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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES, was out of compliance.

A-0395 RN SUPERVISION OF NURSING CARE A registered nurse must supervise and evaluate the nursing care for each patient. Based on document review and interviews the facility failed to complete and document the nursing admission assessments for patients upon admission to the facility. Based on interviews and document review, the facility failed to ensure nursing care was provided and met the continuous care needs of patients. Specifically, nursing staff failed to implement preventive measures in order to prevent a new pressure injury or prevent further injury once a pressure injury was identified. Additionally, the nursing staff failed to provide continual wound evaluation and care in one of three wound patients (Patient #3).

A-0405 Standard: Preparation and administration of drugs.
(1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. Based on observations, interviews and document review, the facility failed to administer medications in accordance with standards of practice and facility policy. Specifically, the facility failed to ensure the nursing staff completed the two patient identifier process prior to administering anticoagulant medications in one of one high risk medication administration observations (Patient #5).

Based on interviews and document review, the facility failed to ensure nursing care was provided and met the continuous care needs of patients. Specifically, nursing staff failed to implement preventive measures in order to prevent a new pressure injury or prevent further injury once a pressure injury was identified. Additionally, the nursing staff failed to provide continual wound evaluation and care in one of three wound patients (Patient #3).

Findings include:

Facility policies:

The Skin Integrity Assessment policy dated 6/2/17, read all patients will undergo a skin assessment at the time of admission and directly after a patient transfer to a new unit/department. Additional skin integrity assessments will be performed every shift by the registered nurse (RN). The skin integrity assessment will be documented in the patient medical record. The RN will determine potential for skin breakdown based on patient mobility, incontinence, and the existence of established wounds. Under section II and IV of the policy, preservation of skin integrity and repositioning of the patient is reviewed. Any skin surface prone to pressure ulceration should be assessed for irritation, pain and injury. To minimize pressure and maintain skin integrity, patients unable to move or reposition independently were required to be repositioned every two hours. The RN will perform subsequent skin integrity assessment and evaluation every shift or more frequently dependent on patient condition.

The Patient Assessment and Reassessment policy dated 10/15/20, read upon admission the initial patient assessment will be performed and documented. The RN is to assess and document patient vital signs, current medical condition, treatment history, patient's mental status, skin integrity, pain status, recent hospitalizations, physical limitations or disabilities, dietary needs or restrictions, active medications and patient allergies. Additionally, the RN will evaluate musculoskeletal, neurological, respiratory, cardiovascular, gastrointestinal, renal and endocrine systems. The RN will perform subsequent patient assessment, evaluation and documentation every shift or more frequently dependent on patient condition, diagnostic tests and invasive/non-invasive procedures.

The Wound Care Guidelines for Nursing policy dated 3/12/21, read wound care management, assessment and documentation will be performed by nursing staff. The wound assessment comprised: location, description and type of wound, length of time the wound has been present and the current wound treatment. The RN will comply with the general wound care guidelines unless a wound care management order has been ordered by the wound care registered nurse (WCRN) or physician. Orders for wound care management were to be performed as ordered.

The wound assessment will be documented by the RN in the Skin Assessment section upon admission and every shift. Dressing changes will be documented in Nursing Notes. The RN will indicate the type of dressing applied, cleansing solution used and indicate any additional wound care product used. Lastly, the RN will initial, date and time new dressings applied to the wound.

1. The facility failed to ensure nursing staff implemented measures for prevention of skin breakdown, new pressure injury and prevent continued injury to an existing pressure wound.

A. Documents were reviewed.

a. According to the Skin Integrity Assessment policy, non-ambulatory and incontinent patients were at risk for skin integrity alteration, increased skin breakdown, skin irritation and pressure injury. Patients were to be repositioned and turned every two hours and as needed (PRN) to preserve skin integrity. The RN would perform a skin integrity assessment during every shift.

b. According to the Wound Care Guidelines for Nursing policy, the RN would comply with the wound care order placed by a WCRN or physician. Wound care and dressing changes performed by the RN would be documented in the Nursing Notes section. Additionally, the RN would initial, date and time the new dressing placed on the wound. Wound assessments performed by the RN would be documented in the Skin Assessment section.

c. The medical record for Patient #3 was reviewed. The medical record lacked evidence of wound care and patient repositioning.

i. Patient #3 was admitted on 4/17/21 at 8:37 a.m. He was diagnosed with sepsis due to Escherichia Coli (a life-threatening medical condition caused by an extreme adverse response to an Escherichia Coli bacteria infection). The initial skin integrity assessment performed on 4/17/21 at 10:34 a.m. revealed Patient #3 was non-ambulatory, incontinent and had an elevated risk for skin integrity impairment and breakdown. There was no documentation of a pressure injury to the coccyx or sacrum upon admission.

Patient #3 was hospitalized from 4/17/21 to 6/15/21, a total of 59 days. Subsequent skin integrity assessments revealed Patient #3 remained non-ambulatory and incontinent for the entire duration of his hospitalization.

ii. On 4/23/21 at 8:21 p.m., (six days after admission), the RN for the patient documented Patient #3 had developed a moisture related pressure injury on the coccyx or sacral area . Patient #3's physician was not advised of the pressure injury and a wound consultation for pressure injury evaluation was not ordered.

