HospitalInspections.org

Based on observation, interview, record review and policy review the facility failed to:
- Ensure that a Registered Nurse (RN) monitored, supervised, instructed or intervened after delegation of a nursing task to an Unlicensed Assistive Personnel (UAP, individual who assists patients with health care needs under the supervision of a registered nurse) Orthopedic Technician (Ortho Tech) for one patient (#45) of one patient observed during a Peripheral Intravenous (PIV) Insertion (small, flexible tube placed into a vein in order to administer medication or fluids within the vein) procedure.
- Identify, stage (a process by which pressure sores are classified as to the degree of tissue damage from Stage I-IV, with IV being the worst), measure, and document pressure sore assessments, for three (#21, #34, and #38) of five patients reviewed with pressure sores (an opening in the skin caused by pressure over a bony prominence).
- Apply the appropriate, physician ordered, treatment to a pressure sore for one (#34) of five patients reviewed with pressure sores.
- Consistently reposition two patients (#21 and #34), with the use of appropriate positioning devices, to keep pressure off of the patient's buttocks and his heels off of the mattress, resulting in additional facility-acquired pressure areas.
These failures had the potential to affect all patients in the Orthopedic Hospital preoperative suites to high risk for infection, safety and poor outcomes. These failures also had the potential to affect all patients by allowing them to develop pressure sores, by not evaluating the deterioration and/or improvement of pressure sores and by not providing adequate treatment to hasten healing. The facility census was 450.

Findings included:

1. Record review of the policy dated 10/2012 titled, "Peripheral Intravenous (PIV) Insertions Within Perioperative Services," showed the purpose was to assure safe and effective care of the patient within perioperative service requiring PIV insertion.

Record review of the undated facility document titled, "Delegation/Competency," provided by Staff M, Accreditation Manager, showed the following:
Delegation
- We adhere to the Missouri State Board of Nursing (MSBN) and the Nurse Practice Act regarding delegating selected nursing care tasks to unlicensed health care personnel.
- We utilize the Decision Tree for Delegation to Nursing Assistive personnel (NAP) to determine IV (within the vein) starts by Ortho Techs.
Competency
- The RN who delegates the task of an IV start to the Ortho Tech is responsible for monitoring that the task is performed correctly. If the delegating RN identifies any concerns, the task is stopped and reported to the Nurse Supervisor.

Ortho Techs are UAP's employed by the Orthopedic Hospital for the specific task of inserting PIV's in perioperative patients.

2. Record review of the American Nurses Association (ANA) document titled, "Joint Statement on Delegation," dated 2005, showed the following:
- The ANA and the National Council of State Boards of Nursing (NCSBN) both defined delegation as the process for a nurse to direct another person to perform nursing tasks and activities.
- NCSBN describes this as the nurse transferring authority while ANA calls this a transfer of responsibility.
- Both mean that a RN can direct another individual to do something that that person would not normally be allowed to do. Both papers stress that the nurse retains accountability for the delegation.
- The RN takes responsibility and accountability for the provision of nursing practice.
- The RN uses critical thinking and professional judgment when following the Five Rights of Delegation to be sure that the delegation or assignment is: The right task, under the right circumstances, to the right person, with the right directions and communications and under the right supervision and evaluation.

3. Observation on 08/03/16 at 2:25 PM showed Staff AAA, RN, in Patient #45's perioperative (preop, the period of time extending from when the patient goes into the hospital,
for surgery until the time the patient is discharged home) room to prepare the patient for surgery and complete the preoperative assessment and report. She stood at the right side of the patient's bed.

Observation on 08/03/16 at 2:50 PM showed Staff OO, Ortho Tech, entered Patient #45's preop room to insert an intravenous (IV) catheter (used to administer fluids into the vein). Staff OO performed hand hygiene then touched the vital signs monitoring screen before putting on gloves and without performing hand hygiene. She opened the IV sterile kit and put it on the contaminated bed and sat down to the left side of the patient. She put the blood pressure (BP) cuff on the patient's left arm to act as a tourniquet and proceeded to locate a vein. Patient #45 and his wife proceeded to explain to the Ortho Tech that he was, "A very hard stick (difficult to find a vein to penetrate)". He stated that he had endured many operations for broken bones and had been given so many IV medications,"that they had to put the last one in up here" and he pointed to the left subclavian (upper chest) area. Staff OO proceeded to attempt to find an IV site in the patient's left hand. She penetrated the skin but did not receive a flash of blood but continued to move the IV catheter around up and down and sideways while Patient #45 groaned, grimaced, gritted his teeth and pulled his hand back. Staff OO taped the IV in place and attempted to flush the IV even though she never received a 'flash' of blood which would indicate the catheter is within the vein and viable. Patient #45 continued to groan, grimace, close his eyes and grit his teeth. Staff OO removed the catheter from his left hand and held contaminated gauze with dirty gloves on the site. The patient stated, "I'll give you only one more chance".

