HospitalInspections.org

Based on medical record (MR) review, document review, and interview, the facility failed to ensure compliance with the Condition of Participation (CoP) of Nursing Services as evidenced by deficient practices identified during survey. These findings place all patients at risk for harm.

Findings include:

The facility failed to ensure that:

-- Staff assessed and documented, in the MR, a patient's (Patient #1) bowel status daily. See Tag A395

-- Staff put interventions in place to prevent pressure ulcer development in 2 patients (Patient #2 and Patient #1). See tag A395

Based on document review, medical record (MR) review and interview, 1) in 1 of 10 MRs reviewed (Patient #1), nursing staff failed to assess a patient's bowel status for 7 days. 2) In 3 of 10 MRs (Patient #1 and Patient #2 [2 admissions]) reviewed, both patients developed hospital acquired pressure injuries (skin breakdown) during admission. 3) In 6 of 6 MRs reviewed (Patient #1 - Patient #5 [Patient #2 had 2 admissions]) of patients identified as being at risk for pressure ulcer development, all lacked consistent documentation of turning and positioning. This lack of nursing assessment, documentation and consistent turning and positioning led to untoward patient outcomes.

Findings regarding (1) include:

-- Review of the facility's document titled "Bowel Regime Guidelines," undated, indicated that the patient's date of last bowel movement is communicated during shift report, during inter-disciplinary case conference and documented in the MR and/or Kardex (medical information sheet). Consider use of a stimulant laxative as a rescue method with other laxatives if the patient has not had a bowel movement for 2 days or longer.

-- Review of Patient #1's MR revealed, she was admitted to the hospital on 3/17/19 with crushing chest pain. The patient was anemic with a hemoglobin (Hgb) of 10.7 (normal 12.2) and hematocrit of 34.1 (normal 35-47). On 3/25/19 Patient #1 had a double contrast barium enema to determine the source of anemia. Open heart surgery was performed on 3/28/19. There is no documentation of Patient #1's bowel status from 3/25/19 (after bowel prep for barium enema) to 4/2/19. On 4/2/19 an abdominal x-ray revealed barium still present in the colon. Multiple interventions were then necessary and administered, including Miralax, Milk of Magnesia (MOM), Fleets enemas, Dulcolax suppository and Colace.

-- During interview of Staff A, Nurse Manager on 5/16/19 at 11:00 am, he/she acknowledged the above findings.

Findings regarding (2) include:

-- Review of Patient #2's MR indicated he was admitted to the hospital on 3/2/19 with a diagnosis of shortness of breath and malaise. Small bedsore was noted on the left buttock with no redness or drainage.

Nursing documented on the Skin Assessment form on admission on 3/3/19 at 12:05 am, that Patient #2 had an ulcer in the sacral area (lacked description).

On 3/14/19 documentation by the Wound, Ostomy, Continence Nurse (WOCN) at 10:02 am revealed the following skin breakdown on Patient #2:
- 1-centimeter (cm) x 0.3 cm purple mark on right hip surrounded by a large area of blanchable redness
- 3 cm x 0.5 cm purple mark on right ischial (lower back part of hip bones) area surrounded by red blanchable skin
- 2 cm x 0.5 cm purple mark on left ischial (lower back part of hip bones) area surrounded by red blanchable skin
- 3 cm x 3 cm red slow to blanch skin on the left hip
Patient has 3, possibly 4, hospital acquired deep tissue injuries. Discussed with spouse the likelihood of these injuries opening to become pressure injuries that could be quite deep.

On 3/19/19 at 8:00 pm (night prior to discharge) nursing documented, Patient #2 had an open sore on his right hip, open sore noted on both buttocks and bottom was red. Bilateral heels were red and there was an open sore on the right outer aspect of the ankle.

-- On 4/1/19 - 4/11/19 Patient #2 was readmitted to the hospital with a diagnosis of septic vs hypovolemic shock, decubitus ulcer and a urinary tract infection. On 4/3/19 he had a debridement (removal of damaged tissue) of the pressure ulcer over the right ischial tuberosity (lower back part of hip bones). The edges of the wound were debrided, necrotic (dead) tissue was removed, bone was seen at the base of this. Negative-pressure wound therapy (NPWT) was initiated (therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds).

