HospitalInspections.org

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The facility failed to ensure nursing staff followed the facility's established policy regarding completing a comprehensive assessment of a patient's pressure injuries; the facility failed to ensure nursing staff notified a patient's physician regarding a change in patient status; the facility failed to follow a physician order to obtain a patient's daily weight; and the facility failed to ensure a patient's weight was verified to determine the accuracy of the weight loss or gain.

A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP2 and EMP3) regarding the survey team's concerns related to Nursing Services on March 2, 2022, at approximately 1322.

Cross reference
482.23(b)(3) Nursing Care Plan

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure nursing staff followed the established facility policy by completing a comprehensive assessment of a patient's pressure injuries for one of one applicable medical record reviewed (MR1); the facility failed to ensure nursing staff notified a patient's physician regarding a change in patient status for one of one applicable medical record reviewed (MR1); the facility failed to follow physician orders for obtaining daily weights for one of one applicable medical record reviewed (MR1) and the facility failed to ensure a patient's weight was verified to determine the accuracy of the weight loss or gain for one of one applicable medical record reviewed (MR1).

Findings include:

Review on February 28, 2022, of the facility's "Skin - Alteration in Skin Integrity, Pressure-Related and Non-Pressure-Related Wounds [51]" policy, last revised May 2021, revealed "I. Purpose The intent of this policy is to: Provide inpatient standard guidelines for the assessment, care, and management of pressure-related and non-pressure-related wounds. Apply evidence-based principles of wound care and delineate wound care responsibilities for various members of the health care team. Address wounds acquired prior to admission, surgical wounds, and hospital acquired wounds. ...II. Definitions ...D. Pressure Injury: a pressure injury is localized damage to the skin and underlying soft tissue usually over a boney prominence or related to a medical or other device. The injury can be present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense pressure, prolonged pressure, or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities ad condition of the soft tissue. E. Pressure Injury Staging: Stage 1 Pressure Injury: Non-blanchable erythema of intact skin. Description Intact skin with a localized area of non-blanchable erythema, which may appear different in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. Description Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. ... Stage 3 Pressure Injury: Full-thickness skin loss. Description Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. ... If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Description Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible .... If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: obscured full-thickness skin and tissue loss. Description Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. ... Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Description Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidural separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4) ... III. Policy & General Instructions A. Admission Wound Assessment and Management 1. Assessment: Wounds are assessed by the RN at the time of admission, generally within two hours, during the head to toe assessment. Dressings must be removed for the assessment, unless otherwise indicated or directed. 2 RN skin assessment is performed on admission for patients with altered skin integrity. Comprehensive assessment of any wound includes Location Left or right; anatomical site; lateral, medial, posterior, inferior, distal, proximal, superior, inferior. Shape of wound - irregular, round, oval, square/rectangular, linear, butterfly or other recognizable shape; Size - length, width, depth (in centimeters (cm)) ...Edges - describe appearance of the wound edges ...Direction and length of tunnelling or undermining ...Appearance of the wound bed/base Pink - epithelial tissue Beefy red - granulation tissue Slough - yellow or white tissue that may adhere to wound bed in strings or thick clumps ...Exudate/draining ...Peri-wound assessment the appearance of the skin up to 4 cm surrounding the edge of the wound ...Wound pain Staging if pressure injury ... 3. Initial Wound Management: ...Wound present on admission must be reported to the appropriate physician/advanced practitioner and consults placed as needed (e.g. ... Wound Care ...)"

A request was made of EMP1 on March 2, 2022, for a facility policy, procedure, guideline, or protocol facility staff are to follow regarding assessment and monitoring of hospital acquired pressure wounds. None was provided.

Interview with EMP1 on March 2, 2022, at approximately 1300 revealed the facility's "Skin - Alteration in Skin Integrity, Pressure-Related and Non-Pressure-Related Wounds [51]" policy applied to patients admitted with pressure related wounds and patients who develop pressure related wounds while an inpatient.

1) Review of MR1 on February 28, 2022, revealed this patient was admitted to the Intensive Care Unit (ICU) on January 12, 2022, with acute hypoxic Respiratory Failure Secondary to COVID-19, was intubated (a breathing tube place into the mouth and then into the airway to help move air in and out of the lungs) and placed on a ventilator (breathing machine).

Review of MR1 on February 28, 2022, revealed nursing documentation dated January 13, 2022, through January 24, 2022, indicating this patient had a dark purple SDTI pressure injury to the right buttock.

Interview with EMP1 and EMP2 on February 28, 2022, at approximately 1400 revealed SDTI indicates a Suspected Deep Tissue Injury.

