HospitalInspections.org

Based on record review, observation, and interview, the registered nurse failed to supervise and evaluate the nursing care provided to each patient. This deficient practice is evidenced by:
1. failing to ensure the condition of patients' skin was accurately assessed on admit, daily per shift, with changes, and/or upon discharge for 2 (#2, #4) of 4 (#1-#4) sampled patients reviewed for skin assessments at the hospital's main campus and 1 (#10) of 3 (#5, #9, #10) sampled patients reviewed for skin assessments at the hospital's offisite campus;
2.failing to ensure a patient's (#10) unstageable hip ulcer was treated to prevent the wound from worsening for 1( #10) of 1 patients reviewed with a pressure ulcer from a patient sample of 7 who were reviewed for wounds (#1-#4 at the hospital's main campus and #5, #9, and #10 reviewed at the offsite campus); and
3.failing to ensure a patient with an unstageable hip ulcer (#10) and a patient with a thigh wound (#9) had been assessed for treatment by the wound care nurse practitioner, as ordered, for 2 (#9, #10) of 3 (#5, #9, #10) sampled patients reviewed for wounds at the hospital's offsite campus.

Findings:

1. Failing to ensure the condition of patients' skin was accurately assessed, on admit, daily per shift, and/or upon discharge.

Review of the hospital policy titled Skin/Wound Care last revised 12/01/2018 revealed in part: the purpose is to identify patients at risk for skin breakdown and pressure injury formation and skin abnormalities and provide interventions for the prevention, assessment and treatment of such. The procedure included a skin assessment to be completed by the registered nurse on all patients at admission, weekly, after a fall/injury, upon new skin findings, and at discharge. Description of skin abnormalities should be documented according to assessed findings including the initiation of the impaired skin integrity treatment plan. Wound care protocol/prevention will be implemented as applicable and as ordered by the Physician/Non-Physician Practitioner (NNP).

Patient #4
Review of Patient #4's medical record revealed an admission date of 10/07/2020 with an admission diagnosis of suicidal ideation with a plan. Further review revealed the patient had the following co-morbid diagnoses: Non-insulin dependent Diabetes Mellitus, broken humerus- right arm, and bilateral BKA (below the knee amputations).

Further review of Patient #4's medical record revealed his Braden Skin Risk Assessment score was 17 on 10/7/2020 and on 10/11/2020 (score of less than 18 indicates patient is at risk for skin breakdown).

Review of Patient #4's Skin Assessment and Wound Documentation forms revealed the following entries:
10/07/2020: Admission Assessment: Surgical incisions, bilateral BKA, no wounds, and skin intact.

10/11/2020 3:00 p.m.: Bilateral BKA, no wounds, and skin intact.

Review of Patient #4's daily nurses' note documentation from 10/07/2020 - 10/13/2020 revealed the patient's skin was documented as BKA, integumentary assess, or left blank. There was no other detail/description of the condition of the patient's skin documented.

Review of a medical progress note, dated 10/12/2020, completed by S5NP, revealed the following: Various scabs present to Bilateral BKA, positive for purplish bruising on right elbow, right anterior thigh wound with large scabbed area, positive for serosangunious drainage, consult S3WC for follow-up regarding possible infection.

Patient #4's medical record was reviewed and S2DON confirmed there was no documentation in the record regarding the skin breakdown and bruising/swelling of the patient's arm and middle finger of his right arm referenced in S5NP's progress note from 10/12/2020. She indicated she was going to perform a body audit and surveyor requested to observe the patient's audit.

On 10/13/2020 at 1:50 p.m. an observation was made of Patient #4's skin during a full body audit performed by S2DON. The patient was observed to have numerous blackened scabbed areas on his bilateral thighs and forearms, ranging from pencil eraser size to the size of a nickel. He had a large, partially scabbed wound, measured to be 4 cm in width and 5 cm in length (approximately half dollar sized) that was red and moist with serosanguinous drainage noted when the dressing (dated 10/12/2020) was removed for observation. The patient's right arm (broken arm) was noted to be edematous from the elbow down and had a large, yellowish- green bruised area, covering his entire upper arm. A light purplish-blue 2" x 3" bruise was also noted on his left upper arm. The patient's middle finger on his right hand was noted to have a grayish-black scab on the tip, was edematous, and was noted to be twice the size of his other fingers. The patient reported the tip of his finger needed to be amputated. Moisture related skin redness was also noted in the patient's groin and leg creases (where the disposable brief contacted the patient's skin). S2DON confirmed there was no documentation of the wound dressing change or a description of the wound in Patient #4's medical record.

