HospitalInspections.org

Based on document review and interview, the facility failed to ensure a registered nurse evaluated the care that was being provided to 2 of 10 patients (see tag 395) and failed to ensure that a nursing care plan was initiated for 1 out of 10 patients that reflected the nursing care to be provided to meet the patient's needs (see tag 396).
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The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that Nursing Services provided health care in a safe environment.

Based on document review and interview, the facility failed to ensure a registered nurse evaluated the care that was being provided to 2 of 10 patients.

Findings include:
1. Review of Policies and Procedures revealed the following:
Policy titled "Adult Skin and Wound Care Protocol", PolicyStat ID: 8300864, effective date 07/15/2021 indicated when a pressure injury is present on admission, or if the patient is at risk for skin injury (Braden Score less than or equal to 18), initiate the Skin/Wound Care Protocol/Power Plan/order set. When indicated in the protocol, notify the Skin Care Champion or WOC (Wound Ostomy Care) nurse. The policy also indicates that a complete skin assessment is performed at least daily, or according to unit standards (every 12 hours or per shift), and upon change in patient condition and documented in the electronic medical record.

2. Review of patient #4 medical record revealed the following:
(A.) The patient was admitted to acute care hospital on 01/15/2023.
(B.) Upon initial nursing assessment, the patient had an area of concern on the sacrum described as an area with erythema, blanching and severe tenderness; a Braden score of 14; a mepilex dressing was applied and documented.
(C.) No further documentation of assessment, wound consult order placecd or dressing change of area was found in patient medical record.
(D.) An unstageable pressure injury and infection to the drainage placement site was discovered by nurse on duty prior to discharge on 01/21/2023. Patient discharge date changed by provider on 01/21/2023

3. Review of patient #6 medical record revealed the following:
(A.) Patient was admitted to acute care hospital on 01/18/2023 with diagnosis of Left pneumothorax status post chest tube placed by Interventional Radiology.
(B.) Daily dressing change order was placed by Medical Doctor on 01/18/2023.
(C.) Medical record lacked change of dressing from 01/18/2023 until subsequent removal of chest tube on 01/20/2023.

4. Facility Documents review revealed the following:
An incident report was filed on 01/21/2023 at approximately 1756 by charge nurse on duty regarding patient #4, reporting new unstageable pressure injury to the sacrum area.

5. In interview on 02/20/2023 at approximately 1300 hours with A1 (Registered Nurse Quality Coordinator), it was confirmed that no further documentation was found in Patient #4 medical record after initial nursing assessment on 01/15/2023 and when unstageable pressure injury to sacrum area was discovered on 01/21/2023.

6. In interview with A1 on 02/20/2023 at approximately 1330 hours, it was confirmed that medical record for patient #6 lacked dressing change documentation from 01/18/2023 to 01/20/2023.

Based on document review and interview, the facility failed to ensure that a nursing care plan was initiated for 1 out of 10 patients that reflected the nursing care to be provided to meet the patient's needs.

Findings include:
1. Review of policies and procedure revealed the following:
A. Policy titled "Assessment and Reassessment of Adult Inpatients", PolicyStat ID: 7551065, effective date 02/20/2020 indicates nursing personnel are to initiate any plan not auto-generated appropriate for the patient based on nursing assessment of primary problems.
B. Policy titled "Adult Skin and Wound Care Protocol", PolicyStatID: 8300864, effective date 07/15/2021 indicates when a pressure injury or other skin injury is present on admission, or if the patient is at risk for skin injury (Braden score less than or equal to 18), initiate the Skin and Wound Protocol/Power plan/order set. When indicated in the protocol, notify the Skin Care Champion or WOC (wound ostomy care) nurse.

2. Review of patient #4 Medical record revealed the following:
Initial nursing skin assessment on 01/15/2023 indicated that patient # 4 presented to acute care hospital with a pressure injury on admission, a care plan was not initiated and/or a wound care nurse consultation was not ordered. No further documentation of pressure injury area was noted prior to discovery of unstageable pressure ulcer on 01/21/2023.

3. During an interview with A1 (Registered Nurse Quality Coordinator) on 02/20/2023 at approximately 1300 hours, he/ she confirmed patient #4 medical record on 01/15/2023 indicated a pressure injury area on sacrum of Patient #4 without care plan or placement of wound care nurse consult.