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Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:

1) failure of the RN to ensure a nurse consult for a wound evaluation was conducted by the wound care team for 1(#4) out of 4 (#1, #3, #4, #5) patients reviewed for wound care; and

2) failure of the RN to ensure patients' wounds were assessed and/or measured every 12 hours per hospital policy for 3 (#1, #3, #4) out of 4 (#1, #3, #4, #5) patients reviewed for wound assessments out of a total patient sample of 5; and

3) failure of the RN to ensure vital signs were obtained and documented every 4 hours according to hospital policy for 4 out of 4 (#2, #3, #4, #5) patients' records reviewed for vital signs out of a total patient sample of 5.

Findings:

1) failure of the RN to ensure a nurse consult for a wound evaluation was conducted by the wound care team

Review of the Telemetry Standards of Care revealed in part, Wound, Ostomy, continence nurse will be notified for any new or present on admission pressure ulcers or other types of open wounds. WOC (Wound Care) Photo Triage will be utilized for all new, worsening or present on admission/transfer skin integrity abnormalities.

Review of Patient #4 EMR (navigated by S6Acute Care) revealed the patient was admitted on 10/02/2020. Further review of the EMR revealed a nurse referral for a wound care consult, dated 10/02/2020, and a photo of a wound dated 10/02/2020 and labeled pressure injury leg left; posterior; proximal; upper. With continued review of the EMR revealed no wound measurements were documented during the patient's hospital stay from 10/02/2020 until discharge on 10/12/2020 and the patient's wound was not assessed by the wound care team.

An interview was conducted with S2Unit Director on 10/13/2020 at 1:41 p.m. She reported when a nurse submits a nursing wound care nurse referral, the nurse wants a second set of eyes to look at the wound. S2Unit Director stated the Nursing Wound Care nurse referrals are placed at the bottom of the daily list for the Wound Care Team to conduct the assessment, the physician wound care referrals are the first wounds assessed prior to the wound care nurse referrals. The wounds are triaged for the day by a photo triage if a photo was provided for the wound care nurses. This patient's wound was only a nursing wound care referral and a photo was not included in the referral/consult. S2Unit Director confirmed the patient's wound was not documented as measured by the nurses during the patient's hospitalization.

An interview was conducted with S8RN Wound Care on 10/13/2020 at 1:15 p.m. She reported the physician wound care consults are the first consults completed by the wound care nurses daily and if there is time the nurse wound care referrals are conducted. S8RN Wound Care went on to report that the wound care nurses do not always get to complete the nurse wound care referrals on a daily basis.

An interview was conducted with S1CNO on 10/14/2020 at 1:15 p.m. She reported the patients' nurses should be doing wound assessments every 12 hours (once a shift) and this includes measurements to ensure the wound is improving. S1CNO also stated the expectation is for the nurse to communicate to the nurse taking over the care of the patient to follow up with the wound care team for a wound evaluation.

2) failure of the RN to ensure patients' wounds were assessed and/or measured every 12 hours per hospital policy

Review of the hospital policy titled, Skin Assessment and Wound Management, revealed in part, those patients suffering from the results of pressure sores shall have their treatment options directed by the... Braden Protocol and their nursing care documented on the Skin Assessment and Wound Management Flowsheet each shift.

Review of the hospital policy titled, Treatment of Skin Tears, revealed in part, the nurse is responsible for documenting skin tears upon occurrence, every shift and following change in caregiver until skin tear is scabbed or healed. Document on the Skin Assessment/Care flow sheet: length, width, and depth-description of wound, assessment of peri-wound skin-wound drainage (bleeding, exudate), whether skin tear has an intact or absent skin flap, dressing if clean, dry, intact.

Review of the hospital policy titled, Nursing 24 hour assessment, revealed in part, instructions for completion of assessment flowsheet in the EMR...3. Reassessment shall occur: a. At a frequency not less than that specified in ....Use of Nursing Process at least every 12 hours. b. To determine the patient's response to treatment and/or discontinuation of treatment.

Review of the hospital's policy for Discharge Navigator revealed in part, Patients discharged to another facility must have their discharge assessment summary completed. Patient discharged to the nursing home after admission in the hospital will be accompanied with appropriate paperwork. These patients will also have a skin assessment documented at the time of discharge. Skin must be assessed at time of discharge and abnormalities documented.

