HospitalInspections.org

Based on record review and staff interviews, it has been determined that the hospital failed to meet the Nursing Services Condition of Participation (COP) relative to providing the necessary treatment and services, consistent with professional standards of practice, and hospital policy to prevent, identify, and/or treat new wound areas for 3 of 8 patients reviewed related to wounds. Additionally, the hospital failed to follow their own policy related to "Discharge Planning".

Findings are as follows:

-The hospital failed to follow their policy related to "Pressure Ulcer/Skin Integrity/Mucosal Injury". (Refer to A 0395)

-The hospital failed to ensure that all staff adhere to the policies and procedures related to "Discharge Planning". (Refer to A 0813)

Based on record review, surveyor observation and staff interviews, it has been determined that the hospital failed to provide nursing care in accordance with accepted standards of nursing practice, and hospital policy relative to skin assessments, documentation, wound care, and physicians' orders for 3 of 8 patients reviewed for wound care, Patient ID #1, 2, and 3.

Findings are as follows:

Review of the hospital Policy titled, "Pressure Ulcer/Skin Integrity/Mucosal Injury" which states in part:

"Policy:
1. Skin Assessment and monitoring of wounds...

B. Pressure ulcers require a wound consult, and staging, are deferred to wound care nurses and physicians/licensed independent practitioners (LDA)...

D. Skin Integrity a. The patient's skin integrity from head to toe is assessed upon admission, on each shift, and at discharge...

Wound Assessments and Follow up/tracking assessments;

a. Initial assessments are conducted within 24 hours of admission;
b. An LDA is initiated for documentation on discovery;
c. Detailed assessments are completed;
-Upon discovery of any new wound"

1. Record review for Patient ID #1 revealed s/he was admitted to the hospital on 9/15/2024 with a complaint of a rapid heart rate and a fever of 102 degrees Fahrenheit (F; the normal body temperature range varies from 97°F to 99°F) after transfer to the emergency department (ED) from a skilled nursing facility for an evaluation. While at the hospital, the patient was noted to have wounds on his/her right leg, which the patient has reportedly had for approximately a year. A physician's order for a wound consult was provided on 9/16/2024.

Record review of Wound Nurse, Staff B's, documentation dated 9/16/2024 indicated an assessment of the wounds on the patient's right lower extremity was conducted and documented as follows:

"RLE [right lower extremity] wound fully granulating [new connective tissue that forms in a healing wound], right ankle 75% slough [slough can impede healing if left untreated]. Right heel unstageable pressure ulcer [an unstageable pressure ulcer is a pressure ulcer characterized by full thickness tissue loss that's covered by necrotic tissue, eschar, or a non-removable dressing, making it difficult to determine the wound's depth and stage] due to 100% eschar."

Treatment orders provided for all wounds revealed the following "Alginate covered with rolled gauze daily."
Review of a nursing skin assessment conducted by Nurse, Staff G, dated 9/21/2024 revealed "buttocks/coccyx" and "thigh/coccyx."

Review of a nursing skin assessment conducted by Nurse, Staff G, dated 9/22/2024 revealed "buttocks/coccyx."

During a surveyor interview with Wound Nurse, Staff B, on 9/26/2024 at approximately 1:15 PM, she revealed that she was consulted on 9/16/2024 regarding Patient ID #1's leg wounds. Additionally, she indicated that she saw the patient and implemented treatments for those areas. Staff B further revealed that once she implements a treatment for a patient, she does not continue to follow them, unless another consult is requested. Lastly, Staff B revealed that she was not contacted or made aware that Patient ID #1 had developed new pressure areas on his/her coccyx, and buttocks.

During an interview with Nurse, Staff G, on 9/26/2024 at approximately 3:00 PM, she revealed that she documented the wounds on the patient's coccyx and buttocks on 9/21 and 9/22/2024 which were red, and that she photographed and documented the areas. She further revealed that on 9/22/2024 the coccyx wound had opened, and she recorded the measurements. Lastly, Staff G revealed that she did not contact the physician or Wound Nurse and therefore did not follow protocol and procedure in accordance with the hospital's policy, to make them aware of Patient ID #1's newly identified pressure areas.

