HospitalInspections.org

Based on document review and interviews, the facility failed to ensure a registered nurse supervised and evaluated nursing care for all patients. Specifically, nursing staff failed to implement preventive measures in order to prevent a new pressure injury or prevent further injury to an existing pressure injury. Additionally, the nursing staff failed to notify a physician when a change in condition occurred with a patient (Patient #2).

Findings include:

Facility policies:

According to the Wound Management policy, a complete skin assessment is required upon admission to the hospital. Documentation of skin assessments is required. Under subsection B of the policy, protection and prevention of skin breakdown is discussed. To minimize pressure, turning the patient every two hours is required. A specialty bed should be utilized as adjunct therapy but is not a replacement for turning the patient.

The Bed Requests, Storage and Mattress Selection policy, provides information on the process for requesting and ordering specialty beds. Under subsection C, the indications for use of specialty mattresses are listed. Patient diagnosis and conditions automatically qualify for specialty mattress include but are not limited to, spinal cord injury with stabilized spine, myocutaneous flap surgery within the past 90 days, and bed bound patients.

1. The facility failed to implement preventative measures to include the use of specialty beds and turning the patient every two hours, to prevent skin breakdown and pressure injuries for a paraplegic patient resulting in the patient acquiring an immobility related pressure injury.

A. Document Review

(1) A review of Patient #2's medical record was completed.

Review of Patient #2's medical record revealed she had a medical history to include paraplegia (the loss of the ability to move lower extremities). Patient #2 was admitted to the facility on 11/19/19 for increased oxygenation needs as well as a fractured leg. The initial nursing assessment documented by Registered Nurse (RN #13) on 11/19/19 at 9:00 p.m. revealed Patient #2 was non-ambulatory due to paralysis (unable to move) of her lower extremities. Under the skin assessment, an abrasion on the patient's right hand was documented. There was no documentation of a pressure injury to the coccyx or sacrum upon admission.

Two days later, on 11/22/19 at 2:52 p.m., the Occupational Therapist (OT) documented communication with the registered nurse (RN) caring for the patient in regards to the patient needing an immersion mattress instead of a normal hospital bed due to the patient's paraplegia. On 11/22/20, the Registered Nurse (RN #13) documented she ordered a specialty bed and noted an abrasion on the patient's lower back and coccyx.

On 11/23/19 @ 10:57 a.m., Physician #8 documented in the Hospitalist Progress Note the patient had a stage one sacral ulcer and a wound consult was ordered.

On 11/25/19 at 8:00 a.m., the RN for the patient documented a pressure injury - immobility related on posterior right buttocks. On 11/25/19 at 1:41 p.m., the wound nurse conducted a new consult on Patient #2.

Prior to the discovery of the wound on 11/22/19, there was no evidence in the medical record a specialty mattress had been ordered to prevent skin break down for Patient #2. Additionally, there was no indication in the medical record the patient was turned/repositioned every two hours. The facility failed to implement preventative measures according to facility policy resulting in a patient acquiring a pressure injury.

B. Interviews

(1) On 10/15/20 at 11:05 a.m., Registered Nurse (RN #3) was interviewed. RN #3 stated a skin assessment should be completed upon admission of a patient. RN #3 stated it was important to complete a skin assessment upon admission in order to obtain a baseline assessment of the patient. RN #3 stated on the general surgery floor, there was a "turn-team" for all the patients who needed to be turned. RN #3 further stated every two hours, two staff members turned all the patients assigned to the turn-team. RN #3 stated when the patient was turned, it was not documented every time the turn was completed.

(2) On 10/15/20 at 12:20 p.m., an interview was conducted with Registered Nurse (RN #5). RN #5 stated she was a wound care nurse and assessed patients when a wound care consult was placed by the physician. RN #5 stated other RN's admitting patients or caring for patients had pressure injury guidelines at their disposal in order to provide preventive measures. RN #5 stated RN's could initiate these preventive measures themselves.

