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Based on record review and interview the facility failed to ensure that the Registered Nurse (RN) performed chest tube dressing assessments and chest tube dressing changes as per protocol and/or physicians orders in 8 of 10 records reviewed (Patient (Pt) #1, 2, 3, 4, 7, 8, 9, 10), in a total sample of 10 medical records reviewed of patients with a chest tube.

Findings include:

Per interview with Chief Nursing Officer (CNO) A on 06/21/2022 at 11:00 am, CNO A stated that the facility does not have a specific policy related to nursing assessments for chest tubes, but the nursing staff reference the American Association of Critical Care Nurses (AACN) Procedural Manual for High Acuity, Progressive, and Critical Care, 7th edition, for guidance with managing chest tubes. CNO A stated that per facility nursing protocol, nursing staff should perform nursing assessments of the chest tube dressing site at least every 4 hours and document evidence of this assessment in the patient's medical record.

Per interview with Registered Nurse (RN) B (Team lead) on 06/21/2022 at 11:25 am, RN B stated that per nursing protocol, nursing staff should perform an assessment of the chest tube dressing site at a minimum every 4 hours and document this assessment in the patient's medical record. RN B stated that the chest tube dressing should be changed according to physician orders.

Review of Pt #1's medical records revealed Pt #1 was admitted to the facility on 02/17/2022 at 5:25 pm with a diagnosis of Hemothorax (collection of blood in the space between the chest wall and the lung). Review of Pt #1's nursing assessment flowsheets revealed Pt #1 had a chest tube inserted by the physician on 02/18/2022 at 11:52 am, and the chest tube was removed on 02/19/2022 at 11:01 am.

Per review of Pt #1's nursing assessment flowsheets titled, "Right lateral chest puncture;incision" (chest tube dressing site), Pt #1's chest tube dressing was assessed by the nurse on 02/18/2022 at 8:20 pm, and there was no documented evidence of a reassessment until 02/19/2022 at 1:24 am (5 hours later). This practice was inconsistent with the facility nursing protocol to assess the chest tube dressing site a minimum of every 4 hours.

Review of Pt #2's medical records revealed Pt #2 was admitted to the facility on 04/22/2022 at 5:22 am with a diagnosis of left Pleural Effusion (buildup of fluid between the tissues that line the lungs and the chest). Review of Pt #2's nursing assessment flowsheets revealed Pt #2 had a chest tube inserted by the physician on 04/22/2022 at 8:30 am, and the chest tube was removed on 04/24/2022 at 11:25 am.

Review of Pt #2's medical records revealed a physician order on 04/22/2022 at 9:36 am for nursing staff to "Change Chest Tube Dressing Daily."

Per review of Pt #2's nursing assessment flowsheets titled, "Right lateral chest puncture; incision" (chest tube insertion site) and review of Pt #2's nursing progress notes, there was no documented evidence of nursing staff changing Pt #2's chest tube dressing on 04/23/2022, as per physician orders (daily dressing changes).

Review of Pt #3's medical records revealed Pt #3 was admitted on 03/01/2022 at 5:49 am with a diagnosis of Adenocarcinoma of lung. Review of Pt #3's nursing assessment flowsheets revealed Pt #3 had a chest tube inserted by the physician on 03/01/2022 at 11:42 am, and the chest tube was removed on 03/03/2022 at 12:45 pm.

Review of Pt #3's medical records revealed a physician order on 03/01/2022 at 4:53 pm for nursing staff to "Change Chest Tube Dressing Daily."

Per review of Pt #3's nursing assessment flowsheets titled, "Right lateral chest puncture; incision" (chest tube dressing site) and review of Pt #3's nursing progress notes, there was no documented evidence of nursing staff changing Pt #3's chest tube dressing on 03/02/2022, as per physician orders.

