 12/12/23 at 5:00 PM Patient #18 was a direct admit to the neurological intensive care unit (ICU). Patient #18 had a history of a ischemic stroke on 09/28/23 with a stent completed and atrial fibrillation. The history stated this patient was admitted with left sided weakness.

An electroencephalogram (EEG) was completed on 12/12/23 with abnormal findings listed. Orders were received on 12/13/23 for a continuous video EEG due to possible seizure activity.

Review of the Braden score (prediction of pressure score risk) on 12/12/23 revealed a score of 14. On 12/13/23 at 11:35 AM the Braden score was 12.

Review of the Adult Skin and Wound Care form revealed when a Braden score is 18 or less a skin assessment should be completed every eight hours of all bony prominence and areas of pressure. Turn and reposition the patient at least every two hours at minimum 20 degrees.

Notes on 12/12/23 at 11:00 PM revealed staff applied a preventive cushion foam dressing to the coccyx and the patient was placed on a low air loss bed to prevent skin breakdown.

Interview with Staff E on 01/30/24 at 2:40 PM revealed all bed bound patients are turned every two hours. Bathing is completed by the nursing assistant (NA) or RN with some getting bathed on days and others at night. Staff E further stated hourly rounding is completed to check if the patient needs anything or needs to use the bathroom.

The medical record revealed Patient #18 was transferred from the ICU to the ninth floor on 12/13/23 at 9:46 AM. A Braden score of 12 was listed upon transfer. The medical record revealed repositioning was completed every two hours daily. Documentation in the medical record on 12/13/23 at 11:35 AM listing this patient was positioned on his/her left side, notes at 3:54 PM revealed this patient continued on her left side.

Review of the record revealed skin breakdown was documented on 12/18/23 at 8:10 PM identified as bruising and excoriation noted on the buttocks and coccyx. Orders were placed for wound therapy to see.

Review of the wound care nurse documentation dated 12/20/23 at 11:07 AM revealed the presence of an acute and pressure injury likely from friction/moisture limited to breakdown of skin which was not present on admission. Location is left ischium measuring 2 centimeters (cm) by 1 cm and and left buttocks measuring 0.5 cm by 1 cm. Orders were received to cleanse skin with soap and water, pat dry, apply Cavilon (barrier film) to sacral wound and to left ischial area on Tuesday and Friday and as needed.

Review of the video EEG was completed on 02/02/24 at 3:25 PM with Staff A. This review revealed Patient #18 was in a semi-fowlers (SF) position (lying on back with head of bed half way up) on 12/13/23 at 11:35 AM with visitors at the bedside. The video at 3:34 PM showed this patient continued to be in a SF with no one in the room until 7:38 PM when a staff member came in to complete vital signs (VS) then left the room without turning or re-positioning the patient. Video surveillance on 12/14/23 at 1:00 AM showed this patient remained in this SF position. A staff member was in the room at 4:10 AM, appeared to open the adult diaper then re-taped it with this patient remaining in the same SF position and no repositioning done. A staff member came into the room at 4:35 AM and appeared to be flushing the intravenous (IV), but when checking the medication record Labetolol (BP medicine) was given at this time. Vital signs were completed at 4:47 AM, Oxygen was applied by nasal cannula and this patient remained in the same SF position. The video at 5:57 AM showed staff in the room talking with this patient, scanned the name band and gave medication in what appeared to be applesauce with a spoon. Vital signs were again completed at 8:15 AM with a male visitor present having a conversation with Patient #18. Visitors were present at 9:47 AM and were assisting this patient with eating breakfast. On 12/14/23 at 12:17 PM staff were at the bedside to change Patient #18's adult diaper, change the external catheter and repositioned this patient onto the left side. This was the first observed repositioning of the patient in 24 hours and 17 minutes.

An interview with Staff A at the time of the video review verified after observing the video for the 24 hour time period Patient #18 was turned only once and had the adult diaper changed one time. Staff A further verified the medical record had documented the patient had been turned and repositioned every two hours, but the video lacked evidence that this was completed.

The findings of not turning this Patient #18 every two hours as ordered was verified with Staff A, Staff B, and Staff D on 02/02/24 at 5:30 PM.

1b) The medical record documented under activities of daily living (ADL) Patient #18 was a total care for a bath. A complete bed bath, back rub and oral care was documented as completed in the ICU on 12/13/23 prior to transferring to the step down unit. No documentation was found of a bath being completed again until 12/22/23 at 7:00 PM by Staff C.

Interview with Staff C was completed on 02/02/24 at 1:45 PM. Staff C stated they remember this patient stating she hadn't had a bath since she was admitted to the hospital so they stayed and gave her a bath. Staff C further stated the nursing assistants usually bath the patients.

Interview with the facility nurse educator Staff F on 02/02/24 at 2:00 PM revealed all patients should be offered a bath daily. The nursing assistants will get vital signs first, set up for breakfast, then start the baths. Staff F further stated the daily bath is an expectation which should be offered and documented if refused.

The findings of not offering a daily bath for nine days was verified with Staff A and Staff B on 02/02/34 at 3:00 PM.

1c) The medical record revealed Patient #18 had a external female urinary collection device. The medical record was reviewed with Staff B. No documentation was found this device was changed on 12/13/23, 12/15/23 and 12/17/23.

Interview with Staff A revealed the facility does not have a policy to change the external catheter and would follow the manufacturer guidelines.

