HospitalInspections.org

Based on interview, record review, and policy review, the facility failed to ensure a registered nurse evaluated the nursing care for each patient (A395).

Based on interview, record review, and policy review, the facility failed to ensure a registered nurse evaluated the nursing care for one of 10 patients reviewed (Patient #1). The census was 44.

Findings include:

Review of the medical record for Patient #1 revealed an admission date of 11/17/23 and a discharge date of 11/29/23. He was arrived to the emergency department on 11/17/23 with a chief complaint of possible stroke per his family. Patient #1 had a past medical history of a recent hip fracture with open repair, hypertension, and atrial fibrillation. Patient #1 was diagnosed with a transient ischemic attack and the results of his MRI were pending. He was sent to the hospital floor on 11/18/23.

Review of pressure ulcer risk assessment dated 11/19/23 at 8:00 P.M. revealed Patient #1 scored a 19 which meant he was not at risk for developing pressure ulcers. Review of further documentation on 11/19/23 at 10:00 P.M., and 11/20/23, 11/21/23, 11/22/23, 11/23/23, 11/24/23, and 11/25/23 at 8:00 A.M. and 8:00 P.M. revealed he scored a 16 which put Patient #1 at risk for developing pressure ulcers.

Review of a wound care nurse assessment dated 11/20/23 revealed skin interventions included offloading pillows or devices to heels. It also listed to elevate the heels while in bed.

Review of the compression stocking application and removal documentation revealed they were applied on 11/18/23 and removed at 10:00 P.M. on 11/18/23. Circulation checks were completed with each application and removal. Patient #1 also had documentation reflecting this daily during his stay on 11/19/23, 11/20/23, 11/21/23, 11/22/23, 11/24/23, 11/25/23, 11/26/23, 11/27/23, 11/28/23, and 11/29/23.

Review of the turn and reposition documentation for Patient #1 revealed he was turned a repositioned on 11/18/23 at 2:00 P.M. 4:00 P.M., 6:00 P.M., 8:00 P.M., and 10:00 P.M. He was documented as turned and repositioned on 11/19/23, 11/20/23, 11/21/23, 11/22/23, 11/24/23, 11/25/23, 11/26/23, 11/27/23, and 11/28/23 at Midnight, 2:00 A.M., 4:00 A.M., 6:00 A.M., 8:00 A.M., 10:00 A.M., 12:00 P.M., 2:00 P.M., 4:00 P.M., 6:00 P.M., 8:00 P.M., and 10:00 P.M. He was finally documented as turned and repositioned on 11/29/23 at Midnight, 2:00 A.M., 4:00 A.M., 6:00 A.M., 8:00 A.M., 10:00 A.M., 12:00 P.M., 2:00 P.M., and 4:00 P.M.

Review of heel protector application and removal documentation for Patient #1 revealed no documentation until 11/26/23 at 2:22 P.M. They were subsequently documented as applied and removed on 11/27/23, 11/28/23, and 11/29/23.

Review of wound documentation for Patient #1 revealed the only wound listed for him from 11/18/23 until 11/25/23 was a right hip incision times two places. Review of wound documentation for Patient #1 dated 11/26/23 revealed he had developed a skin tear on his left shoulder and right wrist after a fall. Review of wound documentation on 11/27/23 at 10:00 A.M. for Patient #1 revealed a black unstageable pressure ulcer to his left heel that was not present on admission. The measurements for his left heel were 2.6 centimeters (cm) long by 2.1 cm wide by 0.1 cm deep.

Interview on 01/09/24 at 12:46 P.M. with Staff A confirmed Patient #1 did score at risk on the pressure ulcer risk assessment and staff documented no interventions were put into place. Staff A stated that based on his risk assessment score of being at risk one of the interventions would have been to elevate his heels while in bed.

Interview on 01/10/24 at 9:00 A.M. with Staff H revealed when she went to work on 11/26/23 for the night shift Staff I informed her Patient #1 had developed a pressure ulcer on his left heel. She reported she was not sure what interventions were in place before then because that was the first time she had cared for him.

Interview on 01/10/24 at 9:07 A.M. with Staff I revealed on 11/26/23 around 2:00 P.M. she entered Patient #1's room and found his daughter bathing him. She stated Patient #1's daughter reported to her that she bathed Patient #1 daily. Staff I informed her that Patient #1 had already had a bath that morning, but she would assist her to bathe Patient #1. Staff I reported she helped his daughter remove his socks when she was called out of the room. She exited the room and was gone for approximately less than ten minutes and when she returned Patient #1's daughter informed her that a wound was found on his left heel. Staff I then assessed the wound and notified the physician and the wound nurse. She then reported she applied heel protectors to Patient #1's heel. She confirmed that heel protectors had not been in his room prior to her applying them and there were no extra pillows to float his heels while in bed. Staff I confirmed Patient #1's left heel had an area of an unstageable pressure injury that was completely black from eschar with no drainage or odor.

Interview on 01/10/24 at 10:00 A.M. with Staff C revealed that she was notified of Patient #1's wound on his left heel after the staff had completed an incident report. She reported she assessed him on 11/27/23 and found it to be an unstageable pressure injury. She reported she also had the wound nurse practitioner assess the wound and he ordered heel protectors and a seat cushion from that time one.

Review of the facility policy titled, Skin Integrity-Patient & Mucosal Injury, reviewed April 2023, revealed if a patient scores between a 15 and 18 on the pressure ulcer risk assessment they were considered at mild risk. Interventions for patients at mild risk included: Turning and/or repositioning every one-two hours; Protect/float heels; Maximize remobilization; Manage moisture, friction, and shear; Head of bed 30 degrees, as tolerated; Inspect under and around medical devices.

This deficiency represents non-compliance investigated under Substantial Allegation OH00148757.