During a surveyor interview with Physician, Staff I, on 9/26/2024 at approximately 3:15 PM he revealed that he was assigned to the patient on 9/23/2024, the day of the patient's discharge from the hospital. Additionally, he revealed that he had not cared for the resident prior to that day and was unaware that the patient had pressure wounds on his buttocks, coccyx, and scrotum. When Staff I revealed that when he documented on the patient's discharge summary that his/her skin was "color good, texture, turgor normal, no rashes or lesions, Genitalia, normal male without lesion, discharge, or tenderness" that he checked off his answers with the use of a template and did not actually turn or look at the patient's skin because he was not informed that there were any concerns with Patient ID #1's skin, other than the wounds on his/her right leg.

During a surveyor interview with the Risk Manager and Unit Manager, Staff F, on 9/26/2024 at approximately 3:50 PM, they were unable to provide evidence that the hospital's policy regarding the identification of wounds was followed relative to notifying the Physician and requesting a consult with the wound nurse to assess the wounds and put a treatment in place was followed for Patient ID #1.

2. Record review for Patient ID #2, revealed s/he was admitted to the hospital from the ED on 9/17/2024 with diagnoses of pneumonia related to the Covid 19 virus, and a non-healing surgical wound on the patient's back.

Record review of Patient ID #2's Braden Scale (for predicting the risk of acquiring a pressure wound) revealed a risk score of 12, indicating s/he was at a high risk for developing a pressure ulcer.

Additionally, the record revealed a wound consult was ordered upon admission for his/her non-healing surgical wound.

Review of the skin assessments for Patient ID #2, dated 9/17 and 9/18/2024, revealed integumentary (skin) as Within Defined Limits (WDL), indicating the assessments failed to identify the non-healing surgical wound on the patient's back.

During a surveyor interview with the Risk Manager and Unit Manager, Staff F, on 9/26/2024 at approximately 3:50 PM, they were unable to provide evidence that the skin assessments completed by nursing staff on 9/17 and 9/18/2024 were complete and accurate.

3. Record review for Patient ID #3, revealed s/he was admitted to the hospital on Friday, 9/6/2024. Additionally, the record revealed s/he was transferred to the ED for evaluation of hypernatremia (a condition where there is too much sodium in the blood) and lethargy.

Further record review for Patient ID #3 revealed diagnoses of Parkinson's disease, diabetes, stage 4 pressure ulcer (the most severe type of pressure ulcer which involves full-thickness skin lass that extends into the muscle, bone, tendon or joint) to the right buttock, and dementia.

Review of the Physician orders revealed an order dated 9/6/2024 for a wound nurse consult was ordered for the patient's stage 4 pressure ulcer on his/her right buttock.

Review of a nursing skin assessment dated 9/7/2024 revealed that the patient had a stage 4 pressure ulcer on his/her right buttocks and a newly identified deep tissue injury (a type of pressure ulcer that occurs when prolonged pressure or shear forces damage the tissues beneath the skin) was identified on the patient's right heel.

Record review revealed that Patient ID #3 was not seen by the wound nurse until 9/9/2024, 3 days after his/her admission and 2 days after the newly identified pressure injury was found on the patient's right heel.

Further record review failed to reveal evidence that a physician's order to treat the wound on the patient's right heel or for the stage 4 pressure ulcer on his/her right buttocks were implemented from the patient's admission on Friday, 9/6/2024 until s/he was seen by the wound nurse on Monday, 9/9/2024, indicating the wound went untreated for approximately three days.

During a surveyor interview with the Risk Manager on 9/26/2024 at approximately 2:15 PM, she revealed that the Wound Nurse works Monday through Friday and is not available on the weekends. Additionally, she was unable to provide evidence that Patient ID #3's stage 4 pressure wound on his/her right buttocks or the newly identified deep tissue injury on the patient's right heel were treated until 9/9/2024.

Based on record review and staff interview it has been determined that the hospital failed to adhere to hospital policy and procedures to ensure that the After Visit Care Summary (AVS) form, which is used in place of the Continuity of Care form, and discharge summary, includes the patient's diagnosis, and information regarding follow-up care. The hospital failed to provide complete documentation and communicate to the clinical caregiver accepting responsibility of the patients' post discharge, for 4 of 4 patients reviewed, Patient ID #'s 1, 2, 3 and 4.