In an interview on 10/13/2020 at 2:11 p.m. with S5NP, she confirmed her assessment of Patient #4 on 10/12/2020 was the first time she had seen the patient. S5NP reported she had started the patient on Doxycycline based upon the multiple scabbed areas located on his arm, both legs and the large scabbed area draining serosanguinous fluid due to the wound possibly being infected. S5NP further reported Patient #4's arm from his elbow down was edematous and bruised and confirmed that was the arm with the fracture (Patient was admitted with a fracture). S5NP also indicated she was particularly concerned with the tip of Patient #4's middle finger on his right hand being blackish-gray colored and swollen. She indicated the patient had reported that part of that finger needed to be amputated. S5NP indicated she needed to talk to S3WC about Patient #4's finger because they may have to send the patient to the ED for a higher level of care because he may need to have surgery on his finger. S5NP confirmed the patient's multiple skin issues she had observed on 10/12/2020 were not new and were likely to have been present on admission due to their appearance.

Patient #2
Review of Patient # 2's medical record revealed an admission date of 12/16/2019 with an admission diagnosis of major depressive disorder and co-morbid diagnoses of Diabetes Mellitus, Cirrhosis, and Chronic Kidney Disease, Stage III. Further review revealed the patient had bilateral lower extremity edema with venous stasis changes to both lower legs, an ulcer of the medial aspect of the right great toe, and was being treated for cellulitis in his legs.

Review of a wound care note, dated 12/24/2019, by S3WC, revealed the following: Venous stasis changes to right lower leg and ulcers of right great toe. Diffuse atherosclerotic plaque in both lower legs (per Doppler report) not a candidate for compression therapy. Cellulitis of lower extremity right lower leg. Right great toe appears to have had a blister on medial aspect that burst and left a small ulcered area: 1.2 x 1.4 x 0.1 (no units of measure indicated in note) 100 % granulation tissue, scant serosangunious drainage, and peri-wound is intact. No pain with palpation or signs/symptoms of infection. Measurement of right lower leg shows foot 25 cm, ankle 26 cm and calf 44 cm. DP pulse non-palpable but is dopplerable. On doxycycline for cellulitis. Assessment/Plan: Bilateral peripheral vascular disease.

Review of Patient #2's medication administration record revealed the following wound treatments:
Start date: 12/25/2019: Clean left small toe laceration with wound cleanser, pat dry, apply Silver alginate, cover with clean gauze and secure with coban wrap, change every other day and as needed.
Start date: 01/01/2020: Cleanse left lower leg with wound cleanser, apply bactroban ointment to multiple scabbed areas. Wound care documented through 01/13/2020.
Start date: 01/01/2020: Right posterior thigh ulcer: Clean with wound cleanser, apply silver alginate, cover with telfa dressing and change every other day and as needed. Wound care documented through 01/13/2020.
Start date: 01/03/2020: Cleanse right medial great toe ulcer with wound cleanser, apply silver alginate, cover with telfa dressing and change every other day and as needed. Wound care documented through 01/13/2020.

Review of Patient #2's skin assessments/body audits, on 10/13/2020 at 10:15 a.m., with the assistance of S2DON, revealed the following Skin Assessment and Wound Care documentation:

12/16/2019 admit assessment: Body diagram had lower extremities circled with a hand written notation: Scaly, venous stasis, discoloration BLE (bilateral lower extremities). Further review revealed there was no description of the discoloration to the patient's bilateral lower extremities. S1Adm, also present during the record review, confirmed the patient's skin assessments should have been more descriptive.

12/21/2019 05:00 a.m.: Venous stasis ulcer bilateral lower extremities and skin tear to right thigh. Additional review revealed no description of the size and appearance of the wounds. S2DON indicated there was no photo with this skin assessment.