There was no documentation in MR1 indicating nursing staff documented a complete comprehensive assessment including the shape, size, edges, appearance, or peri-wound assessment of this patient's dark purple SDTI pressure injury to the right buttock from January 13, 2022, through January 23, 2022.

Interview with EMP1 and EMP2 on March 2, 2022, at approximately 1000 confirmed there was no documentation in MR1 indicating nursing staff documented a complete comprehensive assessment including the shape, size, edges, appearance, or peri-wound assessment of this patient's dark purple SDTI pressure injury to the right buttock from January 13, 2022, through January 23, 2022.

Review of MR1 on February 28, 2022, revealed nursing documentation dated January 23, 2022, indicating this patient had a sacral slit.

There was no documentation in MR1 indicating nursing staff documented a complete comprehensive assessment including the shape, size, edges, appearance, or peri-wound assessment of this patient's sacral slit on January 23, 2022.

Interview with EMP1 and EMP2 on March 2, 2022, at approximately 1000 confirmed the nursing documentation dated January 23, 2022, indicating this patient had a sacral slit and there was no documentation in MR1 indicating nursing staff documented a complete comprehensive assessment including the shape, size, edges, appearance, or peri-wound assessment of this patient's sacral slit on January 23, 2022.

Review of MR1 on February 28, 2022, revealed nursing staff consulted EMP3 (wound care nurse) on January 24, 2022, for wounds to this patient's sacrum and right buttock.

Review of MR1 on February 28, 2022, revealed EMP3's wound care documentation dated January 24, 2022, indicating this patient's right buttock area wound appearance had fragile tissue, the wound may be an evolving DTI (Deep Tissue Injury) vs COVID skin related injury; the appearance and location of the buttock wound is on the fleshy aspect of the buttock, the skin is fragile and friable; the wound bed is beefy red with areas of black to the wound bed, and the skin to the peri wound is fragile and peeling with dark purple visible beneath the wound bed.

Interview with EMP1 and EMP3 on March 2, 2022, at approximately 1300 confirmed EMP3's documentation that MR1's right buttock area wound appearance had fragile tissue, the wound may be an evolving DTI (Deep Tissue Injury) vs COVID skin related injury; the appearance and location of buttock wound is on the fleshy aspect of the buttock, the skin is fragile and friable; the wound bed is beefy red with areas of black to the wound bed, and the skin to the peri wound is fragile and peeling with dark purple visible beneath the wound bed. EMP3 revealed MR1's suspected deep tissue injury to the right buttock area was considered a hospital acquired pressure area.

Review of MR1 on February 28, 2022, revealed EMP3's wound care documentation dated January 24, 2022, indicating this patient's sacral wound was an evolving DTI; the wound bed was beefy red, the depth was not able to be determined due to the body habitus and the per wound skin was light-dark purple with gray moist tissue that peels away with cleaning.

Interview with EMP1 on March 2, 2022, at approximately 1300 confirmed EMP3's documentation that MR1's sacral wound was an evolving DTI; the wound bed was beefy red, the depth was not able to be determined due to the body habitus and the per wound skin was light-dark purple with gray moist tissue that peels away with cleaning.

Interview with EMP3 on March 2, 2022, revealed MR1's pressure injury to the right buttock and the sacral wound were measured together as one wound with the length of 14 centimeters (cm) and the width of 10 cm with scant yellow drainage.

2) A request was made of EMP1 on March 2, 2022, for a facility policy, procedure, guideline, or protocol facility staff are to follow regarding physician notification regarding a change in patient condition. None was provided.

Interview with EMP1 on March 2, 2022, at approximately 1300 revealed the facility's "Skin - Alteration in Skin Integrity, Pressure-Related and Non-Pressure-Related Wounds [51]" policy staff reference regarding physician and advanced practitioner notification of a change in a patient's condition related to the development of a hospital acquired pressure wound.

Review of MR1 on February 28, 2022, revealed nursing documentation dated January 13, 2022, through January 24, 2022, indicating this patient had a dark purple SDTI pressure injury to the right buttock.

Interview with EMP1 and EMP2 revealed MR1's hospital acquired dark purple SDTI pressure injury to the right buttock was considered a change in this patient's condition and required MR1's physician notification.

There was no documentation in MR1 indicating this patient's physician was notified from January 13, 2022, through January 24, 2022, of MR1's hospital acquired hospital acquired dark purple SDTI pressure injury to the right buttock.

3) Review on February 28, 2022, of the facility's "Patient Care Process: Including Admission, Assessment/Reassessment And Patient Plan of Care [B-02]" policy, last revised July 2021, revealed "I. Purpose: The patient care process provides the framework for the documentation of care provided to patients. Key components include: assessment, reassessment, nursing diagnosis, planning, intervention, and evaluation. ... B. Admission 1. An initial "head to toe" assessment including vital signs, height, weight, home medications, allergies/adverse reaction, and the presence of any medical device of each inpatient is generally completed by licensed staff within 2 hours of admission. The RN in collaboration with the physician/advanced practitioner and appropriate members of the health care team, then determines the need for care and the type of care to be provided. ..."