Findings are as follows:

Review of the hospital policy titled "Discharge Planning" Revised 8/2023 states in part:

Continuity of Care Post Discharge
2. The system will include the following:
2.1 Discharge instructions prepared for each patient and communicated at the time of discharge to the clinical caregiver accepting responsibility post discharge.
2.2 Discharge instructions will include the patient's diagnosis, information re: follow-up care and discharge instructions prepared for each patient and communicated to the clinical caregiver accepting responsibility post discharge care at the time of discharge.
2.3 any arranged services or appointments, special instructions/restrictions, and education regarding post hospital care and medications.

Review of the hospital policy titled "Provider Orders", revised 7/2024, states in part:

Purpose: to establish procedures for obtaining complete medication orders from authorized members of the medical staff.

"Definition: Substances included in the joint Commission definition of medications are as follows ...
Any product designated as a drug by the FDA, including enteral nutrient solutions, oxygen, and other medical gasses."

1. Review of the record for Patient ID #1, admitted on 9/15/2024, with rapid heart rate and fever of 102, was sent to the ED from a skilled nursing facility for evaluation. The patient was noted to have chronic wounds on their right leg.

On 9/21/2024 and 9/22/2024, nursing skin assessments noted new wounds on the patient's coccyx and buttocks. Further review of the record for patient ID #1, revealed he/she was discharged to a skilled nursing facility on 9/23/2024.

A review of the "After Visit Summary" (AVS) report (used in place of the continuity of care form), which was sent to the skilled nursing facility upon Patient ID#1's discharge from the hospital, lacked identification, and treatment for, the pressure wounds on the patient's buttocks, and coccyx.

2. Record review for Patient ID #2, reveals she/he was admitted to the hospital from the emergency department (ED) on 9/17/2024 with a diagnosis of pneumonia related to the Covid 19 virus, and a non-healing wound surgical wound on the patients back. The patient was maintained on 2-4 liters of oxygen while inpatient.

The patient was discharged on 9/23/2024 to a skilled nursing facility.

A review of the AVS report which was sent to the skilled nursing facility failed to include orders for oxygen, and failed to provide orders for the treatment of the non-healing wound surgical wound on the patients back.

3. Record review for Patient ID #3, admitted to the hospital on 9/6/2024, reveals she/he was sent to the emergency department (ED) for evaluation of hypernatremia and lethargy. The medical history includes Parkinson's disease, diabetes, stage 4 pressure ulcer to the right buttock, and dementia.

During a review of the wound nurse's consultation dated 9/9/2024, the following was identified:
-The right heel deep tissue injury, treatment with skin prep daily.
-The ischium a stage 4 pressure, treatment with Alginate AG packing daily.

The patient was discharged on 9/12/2024 to a skilled nursing facility.

A review of the "After Visit Summary" (AVS) report lacked physician's orders, and did not provide documentation or treatments related to a pressure ulcer on the patient's right ischium and deep tissue injury on the patient's right heel.

4. Review of the record for patient ID #4, revealed that he/she was admitted to the hospital on 9/22/2024, from home, for evaluation of bilateral lower leg cellulitis.

The patient had a wound nurse consult on 9/23/2024, which identified the following wounds:
-Bilateral lower extremity scattered full thickness venous stasis ulcers, not measurable, serous drainage, provide a xeroform cover with rolled gauze daily.
-Right hallux (the innermost digit, such as the big toe) ulcer, treatment order xeroform cover rolled gauze daily.
-Bilateral posterior upper thighs pressure ulcers, treatment order Triad every shift.

The patient was discharged home on 9/26/2024.

A review of the AVS report failed to identify the wounds and provide treatment orders for the above identified wounds. The AVS indicated a referral to home healthcare, for nursing, physical therapy, and occupational therapy, however it does not identify a home care agency.

During surveyor interview with the Risk Manager and the Chief Nursing Officer on 10/2/2024, via phone at 1:45 PM, they were unable to produce evidence that the AVS reports contain all of the necessary information required for the continuity of care for each patient upon discharge relative to the conditions, treatments, and physician orders.