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Based on review of policy and procedures, medical records, and staff interviews the facility staff failed to evaluate and monitor 2 of 6 Emergency Department patients per policy (#5, #6), failed to prevent and identify pressure ulcers in 1 of 1 sampled patients (#12) and failed to document accurate staging of pressure ulcers in 1 inpatient with pressure ulcers. (#22)

The findings included:

1. Review on 07/31/2019 of the facility policy titled, "ASSESSMENT AND REASSESSMENT IN THE EMERGENCY DEPARTMENT," approved 11/2017, revealed " ... POLICY: 1) Information is gathered through analysis of assessment data and is integrated/documented to identify and prioritize the patient`s need for care. Needs are prioritized as follows: ...b) Category II Urgent: Cases that are urgent in nature but not life-threatening. Reassessment is performed every hour or as needed. C) Category III Non -Urgent: Cases that require moderate routine treatment. Reassessment is performed every 2 hours or as needed ..."

Review on 07/31/2019 of the facility policy titled, "Assessment-Adult Vital Signs ...", approved 05/2018, revealed " ...3) Vital signs, (including temperature, pulse, respiratory rate, blood pressure) are taken/ recorded on admission and routinely at least twice a day or per unit specific guidelines or as indicated by patient status/changes in condition ..."

Review on 07/31/2019 of the facility policy titled, "Patient Rights- Pain Management," approved 07/2017, revealed " ...2) The patient`s pain is documented in the medical record utilizing the patient`s self- reporting in describing the pain regarding: a) location: b) type, i.e., constant, intermittent, sharp, dull, burning, aching: c) chronology, i.e., acute or chronic; d) severity or intensity with use of rating scale; e) duration ...5) Pain assessment is performed: at time of admission: at least once a shift; at the time of the report of pain; within one hour following any intervention provided for relief of pain ..."

1.a. Medical record review on 07/30/2019 of Patient #5, revealed a 63-year-old male that presented to the emergency department on 03/01/2019 at 0047 for chest pain. Review revealed Patient #5 vital signs were taken at 0059. Review revealed Patient #5 was triaged at 0101 and prioritized as a Category III Non-Urgent. Review revealed no reassessment was performed prior to his departure from the ED. Review revealed no pain assessment was performed during the encounter. Patient #5 left without being seen by a provider at 0346.

Interview on 07/30/2019 at 1535 with a Registered Nurse (RN #9), revealed initial assessments were performed in triage and "no reassessments unless provide an intervention." Interview revealed pain assessments were done upon arrival in triage and pain reassessments were done with any intervention related to pain.

Interview on 07/31/2019 at 0953 with the Nurse Manager for the Emergency Department, revealed they [hospital staff] want reassessments performed while patients are waiting in the waiting room for an assigned room. The Nurse Manager revealed it is "expected for assessments to be performed according to their levels [categories]." The Nurse Manager revealed the practice was for vital signs to be taken at least every two hours. Interview revealed it was the expectation for staff to evaluate and reevaluate pain according to policy. The Nurse Manager confirmed policy was not followed.

1.b. Medical record review on 07/30/2019 of Patient #6, revealed a 36-year-old female that presented to the emergency department on 06/07/2019 at 1309 for chest pain. Review revealed Patient #6 was triaged at 1315 and prioritized as a Category II Urgent. Review revealed Patient #6 received assessments after triage at 1548 and 1701. Review revealed a reassessment was not performed between 1701 and 1935 (two hours and 34 minutes). Review revealed Patient #6 was assessed by a Registered Nurse for pain at 1317 with failure to reveal the location, type or duration of the pain. Review revealed Patient #6 was assessed by a Medical Doctor for pain at 1702, (3 hours, 44 minutes later) "Patient describes pain as a squeezing like its squeezing my heart and states it radiates into her left arm." Patient reports breathing makes the pain worse." Patient #6 received intravenous pain medication at 1728. Review revealed Patient #6 was assessed by a Registered Nurse for pain at 1801, "Pt [patient] states she feels a lot better after medication." Further review revealed no pain scale or description of the pain at 1801. Review revealed Patient #6 was discharged at 1935.

Interview on 07/30/2019 at 1535 with RN #9, revealed initial assessments were performed in triage and "no reassessments unless provide an intervention." Interview revealed pain assessments were done upon arrival in triage and pain reassessments were done with any intervention related to pain.

