HospitalInspections.org

Based on the review of medical records, facility's policies/procedures, and staff interviews, it was determined that the nursing staff failed to provide quality care/treatment for two patients (P) (P#1 and P#3) of three patients (P#1, P#2, and P#3) reviewed by failing to turn P#1 and P#3 every two hours as per the facility's protocol.


Findings included:


1. A review of P#1's medical record revealed that P#1 was admitted to the facility on 1/25/25 with the diagnosis of Seizures (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain).


A review of the History and Physical (H&P) on 1/26/25 at 4:19 a.m. revealed that P#1 presented to the ED with stroke-like symptoms, severely altered mentation, and left-sided facial droop. Documentation revealed that P#1 had a seizure in the ED, now postictal (recovery period that begins after a seizure ends and lasts until the patient returns to their normal state). Keppra (a medication used to treat certain types of seizures in people with epilepsy) was ordered, and to follow up with Neurology (a medical specialty that studies and treats disorders of the nervous system).


A review of the physician orders revealed an order for a moisture barrier cream on 1/26/25 at 9:46 p.m. for routine, Hydraguard (a water-resistant cream that moisturizes and nourishes the skin), every eight hours scheduled, and with morning care and after each episode of incontinence.
Continued review of the physician orders revealed an order for Skin Integrity Impairment Prevention on 1/26/25 at 9:46 p.m. for routine, as directed, and PRN (as required).


A review of the Wound Care Progress Note on 2/3/25 at 1:48 p.m. revealed that a consultation was placed to evaluate a wound/skin tear on P#1's sacrum. Documentation revealed a defined area of dark discoloration along with some partial-thickness skin loss over the coccyx (bottom) suggestive of DTI (Deep Tissue Injury - a discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) pressure injury. Recommendation revealed offloading the sacral area/buttocks with side-to-side tilts and Venelex (an ointment used in the management of dermal ulcers, including pressure ulcers) with silicone foam dressing to protect the skin from friction injury. P#1's Braden score (a measurement of a patient's risk of developing pressure ulcers) was 15.


During the electronic medical record review, documentation revealed that on admission to the facility's PCU (Progressive Care Unit), P#1's skin assessment was documented as normal, warm, and intact. Documentation failed to reveal that P#1 had any wounds/ulcers present on admission.


A continued review of the electronic medical record review at the facility revealed that P#1 was not turned every two hours as per protocol when she (P#1) was in the PCU unit, and turning was missed on the following days and times:
1/26/25 - At 8:00 p.m. and 10:00 p.m.
From 1/27/25 to 1/29/25 - At 6:00 a.m.
1/30/25 - At 2:00 a.m.
1/31/25 - At 6:00 a.m.
2/2/25 - At 6:00 a.m., 12:00 p.m., and 4:00 p.m.


Documentation revealed that P#1 was transferred to another unit in the same facility (6C - Medical-Surgical Unit) on 2/2/25 at 5:36 p.m.


A Continued review of the electronic medical record revealed that during P#1's skin assessment on admission to the 6C unit, a localized skin abnormality was documented to have been observed on 2/2/25 at 6:16 p.m., a skin tear was documented on 2/2/25 at 6:22 p.m., and a silicone foam border dressing was applied. Documentation also revealed that a wound care consultation was documented on 2/3/25 at 1:48 p.m.


2. P#3 was admitted to the facility via the Emergency Department (ED) on 8/19/24 with a diagnosis of Advance Care Planning (the process of preparing for and discussing future medical care decisions in case someone becomes unable to communicate wishes) and Anemia (a condition in which the blood does not have enough healthy red blood cells and hemoglobin).


Documentation of the physical examination on 8/19/24 at 4:32 a.m. under the Emergency Documentation revealed that P#3's skin examination was normal, warm, dry, and normal in color.


A review of the History and Physical (H&P) on 8/19/24 at 10:03 a.m. revealed that P#3's skin was warm, dry, and intact without rash. Documentation also revealed a left lower extremity skin tear, and wound care was consulted on 8/19/24.


Further review of P#3's electronic medical record revealed documentation on 8/19/24 at 7:08 p.m. that P#3 had a history of stage 4 decubitus (most severe form of skin damage caused by prolonged pressure on the body) from a previous admission and was admitted with a dressing on the left lower leg.


A continued electronic medical record review revealed that a wound consultation was received for a left lower extremity skin tear with a history of stage 4 decubitus on 8/19/24. Documentation also revealed that P#3 was alert, resting in bed with nursing in attendance, and P#3 stated that the wound on her left leg was caused by the immobilizer she had to wear for support for her knee and hip for several years. P#3's Braden score was 14.