12/28/2019 10:35 a.m.: No documentation of the patient's venous stasis ulcers on his bilateral lower extremities, skin tear to his right thigh, or the abrasion to right foot. S2DON also confirmed there were no photos of the redness referenced in Patient #2's groin and buttocks referenced in the assessment.

01/04/2020 10:30 p.m. No documentation of a description of the size or of the appearance of the laceration on the patient's toe. Further review revealed there was no reference made to the patient's venous stasis ulcers on his bilateral lower extremities, skin tear to his right thigh, or the ulcer to the right medial great toe (previously referred to as an abrasion to the right foot).

01/09/2020 12:30 p.m. Photo of a wound documented as a right outer ankle ulcer. S2DON confirmed there was no correlating skin assessment documented and verified there were no nurses' notes describing the size and appearance of the ulcer.

01/11/2020 06:00 a.m.: Skin tear laceration to bilateral lower extremities, edema, and a blister to fifth toe (previously referred as abrasion). Further review revealed there was no description of the appearance or size of the wounds referenced above or the degree of edema.

01/13/2020 10:00 a.m.: No documented evidence of assessment of the blistered area on the patient's fifth toe and skin tear lacerations to bilateral lower extremities.

Review of Patient #2's daily nurses' notes revealed the following, in part:
12/18/2019 - 7:00 a.m. and 7:00 p.m.: skin documented as cradle scalp and elephant leg skin. Further review revealed no other detail/description of the condition of the patient's skin.

Review of daily nurses' notes for 12/18/2019: 7:00 p.m. -7:00 a.m., 12/22/2019: 7:00 p.m. - 7:00 a.m., 12/24/2019: 7:00 a.m. - 7:00 p.m., 01/03/2020: 7:00 p.m. - 7:00 a.m., 01/10/2020 - 7:00 a.m. - 7:00 p.m.: revealed the skin assessment was documented as integumentary assess, or as wounds-see wound care packet with no other detail/description of the condition of the patient's skin.

12/25/2019: 7:00 p.m. - 7:00 a.m.: skin documented as tear (no location or description of the wound), wounds (see wound care packet) and integumentary assess. There was no other detail/description of the condition of the patient's skin.

12/27/2019: 7:00 a.m. - 7:00 p.m.: skin documented as other: BLE discoloration. Further review revealed no other detail/description of the condition of the patient's skin.

In an interview on 10/13/2020 at 10:40 a.m. with S2DON, she confirmed Patient #2 had no other body audits performed after 01/13/2020 and verified there was no body audit performed when Patient #2 was discharged. S2DON reported routine skin assessments and wound care documentation was performed weekly, on Saturdays. She verified patients' skin should be assessed daily and those assessments should be documented in the nurses' notes. S2DON reported patients' skin could be fully visualized and assessed when the patients showered. S2DON confirmed each time a new wound was found it should be documented in the patient's record, a photo should be taken, and a skin assessment should be completed. S2DON further confirmed each skin assessment should be comprehensive and should include all of the patients' identified wounds to date. S2DON agreed the day to day documentation of skin issues should have been descriptive to include size, color, appearance, presence/absence of drainage, and presence/absence of odor.

In an interview on 10/13/2020 at 10:45 a.m. with S1Adm, she confirmed patient skin assessments should have been performed on admission, weekly, with new findings, and at discharge. S1Adm confirmed the skin assessments were not descriptive and they should have been. S1Adm further indicated another Braden skin assessment should have been done and pictures should have been taken when any new finding is discovered.

Patient #10 (offsite campus)
Review of Patient #10's medical record revealed an admission date of 10/07/2020.

Review of Patient #10's Skin Assessment and Wound Care Documentation forms revealed the following:
10/07/2020: admission body audit: Wounds - #1 Pressure Ulcer- eschar, no drainage, Wound #2 discoloration (dark) and skin tear in the crease of the buttocks, no drainage; Wounds #3: scratches and scabs in various stages of healing covering both arms and legs, Wound #4: circular spots slightly darker than skin color neck area- all of the above indicated on body audit body diagram. A photo was also taken of the above referenced wounds.

