HospitalInspections.org

Based on review of hospital policy and procedures, medical record reviews and staff interviews, the nursing staff failed to provide supervision of nursing care, by failing to remove and assess a cervical collar per hospital policy to prevent skin breakdown for 1 of 1 patient medical records reviewed with a cervical collar. (Patient #14)

Findings included:

Review of the hospital policy titled "Pressure Injury Prevention and Management/Skin Tears/MASD (moisture associated skin damage)/Wounds/Incisions/, Risk Assessment, Appendix A: Pressure Injury Prevention Guidelines," last revised 11/2017, revealed "Pressure Injury Prevention Measures for ALL Patients *...Device care q (every) shift or more frequently, as appropriate ..."

Review of the hospital "Inpatient Skin/Wound Team Device Care Management Guide", last reviewed December, 2017, revealed "qshift (every 12 hours) ...* Collars (Aspen, Aspen Vista, Miami J) - remove, cleanse skin, change pads..."

Review of the closed medical record for Patient #14 revealed a 59 year-old male presented to the Emergency Department on 12/13/2018 at 2258 and was admitted to the hospital on 12/14/2018 at 0220 with trauma and multiple fractures after a motor vehicle crash. Review of the nursing triage notes documented at 2300 revealed "cervical collar in place." Review of the nursing note documented on 12/14/2018 at 0337 by a Registered Nurse revealed skin care was performed for multiple abrasions to the upper and lower extremities bilaterally during the skin assessment. Nursing notes revealed the patient arrived with a Philadelphia cervical collar in place and was changed to a regular Aspen cervical collar with long back pad. Nursing notes revealed the patient's wife arrived and was updated on the plan of care. Review of trauma physician team notes revealed documentation to continue cervical collar. Review of the nursing notes flow sheet from 12/14/2018 through 01/20/2019 revealed documentation of a cervical collar assessment with pad changes on 12/15/2018 at 0000, 0800 and 2200, on 12/16/2018 at 2200, on 12/17/2018 at 1442 and 2045, on 12/18/2018 at 2000, on 12/19/2018 at 2130, on 12/20/2018 at 1600, on 12/21/2018 at 0330, 1200 and 2200, on 12/22/2018 at 1330, on 12/23/2018 at 0030, on 12/24/2018 at 0600 and 2200, on 12/25/2018 at 1000 and 2318, on 12/26/2018 at 2225, on 12/27/2018 at 1930, on 12/28/2018 at 0750 and 2000, on 12/30/2018 at 0655, on 12/31/2018 at 0400, on 01/01/2019 at 0400, 0730 and 1940, on 01/02/2019 at 0740 and 1956, on 01/03/2019 at 2000, on 01/04/2019 at 1930, on 01/05/2019 at 0800 and 2000, on 01/07/2019 at 1600, on 01/08/2019 at 1520 on 01/10/2019 at 0900, on 01/15/2019 at 1300, on 01/18/2019 at 0800 and on 01/19/2019 at 1600. Review of the nursing notes flow sheet from 12/14/2018 through 01/20/2019 revealed no evidence of a cervical collar assessment for day shift (7a-7p) or night shift (7p-7a) on 12/14/2018, 01/06/2019, 01/09/2019, 01/11/2019, 01/12/2019, 01/13/2019, 01/14/2019, 01/16/2019, 01/17/2019 and 01/20/2019. Review of the nursing notes flow sheet revealed no evidence of a cervical collar assessment completed on the day shift (7A-7P) on 12/16/2018, 12/18/2018, 12/19/2018, 12/23/2018, 12/26/2018, 12/27/2018, 12/29/2018, 12/30/2018, 12/31/2018, 01/03/2019 and 01/04/2019. Review of the nursing notes flow sheet revealed no evidence of a cervical collar assessment completed on the night shift (7P-7A) on 01/07/2019, 01/08/2019, 01/10/2019, 01/15/2019, 01/18/2019 and 01/19/2019. Closed medical record review revealed Patient #14 left AMA (against medical advice) on 01/20/2019 at 1816. Review of the medical record revealed the nursing staff failed to assess the cervical collar every shift as per hospital policy.

Interview on 02/14/2019 at 1241 with RN #5 revealed she had worked at the facility for 15 years. Interview revealed she cared for Patient #14 on January 4, 2019. Interview revealed she recalled Patient #14 and his wife. She stated she removed Patient #14's cervical collar on 01/04/2019, assessed and cleaned the area underneath the collar and noted a small reddened area on the clavicle, where the base of the cervical collar rested. Interview revealed she placed a foam pad over the reddened area to prevent further rubbing on the bony prominence. Interview revealed the cervical pads she removed were "very dirty". She stated Patient 14's wife kept the dirty pads stating she (the wife) "wanted to prove how dirty the pads were." Interview revealed staff were expected to remove the cervical collar, assess and clean the area underneath the collar and change the pads if soiled every shift (every 12 hours). Interview revealed staff were expected to change the collar pads more often if pads became soiled. Interview revealed the wound vac dressing had been changed on the day shift. Interview revealed the patient's wife expressed concerns about the exposed foam resting on the patient's "good skin", so she changed the dressing again on night shift. Interview revealed there were no injuries related to the foam exposure, however there was a potential for harm over time if the foam rested on "good skin". She stated the nursing staff changed the wound vac every 3 days and would not have expected any harm to occur prior to the next dressing change. Interview confirmed the findings.

Interview on 02/14/2019 at 1205 with Assistant Nurse Manager #1 revealed patients with cervical collars should receive device care, to include removal of cervical collar, assessment and cleansing of skin underneath the collar and change collar pads if soiled or worn, every shift (every 12 hours). Interview during review of the medical record revealed the nursing staff did not provide cervical collar care per the hospital policy. Interview revealed the physicians/providers did not write orders for device care, however the nursing staff were expected to follow the device care policy/protocol. Interview confirmed the nursing staff failed to follow the "Device Care" policy/protocol. Interview confirmed the findings.

Interview on 02/14/2019 at 1010 with Nurse Manager #2 revealed she recalled Patient #14 and his wife. Interview revealed the nurse manager or her assistant nurse manager met with the patient and/or wife almost daily, due to the wife complaining about patient care. Interview revealed patients should be bathed every 24 hours. Interview revealed the wife complained the patient was not receiving baths daily. Interview revealed she spoke with the wife and explained the patient had been refusing to allow the staff to bath him. Interview revealed the patient would deny he had refused his bath in front of his wife, however the nurse manager reviewed the nursing notes and verified the staff had documented the patient's bath refusals. Interview revealed the patient's wife had complained that the patient had laid in stool and had not been cleaned. Interview revealed the nurse manager reviewed the medical record and found no evidence in the medical record. Interview revealed the management team and the staff placed check boxes for turns, pain management, baths, physical therapy in room, etc., on the white board in the patient's room to assist the patient and wife to know when and what type of care had been provided during the shift. Interview revealed the wife complained about the patient having pressure sores on his sacrum, back and neck. Interview revealed the nurse manager and other nursing staff assessed Patient #14 and found no evidence of pressure sores documented on sacrum or back. Interview revealed documentation in the medical record revealed a reddened area on the clavicle underneath the cervical collar was identified on 01/04/2019 and the nurse placed a foam pad over the reddened area to prevent further rubbing of the cervical collar on the bony prominence of the clavicle.

NC00147303