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Based on record review and interview, the Medical Executive Committee (Med Exec) failed to implement, and enforce bylaws, rules and regulations to carry out its responsibilities by ensuring 1 of 1 physicians' (# K) described the patients' condition, and full course of hospital, care and treatment for 1 of 10 patients reviewed.

Findings Include:

Physician (#K) failed to include updates of patient (#2)'s current medical and physical changed of the patients' condition in the physicians' progress notes.

Physician (#K) failed to update and include all of patient (#2)'s hospitalization conditions and treatments in the discharge summary.

Physician (#K) failed to complete medical records as required.

Facility Policy:

Part Three: General Responsibility For Conduct of Care

Part 3.1 Generally

The "HCA Houston Healthcare Medical Staff Rules and Regulations," amended October 23, 2019, reads, A member of the Medical Staff shall be responsible for the medical care and treatment of each patient in the hospital, for the prompt completeness and accuracy of those portions of the medical record for which he is responsible, for necessary special instructions, and for transmitting reports of the condition of the patient to the referring Practioner, and if any, to relatives of the patient.

7.0 GENERAL

The admitting practitioner shall be designated as the attending practitioner unless an order is written at any time during the hospitalization for another practitioner to assume care of the patient.
The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient. All patient medical record entries must be dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. Its contents shall be pertinent and current.

7.3 PROGRESS NOTES

7.3.1 GENERALLY

Pertinent progress notes, sufficient to permit continuity of care, shall be recorded at the time of observation. Final responsibility for an accurate description in the medical record of the patient's progress rests with the attending Practitioner. Each of the patient's clinical problems responsible for this admission should be clearly identified in the progress notes and correlated with specific orders, as well as results of tests and treatment.
Progress notes by the attending Practitioner must be written daily on acutely and critically ill patients and on those where there is difficulty in diagnosis or management of the clinical problem.

Medical Record Reviewed:

Review 09/17/2020 at 3:00 PM of the Initial Admission nursing assessment dated 6/28/2020 @19:30 indicated the patient was ambulatory with 1 person assist, and had a previously removed right great toe nail, no drainage to nail bed. The "Skin integrity impairment risk" was "Yes"; "Existing wound: No."

The nursing assessment 07/07/2020 at 20:00 identified "Press injur immobility related Posterior Heal right ...Purple/maroon/deep red ...Stage 1 pressure injury." Also, Sacrum ... Pink/red/erythema/intact ... Stage 1 pressure injury." The assessment identified ambulation as "Supervised/assist."

NE1 Photographic Wound Documents dated 07/8/2020 and 07/23/2020 were labeled with Patient #2's information, location Sacrum, Stage 3, Non-intact Skin, Exudate-serous, amount-moderate. 07/08/2020. No physician signature, date, time or agreement of pressure ulcer finding.

Nursing 07/10/2020 at 20:00 identified "Press injur immobility related Posterior Heal right" and "Sacrum" as "Unstageable." It also indicated ambulation was now "No."

Nursing assessment 07/11/2020 at 20:00 identified "Press injur immobility related Posterior Heal right ...Opaque serum filled blister ... Stage 2 pressure injury" and "Sacrum" as "Red/moist/smooth/shallow .... Stage 2 pressure injury." Additionally, "Posterior Heal Left ...Pink/red/erythema/intact ... Stage 1 pressure injury." It also indicated ambulation was now "Bedrest."

Nursing assessment 07/13/2020 at 08:00 identified "Sacrum ...Red/moist/bumpy/ granulation .... Stage 3 pressure injury."

Nursing assessment 07/18/2020 at 20:00 identified "Press injur immobility related Press injur immobility related Posterior Heal right" and "Posterior Heal left" as "Unstageable." "Sacrum" as "Yellow slough .... Stage 3 pressure injury."

Nursing assessment 07/20/2020 at 20:00 identified "Press injur immobility related Posterior Heal right", "Press injur immobility related Posterior Heal left" and "Sacrum" all as ""Red/moist/smooth/shallow .... Stage 2 pressure injury."

Nursing assessment 07/22/2020 at 16:10 identified "Press injur immobility related Posterior Heal right", "Press injur immobility related Posterior Heal left ...Black/tan eschar ...Unstageable." "Sacrum ...Yellow slough .... Stage 3 pressure injury."

Nursing assessment 07/23/2020 at 20:00 identified "Press injur immobility related Posterior Heal right ...Stage 3 pressure Injury," "Press injur immobility related Posterior Heal left ...Black/tan eschar ...Unstageable." "Sacrum ...Yellow slough .... Stage 3 pressure injury." Photo of the sacral wound 7/23/2020 measured the open area at 13 cm wide by 6.5 cm long. No depth measurement was provided.

Review on 09/30/2020 of attending physician (#K) documented progress notes daily from 07/01/2020 through discharge date 07/24/2020 identify the skin condition exclusively as "RT FOOT CELLULITIS." The daily physician notes do not describe the cellulitis nor any other skin integrity issue including the multiple open areas that progressed during the hospital stay.