10/09/2020: Wound #1: Pressure Ulcer: Eschar, no drainage, Wound #2 discoloration (dark) and skin tear in the crease of buttocks, no drainage; Wounds #3: scratches and scabs in various stages of healing covering both arms and legs, Wound #4: circular spots slightly darker than skin color neck area- all of the above indicated on body audit body diagram. A photo was also taken of the above referenced wounds.

Review of Patient #10's daily nurses' note documentation from 10/08/2020 - 10/13/2020 revealed the patient's skin was documented as integumentary assess or the section was left blank. There was no other detail/description of the condition of the patient's skin documented. S2DON confirmed the referenced lack of skin assessment documentation in the daily nurses' notes.


2.Failing to ensure a patient's (#10) unstageable hip ulcer was treated to prevent the wound from worsening.

Review of Patient #10's medical record revealed an admission date of 10/07/2020 with admission diagnosis of Bipolar Depression with Suicidal Ideations and Comorbid diagnoses of Hepatitis C and Urinary Tract Infection.

Review of Patient #10's Skin Assessment and Wound Care Documentation forms revealed the following:
10/07/2020: admission body audit: Wounds - #1 Pressure Ulcer- eschar, no drainage, Wound #2 discoloration (dark) and skin tear in the crease of the buttocks, no drainage; Wounds #3: scratches and scabs in various stages of healing covering both arms and legs, Wound #4: circular spots slightly darker than skin color neck area- all of the above indicated on body audit body diagram. A photo was also taken of the above referenced wounds.

10/09/2020: Wound #1: Pressure Ulcer: Eschar, no drainage, Wound #2 discoloration (dark) and skin tear in the crease of buttocks, no drainage; Wounds #3: scratches and scabs in various stages of healing covering both arms and legs, Wound #4: circular spots slightly darker than skin color neck area- all of the above indicated on body audit body diagram. A photo was also taken of the above referenced wounds.

Review of the medical record revealed a multidisciplinary note dated 10/09/2020 indicating S3WC had been called for a wound care consult.

Further review of Patient #10's medical record revealed no orders for wound care for the unstageable pressure ulcer on the patient's hip.

Review of Patient #10's entire medical record revealed no documented evidence that the unstageable pressure ulcer located on the patient's right hip was being treated.

On 10/14/2020 at 10:13 a.m. an observation was made of Patient #10's skin. Patient #10 was seated in a wheelchair and was noted to be thin and frail. Multiple dark reddish/black circular scabbed wounds were observed on her shins bilaterally, and purplish, red skin tears were noted on her arms bilaterally. A large (approximately the size of a silver dollar) unstageable pressure ulcer was noted on the bony prominence of the patient's right hip/thigh area. The ulcer was covered with Eschar and the borders around the wound were a dark, reddish purple color. No drainage was noted. The pressure ulcer had not been dressed prior to the observation. S2DON measured Patient #10's wound and the measurements were as follows: 4 ½ cm length x 1 cm width x 1 millimeter depth. During the observation the patient reported she already had the pressure ulcer when she was admitted. Patient #10 indicated she wants the wound to get better because it has been there for a while.

In an interview 10/14/2020 at 10:20 a.m. with S2DON, she confirmed there were no wound care orders to treat Patient #10's unstageable right hip pressure ulcer and she verified the wound was not being dressed and no topical treatments were being applied. S2DON reported they were just taking pressure off of it by turning/repositioning the patient every 2 hours and leaving the wound open to air.

In an interview on 10/14/2020 at 10:48 a.m. with S4MD, he reported he believed there was a wound care consult ordered on Patient #10 and the wound care consultant was called. He indicated he had not known the patient had not been seen, and indicated that wasn't was communicated to him by the nursing staff. He said he assumed S3WC had seen Patient #10 already and had addressed treatment of the patient's wounds.

In an interview on 10/14/2020 at 11:50 a.m. with S3WC, he reported this was the first he had heard about Patient #10 needing a wound consult. When he was told there was documentation in the record that he had been called, he indicated he could have forgotten about Patient #10 and further indicated if he had not seen a patient who had an ordered consult within 24 hours the staff just needed to call him back to follow-up.