Review of the manufacturer guidelines titled "Sage Primafit External Urine Management for the Female Anatomy" instruct staff to change the device every 12-24 hours.

The findings of not changing the urinary management device per the manufacturer guidelines was verified with Staff A and Staff B on 02/02/24 at 3:00 PM.

1d) The medical record for Patient #18 revealed she was a direct admit on 12/12/23 at 5:00 PM and taken directly to the neurological intensive care unit (ICU).

The first documentation of a pain for Patient #18 was on 12/13/23 at 5:10 AM scored an 8/10 (scale to rate pain severity with a score of seven to ten being the most severe) in her shoulder and occurring with repositioning. Pain medication was administered. Pain was documented on 12/16/23 at 6:07 PM as a 2/10 but no description of where it was located or any alleviating measures being administered. On 12/17/23 at 1:03 PM pain was reported as 4/10 with no description of where the pain was. Nursing notes on 12/18/23 at 1:12 PM listed a pain of 10/10 with no description of where the pain was located. The patient was medicated with Tylenol 650 milligrams (mg).

Review of the policy titled "Pain Assessment, Management, and Reassessment," reviewed 12/08/23, revealed the patient's pain experience is assessed on an ongoing basis in all patient care settings. Emergency center and in-patient patients are routinely assessed for pain A pain assessment should be included on admission and with any new onset of pain. This assessment should include pain location, intensity, quality, onset, duration and what makes the pain feel better or worse. A numeric pain score is used for patients who are verbal and able to self report. The score identifies zero is no pain, 1-3 is mild pain, 4-6 is moderate pain, and 7-10 is severe pain. If the patient is non-verbal a FACES score should be used with descriptions of smiling for no pain to crying for severe pain.

The findings of not following the facility policy for completing an appropriate pain assessment for Patient #18 was verified with Staff A on 02/02/24 at 11:50 AM.

2) The medical record for Patient #2 was reviewed on 01/31/24. Patient #2 was admitted to the emergency department (ED) on 12/31/23 at 2:57 PM with complaints of right lower quadrant abdominal pain. This patient complained of nausea and vomiting with pain which started two days prior. Vital signs were completed at 3:13 PM and documented within normal range. Laboratory (lab) work was ordered along with a ultrasound of the pelvis.

No documentation of a pain assessment using a numerical rating to assess pain severity was completed upon admission for Patient #2. This patient was discharged home on 12/31/23 at 6:53 PM.

The findings of not following the facility policy for completing an appropriate pain assessment on admission to the ED for Patient #2 was verified with Staff A on 02/02/24 at 11:50 AM

3) The medical record for Patient #5 was reviewed on 01/31/24. Patient #5 came to the ED on 01/21/24 at 6:45 PM with complaints of left shoulder pain, chest pain and bright red blood in her stool.

Vital signs at 6:49 PM were recorded as temperature (T) 36.7 degrees Celsius, blood pressure of 120/71, heart rate of 77, respirations of 18, and oxygen saturation of 97%. Lab work was ordered by the physician with results documented as within normal limits (WNL). A 12-lead electro cardiogram (ECG) was completed at 6:54 PM and documented the patient with normal sinus rhythm with a heart rate of 73. A urine specimen reported back at 7:45 PM as within normal limits and a negative pregnancy test.

Physician notes documented a review of all the ordered tests and no need for interventions. Patient #5 was discharged from the ED at 8:50 PM with no documentation of a numeric score to assess pain severity being completed from admission to discharge.

Interview with Staff A on 02/01/24 at 10:00 AM verified the findings of not following the policy for an appropriate pain assessment upon admission to the ED.

4) The medical record for Patient #11 was reviewed on 02/01/24. Patient #11 was admitted to the ED on 12/03/23 at 10:40 AM with complaints of left sided rib pain from a fall two weeks prior. Vital signs were completed at 11:20 AM with a heart rate of 100 and blood pressure of 147/87, which were both slightly elevated.

The physician was into see this patient at 11:51 AM with orders for lab work. Physician notes stated the testing and imaging from previous ED visit was reviewed and interpreted. This patient was offered muscle relaxers and non-narcotic pain medication in the ED, which she refused.

No documentation was found Patient #11's pain was assessed for severity using a numeric scale. Discharge instructions were provided at 2:52 PM with this patient becoming angry and refusing to sign the paperwork due to requesting narcotics even after talking with the charge nurse and physician. Patient #11 was discharged home at 3:01 PM with instructions in hand.

The findings of not following the facility policy for completing an appropriate pain assessment on admission to the ED for Patient #11 was verified with Staff A on 02/02/24 at 11:50 AM.

5) The medical record for Patient #14 was reviewed on 02/01/24. Patient #14 was admitted to the ED on 01/23/24 at 1:21 PM with complaints of chest pain and shortness of breath (SOB). A ECG was ordered and completed at 1:28 PM along with lab work and chest xray.

A physician assistant (PA) was into see the patient at 3:35 PM with an assessment completed. Notes from the PA revealed based on patients history, physical exam, labs, and imaging results, no evidence of acute condition needing immediate intervention or admission today. Patient complained of sporadic chest pain for three months that can sometimes cause SOB. There were no current symptoms. This note stated the attending physician agreed with the findings and this patient would be discharged home.

No documentation was found Patient #14's pain was assessed for severity using a numeric scale.

The findings of not following the facility policy for completing an appropriate pain assessment in regards to completing a pain assessment on admission to the ED for Patient #14 was verified with Staff A on 02/02/24 at 11:50 AM.