HospitalInspections.org

Based on a review of clinical records, facility documentation and an interview with staff, the nursing services were not well-organized with a plan of administrative authority and delineation of responsibilities for patient care, as the nursing staff failed to ensure that facility policies and best practice were followed regarding patient personal care.

Findings were:

Patient #1 arrived at the emergency department of PMH on 6-22-20 at 10:43 pm. His chief complaints were shortness of breath and fever. Patient #1's mom had tested positive for Covid-19 4 days prior and the patient's pediatrician had sent him to the ER for an evaluation.

Patient #1 presented with a 3-day history of difficulty breathing, which was constant and worsening. His oxygen saturation level was 83% on room air. The patient's medical history included the following:
* Cerebral palsy
* Spastic quadriplegia
* Seizures
* Colectomy with colostomy placement
* Jejunostomy tube placement

Patient #1 was admitted to the Covid-19 ICU (with enhanced isolation precautions) and intravenous fluids, intravenous antibiotics, a Covid-19 test and an Infectious Disease consult (in part) were ordered.

During patient #1's stay, documentation of personal care and area assessments were as follows:

Bathing
* 6-24-20 at 3:00 am
* 6-25-20 at midnight
* 6-27-20 at 1:15 pm
**No other baths were documented during the patient's stay**

Oral Care
* 6-23-20 at 8:00am, 12:00 pm, 4:00 pm and 8:00 pm
* 6-24-20 at midnight, 4:00 am, 8:00 am, 12:00 pm, 4:00 pm and 8:00 pm
* 6-25-20 at midnight, 4:00 am and 8:00 am
* 6-26-20 (none)
* 6-27-20 (none)
* 6-28-20 at 9:30 am
**There was no documentation of any oral care performed between 9:30 am on 6-28-20 and 4:15 am on 7-1-20, when the patient discharged home.

Gastro-jejunostomy tube/site assessments
* 6-23-20 at 3:30 am, 8:00 am, 12:00 pm, 4:00 pm and 8:00 pm
* 6-24-20 at 8:00 am, 12:00 pm, 4:00 pm and 8:00 pm
* 6-25-20 at 8:30 pm
* 6-26-20 at 9:00 am
* 6-27-20 at 9:00 am and 8:30 pm
* 6-28-20 at 9:30 am and 9:15 pm
* 6-29-20 at 9:00 am
**There was no documentation of any tube/site assessments performed between 9:00 am on 6-29-20 and 4:15 am on 7-1-20, when the patient discharged home.

Colostomy assessments
* 6-23-20 at 2:20 am, 3:30 am, 8:00 am, 12:00 pm, 4:00 pm and 8:00 pm
* 6-24-20 at midnight, 8:00 am, 12:00 pm, 4:00 pm, 6:00 pm and 8:00 pm
* 6-25-20 at 2:00 am, 10:00 am, 2:00 pm, 8:30 pm
* 6-26-20 at 9:00 am, 4:00 pm and 7:30 pm
* 6-27-20 at 9:00 am and 8:30 pm
* 6-28-20 at 9:30 am and 9:15 pm
* 6-29-20 at 9:00 am
**There was no documentation of any assessment or care provided to the patient's colostomy site between 9:00 am on 6-29-20 and 4:15 am on 7-1-20, when the patient discharged home.

In an interview with staff #5 on 10-1-20, staff #5 confirmed that the clinical record contained no documentation of any dressing changes to the patient's gastro-jejunostomy site.

Patient #1 was discharged home to the care of his mother on 7-1-20 at 4:15 am.

Facility policy titled Daily Documentation (EMR/Paper Chart) stated, in part:
" ...
III. Policy:
Nursing documentation will be done each shift with reassessments occurring at change of shift, change of caregiver, change in condition, post intervention, prn or per physician's order.
IV. Procedure:
Steps:
1. Daily assessments and/or reassessments will be done at change of shift, change of caregiver, change in status, prn or per physician's order. An RN [registered nurse] must do an assessment/reassessment on patients at least every 12 hours.
...
4. Assessments/reassessments will include vital signs, intake and output, pain, sepsis screen, neurological, neurovascular, cardiovascular, respiratory, gastrointestinal, genitourinary, integumentary, musculoskeletal, wounds, intravenous access and therapy, tubes and drains, and patient safety related to falls, tissue integrity and VTE [venous thromboembolism] prophylaxis."

According to https://www.infectioncontroltoday.com/view/aacn-updates-patient-bathing-practices-protocol, current American Association of Critical-Care Nurses (AACN) practice recommendations regarding bathing patients included the following:
"A new AACN Practice Alert outlines updated, evidence-based protocols related to bathing adult patients ...
Based on the latest available evidence, the expected practice related to bathing adult patients includes:
* Provide a daily bath for bed-bound patients to improve hygiene and promote comfort. More frequent baths may be performed upon patient request or to respond to patient needs."

The current American Association of Critical-Care Nurses (AACN) practice recommendations regarding oral hygiene found at https://www.aacn.org/~/media/aacn-website/clincial-resources/practice-alerts/oralcarepractalert2017.pdf included the following:
"Expected Nursing Practice
1. Develop and implement a comprehensive oral hygiene program for patients in critical care and acute care settings, including both intubated patients who are at high risk for ventilator associated complications, including VAP [ventilator-associated pneumonia] and non-intubated patients.
a. Brush teeth, gums, and tongue at least twice a day using a soft, compact head (pediatric or adult) toothbrush.
b. Provide oral moisturizing to oral mucosa and lips every 2 to 4 hours.
c. Use an oral chlorhexidine gluconate (0.12%) rinse twice a day in intubated patients to reduce risk of VAP."

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 10-1-20.