Review on 09/30/2020 of physician (#K)'s discharge summary dated 07/24/2020 read "Discharge date 07/07/2020, Hospital course: PT STABLE." The patient was discharged on 07/24//2020. Also "FEVER RT FOOT CELLULITIS, ARTERIAL DOPPLERS/ SEVERE PVD/ LIKELY TO TREAT WITH CONCERVATIVE TREAT FOR NOW. WILL REQUEST DR. DAVIS CONSULT, PODIATRY PLAN NOTED. WILL REPEAT CXR/CLINICAL IMPROVEMENT" which is word for word from the 07/07/2020 through 07/23/2020 daily progress notes.

Interview:

During an interview 09/30/2020 at 11:00 AM, Staff P, Chief Medical Officer stated it was the responsibility of the attending physician to address and document patient conditions, treatments and progress in the medical record and discharge summary. Staff P, Chief Medical Officer confirmed, after review of patient (#2)'s medical record that physician (#K) had not documented the patient conditions, treatments and progress in the medical record and discharge summary as required.

During an interview 09/30/2020 at 1:00 PM, Staff A, Director of Quality stated after review of patient (#2)'s medical record confirmed that no documentation was found from attending physician (#K) that identified the decubiti, treatments or progress in the medical record and discharge summary as required. She further stated, "We dropped the ball on this one."

Interview on 9/30/2020 at 1:00 pm. with the Director of 5 North Medical Surgical Unit Employee ID #F confirmed the Photographic Wound Documents dated 7/08/2020 and 07/23/2020 had no physician signature, date or time and the physician should have signed and acknowledged the assessment.

Based on interview and record review the facility Governing Body failed to enforce and ensure it's own Policy and Procedures were followed in that nursing staff caring for wound care patients did not follow the wound and skin care guidelines and protocols in 1 of 10 records reviewed (Patient ID #2).

Findings:

Registered Nurse failed to:

Failed to reposition patient every 2 hours
Failed to complete skin assessments/alterations every shift
Failed to notify physician of skin injury
Failed to consult Wound Care RN,
Failed to take required photographs for staging of wound
Failure to document wound measurements including length width & depth
Failed to use proper pressure support surfaces (mattresses) as indicated

Policy Reviewed:

Review on 9/29/2020 at 11:00 a.m. of the facility's current policy titled "Wound and Skin Care Guidelines, Policy Stat ID: 5773802 Last Revised 12/2018 reads in part:

Purpose: 1. To identify patients who have wounds or at high risk of skin breakdowns and to describe the process and documentation format of wound and skin assessment. 2. To provide guidelines for proper management and care of skin breakdown. 3. To provide guidelines for proper wound irrigation and application of appropriate dressing material. 4. To ensure continuity of applied dressing(s) and initiation of wound care protocols as ordered by the physician. 5. To provide intervention for prevention of skin breakdown.

Policy: 1. Responsible personnel: a. Licensed nursing personnel, i. Primary RN - assessment each shift and on admission, ii. Charge RN - assist in identification of wounds and staging of ulcers as appropriate, iii Wound Care RN - assist in identification of wounds, staging of ulcers and treatments recommendations.

Assessment: 1. Patients will be assessed upon admission to the nursing unit and within 24 hours of admission into the hospital. Skin will continue to be assessed every 12 hours for breakdown or signs of being at risk for breakdown. 2. Pressure Injury risk is completed upon admission and every 12 hours ....4. c. i. For Stage 3 Stage 4 and Unstageable pressure injury another licensed professional should be consulted prior to documentation of the wound in the medical record to verify proper wound stage and Wound Care Nurse Should be consulted ....5. Pictures of the wounds are taken at admission, upon development of a new pressure injury, and weekly on Wednesdays to document the wound status, a photo is attached to the NE1 Photographic Wound Documentation sheet and placed in the patient's chart.
Reassessment: 1. All patients should be reassessed at least every 12 hours. 2. If wounds are present during any of the assessment findings, notify the MD and begin to activate the Pressure Injury Treatment Algorithm or Non-Pressure Treatment Algorithm.

Treatment: 1. Treatment and prevention is based on skin assessment and/or wound assessment findings c. For Dressing and treatment of existing wounds, i. Follow the physicians order for the type and frequency of treatment and consult Wound Care Nurse if appropriate, ii. For Pressure injury, if no prior treatment orders are written, refer to the Pressure Injury Treatment Algorithm (Appendix4) ... ...Utilize the appropriate treatment based on wound assessment, iii. Removal of necrosis is necessary for proper wound management. 1. Contact MD and consult Wound Care Nurse if necrotic tissue (tissue that is yellow, white, grey, green, tan, brown or black) is present in any wound.