Patient #1
Patient #1 was admitted to the hospital on 6/27/2020 and discharged 7/13/2020. With review of his EMR (navigated by S6Acute Care) revealed the patient had eight skin abnormalities documented during the course of his admission. Some of the skin abnormalities were blisters and/or abrasions.

With further review of the EMR revealed Wound #1 was documented being located on buttock right blister Stage II. The wound was first assessed on 07/06/2020 and the measurements were documented on 07/07/2020 at 12:15 p.m. The measurements were listed as 2 cm x 2.5 cm. The wound was not documented as being assessed on 07/08/2020, 7/11/2020, and 7/12/2020. There is no documentation the wound was assessed on the day of the patient's discharge on 07/13/2020.

With review of the EMR revealed Wound #4 was a pressure injury right heel with lateral deep tissue injury and was first assessed on 07/07/2020. The measurements were listed as 1 cm x 1 cm on 07/07/2020. There is no documentation the wound was measured again during this hospitalization. The wound was not documented as being assessed on 07/08/2020 and on 07/13/2020 (day of discharge). The wound was assessed once on 07/12/2020 at 3:43 pm.

With review of the EMR revealed Wound #5 was a pressure injury right; Lateral DTI (deep tissue injury) and was first assessed on 07/07/2020 with measurements of 2 cm x 5.5 cm. There is no documentation the wound was measured again during this hospitalization. The wound is not documented as being assessed on 07/08/2020 and on 07/13/2020 (the day of discharge). The wound was assessed once on 07/12/2020 at 3:43 p.m.

With review of the EMR revealed Wound #6 was a Pressure injury toe -right 4th toe first assessed on 07/07/2020 with measurement of 1.5cm x 1 cm. There is no documentation the wound was measured again during this hospitalization. The wound was not documented as being assessed on 7/08/2020 and on 07/13/2020 (the day of discharge). The wound was assessed once on 07/11/2020 at 7:10 a.m. and 7/12/2020 at 3:43 p.m.

With review of the EMR revealed Wound #7 was a Pressure injury right foot, 1st metatarsal head, DTI vs bulla, first assessed on 07/07/2020 with measurements of 2.6 cm x 2 cm. There is no documentation the wound was measured again during this hospitalization. The wound was not documented as being assessed on 07/08/2020 and on 7/13/2020 (day of discharge). The wound was assessed once on 7/11/2020 at 7:10 a.m. and 7/12/2020 at 3:43 p.m.

With review of the EMR revealed Wound #8 was on the patient's left shoulder and was first assessed on 07/11/2020 with measurement of 4.7 cm x 6.5 cm. A foam dressing was placed on the wound. There was no documentation the wound was measured again during this hospitalization. The patient was discharged on 07/13/2020.

On 10/13/2020 at 10:15 a.m. an interview was conducted with S2Unit Director. She reported she would expect wound measurements and site assessment every 24 hours and if the wound had drainage she would expect the nurse to chart by exception. She reported there was not a protocol for either the day nurse or the night nurse to do the wound measurements. She would expect the nurse that doesn't do the measurements to check the measurements of the previous nurse to see if there were any changes. S2Unit Director was navigating the patient's record on a separate computer in the room while S6Acute Care was navigating the EMR for the surveyor.

Patient #3

Patient #3 was admitted to the hospital on 10/03/2020 and discharged on 10/12/2020. With review of Patient #3's EMR (navigated by S6Acute Care) revealed the patient had fallen at home prior to his hospital admission and had wounds from his fall at home.

Wound #1
With review of the EMR revealed Patient #3 had a pressure injury to left anterior knee, which was present on the hospital admission. The wound measurements were documented on 10/03/2020 at 7:42 p.m. as 3 cm x 2 cm and the wound measurements on 10/05/2020 at 10:20 a.m. were documented as 3 cm x 2.2 cm. These were the only measurements documented during the patient's hospitalization. The patient was discharged on 10/12/2020.

Wound #2
With review of EMR revealed Patient #3 had a pressure injury to his face present on his hospital admission. The wound measurements were document as 1.5 cm x 1.5 cm on 10/03/2020 at 7:42 p.m. and 2 cm x 2 cm on 10/05/2020 at 10:20 a.m. These were the only measurements of the wound during the patient's hospitalization. The patient was discharged on 10/12/2020.