-- On 5/2/19 Patient #2 was readmitted to the hospital with a diagnosis of pneumonia. Braden scale scores were calculated daily from 5/2/19 - 5/16/19 and ranged from 8-12 (indicating Patient #2 was very high risk/high risk for skin breakdown). The WOCN saw the patient on the day of admission (5/2/19) and documented 2 pressure ulcers were present on right and left ischium (lower back part of hip bones). Patient #2 had NPWT in his right ischium (lower back part of hip bones) decubitus. Then on 5/7/19 at 8:37 am WOCN documentation indicated, the coccyx (tailbone) and just to the right is red and non-blanchable. There are small areas beginning to open on the coccyx (tailbone). This represents a stage 2 pressure injury, that was not present on admission (5/2/19).

-- Review of Patient #1's MR, hospitalized from 3/17/19 - 4/15/19, revealed she developed a stage 3 pressure ulcer during her hospital stay. Her admission assessment on 3/17/19 indicated no pressure ulcers present. A Wound Ostomy Care RN progress note dated 4/11/19 documented the following: "There is a small superficial full thickness wound on the coccyx (tailbone), stage 3 pressure injury."

-- During interview of Staff B (Director of Nursing) on 5/17/19 at 1:30 pm, he/she acknowledged the above findings.

Findings regarding (3) include:

-- Review of the facility's policy and procedure (P&P) titled "Wound Prevention and Treatment Protocols," last revised 8/2018, indicated a head to toe skin assessment should be done on admission and daily thereafter. If a patient's Braden Scale Score is less than 18 they are considered at risk for skin breakdown. Interventions should be based upon the Braden Subscale Scores for sensory perception, moisture activity, mobility, nutrition, and friction and shear. For each subscale score less than 3, implement "at risk" standards of care (e.g., ensure patient is turned and repositioned at least every 2 hours while in bed and hourly when in a chair, institute written repositioning schedule, assess skin every shift, monitor intake and output, position pillows to elevate pressure points off the bed, etc.).

-- Review of Patient #2's MR, admission on 3/2/19, indicated his Braden scores were calculated daily, for example Braden scores from 3/17/19 - 3/19/19 ranged from 10-12 (indicating Patient #2 was high risk for skin breakdown). All of his Braden Subscale Scores for sensory perception, moisture activity, mobility, nutrition, and friction and shear were less than 3, which required the implementation of numerous preventative measures, as indicated in P&P.

Documentation of turning and positioning from 3/17/19 - 3/19/19 was as follows:
3/17/19 at 2:29 am - position turned right
3/17/19 at 5:57 pm - turned (15 1/2 hours later)
3/18/19 at 2:42 pm - position turned left (9 hours later)
3/18/19 at 5:44 pm - turned (3 hours later)
3/19/19 at 3:49 am - turned (10 hours later)
3/19/19 at 2:21 pm - turned (10 1/2 hours later)
3/19/19 at 4:31 pm - turned (2 hours later)
3/19/19 at 10:41 pm - turned (6 hours later)

Additional nursing documentation from 3/17/19 - 3/19/19 revealed on 3/19/19 at 11:45 pm Patient #2 was turned and positioned every 2 hours.

-- Review of Patient #3 MR indicated he was admitted on 5/12/19 with back pain and difficulty ambulating (broken left foot). His Braden Score on 5/14/19 at 9:43 am was 14 (moderate risk for skin breakdown) and on 5/15/19 at 9:14 am was 15 (low risk for skin breakdown). Braden Subscale Scores for activity, mobility and friction and shear were less than 3, which required the implementation of numerous preventative measures which required the implementation of numerous preventative measures, as indicated in P&P.

Documentation of turning and positioning on 5/14/19 was as follows:
- 5/14/19 at 2:21 pm - turned
- 5/14/19 at 9:39 pm - turned (7 hours later)
- 5/15/19 at 2:30 pm - turned (17 hours later)

-- The same lack of documentation regarding turning and repositioning patients at risk for skin breakdown every 2 hours was found in MRs for Patients #1, #4 and #5.

-- During interview of Staff B on 5/17/19 at 1:30 pm, he/she acknowledged the above findings.