Prior to the discovery of the pressure injury on 4/23/21, there was no evidence in the medical record Patient #3 had been repositioned and turned every two hours. Additionally, skin integrity assessments were not performed during every shift.

iii. On 4/27/21 at 1:08 p.m., the physician for the Patient #3 documented a stage one pressure injury (an area of skin where skin breakdown has begun) in the Critical Care Progress Note. A wound consult order was placed by the physician. Prior to 4/27/21 physician documentation in the Critical Care Progress Notes did not indicate a pressure injury or wound was present for Patient #3.

d. A review of wound care, wound care orders, dressing changes and wound assessments was performed for Patient #3. The medical record lacked evidence related to dressing changes and wound assessments.

i. On 4/27/21 at 3:30 p.m., the WCRN performed the initial wound consult for Patient #3. The WCRN entered a wound care order which instructed the following: the wound should be cleansed, dried, skin barrier protectant applied, and dressed with a foam border dressing (Mepilex) daily and PRN.

ii. On 4/30/21 at 7:22 p.m., the WCRN who saw the patient entered an updated wound care order in the medical record. The wound care order was updated to reflect the following: the wound should be cleansed with wipes, apply Z-Guard (a zinc based barrier protectant) to the sacral and perirectal area (the area surrounding the rectum) and on the adhesive side of Mepilex dressing prior to placement on the sacral area. The wound should be cleansed and re-dressed every 48 hours and PRN. Additionally, the WCRN ordered staff to ensure protection of the perirectal area with the use of patient off-loading (the removal of weight from the sacral and perirectal to help prevent and heal pressure injuries ).

iii. On 5/24/21 at 9:26 a.m., the WCRN assessed the patient and updated the wound care order to reflect the following: cleanse the wound with wound cleanser, pat dry, apply skin prep to perirectal area, pack the sacral wound with Dakins moistened gauze, gauze soaked with Dakins solution prevents and treats skin and tissue infections associated with pressure sores. An ABD pad (a thick and highly absorbent dressing used to provide padding and protection for large wounds) should be placed over the wound and secured with medi-pore tape (a soft cloth tape which is gentle and breathable and used to preserve skin integrity). The wound should be cleansed and re-dressed three times a day.

iv. On 5/27/21 at 11:33 a.m., the physician for Patient #3 documented in the Critical Care Progress Note, the sacral wound had evolved into a stage three sacral ulcer (involving the tissue under the skin which formed a small crater) and a surgical consultation for wound debridement (removal of dead tissue) was ordered.

v. On 5/30/21 at 1:19 p.m., the surgeon for Patient #3 assessed the wound and noted the wound as a stage four sacral ulcer (pressure ulcer which extend below the subcutaneous fat into deep tissues like muscle, tendons, and ligaments. In severe cases, they extend as far down as the cartilage or bone and have a high risk of infection) and performed the surgical debridement on the wound.

Prior to the surgical debridement performed on 5/30/21, there was no evidence in the medical record the RN provided wound care, dressing changes and wound assessments as instructed in the wound care orders entered by the WCRN.

vi. On 5/31/21 at 11:51 a.m., Patient #3 was assessed post wound debridement surgery by the WCRN who ordered new wound care for Patient #3. The wound care order read: cleanse the wound with wound cleanser, pat dry, and fill the dead space (open space within the wound which could delay wound healing) with gauze moistened with sterile water. Cover with an ABD pad and secured with tape. Dressings should be changed twice daily and when soiled.

vii. On 6/2/21 at 11:41 a.m., an updated wound order was entered by the WCRN. The wound order for Patient #3 instructed the RN to do the following: cleanse the wound with wound cleanser, pat dry, apply a liberal amount of Z-Guard to the wound, moistened kerlix (woven gauze used for surgical wounds and wound packing) with Dakins solution and pack the moistened gauze into the surgically debrided wound. Cover the wound with an ABD pad and secure the pad to the skin surface with medi-pore tape. The wound should be cleansed and re-dressed twice a day.

On 6/15/21 at 5:25 p.m., Patient #3 was discharged from the facility. Prior to Patient #3's discharge, there was no evidence in the medical record the RN provided wound care, dressing changes and wound assessments in accordance with the WCRN order.

B. Interviews with staff were conducted and revealed no evidence nursing staff followed facility policy, wound care orders or every two hour repositioning of Patient #3.

a. On 7/14/21 at 3:07 p.m., an interview was conducted with RN #1. RN #1 stated wound assessments and dressing changes were performed for the patient during every shift by the RN. RN #1 stated wound orders were reviewed at the start of every shift and the specific wound care ordered would be implemented.

RN #1 reviewed the medical record for Patient #3. RN #1 stated he was not able to verify the number of times the wound dressing was changed daily. RN #1 stated he was unable to locate dressing change documentation in the Nursing Notes for Patient #3.