Interview on 07/31/2019 at 0953 with the Nurse Manager for the Emergency Department, revealed they [hospital staff] want reassessments performed while patients are waiting in the waiting room for an assigned room. The Nurse Manager revealed it is "expected for assessments to be performed according to their levels [categories]." The Nurse Manager revealed the practice was for vital signs to be taken at least every two hours. Interview revealed it was the expectation for staff to evaluate and reevaluate pain according to policy. The Nurse Manager confirmed policy was not followed.


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2. Review on 07/31/2019 of the Policy titled "Skin Wound Care", approved on 01/2019, revealed "PURPOSE: To provide guidelines for skin assessment/reassessment...To identify the patient at risk for skin impairment and initiate...preventive interventions...POLICY: ...3) All nursing and clinical personnel will monitor...any evidence of patient risk for skin impairment on admission and throughout hospitalization ...The following criteria are used in identifying patients at risk...e) edema...f) altered level of consciousness...g) physical immobilization...17) The need for...proper turning schedule/repositioning, and pressure reduction/relief surface is considered with all high risk patients."

Review on 07/31/2019 of the Policy titled "Patient Positioning", approved on 03/2018, revealed "PURPOSE: To provide guidelines for the proper positioning of patients. POLICY: 1) Nursing and Rehabilitation staff will properly position patients...2)...Proper positioning is maintained to:...c) aid in reduction of edema...g) maintain skin integrity...9) When a patient requires passive repositioning by a caregiver to maintain skin integrity, positioning techniques are: a) reposition patient at least every 2 hours for full body change of position and more often for small shifts in position..."

Closed medical record review on 07/30/2019 revealed, Patient #12 was a 31-year-old male admitted on 03/03/2019 at 1807 with a chief complaint of AMS (Altered Mental Status). Review of the H & P (History and Physical) dated 03/03/2019 at 2126 revealed Patient #12's admitting diagnosis was Acute Liver Failure (a life-threatening condition that occurs when large parts of the liver become damaged and are no longer able to function). Review revealed, "the patient cannot provide any history because he is confused." Review of the Physical Exam revealed..."SKIN: jaundice, no rash...unable to move extremities." Review of the initial ED (Emergency Department) Nurse Assessment by RN #3 dated 03/03/2019 at 1816 revealed Patient #12 had no wounds or pressure ulcers present on admission. Review of ED record revealed Patient #12 was transferred to the ICU (Intensive Care Unit) on 03/03/2019 at 2311. Review of the initial Inpatient Nursing Assessment by RN #4, dated 03/03/2019 at 2332 revealed Patient #12 did not have any wounds present on admission. Review of a Nursing Note by RN #5, dated 03/03/2019 at 2332 revealed, "Agree with primary RN on skin assessment at this time and date." Review of Nursing Flowsheets revealed Patient #12 was not repositioned on 03/05/2019 from 1400 to 2000 (6 hours), and on 03/06/2019 Patient #12 was not repositioned during the 8.5-hour period between 0000 and 0830. Review of the Nursing Flowsheet dated 03/07/2019 revealed Patient #12 was not repositioned for 24 hours and 55 minutes between 1820 and 1915 the next day. The Nursing Flowsheet on 03/09/2019 revealed continued gaps in turning Patient #12 between 1000 and 1400 (4 hours) and a second 4 hour period between 2000 and 03/10/2019 at 0000. The Nursing Flowsheet review dated 03/10/2019 revealed Patient #12 was not repositioned for 14 hours between 0600 and 2000. On 03/11/2019, the Nursing Flowsheet revealed Patient #12 was not turned during the 3.5-hour period between 0830 and 1200 and the 6-hour period between 1400 and 2000 (prior to Patient #12's transfer at 2035). Review of a NP (Nurse Practitioner) Brief Progress Note dated 03/10/2019 (7 days after Patient #12's admission) at 0323 revealed, "Order placed for bariatric bed...Pt. weighs 381 lbs. per bedside RN..."Review revealed the patient was later transferred to Hospital #2 on 03/11/2019 at 2035.

