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Based on document review and interview the facility failed to provide documentation that patients were provided information that allowed the patient to make an informed consent and failed to capture the patient signature on the consent forms in 3 ( #1, #2, #8) of 8 (#1-#8)
patients whose records were reviewed

This deficient practice had the likelihood to effect all patients of the facility.


Findings included


On the morning of 11/17/2020 in a vacant office the medical records for patients #1 through #8 were reviewed. The review identified three patients with incomplete or non existent consents for admission and treatment and one without a signed consent for procedure.

Patient (Pt/pt) #1 was admitted for a three day history of diarrhea. Pt #1 was alert oriented and mobile under her own power, although she moved slowly. She was directly admitted through the Emergency Department to an inpatient floor for symptoms of Gastritis. She exhibited uncontrolled watery diarrhea.

A review of her consent revealed the admission consent was not signed by the pt but signed by a person who was not identified on the consent, as family or friend. The consent was not dated following this unidentified signature. This was confirmed by the Risk Manager who assisted with the medical record review.

Pt #2 was also admitted after being tested as positive for COVID-19 during a visit to her primary care physician. Shortly after her admission her breathing deteriorated and the patient consented to being intubated to ease her breathing difficulty. The patient posted on her Facebook page. "I did my best. I'm going to die on a ventilator. I'm going to be intubated".

A review of pt #2's medical record found no signed consent but a documented conversation was found in the nurses note indicated, the "family aware of need for ventilator status".


Patient #8 was also a COVID-19 patient and the consent was electronically filled out but there was no signature of other documentation the patient consented to the admission or treatment that followed. The consent read, "Contact isolation". The consent was cosigned by staff without further evidence the patient was actually involved with the consent process.

An interview with the Chief Executive Officer and the Risk Manager confirmed there was a telephone available to the patient in his room and, he was alert and oriented and, could have at a minimum given verbal consent which could have been documented as the method consent was obtained. The managerial staff further confirmed "contact isolation" did not prevent nursing staff from interacting with an isolation patient for the purpose of obtaining consent for admission and treatment.

Based on record review and interview the facility failed to ensure their Registered Nurses documented a thorough skin assessment, and documented nursing interventions were provided for one debilitated patient, patient #1 of patients #1 through #8 from May 21 through May 28, 2020.

This deficient practice had the likelihood to affect all patients of the facility.

Findings included

On the morning of 11/17/2020, in a vacant office of the administrative building the medical records for the above patients were reviewed. The review was facilitated by the presence and assistance of the Risk Manager.

Patient (Pt/pt.) #1 was a 71-year-old female pt. who was admitted through the emergency department (ED) of the hospital with a three-day history of nausea, vomiting, stomach cramps, and diarrhea. Initial testing indicated open loops of both small and large intestines, leading the physician to suspect gastritis and some other intestinal condition, rather than a bowel obstruction.

Pt. #1 was in renal failure secondary to dehydration, she was tired and weak upon her arrival to the ED. She was admitted to the Intensive Care Unit (ICU) in critical condition.

Review of the History and Physical (H&P) revealed past medical diagnosis of Hypertension, Coronary Artery Disease, and Congestive Heart Failure. She had pitting edema noted in her bilateral legs. It was recorded in the H&P that pt. #1 had begun exhibiting symptoms of food poisoning after eating chicken at a fast food restaurant. The admitting physician included in his documentation that pt. #1, was having frequent watery stool. The H&P was dictated in the evening of her arrival to the ED, by the admitting physician on 5/19/2020. It was typed and electronically signed before pt. #1 was transferred to the ICU on 5/21/2020. This document was available for the Registered Nursing (RN) staff review, which would provide them additional informational to care for pt. #1.