A request was made of EMP1 on February 28, 2022, for a facility policy, procedure, guideline, or protocol facility staff are to follow regarding following physician orders. None was provided.

Interview with EMP1 on February 28, 2022, at approximately 1300 revealed the facility's "Patient Care Process: Including Admission, Assessment/Reassessment And Patient Plan of Care [B-02]" policy staff reference regarding following physician orders.

Review of MR1 on February 28, 2022, revealed a physician order dated January 12, 2022, instructing nursing staff to obtain daily weights on this patient.

Review of MR1 on February 28, 2022, revealed nursing staff did not obtain daily weights as ordered by the physician on January 23, 24, 27, 28, 29 and 30, 2022, and on February 2, 6, 15, 16, 17, 19, 22, 24, 25 and 27, 2022.

Interview with EMP1 and EMP2 on February 28, 2022, at approximately 1230 confirmed MR1's physician order dated January 12, 2022, instructing nursing staff to obtain daily weights on this patient and nursing staff did not obtain daily weights on January 23, 24, 27, 28, 29 and 30, 2022, and on February 2, 6, 15, 16, 17, 19, 22, 24, 25 and 27, 2022, as ordered by the physician.

4) Review on February 28, 2022, of the facility's "Patient Care Process: Including Admission, Assessment/Reassessment And Patient Plan of Care [B-02]" policy, last revised July 2021, revealed "... C. Reassessment 1. Policies and General Instructions ... c. Every shift, it is the responsibility of the RN to analyze assessment data and data acquired by assistive personnel (e.g. ADLs, vital signs, weights, I&O, meal consumption, etc.) to determine and prioritize patient care needs. Appropriate interventions will be Implemented when variations in the patient's status are identified. ..."

A request was made of EMP1 on February 28, 2022, for a facility policy, procedure, guideline, or protocol facility staff are to follow regarding weighing and reweighing a patient. None was provided.

Interview with EMP1 on February 28, 2022, at approximately 1300 revealed the facility's "Patient Care Process: Including Admission, Assessment/Reassessment And Patient Plan of Care [B-02]" policy staff reference regarding weighing and reweighing a patient.

Review on February 28, 2022, of MR1's weights for January 2022 revealed:
January 13, 2022 (Admission weight) 426 pounds
January 16, 2022 - 430 pounds
January 17, 2022 - 420 pounds
January 18, 2011 - 432 pounds
January 20, 2022 - 427 pounds
January 21, 2022 - 416 pounds
January 22, 2022 - 419 pounds
January 25, 2022 - 464 pounds
January 26, 2022 - 488 pounds
January 31, 2022 - 421 pounds

There was no documentation in MR1 indicating nursing staff completed a reweight on this patient to verify an accurate weight on January 27, 18, 21, 25, 26 and 31, 2022, to determine the accuracy of the weight obtained.

Interview with EMP1 and EMP2 on February 28, 2022, at approximately 1430 confirmed there was no documentation in MR1 indicating nursing staff completed a reweight on this patient on January 27, 18, 21, 25, 26 and 31, 2022, to determine the accuracy of the weight obtained on this patient.

Review on February 28, 2022, of MR1's weights for February 2022 revealed:
February 9, 2022 - 427 pounds
February 10, 2022 - 383 pounds
February 11, 2022 - 371 pounds
February 23, 2022 - 373 pounds
February 26, 2022 - 386 pounds
February 28, 2022 - 400 pounds

There was no documentation in MR1 indicating nursing staff completed a reweight on this patient to verify an accurate weight on February 9, 10, 11, 26 and 28, 2022, to determine the accuracy of the weight obtained.

Interview with EMP1 and EMP2 on February 28, 2022, at approximately 1430 confirmed there was no documentation in MR1 indicating nursing staff completed a reweight on this patient on February 9, 10, 11, 26 and 28, 2022, to determine the accuracy of the weight obtained.

Review on March 3, 2022, of MR1's weights for March 2022 revealed:
March 1, 2022 - 446 pounds
March 2, 2022 - 408 pounds

There was no documentation in MR1 indicating nursing staff completed a reweight on this patient to verify an accurate weight on March 1 and 2, 2022, to determine the accuracy of the weight obtained.

Interview with EMP1 and EMP2 on March 3, 2022, at approximately 1330 confirmed there was no documentation in MR1 indicating nursing staff completed a reweight on this patient on March 1 and 2, 2022, to determine the accuracy of the weight obtained.