HospitalInspections.org

Based on observations, medical record and policy review, and staff interviews, it was determined that the hospital failed: to consistently provide care and services to prevent the development of device related pressure injuries. Hospital staff failed to ensure staff consistently assessed the patient's skin integrity in accordance with policies and procedures, written orders for wound care and management of Multi-Podus boots (A-0144).

The cumulative effect of these systemic practices resulted in the hospital's failure to comply with conditions of participation for Patient Rights.

Based on record review, policy review, and staff interview, hospital staff failed to provide care and ensure a safe environment to prevent the development of medical device related pressure injuries for one of five medical records (Patient #31).

Findings included...

Record review of the facility's policy titled, "Pressure Injury Prevention and Treatment," dated 11/02/2018, showed the definition for pressure injury is: "a localized injury to the skin and or underlying soft tissue, usually over a bony prominence, or related to a medical or other device ... Medical device related pressure injury: medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injuries generally conform to the pattern or shape of the device. The injury should be staged using the staging system ... Hospital acquired pressure injury (HAPI): a pressure injury that was not present on hospital admission.... Strategies for prevention of skin breakdown include "Pressure Relief." Staff is to "take into consideration pressure caused by medical devices that are placed/present ... Assess and pad skin underneath devices ..."

The physician admitted Patient #31 on 09/07/2020 after transferring from an acute care rehabilitation facility, whose diagnoses included Pneumonia, Leukocytosis, and Acute Respiratory Failure. Also, the patient had a C3-C7 posterior cervical laminectomy on 09/16/2020.

A review of Patient #31's medical record showed Employee #61, Certified Nurse Practitioner, completed a universal referral requisition form, dated 09/14/2020 at 10:25 AM, to an outside contracted vendor, for "MP (Multi-Podus) Prevo boots." The licensed practitioner did not document an indication for the MP boots.

Further review of the medical record showed on 09/25/2020; the contracted outside vendor applied, "(B) MP AFO's (Bilateral Multi-Podus Ankle Foot Orthoses) to treat bilateral heel ulceration prophylaxis. The boots are used to support weak limbs or to position a limb with contracted muscles into a more normal position. There were checks in selected boxes to indicate that the vendor provided written/verbal wear and care information to the patient and staff.

There was no documented physician order for the application and care of Multi-Podus boots and care; until 11/12/2020. The physician order directed, "Multi-Podus- 2 (two) hours off and on."

According to a Registered Nurse's admission, progress note dated 09/07/2020 at 7:47 PM, revealed Patient #31's, skin assessment included a healed Stage 2 pressure injury- Allevyn place on left outer calf scab that was bleeding and was covered with 4X4 gauze.

A review of the nursing skin assessments dated 09/07/2020 to 11/10/2020 with Employees #14, Director of Acute Care Therapy and Employee #15, Nursing Director revealed the following documentation: "09/07/2020- leg/left lower- mod (moderate) serosanguinous drainage, sacrum-pressure injury-Stage II; 10/17/2020- rt (right) heel medal- flat/red/irregular-DTI (Deep Tissue Injury); 10/20/2020- Left leg posterior- flat/irregular/pink/pressure injury- Stage II, 11/10/2020- right calf-unstageable, flat, black/pink pressure injury- 5 x2 cm in width."

A review of the Wound /Ostomy/Continence Notes showed the following documentation: 10/19/20 at 1:08 PM, showed the right heel was assessed as "2 cm (centimeters) x 3cm; DTI (Deep Tissue Injury), not present on admission, maroon, intact ..." 10/23/2020, the wound care nurse identified the left calf as unstageable and "not present on admission."

An acute physical therapy evaluation dated 09/24/2020 at 4:33 PM, revealed the patient's lower extremities were "impaired"; and "there is no active movement noted in any extremities or trunk."

An Acute physical therapy treatment note dated 10/02/2020 at 10:19 AM revealed the RN (Registered Nurse) was educated on PROM (Passive Range of Motion) to BUE (Bilateral Upper Extremities) and BLE (Bilateral Lower Extremities) and donning/doffing MP boots and schedule.

According to an acute therapy wound, care/lymph evaluation note dated 11/10/2020 at 3:31 PM revealed the following: "Wound PT (Physical Therapy) Evaluation- Consulted for pressure injury on L (left) calf, possibly due to multipodus boots. Upon examination, noted patient also has wound on R (right) posterior calf; likely has (sic)-same etiology ... [Left] calf: 5.5 cm (centimeters) L (length) x 1.5 cm W (wide). Wound edges are flat and well defined-no odor or drainage. The surrounding skin is dry and hyperpigmented. R (Right) calf: 5 cm L x 2cm W, 95% dry eschar with 5% granulation tissue at ede (sic). Wound edges are flat, well defined. No odor or drainage. Surrounding skin dry but intact ..."

"Assessment/Summary: Wound PT consulted for L(left) calf wound, then noted pt (patient) also with R (right) calf wound. Wounds possibly related to wearing of multipodus boots; will discuss with mobility PT regarding wearing schedule with boots to decrease pressure on these areas. ... Poor wound scores d/t (due to) high percentage of necrotic tissue ...will continue to follow for necrotic tissue management ..."