Wound #3
With review of EMR revealed Patient #3 had a pressure injury elbow posterior that was present on hospitalization. The wound measurements were .5 cm x .5 cm on 10/03/2020 at 7:42 p.m. and .5 cm x .7 cm. on 10/05/2020 at 10:20 a.m. These were the only documented measurements during the patient's hospitalization. The patient was discharged on 10/12/2020.

An interview was conducted with S2Unit Director on 10/13/2020 at 1 p.m. She reported she would expect to see measurements once a shift (every 12 hours) on Patient #3's wounds.

Patient #4

Review of Patient #4 EMR(navigated by S6Acute Care) revealed the patient was admitted on 10/02/2020 and discharged on 10/12/2020.

Further review of the EMR revealed a nurse's referral for wound care consult dated 10/02/2020 and a photo of a wound dated 10/02/2020 and labeled Pressure injury leg Left; Posterior; Proximal; Upper. With continued review of the EMR revealed no wound measurements were obtained during the patient's hospital stay from 10/02/2020 until discharge on 10/12/2020.


3) failure of the RN to ensure vital signs were obtained and documented every 4 hours according to hospital policy

Review of the hospital's policy, titled Vital Sign Assessment, revealed in part, Vital signs measurement (temperature, pulse, respirations and blood pressure) may be delegated to a qualified nursing assistant/patient care tech. It is the nurse's responsibility to assess vital signs as ordered and as relative to the patient's current state of well-being. The nurse will report significant changes to the patient care provider. Vital signs are assessed and documented in the patient's electronic medical record as ordered by the care provider, per approved protocols and whenever a change in patient's condition occurs...Every 4 hours vital signs will be taken as the clock dictates, routinely at 4:00 a.m., 8:00 a.m., 12:00 a.m. unless otherwise ordered. Refer to unit specific policy for vital sign documentation and protocols.

Review of the hospital's Telemetry policy for Standards of Care revealed in part, assessment of vital signs (to include blood pressure, temperature, pulse and respirations) will be done at least every 4 hours or as ordered by the physician.

Patients #2, #3, #4, and #5 were all patients on the telemetry unit of the hospital

Patient #2
Patient #2 was admitted to the hospital on 10/08/2020 to telemetry unit. Review of his EMR (navigated by S6Acute Care) revealed the patient's blood pressure was not documented on 10/10/2020 from 9:29 a.m. until 8:32 p.m.

Patient #3
Patient #3 was admitted to the hospital on 10/03/2020 to telemetry unit. Review of the patient's EMR (navigated by S6Acute Care) revealed on 10/04/2020 the patient's blood pressure was not documented from 8:00 a.m. and 1:56 p.m.

Patient #4
Patient #4 was admitted to the hospital on 10/02/2020 to the telemetry unit. Review of the patient's EMR (navigated by S6Acute Care) revealed on 10/04/2020 the patient's blood pressure was not documented from 8:00 a.m. until 5 p.m.; on 10/05/2020 the patient's blood pressure was not documented from 8:04 a.m. until 10 p.m.; on 10/06/2020 the patient's blood pressure was not documented from 11:35 a.m. until 7:00 p.m.


Patient #5
Patient #5 was admitted to the hospital 10/05/2020 to the telemetry unit. Review of the patient's EMR (navigated by S6Acute Care) revealed on 10/05/2020 the patient's blood pressure was not documented from 8:30 a.m. until 3:00 p.m.

An interview was conducted with S2UnitDirector on 10/12/2020 at 2:00 p.m. She reported the unit switched to doing vital signs from every 8 hours to every 4 hours in November 2019. She further reported at the beginning of the shift the charge nurse is responsible for determining which CNAs and nurses are responsible for the patients' vital signs and it is documented on the white board during report.

An interview was conducted with S1CNO on 10/14/2020 at 1:15 p.m. She reported that each unit follows the protocol for that specific unit. She further reported the last CNO had changed the protocol from vital signs every 8 hours to vital signs every 4 hours on the telemetry unit. She wasn't sure when the vital signs frequency changed. She added that the protocol needed to be shored up since there is some confusion on the timing of the vital signs on the telemetry unit.