Per review of Pt #3's nursing assessment flowsheets titled, "Right lateral chest puncture;incision" (chest tube dressing site), Pt #3's chest tube dressing was assessed by the nurse on 03/01/2022 at 11:00 pm, and there was no documented evidence of a reassessment until 03/02/2022 at 7:27 am (more than 8 hours later). This practice was inconsistent with the facility nursing protocol to assess the chest tube dressing site a minimum of every 4 hours.

Review of Pt #4's medical records revealed Pt #4 was admitted on 04/20/2022 at 8:16 am with a diagnosis of Malignant Neoplasm of Right Lung. Review of Pt #4's nursing assessment flowsheets revealed that Pt #4 had a chest tube inserted by the physician on 04/20/2022 at 1:50 pm, and the chest tube was removed on 04/22/2022 at 8:30 am.

Review of Pt #4's medical records revealed a physician order on 04/20/2022 at 7:36 pm for nursing staff to "Change Chest Tube Dressing Daily."

Per review of Pt #4's nursing assessment flowsheets titled, "Right lateral chest puncture; incision" (chest tube dressing site) and review of Pt #4's nursing progress notes, there was no documented evidence of nursing staff changing Pt #4's chest tube dressing on 04/21/2022, as per physician orders.

Review of Pt #7's medical records revealed Pt #7 was admitted on 04/08/2022 at 5:51 am for biopsy of a lung nodule. Review of Pt #7's nursing assessment flowsheets revealed that Pt #7 had a chest tube inserted by the physician on 04/08/2022 at 10:07 am, and the chest tube was removed on 04/09/2022 at 1:10 pm.

Per review of Pt #7's nursing assessment flowsheets, Pt #7's "Right lateral chest puncture;incision" (chest tube dressing site), was assessed by the nurse on 04/08/2022 at 11:05 pm, and there was no documented evidence of a reassessment until 04/09/2022 at 4:25 am (more than 5 hours later); this practice was inconsistent with the facility nursing protocol to assess the chest tube dressing site a minimum of every 4 hours.

Review of Pt #9's medical records revealed Pt #9 was admitted on 04/15/2022 at 8:05 pm for biopsy of a Pleural Effusion. Review of Pt #9's nursing assessment flowsheets revealed that Pt #9 had a chest tube inserted by the physician on 04/22/2022 at 4:59 pm, and the chest tube was removed on 04/25/2022 at 3:30 pm.

Review of Pt #9's medical records revealed a physician order on 04/22/2022 at 7:56 pm for nursing staff to "Change Chest Tube Dressing Daily."

Per review of Pt #9's nursing assessment flowsheets titled, "Right lateral chest puncture; incision" (chest tube dressing site) and review of Pt #9's nursing progress notes, there was no documented evidence of nursing staff changing Pt #9's chest tube dressing on 04/23/2022 and 04/24/2022, as per physician orders.

Per review of Pt #9's nursing assessment flowsheets, Pt #9's "Right lateral chest puncture;incision" (chest tube dressing site), was assessed by the nurse on 04/23/2022 at 10:30 pm, and there was no documented evidence of a reassessment until 04/24/2022 at 5:17 am (more than 6 1/2 hours later); this practice was inconsistent with the facility nursing protocol to assess the chest tube dressing site a minimum of every 4 hours.

Review of Pt #10's medical records revealed Pt #10 was admitted on 03/11/2022 at 3:35 pm for biopsy of a Pleural Effusion. Review of Pt #9's nursing assessment flowsheets revealed that Pt #9 had a chest tube inserted by the physician on 03/17/2022 at 1:30 pm, and the chest tube was removed on 03/21/2022 at 12:00 pm.


Per review of Pt #10's nursing assessment flowsheets, Pt #10's "Right lateral chest puncture;incision" (chest tube dressing site), was assessed by the nurse on 03/19/2022 at 7:45 am, and there was no documented evidence of a reassessment until 03/19/2022 at 3:37 pm (more than 7 1/2 hours later); this practice was inconsistent with the facility nursing protocol to assess the chest tube dressing site a minimum of every 4 hours.

The above findings were confirmed with RN B and CNO A during medical record review on 06/21/2022 beginning at 11:30 am.