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Based on review of hospital policy and procedure, medical record review and staff interviews, facility staff failed to ensure repositioning of mobility impaired patients per policy and procedure for 2 of 2 records reviewed (Patient #4 and Patient # 5).

Findings included:

Review of the policy "Assessment and Reassessment" last reviewed 06/28/2019 revealed, "Purpose: to determine appropriate care, treatment, and services to meet a patient's initial and changing needs through assessment and reassessment ...Definitions: Assessment - the first step of the nursing process and an essential component of nursing practice ...Policy: 1. A systematic collection and analysis of patient specific data ...5 ... Assessments/reassessments are documented in the patient's medical record. The medical record serves as a mechanism for communication and addresses the patient's care/treatment needs, response to treatment ...and continued care requirements as appropriate ..."

Review of the policy "Skin Integrity Assessment - Adult and Specialty Bed" last reviewed 03/15/2019 revealed, "Purpose: To identify patients with an alteration or potential alteration in skin integrity related to pressure and other contributing skin breakdown factors ...Policy: Nursing, in collaboration with the health care team, assess and manage skin integrity for patients throughout the stay ...Procedural Guidelines: ...4. If the Braden score is 16 or below and/or the patient has skin breakdown and/or open wound the nurse initiates the 'Skin Breakdown Prevention and Pressure Injury/Wound Care Protocol.' Complete documentation in the medical record ....4. Document skin breakdown preventative interventions (i.e. turns, reposition and float heels)."

Review of the 'Skin Breakdown Prevention and Pressure Injury/Wound Care Protocol" last reviewed 11/07/2018 revealed, "Activate protocol for Braden score what is equal to or less than 16 or patient at increased risk for skin breakdown ...4. Skin Care Bundle: Enter all three items and complete all three items for preventative care: ...Turn patient every 2 hours ...Float heels using pillow underneath or use heel boots ..."

1) Review of the medical record revealed Patient #4 was a 78-year-old female admitted to the facility from home via EMS on 08/29/2019 with a complaint of altered mental status and lethargy of one- or two-weeks duration. Review of the admission "History and Physical" dated 08/29/2019 at 1931 revealed Patient #4's history included Atrial fibrillation, anemia, bradycardia, cancer of the cervix and lung, and hypothyroidism. Review of an initial skin assessment dated 08/29/2019 at 2200 revealed documentation of two areas of concern: a "gluteal fold" pressure injury and redness of the groin and buttocks. Review of the initial Wound Care Consult note by a registered nurse (RN #4) dated 09/03/2019 at 1544 revealed, "Posterior skin with a unstageable wound to the sacrum. Wound bed is necrotic. Small satellite pressure ulcers. Wound likely started as a DTI and is evolving into an unstageable wound with a superficial skin bridge that will likely necrose ..." Review revealed the dimensions were 4.5 (1.77 inches) centimeters in length 2 (0.78 inches) centimeters in width and 0.3 (0.12 inches) centimeters in depth. Review of Braden scores revealed they ranged from 9 to 15, and the scores on the final two inpatient days were 11 and 12 respectively. Review of a Wound Care Consult note by RN #3 dated 09/22/2019 at 0846 revealed, " ...wound to sacral extends to right buttock, wound bed red with brown soft slough to center, wound edges irregular in shape and macerated, blanchable redness extending around it ..." Review revealed the dimensions were 6 (2.36 inches) centimeters in length, and 7 (2.76 inches) centimeters in width, no depth was recorded.

Review of turning and repositioning documentation revealed no evidence of turning and repositioning on 09/21/2019 0700 to 1900 (12 hours); 09/20/2019 0600 to 1500 (9 hours); 09/19/2019 1400 to 1900 (5 hours); 09/17/2019 0400 to 1900 (15 hours); 09/16/2019 0800 to 1400 (6 hours); 09/15/2019 0600 to 1900 (13 hours); 09/14/2019 0700 to 1000 (3 hours) and 1000 to 1400 (4 hours); 09/13/2019 0700 to 1800(11 hours); 09/12/2019 0800 to 1900 (11 hours) and 2200 to 0400 (6 hours) on 09/13/2019; 09/09/2019 0600 to 1900 (13 hours); and 09/07/2019 0700 to 1900 (12 hours). Review of the Discharge Summary by a physician, MD #1, dated 09/22/2019 at 1053 revealed Patient #4 was to be discharged home that day with home hospice services, and Patient #4 was transported home at 1215.

Review of internal facility monitoring revealed Patient #4's position documentation was noted to have been unchanged for 12 hours on 09/07/2019 and for 13 hours on 09/09/2019.

