HospitalInspections.org

Based on medical record review, policy review, and staff interview, the hospital's nursing staff failed to ensure nursing care was provided and/or delegated to meet the needs of the patients admitted to the hospital. Also, the hospital's nursing staff failed to follow the hospital's policy, "Pressure Injury Prevention and Management".


During a review of Patient # 1's medical records on 10/08/2024 at 12:45 PM with Staff # 13 the following was revealed,

Patient # 1

Patient # 1 was admitted to the hospital on 07/27/2024 at 4:47 PM with pneumonia and generalized weakness. The patient had a history of esophageal cancer requiring radiation treatment, immunosuppression, and stroke. At the time of admission, the patient had a low BMI (body mass index), decreased mobility, malnutrition secondary to esophageal cancer, dehydration, and confinement to the bed.

Staff # 26 (Emergency Room Physician) documented the following assessment on 07/27/2024 at 10:59 AM,

"Review of Systems ...
Gastrointestinal: Positive for diarrhea and vomiting
Skin: Negative ...
Physical Exam:
Constitutional: .... He is well-developed and underweight. He is ill-appearing.
Skin: Skin is warm and dry. No rash."

Staff # 27 (Emergency Room Triage Registered Nurse) documented the following triage assessment on 07/27/2024 at 10:25 AM:

"Skin Color/Condition Assessment: WDL (within defined limits).

The patient did not have any skin rashes or wounds present on admission on 07/27/2024. The Patient was at risk for skin breakdown and pressure injury due to low mobility, decreased BMI (body mass index), poor nutritional status, and excessive moisture due to diarrhea.

On 08/06/2024, the patient was noted to have a hospital-acquired deep tissue pressure injury to his buttocks by the wound care nurse. The wound care nurse reported a safety incident through the hospital's internal safety event reporting on 08/06/2024.

A review of the hospital's policy, "Pressure Injury Prevention and Management" with a revision date of 07/2021 revealed,

"OBJECTIVE: To establish guidelines in an effort to prevent and assist in the management of pressure injuries; to establish guidelines for the systematic assessment of patients for risk of pressure injury development and the identification of the specific factors placing them at risk for development of a pressure injury; provide guidelines for preventative interventions based upon the risk assessment; provide guidelines for the initial response to an identified pressure injury; and outline procedures for documentation and communication procedures ...

Interventions to Address Increased Risk for Pressure Ulcers:

Reposition at least every 2 hours and based on risk for additional pressure ulcers; document position change ...Check incontinent patients for urine/stool at least every 2 and PRN ..."

An interview was conducted with Staff # 28 (Clinical Director of West 3B) (Medical Intermediate Care Unit) on 10/08/2024 at 2:45 PM. Staff # 28 stated, "During my investigation into the hospital-acquired deep tissue injury the patient sustained, I found that turns were not being consistently done every 2 hours with documentation and the consult to the wound care nurses was completed too late."

Based on medical record review and staff interviews, the hospital's pharmacy staff failed to follow the drug manufacturer's prescribing information when verifying the physician's order for a patient's prescription.

During a review of Patient # 1's medical records on 10/08/2024 at 12:45 PM with Staff # 13 the following was revealed:

Patient # 1

Patient # 1 was admitted to the hospital on 07/27/2024 at 4:47 PM with pneumonia due to Klebsiella, and generalized weakness. The patient had a history of esophageal cancer requiring radiation treatment, immunosuppression, and stroke.

Due to the patient's esophageal cancer, the patient was unable to swallow food or medications by mouth and required a PEG (Percutaneous Endoscopic Gastrostomy) tube for nutrition. A PEG tube is a flexible feeding tube that is inserted through the abdominal wall into the stomach to provide nutrition to patients who are unable to eat or drink. Medications administered through a PEG tube must be liquid or crushed.

On 08/04/2024, the patient tested positive for the COVID-19 virus after requiring increased oxygen support.

Physician # 25 ordered Paxlovid (nirmatrelvir 150 mg tablets; ritonavir 100 mg tablets) on 08/04/2024. The order revealed,

"Ordered Dose: 3 Tablets. Frequency: 2 times daily. Admin Instructions: Follow package instructions. Route: Gastric Tube."

Staff # 21 (Registered Pharmacist) verified the order and gave instructions, "crush via GT" (GT refers to Gastric Tube or PEG tube).

The medication administration of Plaxlovid to Patient # 1 was as follows:

"08/04/2024 at 9:36 PM administered via PEG tube.
08/05/2024 at 8:52 AM administered via PEG tube.
08/05/2024 at 9:52 PM hold administration due to displaced PEG tube.
08/06/2024 at 9:18 AM not given.
08/06/2024 at 9:17 PM administered via PEG tube.
08/07/2024 at 10:06 AM not given due to "cannot be crushed."
08/07/2024 at 9:34 PM administered via PEG.
08/08/2024 at 9:54 AM not given due to "cannot be crushed per pharmacy."
08/08/2024 at 9:20 PM administered via PEG tube.
08/09/2024 at 10:33 AM not given due to "cannot be crushed."

A review of the Manufacturer's Prescribing Information for Paxlovid revealed,

"Paxlovid is indicated for the treatment of mild-to-moderate coronavirus disease 2019 (COVID-19) in adults who are at high risk for progression to severe COVID-19, including hospitalization or death ...
2.1. Important Dosage and Administration Information
... The tablets should be swallowed whole and not chewed, broken, or crushed ..."

An interview was conducted with Staff # 21 (Registered Pharmacist) on 10/08/2024 at 1:00 PM in the administrative conference room. Staff # 21 was asked if he recalled the order for Patient # 1. Staff # 21 acknowledged the order for Patient # 21 and confirmed he was the pharmacist who verified the order with instructions for crushing via PEG tube. Staff # 21 was asked to verify the prescribing information for Paxlovid given by the manufacturer. Staff # 21 acknowledged the prescribing information which included the guidance to not crush the tablets. Staff # 21 stated, "It does say not to crush the tablets, but it doesn't say why".