Observation on 08/03/16 at 2:50 PM showed Staff AAA, RN, who delegated the task to Staff OO was on the right side of the patient's bed standing at the computer. She asked the patient question after question while she typed the answers into the preoperative assessment with her back to Staff OO during the IV procedure.

Observation on 08/03/16 at 3:00 PM showed Staff OO left the patient's room and returned with another sterile IV kit. Again she touched the BP monitoring screen and proceeded to use a rubber band tourniquet on the patient's upper left arm and touched the patient's bare skin to find another vein to access. Without performing hand hygiene she put gloves on and opened the IV sterile package which contaminated all of the items in the IV kit. She inserted the IV into the patient's vein just above the inner antecubital space (inner front elbow area) and covered it with a Tegaderm (a transparent medical dressing used to cover and protect wounds and catheter sites) bandage. Staff OO flushed the inserted IV line and then asked Staff AAA to start the IV drip. While Staff AAA watched, Staff OO pulled back the Tegaderm dressing with her contaminated gloves and then replaced it back over the IV site. Staff AAA moved back to the computer and continued to ask the patient questions and type on the computer.

Staff AAA did not intervene for the failed infection control precautions, the first IV attempt, the patient and spouses concerns, the saline flush or the Tegaderm contamination.

During an interview on 08/03/16 at 3:20 PM, Staff MM, Clinical Supervisor, and Staff NN, Director of Surgical Services, stated that all the patient IV's are inserted by "Ortho Techs".

4. Record review of the facility's policy titled, "Pressure Ulcer Prevention," revised 11/2015, showed the following:
- Assessment for skin breakdown must be completed daily for all patients, every shift for patients with actual skin breakdown and upon admission (admission assessment requires removal of dressings for complete assessment of skin breakdown.)
- Document initial identification of skin breakdown in the "Progress Notes."
- Document a complete wound description with measurements in centimeters (cm-length by width by depth).
- Notify the physician of skin breakdown and obtain orders.
- Consult the wound nurse for pressure sores that are a Stage II (partial thickness skin loss) or greater.
- Assess and measure the pressure sore, preferably with dressing changes, but at a minimum of every seven days.
- Cleanse pressure sores gently, at dressing change, with wound cleanser or Normal Saline (a chemical solution that is similar to the make-up of bodily fluids),
- Utilize pillows for positioning off of bony prominences. Do not position on reddened areas and avoid use of synthetic sheep skin.
- Protect heels: may utilize dressings, and/or pillows.

Record review of the facility's policy titled, "Wound Assessment," reviewed 07/10/15, showed the following:
- A thorough wound assessment should consist of objective criteria and measurements that promote accurate, consistent comparisons to determine the extent of the wound and the effectiveness of wound healing.
- Complete a comprehensive wound assessment during every dressing change, and compare the results to previous assessments so that you can monitor, communicate, treat, and document wound healing progression or complications.
- Equipment would include a disposable wound measuring device;
- Review the patient's medical record for type of wound, previous assessment findings and treatment plan.
- Measure the wound size with disposable wound-measuring device.
- Stage or classify the wound by using the classification system developed by the National Pressure Ulcer Advisory Panel;
- Apply the appropriate wound care treatments and dressing as indicated and ordered.
- Document the procedure.

5. Observation in Patient #21's room, and concurrent interview on 08/02/16 at 2:03 PM, showed the following:
- Staff Y, RN, prepared to change the dressing.
- The pressure sore was located on the patients' left buttock.
- Patient #21 was lying flat on his back rather than being positioned off of his buttocks.
- Staff Y changed the dressing;
- Staff Y placed Patient #21 on his back prior to leaving the room.
- Staff Y stated that the dressing change was ordered to be changed every 72 hours by nursing staff and to determine the increase or decrease in the size of the open area she would "eyeball it" because she did not measure the area.

Staff Y failed to measure and/or document measurements for Patient #21's pressure sore per policy. Staff Y also failed to position the patient off of his back to alleviate continued pressure to his buttock prior to leaving the room.

