HospitalInspections.org

Based on interview and record review, the hospital failed to ensure staff documented observations three times an hour, as required per hospital policy, of 2 (#3, #4) of 5 (#1, #2, #3, #4, #5) sampled patients who were restrained for non-violent behaviors. The nursing staff also failed to document 2 hour nursing assessments, as required per hospital policy, in the patient's medical record for 1 (#4) of 5 (#1, #2, #3, #4, #5) sampled patients with restraints.

Findings:

Review of the hospital's policy titled Restraint and Seclusion Utilization revealed the following in part:
5. Order for restraint and seclusion
5A. Order for restraint with non-violent or non-self-destructive behavior
a. Duration of order for restraint must not exceed 24 hours for the initial order and must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release.
7. Monitoring the patient in restraint or seclusion
b. An RN will assess the patient at least every two (2) hours
d. A trained staff member monitors each patient in restraint and seclusion at least three (3) times and hour for safety, and to confirm that the patient's rights and dignity are maintained. This check will be documented in either electronic record or on paper.

Patient #3
Review of Patient #3's medical record revealed he had a physician's order for non-violent restraints on 04/26/21 at 3:34 p.m.

A review of Patient #3's restraint documentation on 04/27/2021 at 10:47 a.m. revealed there had not been observations documented since 8:45 a.m. (2 hours).

In an interview on 04/27/21 at 10:57 a.m. with S6RN, she said she should assess patients in non-violent restraints every 15 minutes or at least 3 times an hour. She verified she had not documented an assessment since 8:45 a.m. on her restraint rounding sheet.

Patient #4

Review of Patient #4's medical record revealed a physician's order for restraints on 04/26/2021 at 12:28 p.m. for attempts to remove device, non-violent soft bilateral upper extremities.

Review of Patient #4's medical record revealed nursing staff failed to document three safety checks an hour on 04/24/2021 from 3:15 p.m. to 6:45 p.m. (3 1/2 hours).

Review of Patient #4's electronic medical record revealed nursing staff failed to document 2-hour nurse assessments of non-violent restraints on 04/24/2021 from 4:00 p.m. to 8:00 p.m. (4 hours).

In an interview on 04/27/2021 at 3:30 p.m. with S4RN, she stated according to review of Patient #4's medical records, nursing staff did not complete documentation on 15-minute safety checks and 2-hour nursing assessments of patient #4 while in non-violent restraints on 04/24/2021.

Based on observation, interview and record review the hospital failed to ensure a registered nurse supervised and evaluated the care of each patient. This deficient practice is evidenced by the nursing staff:
1. failing to accurately assess wounds for 2 (#2, #3) of 4 (#2, #3, #5, #R2) patients sampled with wounds; and
2. failing to measure and photograph pressure sores routinely to determine if treatment interventions were effective for 2 (#2, #3) of 4 (#2, #3, #5, #R2) patients sampled with wounds; and
3. failing to assess pressure ulcers each shift as per hospital policy for 2 (#2, #3) of 4 (#2, #3, #5, #R2) patients sampled with wounds.


Findings:

Review of the hospital's policy titled Pressure Injuries revealed in part:
Documentation:
1. Wound care should be documented on admission and with each shift assessment.

Review of the hospital's policy titled Photograph Documentation of Skin Breakdown revealed in part:
2. The nurse manager or wound care nurse will photograph pressure ulcers, unstageable, Stage 2, SDTI, Stage 3 and Stage 4 on admission, once a week, change in level of care and at the time of discharge. The photos will be taken utilizing the "NE1 can stage" wound assessment tool.
Guidelines 7. Use NE1 can stage wound assessment tool (which promotes consistent assessment, staging, measurement, and documentation of wounds).

1. Failing to accurately assess wounds.

Patient #3
Review of Patient #3's medical record revealed he was a current patient that had been admitted on 4/15/2021 at 12:08 p.m. with diagnosis including Edema Lower Extremities and Altered Mental Status.

Review of Patient #3's medical record revealed the only daily descriptions of wounds during nursing assessments were of the sacrum, bruising to the arms, a wound to the back. and 1 assessment of a wound to the buttock.

Review of Patient #3's skin assessments revealed the following inconsistent skin/wound assessments of the sacrum:
04/15/2021 Posterior Sacrum Stage 3 pressure sore, black tan eschar.
04/16/2021 at 8:00 a.m. Stage 3, eschar
04/17/2021 at 8:00 a.m. Unstageable black eschar
04/18/21 at 7:45 a.m. Unstageable, eschar
04/19/21 at 8:00 a.m. Pre stage 1 pressure ulcer
04/19/21 at 7:43 p.m. Eschar Stage 3
04/19/21 at 8:00 p.m. Stage 2
04/21/21 at 8:00 p.m. Eschar, Stage 3

Further review of the back wound revealed the last assessment documented by the nurse was on 04/26/21 at 8:00 a.m. as a Stage 2 injury. The only documentation of a description by the nurse of the wound to the lower buttock was on 04/26/21 at 8:40 a.m. as a right lower butt unstageable.

