HospitalInspections.org

Based on interview and record review the facility failed to ensure a Registered Nurse (RN) performs skin/wound assessments and interventions to prevent skin irritation and pressure injuries in 2 of 10 patient records reviewed (Patient (Pt) #1 and Pt #2) in a total sample of 5 Intensive Care Unit (ICU) and 5 Neonatal Intensive Care Unit (NICU) medical records reviewed; and failed to ensure proper placement and patency of gastric tubes used for tube feeding in 1 of 5 ICU medical records reviewed (Pt #1) in a total sample of 10 medical records reviewed.

Findings Include:

Review of policy and procedure titled, "Intensive Care Unit (ICU) Standard of Care" last reviewed 08/2021 revealed the following:
1. Perform and document head to toe assessment every 4 hours.
2. Repositioning every 2 hours
3. Bath every night

Review of policy and procedure titled, "Maintenance of Skin Integrity: Adult" last revised 03/2019 revealed the following:
1. Perform skin inspection/assessment on admission, daily, and prn (as needed).
a. Inspect the skin for the presence of wounds and pressure ulcers/injury
2. Consult wound nurse for the occurrence of any hospital acquired pressure/ulcers/injuries.
3. Report and obtain treatment order from Provider for skin breakdown.
4. Initiate appropriate individualized interventions which address and minimize the effects of risk factors.
5. Silicone bordered foam dressings (Mepilex border) may be used to intact skin for prevention. Skin may be inspected under the dressings as needed. Change the dressings every 3 days and prn if soiled.
6. Document the patient's skin assessment, plan to protect the skin, and measures implemented.

Review of "Pressure Injury Prevention Tips for Prone Positioning" from the National Pressure Injury Advisory Panel (NPIAP) dated 2020 (provided by hospital when asked for their policy on proning) revealed that "Prone positioning (laying face down) in ARDS (Acute Respiratory Distress Syndrome) enhances oxygenation by improving alveolar recruitment and ventilation-perfusion ratios while decreasing the strain on lung tissue and the risk of ventilator injury."
Per the NPIAP when manually proning patients staff should:
1. Assess all pressure points prior to proning (anterior surfaces) and prior to returning to supine position (posterior surfaces); when alternating arm position in "swimming arm position" assess integrity of skin of arm/head/face.
2. Shift patient's head every 2 hours, reposition head every 4 hours.
3. Microshifts and small position changes should be performed while proned.
4. Reposition into swimmer position (Alternating the position of the arms and direction of the head, in a manner that is similar to a freestyle swimmer).
5. Pillows are needed to offload pressure points.
6. Endotracheal tubes securement devices may contribute to increased skin breakdown in proned patients (Pts). Assess skin carefully.
7. Assess the skin under and around medical devices.
8. Document all skin assessments and preventative measures.


Intensive Care Unit (ICU):

Skin/wound assessments and interventions:

Review of Pt #1's medical record revealed Pt #1 was admitted to the hospital on 12/14/2021 at 8:03 pm with a diagnosis of COVID-19 Pneumonia and Acute Hypoxic Respiratory Failure. Per Pt #1's medical records, Pt #1 was transferred to the ICU on 12/20/2021 at 1:50 am; and on 12/23/2021 at 5:42 pm, Pt #1 was intubated (tube inserted into the trachea for ventilation) and placed on a ventilator (a machine used for artificial respiration). Per Pt #1's Admission History and Physical Note dated 12/14/2021 at 8:16 pm, Pt #1 was 5' 9" and weighed 578 pounds.

Review of Pt #1's Pulmonary/Critical Care Provider note dated 12/23/2021 at 8:16 pm, revealed, "...With patient supine, oxygen saturations were 73-76%. They did not improve for more than 1 hours after intubation...Prone position ordered. Patient's oxygen saturations progressively improved in prone positioning..."

Review of Pt #1's physician order dated 12/23/2021 at 6:28 pm revealed to place Pt #1 in the prone position 12-18 hours daily as tolerated.

