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Based on the manner and degree of the standard-level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 Condition of Participation: NURSING SERVICES was out of compliance.

A-0395 A registered nurse must supervise and evaluate the nursing care for each patient: Based on document review and interviews, the facility failed to ensure interventions were implemented to protect skin integrity for patients who were at risk of pressure injuries in two of two patients reviewed with risk for skin breakdown (Patients #4 and #5).

Based on document review and interviews, the facility failed to ensure interventions were implemented to protect skin integrity for patients who were at risk of pressure injuries in two of two patients reviewed with risk for skin breakdown (Patients #4 and #5).
Findings include:

Facility policy:

The Pressure Injury Prevention and Management policy read, all patients will be evaluated for skin breakdown and reassessment of skin risk will occur, at a minimum of once per shift. Regardless of risk, standard-of-care pressure injury prevention elements should be implemented for all patients.

Reference:

The Elton B. Stephens Company (EBSCO) Information Services Dynamic Health Database, 2024, for adult pressure injury, provided by the facility, read, pressure injury prevention focused on risk assessment, skin care, nutrition, positioning, and mobilization. Skin care-related prevention included frequent skin assessments and minimizing skin exposure to moisture, urine, and stool by using barrier products. Positioning and mobilization-related prevention included frequent repositioning to alleviate pressure.

The Pressure Injury Prevention and Wound Care education tool, provided by the facility, read, interventions for pressure injury were to ensure registered nurses (RNs) and other care team members turn patients frequently (every two hours), update the care plan, and document the interventions according to facility policy.

1. The facility failed to ensure patients at risk of pressure injuries were monitored and had implemented interventions to protect the patient's skin integrity.

A. Record Review

i. Medical record review revealed Patient #4 was admitted to the intensive care unit (ICU) on 10/10/23 for shortness of breath and sepsis (a severe infection in the body) related to Clostridiodes difficile (C.diff). Patient #4 had a stage I pressure injury (pressure-related alteration of intact skin) on their right heel and a stage III pressure injury (a full-thickness loss of skin in which fat tissue is visible) on their sacrum (tailbone). The skin risk assessment done on the day of admission (10/10/23) revealed the patient was at risk for a pressure injury due to their limited bed mobility, nutritional status, and moist skin condition. Patient #4 was transferred to a cardiac medical stepdown unit on 10/25/23 because the ICU level of care was no longer needed for their medical condition.

Medical record review of the nursing documentation in Patient #4's medical record revealed Patient #4's skin was not assessed every shift per facility policy on 10/10/23, 10/24/23, 10/25/23, 10/28/23, 11/5/23, 11/6/23, and 11/7/23. Furthermore, the medical record revealed no evidence that Patient #4 was repositioned or turned off their pressure injury 24 days between 10/11/23 and 11/10/23.

Additional medical record review revealed Patient #4 had orders for a skin barrier cream to be applied to the pressure injury daily and as needed. A review of nursing documentation in Patient #4's medical record revealed 19 days between 10/11/23 and 11/10/23 that Patient #4 did not receive the skin barrier cream as ordered by the provider.

ii. Medical record review revealed Patient #4 was readmitted to a medical unit within the facility on 11/15/23 with hematuria (blood in the urine). A review of the nursing documentation revealed Patient #4 had a stage III pressure injury on their sacrum and the skin risk assessment done on the day of admission (11/15/23) revealed the patient was at risk for a pressure injury due to their limited bed mobility, nutritional status, and moist skin condition.

The medical record review of Patient #4 revealed the skin risk assessment was not completed for the day shift on 11/16/23 per facility policy. Further review of nursing documentation revealed Patient #4 was not repositioned on 11/16/23, 11/17/23, 11/18/23, 11/19/23, 11/20/23, 11/21/23, and 11/22/23.

iii. Medical record review revealed Patient #4 was readmitted to the facility's step-down unit on 11/27/23 for hematuria. A review of nursing documentation revealed Patient #4 had a stage III pressure injury on their sacrum and the skin risk assessment completed on the day of admission (11/27/23) revealed the patient was at risk for a pressure injury due to their limited bed mobility, nutritional status, and moist skin condition. The medical record review of Patient #4 revealed the skin risk assessment was not completed on 11/29/23 and 12/6/23 per facility policy.