3.Failing to ensure a patient with an unstageable hip ulcer (#10) and a patient with a thigh wound (#9) had been assessed for treatment by the wound care nurse practitioner, as ordered.

Review of the hospital policy tilted Assessment process inpatient last reviewed 02/01/2020 revealed in part: the purpose was to assess the immediate presenting problem for acuity criteria and determine the appropriate intensity of care. The policy stated an intake screening and assessment which included a nursing admission assessment was performed on all inpatient admissions in order to effectively identify patient symptomology and formulate an individualized treatment plan specific to the patient's presenting problems ....8. The RN will assess weight, height, vital signs, dental screen, visual status, nutritional screen, sensory/motor function, safety risk factors, fall risk, suicide/homicide/potential for violence risk, infectious potentials, current medications prescribed, and family medical history. 9. The RN completes the appropriate screenings and assessment scales to identify needs for consults and additional services. 10. Any screens, visual, dental, nutritional, etc. that identifies high risk factors triggers a physician notification. The physician will then determine the need for additional consults based on the screenings. An order for a consult could ensue.


Patient #10
Review of Patient #10's medical record revealed the patient had an unstageable pressure ulcer located on the bony prominence of the patient's right hip/thigh area.

Further review of the medical record revealed a multidisciplinary note dated 10/09/2020 indicating S3WC had been called for a wound care consult.

Additional review of Patient #10's medical record revealed no notes indicating the patient had been evaluated by S3WC for wound care for the unstageable pressure ulcer on the patient's hip.

Review of Patient #10's entire medical record revealed no documented evidence that the unstageable pressure ulcer located on the patient's right hip was being treated.

In an interview 10/14/2020 at 10:20 a.m. with S2DON, she confirmed S3WC had been called regarding a wound consult for Patient #10. S2DON reported S3WC usually comes within 24 hours when he is called for a wound consult. She agreed the nurses should have followed up when S3WC had not responded within 24 hours and verified there was no documentation of nursing staff following up on the consult request with S3WC.

In an interview on 10/14/2020 at 10:48 a.m. with S4MD, he reported he believes there was a wound care consult ordered on Patient #10 and the wound care consultant was called. He indicated he did not know the patient had not been seen, and indicated that wasn't was communicated to him by the nursing staff. He said he assumed S3WC had seen Patient #10 already and had addressed treatment of the patient's wounds.

In an interview on 10/14/2020 at 11:50 a.m. with S3WC, he reported this was the first he had heard about Patient #10 needing a wound consult. When he was told there was documentation in the record that he had been called, he indicated he could have forgotten about Patient #10 and further indicated if he has not seen the patient within 24 hours the staff just needed to call him back to follow-up.

Patient #9
Review of Patient #9's medical record revealed an admission date of 10/02/2020 with an admission diagnosis of anxiety. Further review revealed a photograph dated 10/08/2020 of right hip with a darkened area of skin which appeared to have a skin tear. On 10/09/2020 there was a TORB by S4MD for butt paste to affected area BID and an order to notify wound care nurse for a stage I ulcer to right hip. The chart failed to reveal a consultation by the wound care nurse.

On 10/14/2020 at 10:30 a.m. an observation was made of Patient #9's right hip during a skin assessment by S2DON. She had a reddened area approximately 3mm in diameter with a skin tear noted in the center.

In an interview on 10/14/2020 at 10:48 a.m. with S4MD, he stated he was aware the patient had a wound care consultation, but he did not look in the notes to see if the consultation was completed.

In an interview on 10/14/2020 at 11:50 a.m. with S3WC, he stated the message from the nurse for Patient #9's wound care consultation went to his spam folder. He further stated if he is not there within 24 hours, they need to call him back.

In an interview on 10/14/2020 at 12:10 p.m. with S2DON, she verified a wound care consultation was ordered on 10/09/2020 and it was not completed. She further stated moving forward, if a consultation is not completed within 24 hours staff was to notify the supervisor and herself.