In an observation beginning at 1:00 p.m. on 04/27/21, S6RN ICU Educator did a skin assessment on Patient #3. The following wounds/injuries were observed:
Deep tissue injury on back
Red area sacrum 19 cm
Stage 4 sacrum 8 cm X 4.5 cm
Stage 3 buttock 7 cm X 2.75 cm
Stage 3 Left shin
Small deep tissue wound outer aspect L foot
Deep tissue with fungus Right heel
Grade 1 skin tear Right arm 3 cm X 1.25 cm
Grade 4 skin tear left arm

Review of Patient #3's medical record revealed there was no documentation of an assessment in Patient #3's medical record by the staff nurses of a wound to Patient #3's left shin, outer aspect of the left foot, deep tissue injury right heel or the red area to the sacrum.

In an interview on 04/27/2021 at 12:35 p.m. with S5RN, he said a Stage 3 pressure Ulcer is full thickness through the dermis into the muscle layer. He verified it was not possible to go back and forth in a days time between a Stage 3 and Unstagable wound on Patient #3's sacrum.

In an interview on 04/27/2021 at 2:03 p.m. with S5RN, he verified all of Patient #3's wounds should have been assessed and documented in the medical record but were not.

Patient #2
Review of Patient #2's medical record revealed he had been admitted on 10/28/2020 with diagnosis including seizures, altered mental status, diabetes mellitus, and chronic inflammatory demyelinating polyneuropathy.

Review of Patient #2's medical record revealed the following inconsistent skin/wound assessments:
11/22/20 at 8:00 a.m.- Skin Alteration none
11/22/20- 7:50 p.m.- Skin alteration- Present/exists with no description
11/23/20- 8:00 a.m.- Stage 3 Pressure injury
11/24/20- 8:00 p.m. Stage 3
11/27/20 at 9:15 a.m.- unstageable
11/27/20 at 7:21 p.m. unstageable
12/04/20 8:00 a.m. Skin Alteration: Present/exists
12/05/20- 8:00 p.m. Present/exists
12/06/20 8:00 a.m.- Stage 2
12/07/20 10:18 p.m. Pre Stage 1 with skin intact
12/08/20 8:30 a.m. - Stage 2
12/09/20- 8:15 a.m. Unstageable
12/10/20 8:15 a.m. Stage 3

In an interview on 04/27/20 at 10:25 a.m. with S4RN, she verified Patient #2's skin/wound assessments were not consistent and accurate.

In an interview on 04/27/21 at 10:29 a.m. with S5RN, he verified it did not seem possible that a patient's wound could go back and forth from unstageable, to Stage 2 and Stage 3 on a daily basis.


2. Failing to measure and photograph pressure sores routinely to determine if treatment interventions were effective.
Patient #3
Review of Patient #3's medical record revealed a pressure ulcer of the sacrum was documented on a skin assessment on 04/15/2021 and remained on 04/27/21 during an observation of a skin assessment of Patient #3. There were 2 photographs and measurements of the pressure ulcer on the sacrum in the medical record but no photographs or measurements of the other wounds observed during the observation including a deep tissue injury on the back, a red area to the sacrum, Stage 3 pressure ulcer to the buttock, a Stage 3 pressure ulcer to the left shin, a small deep tissue wound to the outer aspect of the left foot, a deep tissue with fungus to the right heel, a Grade 1 skin tear to the right arm and a Grade 4 skin tear to the left arm.

Patient #2
Review of Patient #2's medical record revealed a pressure ulcer to the sacrum was discovered on 11/23/2020 and remained until discharge on 12/10/2020. Further review revealed there were no measurements of the wound by nursing staff in the medical record. Review also revealed only 1 photograph of the wound was taken at the time of discovery.

In an interview on 04/27/21 at 2:03 p.m. with S5RN, he verified there should be photographs in the medical record of all of the wounds and documentation of the size of the wounds.

3. Failing to assess patient's pressure ulcers each shift as per hospital policy.

Patient #2
Review of Patient #2' medical record revealed a Stage 3 wound to the sacrum was discovered on 11/23/2020 at the 8:00 a.m. assessment. Further review revealed the patients wounds were not assessed on the morning shift on 11/24/2020. The wounds were not assessed on the evening shift on 11/26/2020 and 12/03/2020.

Patient #3
Review of Patient #3's medical record revealed a skin assessment on 04/15/2021 that revealed a Posterior Sacrum Stage 3 pressure sore with black and tan eschar. Further review revealed the patients wounds were not assessed on the morning shift on 04/20/2021, 04/21/2021, 04/22/2021, and 04/23/2021. The wounds were not assessed on the evening shift on 04/20/21, 04/23/2021, 04/25/2021 and 04/26/2021.

In an interview on 04/27/20 at 10:25 a.m. with S5RN, she verified patient's pressure ulcers should be assessed every shift.