Review of a WOCN Assessment from Hospital #2 dated 03/12/2019 at 1208 revealed Patient #12 was a transfer received from Hospital #1 on 03/11/2019. Review revealed, "He presented with pressure injuries: L wrist, penis and sacrococcyx. Review revealed L wrist DTI 's (deep tissue injuries) are from patient being in too small of a bed in OSH (outside hospital) per nurse/family report. Review further revealed a DTI to penis at 11 o'clock, linear, dark purple. Review revealed Date First Assessed: 03/12/2019 at 0400. Present on Admission: YES...Other (Comment) Staging: DTI Medical Device Related Pressure Injury...Dressing Status: No dressing ...Wound length (cm) 2.5, Wound width (cm) 0.2...Pressure Injury...Coccyx/Sacrum DTI non blanchable, dark purple areas...Date First Assessed: 03/12/2019 at 1221...Present on Admission: YES...Dressing: No dressing; Open to air ...Pressure Injury Left inner DTI wrist; non blanchable maroon/purple area...Date First Assessed; 03/12/2019 at 1200...Present on Admission: YES...Wound length (cm) 3.5, Wound width (cm) 6...Support Surface: Patient needs the KREG bed (specialty bed) d/t (due to) his girth and limited turning surface in his current bariatric bed..." Review of a Physician Note dated 03/12/2019 from Hospital #2 revealed..."per nursing report, the patient was admitted last evening/night. He presented with pressure injuries; L wrist, penis, and sacrococcyx."

Interview on 07/31/2019 at 1112 with Hospital #1's ICU (Intensive Care Unit) Manager, SDQO (Senior Director for Quality and Operations), the DOC (Director of Compliance) revealed that leadership was already aware of opportunities to improve outcomes related to hospital acquired pressure ulcers. The ICU Manager revealed, "...even right after, we saw some opportunities and had some concerns...we're looking at the turning process." Interview revealed the DOC stated, "Patient #12 was obviously very sick, and staff was concerned about turning him due to his condition. He was a very challenging case." The DOC further stated that the facility recognized it had problems related to hospital acquired pressure ulcers and implemented some interventions, but continued to have some problems.

Interview on 07/31/2019 at 1409 with WOCN (Wound Ostomy and Continence Nurse) #2 revealed, "We only see patients that we are consulted for... " Interview revealed they did not see Patient #12.

Interview on 07/31/2019 at 1439 revealed RN #6 did remember Patient #12 was very swollen, and did not remember any sacral, penis or wrist wounds, but "wouldn't be surprised." Interview revealed RN #6 did not recall consulting the WOCN for Patient #12.

Interview on 08/01/2019 at 0926 revealed RN #7 did not recall any wounds on Patient #12. Interview revealed any type of wound he noted would have been documented in the LDA (lines, drains and airway) flowsheet.

Interview with the admitting nurse (RN #4) on 08/01/2019 at 1007 revealed RN #4 remembered Patient #12 was intubated and very jaundiced. Interview revealed RN #4 did not recall any wounds. Interview revealed RN #4 did not recall putting in a WOCN consult or requesting a specialty bed for Patient #12.

Request for an interview on 08/01/2019 with RN #8, the nurse who discharged Patient #12, revealed the nurse was not available for interview.

Interview on 08/01/2019 at 1500 with ICU Manager revealed "It is typical that we would order a special bed of some kind for a patient with specific needs...I checked with the vendor and the Bari-Air bed was not delivered until 03/10/2019 ...he was not placed on the bed until that time."








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3. Review of policy titled "Skin Wound Care" with approval date of January 2019 revealed "POLICY: 1) All patients' skin is observed on admission and throughout the continum of care by all nursing....All assessments/documentation should include the following: etiology, anatomical location, measurements (in centimeters), length, width, depth, tunneling, and undermining, characteristics of wound bed, wound edges, periwound tissue, exudates and pain....Skin impairment/wound status will be assessed and documented in the electronic record evey shift and with any change in condition of the wound or dressing...."