Documentation of the wound care notes revealed that P#3 had scarring from a previously healed pressure injury, scantly erythematous (redness of the skin, either in a limited area or all over), and blanches (white or pale). Recommendation revealed turning and repositioning was required, protective silicone foam dressing for protection of shear and moisture; Nursing to continue pressure injury prevention.


The electronic medical record review also revealed that P#3 was not turned and repositioned every two hours as per protocol. Documentation revealed that turning/repositioning were missed at the following dates and times:

8/31/24 - P#3 was last turned at 7:00 a.m., and documentation failed to reveal another repositioning until 3:30 p.m.
9/1/24 - Turning/Repositioning was only documented at 8:32 a.m., 5:11 p.m., and 8:00 p.m.
9/2/24 - turned at midnight, and documentation failed to reveal another turning/repositioning until 4:00 a.m., 8:00 a.m., and then last at 4:59 p.m., and then not until 8:00 p.m.
9/3/24 - turned at midnight, and documentation failed to reveal another turning/repositioning until 7:00 a.m.
9/4/24- Documentation revealed that P#3 was last turned at 4:00 a.m. and not turned again until 3:00 p.m. and not until 7:00 p.m.
9/5/24 - Documentation revealed that P#3 was last turned at midnight and not until 7:33 a.m. and 11:31 a.m.
9/7/24 - last turned at 10:00 a.m. and not until 2:00 p.m.
-9/8/24 - Documentation only revealed a turning/repositioning at 6:00 a.m., and not until 8:00 a.m. the next day (9/9/24).
9/9/24 - turning missed at 6:00 p.m.
9/10/24 - last turned at 5:00 p.m. and not until 9:00 p.m. Documentation also revealed P#3 refused turning/repositioning at 1:00 p.m.


A continued review of P#3's electronic medical record revealed documentation of a skin abnormality type on the Right middle sacrum on 9/5/24 at 4:11 p.m., documented as 'purple.'


A review of the facility's policy titled "Patient Rights and Responsibilities - SYSTEM," Policy #11763, last revised 5/3/2023, revealed that individuals would be afforded impartial access to treatment or accommodations that were available and medically indicated, regardless of race, creed, color, sex, national origin, disability, age or source of payment for care.
Patients had the right to expect reasonable safety as far as the facility's practices and environment were concerned. The facility, to the best of its ability, will strive to protect patients from all forms of abuse or harassment. The facility had a process in place for the investigation of allegations or observations of suspected cases of abuse, neglect, or exploitation.
Patients should be informed of the Hospital rules and regulations applicable to their conduct as patients. Patients are entitled to information about the Hospital's mechanism for the initiation, review, and resolution of patient complaints without being subject to coercion, discrimination, reprisal, or unreasonable interruption of care.


A review of the facility's policy titled "Skin Integrity Protection and Wound Management - SYSTEM" Policy #29228, last revised 6/30/23, revealed that nursing staff to assess all patients on admission for individual risk for skin breakdown using the Braden Scale - Skin Integrity - Braden Scale Risk Assessment- Any patient with a Braden score =/<18 is at risk for skin breakdown Additional risk factors would be considered. For patients at risk, initiate skin integrity interventions.
The Braden Scale Risk Assessment for pressure injuries would be performed on admission, every shift, and whenever a patient's condition or level of care changes.
a. Braden = 16-18: Low Risk. Initiate and implement Skin Integrity Interventions.
b. Braden = 13-15: Moderate Risk. Initiate and implement Skin Integrity Interventions. Order waffle overlay for the mattress (unless using Stryker Isotour mattress, specialty mattress, or critical care mattress) and order waffle cushion for the chair.
c. Braden = 12 or less: High risk. Automatic consult to Wound Care Specialist; nursing to implement Skin Integrity Interventions.
GUIDELINES FOR SKIN BREAKDOWN:
Skin breakdown consists of abrasions, blisters, lacerations, pressure injuries, rashes, redness, skin tears, and ulcers (arterial, diabetic, and venous). two RNs or one RN and one LPN to assess the patient's skin on admission. Remove all dressings, assess wounds, clean wounds with normal saline or wound cleanser, and apply new dressing. Label dressing with date, time, and initials.
RN to begin new wound site in Cerner under "Interactive View and I&O - Wound-Ostomy" on admission and when new wound occurs. Nursing to implement Skin Integrity Interventions for a Braden score of 18 or less. See Skin Integrity Interventions. Consult WOC Nurse (in Cerner - Consult to Wound Care Specialist) for pressure-related injuries and ostomy patients. WOC nursing is automatically consulted for a Braden score of 12 or less.