Further review of nursing documentation revealed Patient #4 was not repositioned during the night shifts of 11/27/23, 11/28/23, 11/30/23, 12/4/223, and 12/5/23. Additionally, Patient #4 was not repositioned during the day shifts of 11/29/23, 11/30/23, 12/1/23, 12/2/23, 12/3/23, 12/4/23, and 12/6/23.

iv. Medical record review revealed Patient #5 was admitted to the ICU on 2/9/24 with increased symptoms (change in mental status and ability to walk) of a subdural hematoma (bleeding under the skull) as a result of a fall. The skin risk assessment completed on 2/10/24 revealed Patient #5 was on bedrest and was at risk for a pressure injury due to their limited bed mobility. Medical record review of the nursing documentation in Patient #5's medical record revealed Patient #5's skin was not assessed on the evening shift. Further record review revealed Patient #5 was not turned or repositioned on 2/11/24 during the evening shift.

This was in contrast to the Pressure Injury Prevention and Management policy which read, all patients were to be evaluated and reassessed for risk of skin breakdown at a minimum of once per shift. Additionally, standard-of-care pressure injury prevention elements were to be implemented for all patients, regardless of skin risk.

This was in further contrast to the EBSCO national guidelines followed by the facility which read, skin care-related prevention included frequent skin assessments and minimized skin exposure to moisture, urine, and stool through the use of barrier products. Positioning and mobilization-related prevention included frequent repositioning to alleviate pressure.

This was also in contrast to the Pressure Injury Prevention and Wound Care education tool which read, staff were to turn patients frequently (every two hours), update the care plan, and document the interventions according to facility policy.

B. Interviews

i. On 2/12/24 at 9:30 a.m., an interview was conducted with RN #8. RN #8 stated patients' skin was checked at the beginning of the shift during report with the on-coming and off-going shifts. RN #8 stated a skin risk assessment tool was used to determine the level of risk for a pressure injury and a score of 18 or less was considered a risk that needed special interventions for pressure injury prevention. RN #8 stated patients who were not turned risked pressure injuries that caused infections or delayed the discharge. RN #8 stated patients also experienced an increased risk of sepsis and mortality rate (death) when they were not turned every two hours.

ii. On 2/12/24 at 10:00 a.m., an interview was conducted with RN #9. RN #9 stated skin assessments were done each shift. RN #9 stated patients who were immobile, bedridden, or had diabetes were at the greatest risk for pressure injuries and needed to be turned every two hours. RN #9 stated turning patients every two hours was important because immobility led to wounds that became infected and went to the bone. RN #9 stated patients were asked if they wanted to reposition when staff checked on patients hourly. RN #9 stated when skin assessments were not performed, there was a risk of a pressure injury not being noticed and treated.

iii. On 2/14/24 at 3:06 p.m., an interview was conducted with RN #5. RN #5 stated a patient who was turned every two hours to help prevent pressure injury was a standard of care for patients who were at risk for pressure injuries. RN #5 stated they used wedges to support patients on their sides and knew when a patient was turned because they remembered where the wedges were with the previous turn. RN #5 stated there was no place for documentation when a patient was turned and documentation was not required. RN #5 stated they were unsure if patients were turned every two hours when RN #5 was not involved in the care of the patient.

iv. On 2/15/24 at 10:25 a.m., an interview was conducted with RN #10. RN #10 stated patients were turned every two hours. RN #10 stated patients were turned every three to four hours if they refused to be turned every two hours. RN #10 stated it was not documented in the medical record when a patient refused to be turned. RN #10 stated not all nurses documented the pressure injury interventions every two hours in the medical record because it was the expected standard of care. RN #10 stated it was important for patients to be turned every two hours because it prevented additional pressure injuries that led to sepsis. RN #10 stated pressure injury intervention documentation was important because if it was not documented, it was not performed. RN #10 stated when the documentation was not completed, the care team was unable to see the full care of the patient which affected future decisions for the patient's care.