Patient #2's medical record was reviewed with RN #5. RN #5 explained deep tissue injuries (DTIs), which was the diagnosis of Patient's #2 pressure injury, evolve from the bone outward and would take time for it to show at the skin level. RN # stated extended amount of continuous pressure could cause the injury to progress faster.

(3) On 10/15/20 at 3:17 p.m., an interview was conducted with Registered Nurse (RN #12). RN #12 explained she worked on the orthopedic and spine unit. RN #12 explained paraplegic and quadriplegic patients should be on a specialty mattress and receive turns every two hours. RN #12 stated it was important for these patients to receive preventative measures because they did not have sensation (feeling) where the patient's body was paralyzed and paraplegic patients were often unable to shift their body weight in order to relieve pressure.

RN #12 stated when a patient was on a specialty bed, she would document when a patient was turned. RN #12 further stated it was important to document the turns in order to show the task was completed.

(4) The Director of General Surgery (Director #9) was interviewed on 10/19/20 at 9:07 a.m. Director #9 stated her role was to manage nurses on the general surgery unit and ensure they had the proper education and tools to do their job. Director #9 stated patients less mobile were more likely to have had skin breakdown.

Director #9 stated her staff participated in "turn-team" for all immobile patients and patients needing assistance to turn. Director #9 stated turn-team was completed every two hours and it was the responsibility of the two staff members assigned at the time to turn all the patients on the unit. Director #9 explained the two hour turns were not documented on every patient, every time the turn was performed, rather it was assumed the patient was turned if the patient was listed on the turn team board. Director #9 further explained when a patient refused to be turned, staff were to document the refusal in the chart.

Director #9 stated it was important to implement preventative measures in order to prevent harm to the patient.

2. The nursing staff failed to report a change in condition to the physician overseeing a patient's care.

A. Document review

(1) A review of Patient #2's record was conducted.

On 11/22/20 at 8:00 p.m., the Registered Nurse (RN #13) documented she ordered a specialty bed and noted an abrasion on the patient's lower back and coccyx. Upon review of the medical record, there was no documentation to provide evidence the RN alerted the physician to the new skin concern noted on assessment of Patient #2.

(2) On 10/19/20 at 8:37 a.m., a policy outlining the requirements for a registered nurse to report a change in condition to the physician overseeing the care of the patient was requested. The facility was unable to provide a policy or procedure prior to the exit of the survey.

B. Interviews

(1) On 10/19/20 at 11:21 a.m., an interview was conducted with Registered Nurse (RN #10). RN #10 stated she had worked on the general surgery floor as a registered nurse for four years. RN #10 stated a change in condition was when a patient experiences any change between assessments or when something was noted different from the report received by the following registered nurse. RN #10 stated a new skin issue would be considered a change in condition since it was a change in assessment. RN #10 stated a change in condition should be reported to the primary physician overseeing care of the patient as soon as the change in condition was discovered. RN #10 further explained she would document the conversation with the physician in the patient's medical record. RN #10 explained it was important to notify the provider of a change in condition so the provider could implement necessary changes in the patient's plan of care.

(2) On 10/19/20 at 12:19 p.m., a second interview was conducted with Director #9. Patient #2's medical record was reviewed with Director #9. The RN documentation of the Patient's skin issue noted on 11/22/20 at 8:00 p.m. was discussed. Director #9 stated based upon the documentation the RN completed, the change in skin should have been reported to the provider overseeing care of the patient. Director #9 stated it was important to report the change in condition to the physician so the physician was aware and could order a wound consult if needed.

Based on document review and interviews the facility failed to ensure arrangements for post-hospital care were included in discharge planning needs of the patient. Specifically, the facility failed to arrange and provide oxygen services at discharge for a patient being transferred out of state and establish follow up appointments with orthopedics for a right tibia (leg bone) fracture, cardiology for newly diagnosed diastolic heart failure and any additional services needed.

