HospitalInspections.org

Based on review of documentation and interviews with facility staff, the facility failed to ensure that a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available.

The findings were:


The facility procedure document titled, "Electronic Nursing Documentation and Intervention Documentation Frequency," states, "An admission history is completed and signed by an RN within four hours of admission or as specified in policy of specialty care manual ...Admission History includes documented consideration of psychosocial factors, environmental factor, self-care factor, educational needs, cultural/spiritual needs, and discharge planning factors. Nutritional status, functional status for rehabilitation and evidence of abuse are included ...An RN will assess the patient at a minimum of every 24 hours. Every 24 hours a skin and fall risk assessment will be completed by an RN ...Daily and as activity occurs for patient: Hygiene, Activities of Daily Living, Nutrition every meal ...Positioning NOTE: If patient cannot reposition himself/herself, he/she must be repositioned at least every two hours ..."

The wound care clinical note by the wound care RN on 3/23/18 states, "A joint visit was made with [med/surg] RN for a focused assessment of the wounds to the sacrum and ischium ... Recommendations: Clean the sacral wound daily and as needed for soiling with wound cleaner or sterile saline. Pat dry and pack with Aquacel Ag and cover with a silicone foam dressing. Clean the right and left ishial wounds daily with sterile saline pat dry and apply a silicone foam dressing. Change daily and as needed. Clean the left hip pressure injury with wound cleaner or sterile saline daily and as needed for soiling then pack with Aquacel Ag and cover with silicone foam dressing. The patient would benefit from following up with wound care clinic once discharged. She will also benefit from home healthcare. Maintain the patient on the dolphin bed while she remains in the hospital. Turn every 2 hours and as needed. Use pillows and turn wedges for positioning and off loading pressure. Report any wound or skin concerns to the MD or wound care nurses ... [med/surg] RN was updated on visit findings and recommendations. [med/surg] RN will speak with attending MD on recommendations for wound care and obtain orders from the MD. Wound care nurses are signing off the case."


Staff #6, RN Charge Nurse Med/Surg Unit was interviewed on the unit on 9/25/18 at 0945. Staff #6 was asked how often does the staff perform patient rounding and Staff #6 replied, "They usually round every hour during the day shift and every two hours during the night shift." Staff #6 was asked when the patient's hygiene needs are assessed. Staff #6 replied, "The day tech will ask every morning if the patient wants a shower or bath and the nurses will unhook the patient from the IV pump or remove the heart monitor. If the patient refuses, the tech will document that they refused a shower or bath that day."



A review of the medical record of Patient #1 on 9/25/18 indicated:
1. The Med/Surg clinical note documentation on 3/20/18 revealed:
a.No documentation could be found or provided to the surveyor to indicate that the day shift staff assessed the patient's daily bath/shower needs
b. The only documentation for "positioning" occurred at 2200.

2. The Med/Surg clinical note documentation on 3/21/18 revealed:
a. No documentation could be found or provided to the surveyor to indicate that the day shift staff assessed the patient's daily bath/shower needs
b. Documentation for "positioning" occurred at 0400, 1000, 2011, and 2330

3. The Med/Surg clinical note documentation on 3/22/18 revealed:
a. No documentation could be found or provided to the surveyor to indicate that the day shift staff assessed the patient's daily bath/shower needs
b.The only documentation for "positioning" occurred at 0334.

4. The Med/Surg clinical note documentation on 3/23/18 revealed:
a. No documentation could be found or provided to the surveyor to indicate that the day shift staff assessed the patient's daily bath/shower needs
b. No documentation could be found or provided to the surveyor to indicate that the patient's diaper was changed on this day.
c. Documentation for "positioning" occurred at 0800, 1200, and 1615

5. The Med/Surg clinical note documentation on 3/24/18 revealed:
a. No documentation could be found or provided to the surveyor to indicate that the day shift staff assessed the patient's daily bath/shower needs
b. The only documentation for "positioning" occurred at 2144
c. No documentation could be found or provided to the surveyor to indicate that the clinical staff performed a wound assessment on this day

In an interview with Staff #1 on the afternoon of 9/25/18 Staff #1 acknowledged the finding above.