Repositioning and turning of the patient was reviewed with RN #1. RN #1 stated patients were repositioned and turned every two hours. RN #1 stated he was not able to provide documented evidence patients were repositioned or turned per the facility policy.

RN #1 stated on review, there was a lack of evidence routine nursing services in Patient #3's medical record. RN #1 stated patients were at risk for increased skin breakdown, permanent tissue damage and wound infections if preventative measures were not implemented.

b. On 07/14/2021 at 5:22 p.m., an interview was conducted with RN #2 . RN #2 stated she had provided nursing services for Patient #3 as a RN and on occasion as a Charge RN.

RN #2 stated the RN would perform a wound assessment at least once per shift.

RN #2 stated immobile, incontinent and immunocompromised patients had an increased risk for skin breakdown, pressure injury and infection. Furthermore, she stated patients were at risk for harm and health condition deterioration when preventative wound measures were not implemented for patients.

These interviews were in contrast with facility policy for Wound Care Guidelines for Nursing and the Skin Integrity Assessment policy which stated implementation of preventative measures to ensure repositioning and turning of patients every two hours reduced the risk for skin breakdown, compromised skin integrity and pressure injury in non-ambulatory and incontinent patients.

Based on observations, interviews and document review, the facility failed to administer medications in accordance with standards of practice and facility policy. Specifically, the facility failed to ensure the nursing staff completed the two patient identifier process prior to administering anticoagulant medications in one of one high risk medication administration observations (Patient #5).

Findings include:

Facility policies:

The Patient Identification policy dated 3/11/19, read two forms of identification will be used to verify patient identity. Verbal identifiers consist of the patient's name, the patient's date of birth, in select situations the patient's social security number. Verbal identifiers stated by the patient must be compared to the patient identification armband or the patient medical record. The patient armband may not be a primary identifier for the patient.

The Medication Orders, Dispensing, Administration, and Documentation policy dated 11/6/20, read patient identification will occur prior to the administration of medications. The RN will verify patient identification verbally provided by the patient prior to administering medication.

The Medications, High-Risk policy dated 2/18/21 read, the following were considered high risk medications: insulin, anticoagulants, opiated, injectable potassium salts, injectable magnesium, intravenous oxytocin, chemotherapy medications, TPN/PPN, hypertonic saline solutions, promethazine injection, and continuous renal replacement therapy. All high risk medications will be handled cautiously to decrease the risk for medication errors. Proper patient identification, medication verification and follow up monitoring will be performed when administering high-risk medications.

1. The facility failed to ensure nursing staff completed the two patient identifier process prior to administration of high risk medications.

A. According to the Patient Identification policy, prior to the administration of a medication, the nurse must complete the two patient identifier process prior to scanning the patient identification armband and the medication.

B. Medication administrations were observed.

a. Patient #5 was admitted to the facility on 7/7/21 due to an intertrochanteric fracture, a hip fracture. Patient #5 had a history of diabetes, chronic obstructive pulmonary disease (COPD), hypertension (HTN) and myocardial infarction (MI). Patient #5's medication orders included Lovenox (a blood thinner) for prevention of blood clots due to immobility.

b. On 7/13/21, Registered Nurse (RN) #3 was observed administering medication to Patient #5.

i. At 9:32 a.m., RN #3 entered the room assigned to Patient #5. Upon entering the room, RN #3 accessed Patient #5's electronic medical record, scanned Patient #5's medications and scanned Patient #5's identification armband.

ii. At 9:35 a.m., RN #3 reviewed the medications with Patient #5 and administered the Lovenox subcutaneously by injection.

Observation of the high risk medication administration for Patient #5 was in contrast with the facility policy which required the nurse to obtain two patient identifiers prior to scanning the patient identification armband.

C. Interviews were conducted.

a. On 7/13/21 at 9:55 a.m., an interview was conducted with RN #3. RN #3 stated prior to administration of medications, the two patient identifier process was required. She stated the two patient identifiers asked were the patient's name and date of birth.

RN #4 stated Lovenox was and anticoagulants (blood thinners) which was considered a high risk medication. She stated the two patient identifiers were necessary to prevent the administration of a high risk medication to the wrong patient and potential harm to the patient. RN #3 stated patients were at risk for harm if administered a high risk medication not intended for them .

b. On 7/14/21 at 1:04 p.m., an interview was conducted with Nursing Manager (Manager) #4. Manager #4 stated nurses were expected to verify two patient identifiers before medications were administered to the patient. Manager #4 initially stated visual verification of the patient identification armband and the patient's electronic medical record was sufficient for the two patient identification process.

Manager #4 reviewed the Patient Identification policy.

Manager #4 then stated RNs were expected to ask patients to verbalize two patient identifiers, their name and date of birth. Manager #4 stated the patient's response was confirmed with the patient's identification armband and electronic medical record. She stated the two patient identifier process was important to prevent medication administration errors and to ensure the patient was administered the correct medication. Manager #4 stated administration of high risk medications, such as Lovenox, to the wrong patient would cause the patient harm.