The medical record lacked consistent nursing documentation of skin assessment(s) from 09/07/2020 until 11/10/2020. Subsequently, the patient acquired a deep tissue injury to the right heel, right calf unstageable injury, and Stage II pressure injury to the left calf. Additionally, there was no documented evidence that hospital staff notified the physician of the pressure injuries.

On 11/24/2020 at approximately 12:30 PM, Employee #14 gave the surveyor a paper [undated], titled, "Heel Protection for Your Patient." It showed the wearing schedule, care of patients who are wearing "boots." The care included the following: "For All Multi-Podus Boot Wearers: Please tighten all attachments as you reposition your patient, Inspect skin for pressure areas, Use stabilizer bar located on the backside of the boot to control excessive rotation." When the surveyor queried the employee; where these care instructions are located; she replied, usually it is posted at the head of the assigned patient's bed.

A review of the interdisciplinary care plan dated 09/07/2020 through 11/24/2020 lacked documented evidence of Patient #31's individualized care for the Multi-Podus boots.

The practice lacked evidence that hospital staff followed the hospital policy relative to pressure injury prevention and treatment.

The surveyor conducted a face-to-face interview on 11/02/2020 at approximately 11:00 AM with Employees #12, Wound Specialist, WOCN (Wound Ostomy Continence Nurses), Employee #13, Wound Specialist, WOCN, Employees #14 and #15, regarding the findings.

All acknowledged and confirmed the findings at the time of the record review.

1. Based on observations during the tours of the Dialysis Unit on 11/25/2020 at 9:15 AM, patients received treatment in beds less than 6 feet apart,potentially exposing patients to an unnecessary contamination, as outlined in the CDC Guidelines to COVID-19.

Employees # 31, Dialysis Director, # 32, Dialysis Clinical Coordinator, and #33, Dialysis Administrator observed and acknowledged these findings during the observations.

Findings included...

During an inspection of the Dialysis Treatment Unit,showed that patients receiving Dialysis Treatments on November 25, 2020; the staff treated dialysis patients in beds less than 6 feet apart in the following instances:

1. Beds #1 and #2 were 5 feet' 1" inches apart.

2. Beds #3 and #6 were 4' feet apart.

3. Beds #4 and #5 were 5' feet apart.

4. Beds 11A and 11B were 4.5' feet apart.

Eight of nine patient beds, were positioned less than 6' feet apart during treatments, which does not follow CDC Guidelines in response to Social Distancing and controlling the spread of COVID-19.



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2. Based on observation and staff confirmation, the nursing staff failed to change gloves, sanitize or wash hands, and apply clean gloves during an unstageable community-acquired sacral wound dressing change in one of one observation (Patient # 33).

A review of the Centers for Disease Control and Prevention, 'Hand Hygiene in Healthcare Settings, Healthcare Providers", https://www.cdc.gov/handhygiene/providers/, recommends that healthcare personnel should

"Change gloves and perform hand hygiene during patient care if ... moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs."

Findings included ...

The physician admitted Patient #33, on 10/09/2020, with diagnosis to include respiratory failure, intravenous drug abuse, and sacral decubitus ulcers. Per hospital documentation, a physician ordered the patient's sacral wound to be treated Q (every) Shift with Vash, Santyl, Aquacel Extra and covered with Allevyn border foam dressing.

The surveyor observed a dressing change for Patient #33 on 11/24/2020 at approximately 10:10 AM, in the presence of Employee #46, Registered Nurse (RN), and Employee # 39, Clinical Nurse Specialist. Employee #46, donned gloves, removed old dressing, completed prescribed treatment, and applied a sterile dressing. The employee failed to remove gloves, sanitize hands and apply clean gloves between dressing changes.

The practice lacked evidence that the nursing staff applied nursing standards of care to prevent infection for a dressing change.

At the time of the observation, Employees' #46 and # 39 acknowledged and confirmed the findings.


3. Based on observation and staff interview, the nursing staff failed to ensure that staff followed acceptable standards related to donning personal protective equipment (PPE) to prevent the spread of infection in one of one observation, (Patient# 53).

Review of the Center for Disease Control (CDC) recommendations for the use of Personal Protective Equipment (PPE) showed the gowns are to be fastened in the back of the neck and waist.

https://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf.

Record Review of the hospital's policy titled "Standard Precautions," dated 03/26/2019, showed under "Attachment A" that Personal Protective Equipment (PPE), specifically the gown, should be "Fasten in the back of the neck and waist."

Findings included...

The surveyor conducted a tour of the Pulmonary Unit 4F, on 11/24/2020, at approximately 10:25 AM, in the presence of Employee #16, Nursing Director, and Employee # 18, Patient Care Manager. The surveyor observed Employee #19, Registered Nurse (RN), entering Patient # 53's room (who was on contact isolation precautions) wearing a gown untied at the neck and waist. The surveyor queried Employee # 19 as to the facility's policy for wearing PPE related to gowns. The employee stated the gown should be tied around the neck and the waist.

The practice lacked evidence that the nursing staff followed Infection Control and Prevention standards and hospital policy relative to wearing PPE correctly to prevent the spread of infection in the hospital.

At the time of both observations, both Employee # 16 and # 19 acknowledged and confirmed the findings.