A telephone interview took place in the facility's office on 3/4/25 at 10:00 a.m. with Assistant Manager, Wound/Ostomy Care/Management (AMWO) CC, who stated that part of her duty was to work with all the wound care nurses to standardize processes for wound care practices. AMWO CC stated that the wound care nurses responded to consultations and assessed, stage, recommended care, and collaborated with other multidisciplinary teams if required to come up with a plan of care for the patient.
AMWO CC stated that the nurses on the unit utilized the Braden score to initiate a set of protocol orders for patients, for example, a patient with a skin tear. AMWO further stated that a skin tear would not require a wound consultation as that can be taken care of at the bedside.


A Zoom-call interview took place in the facility's office on 3/4/25 at 10:30 a.m. with Registered Nurse (RN) DD, who stated she could not recall P#1. However, if a patient was at risk of developing a pressure injury on admission, protective measures such as offloading heels and pressure points would be put in place. RN DD stated that a wound care consultation would be put in if a fresh injury or wound was observed on a patient.


An interview took place in the facility's office on 3/4/35 at 11:00 a.m. with RN EE, who stated that she would put in a wound consultation for a patient if a pressure injury was noted. However, if the patient had a skin tear, a wound consultation may or may not be required depending on the location of the skin tear. RN EE stated that if the skin tear was on a pressure injury location, a wound consultation and an incident report would be done so staff could keep track of the wound to prevent deterioration. RN EE further stated that the facility made use of a "turn team" to ensure patients were turned as per protocol.


An interview took place in the facility's office on 3/4/25 at 11:30 a.m. with RN FF, who stated that if a patient had a possible pressure injury, he would report it to the charge nurse and the provider and also put in a wound consultation. RN FF stated that a turn list is populated based on the patient's Braden score; however, patients were turned every two hours. RN FF stated that he could not recall P#1, however, it seemed P#1 always screamed whenever she was being turned.


An interview took place in the facility's office on 3/4/25 at 12:00 p.m. with Certified Wound Ostomy Nurse (CWON) GG, who stated that lack of turning interventions and reduced perfusion to the skin could cause a DTI (Deep Tissue Injury) on a patient. CWON GG stated that the wound care nurses see patients within 24-48 hours after receiving a consultation and assess the wound using measurements and descriptive narrative and also put in wound care orders for nurses to follow. CWON GG stated that wound photographs were not currently taken at the facility, and the staff only relied upon the measurements and wound description documented. CWON further stated that a protocol was in place for the prevention of pressure injuries and skin breakdown that nurses could follow depending on the patient's Braden score.


A Zoom-call interview took place in the facility's office on 3/4/25 at 1:00 p.m. with RN HH, who stated that she received P#1 at about shift change, and during the skin assessments with RN DD, she did not think P#1 had any sores/injury on admission. RN HH stated that P#1 was on two-hourly turns and a HAPI bundle, which included offloading the heels and use of a waffle mattress. RN HH stated that if something suspicious was found, such as redness on a sacrum or any open wounds, especially on high-risk places such as the coccyx, a wound consultation would be put in.
RN HH also stated that she was not quite sure if there was a set of protocols written out regarding wound care, but if she had any questions, she would ask the charge nurse. RN HH further stated that monthly meetings on HAPI prevention were done as well as annual skills day and HAPI bundle bootcamp.


A telephone interview took place on 3/4/25 at 1:45 p.m. with RN II, who stated that the nurses and the patient care technicians work hand-in-hand to ensure patients are turned every two hours. RN II stated that if a patient refused turning, she would try to educate the patient on the implications and also inform the charge nurse. RN II stated that if a patient developed a deep tissue injury (DTI) not present on admission, an incident report would be done, and also a wound consultation. RN II also stated that hourly rounding was done where patients are checked to ensure they were being turned.


A telephone interview took place on 3/4/35 at 2:15 p.m. with Patient Care Technician (PCT) JJ, who stated that she could not recall P#1. However, the staff did their best to ensure patients were being turned every two hours and pressure injury protective measures were in place. PCT JJ stated that the nurses also assist in turning of patients, and if the patient's primary nurse was not available in assisting to turn a patient, the charge nurse will step in. PCT JJ also stated that if she noticed any wound/injury/sore on a patient, she would notify the nurse immediately.


An interview took place in the facility's office on 3/4/25 at 3:00 p.m. with Clinical Manager, PCU (CM) KK, who stated that she did a "SWARM" on P#1 when she received the incident report, which involved an extensive chart review and identifying opportunities for improvement. CM KK stated that during admission, P#1 had a two-nurse skin check, and she (P#1) was put on a turn-team rotation and had protective measures in place. CM KK stated that the outcome of the "SWARM" revealed minimal opportunities documenting the turns, and an action plan had been put in place.