39791

39791

Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept current, a nursing care plan for each patient. This deficient practice was evidenced by failure of the nursing staff to address all of the patients' medical and psychiatric conditions as identified problems on the patients' plan of care for 3 (#2, #3, #4) of 4 (#1, #2, #3, #4) sampled patient records reviewed for care plans at the main campus and 1 (#5) of 3 (#5, #8, #9) sampled records reviewed for care plans at the offsite campus from a total patient sample of 10 (#1 - #10).

Findings:

Review of the policy titled Treatment Planning; Integrated/Multidisciplinary last revised 02/01/2020 revealed in part: The purpose is to document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of the patient's treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided. The Policy stated in part ...The Treatment Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient's involvement, throughout the course of treatment. The treatment plan includes defined problems and needs, strengths and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower levels of care. The procedure includes ....Revising and developing nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths and limitations, and physician's orders. Initiating individualized treatment problem/nursing diagnosis list as identified in the assessment. Revising the plan based on changes in condition and physician's orders. All physician orders will be incorporated into the Treatment Plan.


Patient #2
Review of Patient # 2's medical record revealed an admission date of 12/16/2019 with an admission diagnosis of major depressive disorder and co-morbid diagnoses of Diabetes Mellitus, Cirrhosis, and Chronic Kidney Disease, Stage III. Further review revealed the patient had bilateral lower extremity edema with venous stasis changes to both lower legs, an ulcer of the medial aspect of the right great toe, and was being treated for cellulitis in his legs.

Review of Patient #2's treatment plan revealed potential for impaired skin integrity and the patient's multiple ongoing skin issues were not identified as problems to be addressed on the plan of care. S2DON confirmed impaired skin integrity and the patient's multiple ongoing skin issues were not addressed in the plan of care.

Patient #3
Review of Patient #3's medical record revealed an admission date of 10/05/2020 with admission diagnoses including Diabetes, history of brain injury and pulmonary embolism treated with anticoagulation.

Review of Patient #3's medication record revealed the patient was receiving Apixiban (Eloquis) anticoagulant 5 mg by mouth twice a day for anoxic brain injury.

Review of Patient #3's treatment plan revealed potential for bleeding related to anticoagulant therapy was not identified as a problem to be addressed on the plan of care. S2DON confirmed anticoagulant therapy was not addressed in the plan of care.

Patient #4
Review of Patient #4's medical record revealed an admission date of 10/07/2020 with an admission diagnosis of suicidal ideation with a plan. Further review revealed the patient had the following co-morbid diagnoses: Non-insulin dependent Diabetes Mellitus, broken humerus- right arm, and bilateral BKA (below the knee amputations).

Review of a medical progress note, dated 10/12/2020, completed by S5NP, revealed the following: Various scabs present to Bilateral BKA, positive for purplish bruising on right elbow, right anterior thigh wound with large scabbed area, positive for serosangunious drainage, consult S3WC for follow-up regarding possible infection.

Review of Patient #4's treatment plan revealed potential for impaired skin integrity and the patient's multiple ongoing skin issues were not identified as problems to be addressed on the plan of care. S2DON confirmed impaired skin integrity and the patient's multiple ongoing skin issues were not addressed on the plan of care.

Patient #5
Review of Patient #5's medical record revealed an admission date 03/18/2020with an admission diagnosis of major depressive disorder with an attempted suicide by overdose. She was discharged on 04/03/2020.
Her medical record revealed the following findings:
*multi-disciplinary note dated 03/24/2020 at 4:45 p.m. stated, "Pt c/o burning sensation to her buttock area. Redness is noted to the area. MD has been notified."
*Progress note by S4MD stated the left buttock area is red, improving slowly.
*A photograph dated 03/28/2020 at 2:40 p.m. displays discoloration to the left hip/buttock area.
*Multi-disciplinary note dated 03/31/2020 at 12:37 p.m. stated, ..."red area to buttocks positive for shingles, script for Valtrex to be sent with paperwork".
*Her discharge summary stated, ... "The patient did have a dermatologic lesion to her buttock during her stay, which was assessed in the emergency room and thought to be shingles."

Review of Patient #5's treatment plan revealed altered skin integrity was not identified as a problem to be addressed on the plan of care..

In an interview on 10/13/2020 at 10:30 a.m. with S1Adm, she verified Patient #5's treatment plan was not updated with altered skin integrity.