Prevention: Patient at risk of developing Pressure Injuries or those who have been admitted to the hospital with existing wounds, the following interventions should be put into place. A. Minimize or eliminate friction and sheer, vi. Use pressure support surfaces (mattresses or overlays) as indicated, a. Appendix 2 describes the appropriate mattress selection for patients with respect to mobility, moisture and risk assessment, b. Utilize the algorithm to select the appropriate surface for patient. C. Patients in bed iii. At a minimum the patient should be turned at least every 2 hours.

Record Review:

Record Review on the morning of September 30, 2020

Routine Daily Care Form along with Vice President of Quality, Employee ID # A confirmed patient admission date of June 29, 2020 to discharge date July 24, 2020 documented the patient was turned 21 times with either a 1 or 2 person assist during her 26-day admission.

Records Reviewed of Daily Skin Alteration Assessments:
Patient Veronica Simons was hospitalized 06/29/2020 through 07/24/2020 for a total of 26 days. Record reviewed documented that patient ID # 2 did not receive every 12-hour shift skin assessments on 12 of those days and 1 day with no assessments.


Date AM Shift PM Shift

06/28/2020 n/a admit initial
06/29/2020 No Yes
06/30/2020 No Yes
07/02/2020 No Yes
07/03/2020 Yes No
07/07/2020` No Yes
07/11/2020 No Yes
07/12/2020 No No
07/16/2020 Yes No
07/17/2020 Yes No
07/18/2020 Yes No
07/19/2020 Yes No
07/21/2020 Yes No
07/22/2020 Yes No

Review of nursing notes and daily assessments for the hospitalization period along with the Vice President of Quality, Employee ID #A did not find any documentation of notification of the primary attending physician of the skin injury related to patient ID #2's sacrum decubitus.

Review of Physician Orders along with the Vice President of Quality failed to document a consult for the wound care nurse and no order was documented for an air mattress to reduce pressure point for patient ID #2

Review of NE1 Photographic Wound Documentation forms along with Director of 5th floor medical Surgical Floor, Employee ID #F identified 2 forms. Sacral wound was first identified on 7/08/2020 and was identified as pressure injury immobility related sacrum. Not present on admission, related factors: incontinent - bowel/bladder

7/8/2020 - NE1 Photographic Wound Document was labeled with Patient ID #2 information, location - Sacrum, Stage 3, Non-intact Skin, Exudate - serous, amount - moderate. No Nurse signature, date or time. No physician signature, date, time or agreement of pressure ulcer finding was documented. No identification of whether ulcer present on admission. Picture was attached.

7/23/2020 - NE1 Photographic Wound Document labeled with Patient ID #2 information, location - Sacrum, Stage 3, Non-intact Skin, Exudate - serous, amount - moderate. No physician signature, date, time or agreement of pressure ulcer finding. No identification of whether ulcer present on admission. Picture attached.

Interviews:

Interview with Employee ID #A confirmed patient was identified at risk of skin injury on admission and there was no additional documentation in the patient's records of turning or repositioning of the patient every 2 hours. Employee ID #A stated the nursing electronic records are charted by exception and routine expected care is not charted. No additional documentation was received prior to exit of the survey. Employee ID #A confirmed nursing shift daily skin alteration assessments were not completed as required and should have been completed by the registered nurse every shift.

Employee ID #A stated that the nursing staff when they identified patient with high risk for skin breakdown or patients with skin injuries they are to follow the facility's Wound and Skin Care Guidelines and the Pressure Injury Treatment Algorithm. Employee ID #A stated the nurse does not need to have a physician's order to activate the skin care protocol. Employee ID#A stated that the wound nurse is not always involved unless there is a consult that is needed. The nursing staff are trained to care for wounds, staging, dressing, packing and identifying.

Employee ID #A stated the nurse should communicate with the physician about skin breakdown and let the physician know about wounds. If the nurse or physician needs the wound care nurse to evaluate or treat the wound the nurse can consult her or the physical may place and order to consult the wound care nurse.
Employee ID #A confirmed that at a Stage III wound the patient's doctor should have been notified, patient should have been on an air mattress bed and confirmed the patient was on a basic air mattress which is rated for up to a Stage II decubitus.

Interview on 9/30/2020 at 1:00 pm. with the Director of 5 North Medical Surgical Unit Employee ID #F confirmed every 2-hour position changes were not documented, no order was entered for wound care nurse, no documentation that the attending physician was notified of sacral wound injury, no higher-level air mattress was ordered when Stage III sacral wound was identified. Employee ID #F also confirmed the wound pictures were not taken per the wound care protocol and the documentation of the wound assessment was not completed with all elements necessary including the length, width depth, tissue type, nor was there a signature by the physician , a date and time documented where he reviewed the findings and agreed with the wound assessment. Employee ID #F confirmed there were only two NE 1 Photographic Wound Documents one dated 7/08/2020 and 07/23//2020 that had no Nurse signature or date or time of assessment and no physician signature, date or time and the physician should have signed and acknowledged the assessment. Employee ID # confirmed the pictures should be done on the date the injury was identified and then every Wednesday which is "wound Wednesday".