Skin assessments and interventions:

Review of Registered Nurse (RN) progress note dated 12/25/2021 at 6:35 pm revealed that Pt #1 had "Several blistered areas to chest and abd (abdomen) from prone positioning."

Review of Wound Care RN's progress note dated 12/27/2021 at 2:32 pm revealed that "(Pt #1) developed clear fluid filled blisters in the skin folds under (Pt #1's) bilateral breasts. These are currently unroofed blisters..." Review of Wound Care RN's wound care recommendations revealed to cleanse wound gently with normal saline and gauze and cover area with Mepilex border dressing; change dressing every 3 days and as needed if soiled, saturated, or loose.

Per review of Pt #1's Integumentary (skin) flowsheets on 12/25/2021 at 5:10 pm, the RN shift documentation of Pt #1's "Skin Integrity Observations" revealed Pt #1 had "Blisters" on his/her "Abdomen;Chest".

Review of Pt #1's Integumentary (skin) assessment and Skin Care Interventions flow sheets from 12/25/2021 to 01/03/2022 revealed that there was no documented evidence of an assessment and interventions completed for Pt #1's chest and abdominal blisters on the following RN shift assessments: 12/26/2021 at 8:54 am and 10:41 pm; 12/27/2021 at 8:47 am; 12/28/2021 at 9:01 am and 12:53 pm; 12/29/2021 at 10:25 pm; 12/30/2021 at 10:00 am; 01/01/2022 at 8:37 am; and 01/02/2022 at 6:46 pm.

Per review of Pt #1's RN Integumentary and Skin Care Intervention flowsheets from 12/30/2021 to 01/02/2021 and review of RN progress notes during that time frame, there was no documented evidence of staff performing Mepilex dressing changes and cleansing the site with normal saline every 3 days as per wound care RN orders on 12/27/2021 at 2:32 pm.

Repositioning:

Review of Wound Care RN's progress note dated 12/27/2021 at 2:32 pm revealed that "(Pt #1) developed clear fluid filled blisters in the skin folds under (Pt #1's) bilateral breasts. These are currently unroofed blisters..." Per review of RN wound care recommendations, staff should "Minimize pressure with frequent repositioning and scheduled turning every 2 hours" and "Minimize/eliminate pressure from medical devices..."

Review of Wound Care RN's progress note dated 01/05/2022 at 4:43 pm revealed Pt #1's "Left side of face cheek with medical device related skin injury related to the use of the ET (endotracheal) holder and requiring to be placed in a prone position for extended periods of time...Stage 2...The area was cleansed and a new dressing was applied prior to the new ET tube holder placement." Per Wound Care RN's progress notes, Pt #1's "Right side of face with 2 abrasions noted from the use of the ET tube holder...they were cleansed and covered with a silicone dressing."

Review of Pt #1's Mobility flowsheets revealed the following:
-Pt #1 was in the "Prone-Swimmers Right" position on 12/28/2021 at 3:00 am until 12/29/2021 at 7:36 am (more than 28 hours).
-Pt #1 was in the the "Prone-Swimmers Right" position on 12/29/2021 at 1:30 pm until 12/30/2021 at 2:00 pm (more than 24 hours).
-Pt #1 was in the "Prone-Swimmers Left" position on 1/01/2022 at 2:00 am until 1/01/2022 at 10:00 am (8 hours).

Per review of Pt #1's medical record there was no documented evidence of Pt #1 being repositioned every 2 hours (including Pt #1's head) during the above dates and times.

Per interview with ICU Manager D on 01/28/2022 at 10:45 am, Manager D stated that patients who are intubated on ventilators should be repositioned every 2 to 4 hours depending on the patient's condition. Per Manager D, if a patient is unable to be repositioned, staff should document the reasons why the patient could not be repositioned.