A review of the admitting RN's documentation for pt. #1's initial skin assessment revealed the phrase, "WDL" for pt. #1's skin. Interview with the Risk Manager, staff #4 confirmed "WDL" was an abbreviation for "Within Defined Limits". She further confirmed the Governing Body/Physician medical staff had not approved a document that provided age appropriate, or ethnicity specific parameters for skin assessment. She agreed there was no way to determine what pt. #1's skin appearance was upon admission. A further review of the medical record (MR) for pt. #1 identified in the nursing care plan the phrase, "altered skin integrity", however, there was no further entry in the documentation that explained what part of pt. #1's body had present altered skin integrity or potential altered skin integrity. Staff #4 confirmed there was no clear explanation of the location of the "altered skin integrity" in pt. #1's MR.

Review of the recurring skin assessment failed to describe pt. #1's skin condition. The assessment included pt. #1 had a rectal tube placement for controlling the frequent watery stool, she was continuing to have. The RN routinely documented pt. #1's multiple times per shift loose stool that was leaking around the rectal tube but failed to assess pt. #1's skin condition, where the liquid stool came in contact with her peri anal skin tissue.
An interview with staff #4 indicated the RN staff were not required did not provide wound treatment, should it occur. Wound care would be provided by the Physical Therapy (PT) Department. Staff #4 also confirmed that the PT staff would not be responsible for hygiene needs of pt. #1 each time her bowel evacuated, and leakage occurred around the rectal tube. That would be the responsibility of the RN and Nurse Aide staff.

Further review of the MR for pt. #1 indicated barrier cream had been ordered for use on pt. #1's peri-rectal skin tissue to reduce the risk of skin breakdown, related to stool coming in contact with the skin.

The MR indicated the nurse's aides had documented that on 2 occasions pt. #1 refused her bath at the time she was approached to receive it. There was no further entry documented that a second attempt was made to provide hygiene needs for pt. #1 or that any nurse followed the patient to assess the condition of her peri-rectal skin condition.

Pt. #1 was discharged home on 5/27/2020, with home health (HH) services scheduled. The discharge nurse's assessment did not include the skin assessment and the RN's documentation did not indicate the nurse was aware of pt. #1's skin condition.

On 5/28/2020, the home health nurse evaluated pt. #1 for admission for HH services. The admission nurse photographed pt. #1's back side and contacted pt. #1's physician to advise him of her findings related to pt. #1's skin condition. The physician ordered pt. #1 to be sent back to the hospital for wound evaluation and treatment, if needed. The HH photograph was provided for review. The photograph reflected skin discoloration from the top to the bottom of pt. #1's gluteal fold. The lower portion appeared bright pink and the top portion was covered with black tissue. It was unclear from the photo if the area of blackness was simply dead tissue covering healthy tissue or if the black discoloration represented eschar, which would indicate deep tissue injury.

An interview with the Director of the Therapy Department confirmed she had been notified of pt. #1's arrival in the ED. She evaluated pt. #1's skin and indicated she was surprised by what she found. After evaluating pt. #1's skin, the PT explained she provided a thorough cleansing of pt. #1's buttocks and documented her finds with post hygiene photographs. The PT provided copies of the photographs for review. The area of black tissue had been removed during the cleansing and was found to be dead tissue with a heavy layer of skin barrier cream. There was intact healthy tissue below the black layer of dead skin.

Although pt. #1 had naturally dark skin pigmentation, after the PT had cleansed her buttocks pt. #1, exhibited health pink tissue over most of her buttocks, that included the gluteal folds. Pt. #1 had 2 small breaks in her skin integrity on the fleshy portion of her bilateral buttocks. The photographs indicated shallow stage II wounds that resembled deep cracks in the tissue as opposed to craters in her skin.

An interview with the Risk Manager, confirmed the lack of RN documentation of assessment. The lack of documentation by the RN staff indicated the nursing staff had not considered pt. #1's reduced mobility and decreased mental function related to her renal failure, could lead to increased immobility and skin breakdown. The RN staff also failed to recognize that pt. #1's age, generalized weakness, compounded with fecal incontinence, placed her at high risk for skin breakdown, and secondary infection.