HospitalInspections.org

A. Based on document review and interview, it was determined that for 1 of 1 patient (Pt. #1) reviewed for hospital acquired pressure injury, the Hospital failed to ensure that the registered nurse supervised the care for each patient by ensuring the patient was repositioned every 2 hours to reduce the risk of developing a pressure injury.

1. The Hospital's policy titled, "Skin Integrity: Care and Treatment of the Skin" (effective 7/12/2022), was reviewed on 9/28/2022 and required, "Prevention or management plan will be implemented for patients at risk or with pressure injuries."

2. The Hospital's policy titled, "Nursing Documentation" (effective 10/29/2021), was reviewed on 9/28/2022 and required, "The plan of care is comprised of age and gender/sex-appropriate assessments, screenings, diagnoses/patient problems, goals/outcomes, and patient interventions and is documented in the EHR [electronic health record]... Interventions: Should be documented when the action has been taken, or if change is needed to achieve or improve patient status toward outcomes..."

3. The clinical record of Pt. #1 was reviewed on 9/27/2022 and 9/28/2022. Pt. #1 was admitted to the Hospital's 4 Northwest Telemetry Unit on 7/20/2022 at 10:51 PM, with a diagnosis of large bowel obstruction. Patient had no documented wounds upon admission and was noted to be bedbound with limited mobility. Pt. #1's Braden Score was upon admission was 11 indicating Pt. #1 was at high risk for pressure injury development. Pt. #1's plan of care included reposition every 2 hours as an intervention to prevent risk of pressure injury.

- Nursing flowsheets from 7/21/2022-8/11/2022 were reviewed and lacked documentation that Pt. #1 was repositioned every 2 hours on the following dates/times: 8/1/2022 9:00 PM to 8/2/2022 7:00 PM (22 hours); 8/3/2022 9:00 AM to 8/3/2022 7:00 PM (10 hours); 8/5/2022 4:00 AM to 7:00 PM (15 hours); 8/5/2022 8:00 PM to 8/6/2022 7:00 PM (11 hours); 8/6/2022 8:00 PM to 8/8/2022 7:00 PM (1 day and 23 hours hours); and 8/9/2022 11:00 AM to 8/11/2022 9:00 AM (1 day and 22 hours).

- The nursing skin assessment conducted on 8/9/2022 at 6:00 PM included two new wounds:
- Sacrum Pressure Injury: Length 3.5 cm x Width 4.6 cm x Depth 0.01 cm
- Buttock Left Posterior Excoriation: Length 4.3 cm x Width 4 cm x Depth 0.1 cm

- The Wound Care Consult Note, dated 8/10/2022 at 8:20 AM, included, "Wound Assessment: Patient has mucoid discharge from rectum post stomy placement. Patient has moisture related changes to skin that has now deteriorated to pressure injury. Deep tissue pressure injury noted to bilateral lower buttock and sacrococcygeal location ... ...Length 6 cm; Width 8.4 cm, Depth 0.1 cm ... Q2 [every 2 hour] turns with wedges... Plan: Continue wound care and offloading. Patient has rectal cancer coupled with normal process of the body to produce mucoid discharge after stomy creation. This is causing increase moisture to skin in this region and risk for breakdown. Patient will require diligent offloading to prevent advancement of injury. Due to health, comorbidities, nutritional status, factors for progression of injury and further deterioration is high..."

- Pt. #1 was discharged the following day on 8/11/2022.

4. An interview was conducted with the Wound Care Nurse (E#10) on 9/28/2022, at approximately 10:40 AM. E#10 stated that nurses are expected to do a skin assessment at least every shift (2 times a day for 12 hour shifts). If anything abnormal is assessed, it should be done more often. A physician or a nurse can put in a consult for wound care. E#10 stated that generally I'm consulted for full thickness wounds or if a patient is admitted for a wound. E#10 stated that a Braden Risk Assessment should also be done every shift. If the score is 14 or below, the patient is considered high risk. E#10 stated that Pt. #1 was at high risk due to his immobility, comorbidities, nutritional status, and incontinence. E#10 stated that depending on the person and their condition (i.e. muscle mass, nutrition status, comorbidities, mobility issues, incontinence issues, etc) a pressure injury (like Pt. #1's) can develop in as little as 3-5 days. E#10 stated that skin damage could start in a few hours, starting with redness first, then the skin starts to open up. E#10 stated that Pt. #1's deep tissue injury could not have developed to the extent E#10 assessed on 8/10/2022 in just 24 hours. E#10 stated that at minimum for a deep tissue injury like Pt. #1's, it would have taken at least a few days to develop to that extent and stated, "There should have been some sign of it developing in the few days prior." E#10 stated that interventions to prevent pressure injuries are care plan driven. Immobile patients should be repositioned at least every 2 hours.


B. Based on document review, observation, and interview, it was determined that for 1 of 1 patient (Pt. #1) reviewed for indwelling urinary catheter, the Hospital failed to ensure that the registered nurse supervised the care for each patient by ensuring an order was placed prior to insertion of an indwelling urinary catheter.

Findings include:

1. The Hospital's policy titled, "Urinary Catheter Management and Removal (Adult)" (effective 2/8/2022), was reviewed on 9/28/2022 and required, "Indwelling urinary catheter insertion requires a physician, Advanced Practice Nurse (APN), or Physician Assistant (PA) order."

2. The clinical record of Pt. #1 was reviewed on 9/27/2022 and 9/28/2022. Pt. #1 was admitted to the Hospital's 4 Northwest Telemetry Unit on 7/20/2022 at 10:51 PM, with a diagnosis of large bowel obstruction. Nursing Documentation from 7/20/2022-8/11/2022 was reviewed and indicated that a Foley (indwelling urinary catheter) was inserted by a registered nurse on 7/21/2022 at 1:13 PM. The documentation indicated that the catheter was removed on 8/14/2022. The record lacked an order from a physician, APN, or PA for insertion of the foley.

3. Two Registered Nurses (E#11 and E#12) were interviewed on 9/28/2022, and both stated that a physician's order is needed to insert a foley catheter.