Tube Feeding:

Review of policy and procedure titled, "Enteral (feeding and Decompression) Tube Management (Adult) revealed the following:
1. Measure the external length of the tube between the insertion site (tip of nose and lips) and end of tube.
2. Document "secured at" measurement of the tube.
3. Assess tube during shift assessment and document the following at the start of every feeding or fluid instillation and every 4 hours during continuous feeds/fluids:
a. Tube length measurement every 8 hours and as needed
b. Integrity of securement device
c. Assess for irritation or breakdown due to tube and or securement device; for nasal tubes assess nares and skin around device.
4. Gastric Residuals if ordered are checked every four hours.
5. Verification of tube placement needs to occur prior to administering any fluids, nutrition, or medications.
6. Feeding tubes are flushed with 30-60 milliters of tap water; small bore tubes (nasal gastric) should be flushed every 6 hours during continuous feedings. Large Bore tubes (oral gastric) should be flushed after residuals are refed.
7. If tube position changes more than two centimeters, reconfirm placement of tube.
8. Notify provider if malposition is suspected to determine the need for x-ray.

Review of Pt #1's physician tube feeding orders dated 12/24/2021 at 12:39 pm revealed residuals should be checked every 6 hours (policy states every 4 hours) until specified.

Review of Pt #1's Feeding/Hydration flowsheet documentation revealed Pt #1 had an oral gastric tube (large bore) inserted from 12/23/2021 at 5:30 pm and removed on 12/29/2021 at 4:42 pm. Review of Pt #1's nasal gastric feeding tube flowsheet documentation revealed the following:
-Pt #1's tube feeding residuals were checked and a 60 milliter flush was administered on 12/24/2021 at 9:35 pm; there was no documented evidence that tube feeding residuals were checked and a flush administered again until 12/25/2021 at 11:15 am (more than 13 hours later). (Per physician orders should be every 6 hours).

Review of Pt #1's "GI (gastrointestinal) Tube Oral" RN flowsheet documentation revealed the oral gastric tube length measurement was 61 centimeters (cm) on 12/24/2021 at 9:35 pm, review of the "GI (gastrointestinal) Tube Oral" documentation revealed the following:
-Pt #1's oral gastric tube was measured on 12/24/2021 at 9:35 pm; and then not again until 12/25/2021 at 11:15 am (more than 13 hours later) (should be measured every 8 hours per policy).
-Pt #1's oral gastric tube was measured on 12/25/2021 at 10:51 pm; and then not again until 12/26/2021 at 8:54 am (more than 10 hours later).
-Pt #1's oral gastric tube was measured at 64 cm on 12/27/2021 at 4:51 pm, this measurement was 3 cm more than the measurement of 61 cm taken on 12/24/2021 at 9:35 pm. Per review of Pt #1's RN flowsheets and RN progress notes, there was no documented evidence of the RN reconfirming placement of the oral gastric tube and/or notifying provider to determine the need for an X-ray as per policy.

Review of Pt #1's Feeding/Hydration RN flowsheet documentation revealed Pt #1 had a nasal gastric tube (small bore) inserted on 12/29/2021 at 8:00 am and removed on 01/05/2022 at 5:05 am.

Review of Pt #1's "GI Tube Small bore" (nasal gastric feeding tube) RN flowsheet documentation revealed the following:
-Pt #1 received continuous "Feeding/hydration" through the nasal gastric tube from 12/29/2021 at 5:12 pm until 12/30/2021 at 8:16 pm (15 hours); per review of RN flowsheets, there was no documented evidence of tube feeding residuals being checked for feeding tube placement every 6 hours as per physician orders, and flushes being administered every 6 hours as per policy (nasal gastric small bore tubes).

-RN flowsheet documentation on 12/31/2021 at 4:19 pm revealed Pt #1 was receiving feeding and hydration through Pt #1's nasal gastric tube, per documentation, tube feeding residuals were checked and a flush was given; Pt #1's feeding tube residuals were not documented as being checked again until 01/01/2022 at 8:37 pm (more then 28 hours later).

Review of Pt #1's "GI Tube Small bore" (nasal gastric tube) RN documentation on 12/29/2021 at 2:25 pm revealed the nasal gastric tube length measurement was 10 centimeters (cm). Review of Pt #1's "GI Tube Small bore" (nasal gastric tube) RN documentation revealed the following:
-Pt #1's nasal gastric tube was measured on 12/31/2021 at 4:19 pm; and then not again until 01/01/2022 at 3:47 am (more than 11 hours later) (should be measured every 8 hours per policy).
-Pt #1's nasal gastric tube was measured on 01/02/2022 at 2:00 am; and then not again until 01/02/2022 at 6:46 pm (more than 16 hours later).