Record review of Patient #21's History and Physical (H&P) dated 07/27/16, showed that he was admitted with altered mental status, lethargy (abnormal state of drowsiness, listless) and a low sodium level.

Record review of the patient's nursing wound assessment dated 07/30/16 showed that the dressing was changed but no measurement of wound was made.

Staff failed to measure Patient #21's wound for two dressing changes on 07/30/16 and 08/02/16.

6. Record review of Patient #34's H&P dated 06/30/16, showed the patient was admitted on 07/19/16 with a diagnosis of diabetes (can cause poor circulation resulting in wound development and poor healing). No wounds were identified in the H&P.

Record review of physician's Progress Note dated 07/20/16, showed that no wounds were identified in the assessment.

Record review of a physician's order dated 07/26/16, showed staff were to keep the patient's heels off of the mattress and apply Mepilex (a padded adherent-type dressing) dressings to both heels, changing every three days or as necessary.

Record review of the pressure injury prevention nurse recommendations dated 07/26/16, showed the patient's heels should be protected and floated (kept above the mattress, or any surface) while in bed.

Observation in Patient #34's room, and concurrent interview on 08/03/16 at 9:30 AM showed the following:
- The patient had one sheep skin heel bootie on and one off (lying within the sheets and not to be used per policy).
- The patient did not have the "ordered" Mepilex dressings on his heels, and Staff EE, RN, did not know why.
- The patient's heels were lying directly on the mattress.
- The patient had open areas on both heels, and both were draining.
- Staff EE failed to cleanse, measure and/or stage the heels prior to placing the clean Mepilex dressings. The patient's heels were left on the mattress surface.
- The patient stated that the pressure sores on his heels were facility-acquired.

Record review of pressure sore documentation from 07/19/16 through 08/03/16 showed that on 07/26/16, at 1:30 PM, the patient had a facility-acquired suspected deep tissue injury (SDTI-a purple or maroon localized area of intact skin due to damage of underlying tissue) measuring 3.0 cm by 2.0 cm on the left heel; this area was shown to be open. The patient also had a facility-acquired SDTI measuring 1.0 cm by 1.0 cm on the right heel. Staff failed to stage the open areas on the left heel. On 08/03/16, the patient had a round, pink and white area on the right heel. The patient also had a red, irregular pink and white area on the left heel. Staff failed to measure, stage and/or describe either heel per policy.

7. Record review of Patient #38's H&P dated 07/26/16, showed that he was a transfer from another facility and was admitted with shortness of breath and fever. He was diagnosed with a urinary tract infection, pneumonia, sepsis (a potentially life threatening complication of an infection), and acute renal failure (kidney failure). Previous medical history showed that the patient also had dementia and diabetes. No wounds were identified in the H&P.

Record review of the skin team consult note dated 07/28/16, showed the patient had an ulceration on the coccyx. The skin team recommended a Mepilex dressing to be changed every three days or as needed.

Record review of nursing documentation of wound care between 07/28/16 and 08/03/16 showed:
-07/28/16 dressing changed, no measurement of wound;
-07/29/16 dressing changed, no measurement of wound;
-07/30/16 dressing changed, no measurement of wound;
-08/01/16 dressing changed, no measurement of wound.
Staff failed to follow facility policy for wound measurement for four dressing changes.

During an interview on 08/03/16 at 1:02 PM, Staff V, RN, Nurse Manager, verified that staff had failed to measure Patient #38's wound when they visualized the wound during dressing changes for four dressing changes from admission to the present date.

During an interview on 08/02/16 at 2:40 PM, Staff V, RN, Nurse Manager, stated that she expected all nursing staff to measure, and document those measurements, when they assessed a pressure sore during a dressing change. She stated that measuring was a way to track the improvement or worsening of the pressure sore.

During an interview on 08/03/16 at 1:30 PM, Staff LL, Wound Nurse Manager, stated the following:
- The RN responsible for the patient was to implement the recommendations of the wound nurse.
- Any preventative measure can be implemented by the RN without an order, but a treatment required an order.
- A wound/pressure sore should be measured and staged at the time of identification.
- A SDTI could be deep or resolve without opening. The main preventative measure would be to offload and protect.
- A sheep skin bootie did not relieve pressure on heels.
- Cleansing is preferable before a new treatment is applied.

During an interview on 08/04/16 at 9:48 AM, Staff QQ, Clinical Excellence RN, stated that nurses should assess, clean, measure/stage and re-apply treatments as ordered.



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