Findings;

Facility Policy:

According to Oxygen Therapy and Titration, the purpose was to provide guidelines to deliver supplemental oxygen therapy to spontaneously breathing patients including the goals of the oxygen therapy. Continuous oxygen therapy requires an order from a physician or advanced practice provider. Respiratory Therapists (RT) and Registered Nurses (RN) were expected to execute the order and determine the appropriate delivery device to meet the goal of the ordered therapy.

Discharge of a Patient read, discharge instructions will be completed with an interdisciplinary approach. Staff were expected to complete a final discharge assessment of the patient ' s condition, the physician was to be notified immediately of any abnormalities or if the condition was not safe for discharge. These instructions must include but were not limited to any home care needs, follow up appointments, and medications needed post discharge.

1. The facility failed to ensure a patient being discharged and transported to their home located out of state had oxygen therapy established upon arrival to the out of state location.

Documentation

a. Medical record review was conducted for Patient #2. The record revealed the patient was admitted with a fractured tibia requiring a surgical repair and had a diagnosis of acute respiratory failure, newly diagnosed acute diastolic heart failure, and anemia secondary to a GI bleed during the admission. The record revealed a new oxygen requirement on the final physician note prior to discharge dated 11/30/19 at 5:47 p.m. The new oxygen requirement was listed as 3.5 liters of oxygen per minute (L/min) on the physician note. The final complete set of vital signs recorded showed the patient was on 2 L/min at 9:30 p.m. on 11/30/20. The patient was discharged at 7:01 a.m. but there was no documentation of vital signs taken prior to discharge. Oxygen therapy was listed on the 12/1/19 air lift transportation documentation which stated the patient would require 2 L/min via nasal cannula to maintain oxygen saturation over 94% during transport. No further oxygen therapy arrangements were documented in the record for the patient's final location when transport was completed to the patient's home.

Interviews

a. An interview was conducted on 10/15/20 at 11:05 a.m., with RN #3, who stated the discharge was unusual due to the patient being discharged to an out of state location. RN #3 stated it was important to follow the physician recommendation and order for oxygen therapy because the physician would know the patient's needs. RN #3 stated it was the role of respiratory therapy and case management to evaluate and set up home oxygen needs.

b. An interview was conducted on 10/14/20 at 2:06 p.m., with Assistant Director of Case Management (Director #11) who stated her role was to assist with more complex discharges and provide resources to discharging patients for care after their hospital stay. Director #11 stated the oxygen therapy had been set up for the air lift transportation on 12/1/19. Director #11 stated home oxygen needs were set up by the respiratory therapy department. Director #11 stated respiratory therapy should arrange home oxygen and case management should set up a home health visit to evaluate the patient at home for new needs related to a new diagnosis.

c. An interview was conducted on 10/15/20 at 1:57 p.m., with Director of Case Management (Director #6). Director #6 stated the record revealed the patient had been on 2 L/min on both 11/28/19 and 11/29/19. The oxygen needs of the patient changed on 11/30/19 and it ranged from 2 L/min to 3.5 L/min. Director #6 stated the transfer should have been stopped due the increase in oxygen demands during the day shift on 11/30/19. Director #6 stated the facility expected respiratory therapy to set up home oxygen therapy when needed for patients who had discharged from the facility needing oxygen therapy. Director #6 was unable to locate a home oxygen evaluation for the patient by respiratory therapy. Director #6 stated there was no one scheduled to assess the patient's oxygen needs once she returned to her out of state home. Director #6 stated without clear follow up the patient was at risk to decompensated without the oxygen therapy.

d. An interview was conducted on 10/15/20 at 3:59 p.m., with Interim Director of Respiratory Therapy (Director #7). Director #7 stated once a home oxygen evaluation order had been placed the Respiratory Therapist (RT) would assess the patient's oxygen needs while breathing without oxygen therapy. The patient would need to be at 87% or below to qualify for oxygen therapy. The RT would work with the patient's insurance, verify where the patient lived, and determine what equipment would be needed at the patient's home. Director #7 stated once the physician order was placed, the information was put in the computer to be forwarded to the physician to sign off on the order which will be provided to the outside company who fulfilled the order and equipment needs. No evidence was found in the patient's discharge record regarding home oxygen therapy.