Neonatal Intensive Care (NICU):

Review of policy and procedure titled, "Skin Care of the Neonate" last revised 02/2022 revealed the following:
1. Perform a full skin assessment minimally every 8-12 hours or with each new caregiver.
2. Evaluate any breakdown, bruising, lesions, burns, blisters, and/or rashes.
3. Use Citric Acid Paste for erythema
4. Erythema (redness) and mild scaling are some of the first signs of diaper dermatitis. Apply a thick layer of zinc oxide after cleansing if any erythema is present, or for any infant at risk for diaper dermatitis.
5. Risk for diaper dermatitis includes infants, using antibiotics for greater than two days.
6. Diaper Dermatitis is an acute inflammatory reaction of the skin in the perineal area. Prolonged contact of skin with a mixture of urine and feces is a primary risk factor for diaper dermatitis.
7. Diaper Dermatitis can be complicated by Candida albicans. Candida infection in the diaper area is characterized by the presence of red skin with lesions scattered at edges.
8. Change diaper every 2-3 hours or after a stool

Per review of Pt #2's medical record Pt #2 was born on 11/20/2021 at 2:36 pm and discharged home on 11/30/2021 at 4:30 pm. Pt #2 was admitted to the NICU and intravenous (IV) penicillin (antibiotic) was initiated for the treatment of possible congenital syphilis.

Per review of Pt #2's RN progress notes revealed the following:
-11/26/2021 at 4:03 am: "Butt slightly red, Sensicare applied.
-11/27/2021 at 2:43 pm: "Sensicare to buttocks"
-11/27/2021 at 9:57 pm: "Peri area looking raw continue using Sensicare with diaper changes...Continue with antibiotics every 8 hours."
-11/29/2021 at 4:28 pm: "Diaper rash present. Raised bumps in perianal area noted in afternoon. MD at bedside to evaluate. Nystatin ordered."

Review of Pt #2's Discharge Summary physician note dated 11/30/2021 at 9:17 am, revealed Pt #2 had a "Perineal rash with satellite lesions consistent with candidiasis with slight labial edema present".

Per review of Pt #2's RN flowsheets for "Skin", there was no documented evidence of RN assessments of Pt #2's redness/skin irritation to the perineal area for the RN Shift assessments documented on the following days and times: 11/28/2021 at 1:25 am, 11:49 am, 5:48 pm, and 10:22 pm; 11/29/2021 at 1:36 am, 10:09 pm; and 11/30/2021 at 8:45 am.

Per review of Pt #2's RN flowsheet for Skin Care, there was no documented evidence of a protective barrier/skin ointment being applied to Pt #2's skin (as per policy) after the following documented bowel movements: 11/27/2021 at 8:14 am, 9:25 am, 10:23 am, 5:50 pm, and 8:46 pm; 11/28/2021 at 11:50 am and 5:49 pm; and 11/29/2021 at 3:54 pm, 6:21 pm, and 8:57 pm.

Per interview with Clinical Nurse Specialist (CNS) E on 01/31/2022 at 11:30 am, staff should document skin assessments and skin interventions in the daily cares RN flowsheet. Per CNS E staff do not specifically document when a patient's diaper is changed. Per interview with CNS E, documentation of the Urine and Stool assessments are evidence of diaper changes. Per CNS E, Pt #2 was receiving penicillin which can cause baby's to be more susceptible to diaper rash due to potential yeast overgrowth and increased stooling.

Review of RN flowsheets revealed there was no documented evidence that Pt #2's diaper was checked/changed every 2-3 hours (as per policy for dermatitis) including, but not limited to, the following days and times of urine/stool assessments: 11/27/2021 at 10:23 am until 5:50 pm (more than 7 hours between diaper changes); 11/27/2021 from 8:46 pm until 11/28/2021 at 8:33 am (more than 12 hours between diaper changes).