Review of open medical record of Patient #22 revealed a 44 year old female admitted on 07/08/2019 for sacral wounds with foul smell. Primary diagnosis from History and Physical dated 07/08/2019 at 1126 pm revealed "Pressure injury of skin with infection with super morbid obesity, sacral decubitis ulcers, bedbound who was brought in with complaint of new skin tear and foul-smelling discharge from previous wounds. Review of Wound Ostomy Consult dated 07/09/2019 at 1316 revealed "Wound description and location: Left buttock: Pressure injury: Stage 3.Wound measures 16 cm x 14 cm x 0.2 cm. Wound bed is red. Moderate amount of bloody drainage. Periwound is scarred...Left upper posterior thigh: Pressure Injury: Stage 3.Wound measures 5.5 cm x 6 cm x 0.2 cm. Wound bed is red. Small amount of blood drainage. Periwound is scarred..Right lower posterior thigh: Pressure injury: Stage 3. Wound measures 5.2 cm x 8.3 cm x 0.1 cm. Wound bed is red. Wound has small amount of serous drainage. Periwound is scarred. Right upper posterior thigh: Pressure injury: Stage 3. Wound measures 0.5 cm x 9.5 cm x 0.2 cm. Wound bed is red. Small amount of bloody drainage. Periwound has signs of shearing. ....Recommend continuing with bariatric bed to aid in improper turning for treatments and assessments. Recommend cleansing wounds with VASHE wound cleanser and gently pat dry. Then apply mepilex border to the wounds and change Tuesday, Thursday and Saturday and prn (as needed) soiling. Explained recommendation to pt..." Review of nursing documentation dated 07/12/2019 at 1808 of "Buttocks: Lower top of upper thigh" revealed "Stage II...Mepilex Border Changed." Review revealed there was incorrect staging and no measurements of the wound. Review of Nursing documentation dated 07/16/2019 at 1600 of "Buttocks: lower top of upper posterior thigh" revealed "Stage II, Mepilex border changed..."Review revealed no documentation of measurements and incorrect stage of wound. Review of nursing documentation of "Buttocks lower top of upper posterior thigh" dated 07/18/2019 at 1600 revealed "Stage II, Mepilex border changed." Review revealed incorrect staging and no documentation of measurements of the wound.

Interview on 07/31/2019 at 1410 with Wound Care Nurse #1 revealed wound nurse consults are performed by the Wound care nurses. "Bedside nurses are taught to stage wounds and perform the nursing duties, such as measuring of wounds during the dressing changes." Interview revealed bedside nurses should follow the wound care wound orders and staging of wounds.

Interview on 08/01/2019 at 1040 with RN #1 revealed nurses should measure wounds with each dressing change. Interview revealed bedside nurses are taught to stage pressure ulcers.

Interview on 08/01/2019 at 1600 with the Interim CNO revealed there were opportunities in improvement in documentation of wounds.

Based on observations, review of nurses check lists, review of medical record and interviews with staff, the facility's staff failed to ensure the control of infections by failing to ensure nursing staff followed procedure for cleansing an IV (intravenous) port prior to administering medications in 1 of 1 observed patients receiving IV medications. (#23).

The findings include:

Observation on 07/31/2019 at 1435 revealed RN #2 connected a Saline syringe to the hub of a peripheral IV on Patient #23. Observaton continued with RN #2 connected an IV medication to hub, adminstered the medication, disconnected the medication syringe and connected the saline syringe. Observation did not reveal the RN scrubbed of the hub during the process.

No policy was available for review regarding IV administration in the peripheral line.

Review of "Nursing Skill Checkoff: Administration of IV Push Medications: Saline Lock" with date of "2017 Administering IV Push Medications Skill Check" revealed "...Scrubs the Hub of the port tip and threads of the needless cap for 15 seconds. Allows to dry for 15 seconds....Flushes with 5 ml of preservative free saline into peripheral site....Scrubs the Hub of the port tip and threads of the needleless cap for 15 seconds. Allows to dry for 15 seconds....Removes medication syringe from catheter port....Cleans catheter port and needeless threads with alcohol prep for 15 seconds--allows to dry for 15 seconds. Attach flush syringe (5 ml for peripheral..) Administer flush at the rate mediation was administered."

Review of the medical record of Patient #23 revealed a 59 year old female admitted on 07/25/2019 for Chest pain. Review revealed Patient #23 was on Contact Isolation and Enteric Isolation.

Interview on 07/31/2019 at 1435 with RN #2 revealed RN #2 did not scrub the hub of the IV port between adminstration of saline, medication then saline flush as the procedure indicated.

Interview on 08/01/2019 at 1440 with the Infection Control Nurse revealed scrubbing of the hub is an essential part of the Infection Control process. Interview revealed nurses that do not scrub the hub is "concerning."

NC00152582, NC00151581, NC00152120