e. An interview was conducted on 10/19/20 at 8:02 a.m., with Physician#8. Physician #8 stated the patient had multiple medical issues, including but not limited to atelectasis, diastolic heart failure, and chronic opioid use, which can cause respiratory depression, all contributed to her new need for oxygen therapy. Physician #8 stated the patient could have benefited from a home oxygen evaluation. Physician #8 stated the physician's role was to put the order in for RT to follow up with a home oxygen evaluation. A home oxygen order was not placed for the patient.

2. The facility failed to ensure follow up care appointments were arranged in the patient's home state for post-surgical orthopedic care, newly diagnosed diastolic heart failure cardiology care and GI care following a GI bleed.

Documentation

a. A medical record review was conducted on 10/13/20 of patient #2. The record revealed the patient was admitted with a fractured tibia requiring a surgical repair and had a diagnosis of acute respiratory failure, newly diagnosed acute diastolic heart failure, and anemia secondary to a GI bleed during the admission. Documentation in the medical record showed the patient's fractured tibia was surgically repaired with an open reduction and internal fixation (ORIF) procedure on 11/21/19. The patient was followed by cardiology, GI and orthopedic teams during her admission. Discharge paperwork showed the patient was transferred to her home, out of state, via air lift transportation on 12/1/19. The discharge paperwork showed the patient was to schedule her orthopedic follow up appointment within 10-14 days postoperatively for suture removal and was provided with a local Colorado phone number to schedule the appointment in Colorado. The patient returned to her out of state home early on the 10th day after the surgical repair. No information was provided to the patient on whom she should follow up with in her home state for postoperative orthopedic care and suture removal. The patient was provided with the name of a GI physician in her home state, however contact information was not provided. Finally the patient was told to follow up with her primary care physician (PCP) to get a referral to a cardiologist for follow up on her newly diagnosed diastolic heart failure and fluid overload needs. No appointments were scheduled for the patient in her home state.

Interviews

a. An interview was conducted on 10/15/20 at 11: 05 a.m., with RN #3. RN #3 stated the patient discharged early in the morning as she was being airlifted back to her home located out of state. RN #3 stated the patient had discharge instructions to follow up with her PCP to get the cardiac referral, and phone numbers were provided for follow up visits here in Colorado. No appointments were set up prior to discharge in the patient's home state. RN #3 stated these follow up appointments were to be set up by case management. RN #3 stated follow up care ordered by the physicians was important as the patient needs the care to monitor ongoing issues. RN #3 stated if a patient was discharged to another state, the discharge paperwork should reflect the follow up appointments. No follow up appointments were found in the discharge paperwork.

b. An interview was conducted on 10/14/20 at 2:06 p.m., with the Assistant Director of Case Management (Director #11). Director #11 stated discharge planning begins day one of an admission. Her role as Assistant Director was to assist case managers with more complex discharges to help them work through the issues prior to discharge. Director #11 stated case managers help with all aspects of the patients needs. Director #11 stated she became aware of Patient #2 when her discharge became complicated due to the patient ' s need to be airlifted to her home state. Director #11 was unable to locate recommendations for the patient in the chart and did not see case manager notes regarding the discharge plan. Director #11 stated the patient was wheelchair bound and home health services should have been offered, however she did not see these services were offered. Director #11 stated the case manager needed to set up a home health visit to evaluate any changes in needs after the surgery, new diagnosis of diastolic heart failure and GI bleed.

c. An interview was conducted on 10/15/20 at 1:57 p.m., with the Director of Case Management (Director #6). Director #6 stated she was unable to locate any information Patient #2 had scheduled appointments for orthopedic post-surgical care established in her home state. A GI physician's information was in the record, without contact information. The cardiac follow up was contingent upon Patient #2 scheduling a visit with an unnamed PCP. Director #6 stated the follow up care after discharge was not clear in the record and was not typical of case manager discharge documentation.