v. On 2/14/24 at 2:33 p.m., an interview was conducted with ICU nurse manager (Manager) #6. Manager #6 stated interventions for pressure injuries were used on all patients, regardless of the skin assessment risk for pressure injury. Manager #6 stated all patients needed to be turned or repositioned every two hours for the prevention and treatment of pressure injuries. Manager #6 stated if a patient had pressure injury wounds and was malnourished, the patients were turned every hour. Manager #6 stated staff documented by exception, if an intervention was a standard of care, or a condition was within normal limits, it was not documented. Manager #6 stated a patient turned every two hours was a standard of care practice and therefore, was expected to be performed. Manager #6 stated there was no place to document pressure injury interventions in the medical record except in the skin assessment area. Manager #6 stated they had no way to determine if patients were turned except in follow-up conversations with the staff. Manager #6 stated it was important to document when patients were turned because if it was not documented, it could not be verified that it was performed. Manager #6 stated patients were at risk of further skin breakdown (pressure injuries), delayed discharge, infection, and death when they were not turned every two hours. Manager #6 stated pressure injuries were potentially lifelong events for patients.

vi. On 2/13/24 at 1:49 p.m., an interview was conducted with the director of education (Director) #7. Director #7 stated patient pressure injury interventions were not documented every two hours. Director #7 stated the documentation was completed every shift. Director #7 stated the staff knew the standard of care was to turn the patients every two hours based on education provided during orientation and yearly competency education. Director #7 stated it was better practice to document every two hours because it demonstrated the care the patient received.

vii. On 2/15/24 at 10:40 a.m., an interview was conducted with assistant chief nursing officer (ACNO) #11. ACNO #11 stated the documentation for pressure injury interventions every two hours was charted once a shift because it was considered to be a standard level of care for pressure injury prevention. ACNO #11 stated staff documented by exception and were expected to document when the standard of care was not met. ACNO #11 stated facility leadership ensured patients were turned every two hours when they rounded on the units and watched the care provided by the staff. ACNO #11 stated not all staff were observed and documentation in the medical record showed the patients were turned every two hours. ACNO #11 stated when the documentation was not completed, it was assumed to not have been performed.

This was in contrast to the Pressure Injury Prevention and Wound Care education tool which read, staff were to turn patients frequently (every two hours), update the care plan, and document the interventions according to facility policy.

Based on the manner and degree of the standard-level deficiency referenced to the Condition, it was determined the Condition of Participation §482.56 Condition of Participation: REHABILITATION SERVICES was out of compliance.

A-1132 Services must only be provided under the orders of a qualified and licensed practitioner who is responsible for the care of the patient, acting within his or her scope of practice under State law, and who is authorized by the hospital's medical staff to order the services in accordance with hospital policies and procedures and State laws. Based on document review and interviews, the facility failed to obtain a provider order before a procedure was performed on a patient in one of one patients reviewed who underwent a wound debridement (Patient #4).

Based on document review and interviews, the facility failed to obtain a provider order before a procedure was performed on a patient in one of one patients reviewed who underwent a wound debridement (Patient #4).

Findings include:

Facility Policies:

The Conservative Sharp Debridement policy read, a Certified Wound, Ostomy, and Continence Nurse (CWOCN), Certified Wound Care Nurse (CWCN), Physical Therapist (PT), or provider will be consulted by a provider with an order for evaluation and treatment or conservative sharp debridement of wound(s).

The Pressure Injury Prevention and Management policy read, a stage I pressure injury was non-blanchable erythema of intact skin. A stage III pressure injury was a full-thickness skin loss in which fat tissue was visible.

References:

The Colorado Revised Statutes 2023 Title 12 Professions and Occupations Article 285: Physical Therapists and Physical Therapist Assistants (scope of practice) read, a physical therapist is authorized to perform wound debridement under a physician's order.

The Rules and Regulations of the Medical Staff read, all orders for treatment, diagnostic tests, drugs, biologicals, operative and special procedures must be entered into the electronic health record (EHR). An order requesting a consult must be present in the EHR and identify the consultant.