Request for interview with a wound care specialist, RN #4, who completed the initial wound evaluation, revealed she was not available for interview.

Interview during chart review on 01/08/2020 at 1215 with RN #16 confirmed position change documentation missing in Patient #4's medical record.

Interview on 01/08/2020 at 1435 with the nurse manager, NM #1, on 6 South where Patient #4 had received care in October 2019 revealed "for a time we did not have a clinical educator and we had some documentation issues." NM #1 revealed there had been a high turnover rate during the past six months, and she had been focused on making sure new staff received the training they needed. "It's not just checking boxes, but we need to make sure the boxes are checked, and things have been done."

Interview on 01/08/2020 at 1415 with MD #1 revealed he vaguely recalled Patient #4 and reviewed her medical record. MD #1 revealed, after review of the record, Patient #4 had been admitted with dehydration and a very low blood pressure in addition to some gastrointestinal bleeding. MD #1 revealed "She clearly could eat but was not eating enough to maintain herself and heal properly." MD #1 recalled family members had been divided about how to best treat Patient #4's poor nutritional status and had refused placement of a gastric feeding tube.

Interview on 01/08/2020 at 1655 with a wound care specialist, RN#3, confirmed the pressure ulcer was larger at the time of discharge than admission, and she had recommended another type of specialty bed to reduce pressure on the affected area, but the patient had discharged home the next day.

2) Closed medical record review revealed Patient #5 was a 79-year-old female who presented to the emergency department on 11/08/2019 and was admitted to the facility as an inpatient on 11/09/2019 with a complaint of shortness of breath and was discharged on 11/13/2019 with primary diagnoses of Thrombocytopenia (A low number of cells that help clot blood) and Pleural Effusion on L (left) (fluid buildup up between the lungs and chest). Upon admission on 11/09/2020 at 0400, the patient's Braden score was documented as 19. On 11/11/2019 at 0800, the patient's Braden score descended to 13, and the score remained under 16 throughout her admission, which ended on 11/13/2019 at 1802. There was no evidence the Skin Breakdown Prevention and Pressure Injury/Wound Care Protocol was initiated during the admission. Review revealed no evidence of every 2-hour repositioning on 11/11/2019 between 1600 and 1946, 2100 and 2300.

Interview conducted with the Director of Nursing on 01/09/2020 at 1250 revealed she would expect the Skin Breakdown Prevention and Pressure Injury/Wound Care Protocol to be initiated, and repositioning to be documented every 2 hours on patients with a Braden Score of less than 16.

Based on the review of the hospital policy and procedure, observation, staff interviews, the nursing staff failed to discard PPE (personal protective equipment) prior to entering a protective precautions patient's room for 1 of 1 observation. (#13)

Findings included:

Review on 01/08/2020 of the facility policy titled "Isolation Precautions (Transmission Based) for In-Patient Settings" with an Effective date of 10/30/2019 revealed "Transmission-based precautions are used in addition to standard precautions when inpatients have, or are suspected of having, a highly communicable disease or a condition of epidemiologic importance ..."

Observation on 01/08/2020 at 1322 on an oncology unit revealed RN (Registered Nurse) #5 exited from a room with a patient who was in an Airborne Isolation sign hanging on the door. Observation revealed RN #5 removed a WOW (workstation on wheels) from the room at the same time. Observation revealed RN #5 donned clean gloves, wiped down the WOW with a Sani-wipe then removed the gloves and placed them on top of the WOW. Observation revealed there was a duck bill mask (a mask designed to provide barrier protection against droplets including large respirtatory partilcles) under the gloves on top of the WOW. Observation revealed RN #5 used hand sanitizer then entered another patient's room (Patient #13's room) with the WOW and no PPE (personal protective equipment). Observation revealed RN #5 was quickly corrected by another nurse outside the room to don a mask per the Preventive Precautions Isolation sign on Patient #13's door. Observation revealed the duck bill mask and the soiled gloves were still on the top of the WOW in the Preventive precautions isolation room.

Interview on 01/08/2020 at 1335 with RN #5 revealed "there is no trash can outside the door to throw them (soiled gloves and duckbill mask) away." Interview revealed RN #5 confirmed the duck bill mask and the soiled gloves should not have been taken into the patient's room that was on Protective Precautions.

Interview on 01/08/2020 at 1608 with the Infection Prevention Provider revealed the expectation is for the removal of the PPE, discard it in proper container, perform hand hygiene, then don new PPE needed to enter the next room.

NC00158408; NC00156583; NC00156373; NC00156040; NC00156097.