1. The facility failed to ensure an order was obtained before a wound debridement was performed on a patient.

A. Record Review

i. Medical record review revealed Patient #4 was admitted on 10/10/23 for shortness of breath and sepsis (a severe infection in the body) related to Clostridiodes difficile (C.diff). Patient #4 had a stage I pressure injury (pressure-related alteration of intact skin) on their right heel and a stage III pressure injury (a full-thickness loss of skin in which fat tissue is visible) on their sacrum (tailbone).

The medical record review revealed Patient #4 had a conservative sharp debridement (a procedure to remove nonviable [dead] tissue from a wound with a scalpel, forceps, and scissors) performed by physical therapist (Therapist) #1 on 11/4/23. Additional medical record review revealed there was no provider order for the procedure. The conservative sharp debridement procedure continued to be performed daily on Patient #4 through 11/9/23 by Therapists #1, #2, and #3.

Further medical record review revealed Patient #4 was readmitted to the facility on 11/15/23 with hematuria (blood in the urine). Medical record review revealed Patient #4 continued to need pressure injury treatment for the pressure injury on their sacrum. Patient #4 had a conservative sharp debridement performed by Therapist #3 on 11/16/23 and 11/21/23 with no provider order.

B. Interviews

i. On 2/14/24 at 10:08 a.m., an interview was conducted with Therapist #2. Therapist #2 stated conservative sharp debridement was performed on patients with pressure injury wounds that had nonviable tissue in the wound. Therapist #2 stated the procedure was performed at the bedside and included a scalpel and forceps. Therapist #2 stated providers wrote the orders for physical therapy evaluation and treatment. Therapist #2 stated the only necessary order was for evaluation and treatment because the physical therapists were providers who assessed and treated patient conditions. Therapist #2 stated they added debridement to the patient's plan of care as a necessary intervention for wound care. Therapist #2 stated physical therapy was consulted by wound care nurses when conservative sharp debridement was needed.

Therapist #2 stated the risks of debridement were bleeding, infection, cuts to viable (live) tissue, and pain for the patient. Therapist #2 stated the importance of provider orders for wound debridement was the physician oversight they provided. Therapist #2 also stated facility policies required provider orders and physical therapists used their clinical judgment for conservative sharp debridement under the evaluation and treatment orders.

This was in contrast to the Conservative Sharp Debridement policy which required an order from the provider to perform conservative sharp debridement.

ii. On 2/14/23 at 3:06 p.m., an interview was conducted with registered nurse (RN) #5. RN #5 stated the medical provider ordered the consultation for the wound care staff to evaluate and treat the patients. RN #5 stated an RN was able to consult for wound care if the patient had a pressure injury which existed at the time of admission, but the provider was still responsible to have awareness of the patient's condition and sign the order. RN #5 stated wound debridement was done by the physical therapists and could not be done without a provider order. RN #5 stated it was important to have the order for debridement because it ensured the patient received what they needed for treatment and protected the patient from harm.

iii. On 2/14/24 at 10:44 a.m., an interview was conducted with the director of rehabilitation (Director) #4. Director #4 stated physical therapists needed a consult order from the provider. Director #4 stated once the evaluation and treatment order was received from the physician, the physical therapist assessed the patient and wrote the patient's plan of care for the wound. Director #4 stated the physical therapists used their clinical judgment to determine when the wound needed additional or different treatment but also deferred to the physician when conservative sharp debridement was used.

Director #4 stated it was important to have provider orders because they provided physician oversight for the care of the patient. The risk of a procedure performed without a provider order was harm to the patient if the provider did not want the procedure performed.

The medical record review and interviews were in contrast to the facility's Conservative Sharp Debridement policy which read, a physical therapist would be consulted by a provider with an order for conservative sharp debridement of wounds. Additionally, they were in contrast to the Colorado Revised Statutes 2023 Title 12 Professions and Occupations Article 285: Physical Therapists and Physical Therapist Assistants scope of practice which read a physical therapist was authorized to perform wound debridement under a physician's order. Furthermore, they were in contrast to the facility's Rules and Regulations of the Medical Staff which read all orders for treatment, special procedures, and consultations were to be entered into the EHR by the provider.