HospitalInspections.org

Based on record review and interview the facility failed to ensure that patient safety events/complaints are thoroughly investigated and action plans are developed and implemented to mitigate risk in 2 of 4 patient records reviewed (Pt #5, 10), in a total sample of 4 patient complaints/grievances reviewed.

Findings Include:

Review of policy and procedure titled, "Patient Complaints and Grievances" last revised 09/29/2022 revealed the following:
-Investigation should include review of medical records as well as interviews with associates, providers, and other department associates as appropriate that were involved or can offer input into the concern. Department leaders should be documenting when they make contact with others/who they contact/outcome of that follow up [sic] into the follow-up Review Form to show the actions they took to complete the review.

Pt #5:

Review of Pt #5's "Patient Complaint" form dated 5/04/2022 revealed Pt #5 submitted a complaint to the facility regarding "Provider Response Delay Issue." Per Pt #5's complaint, "On Monday 5/2 evening patient was experiencing chest pain and fell [sic] out of breath. (Pt #5) used his call light to get his nurse. There was no response to the call light. After 4-5 minutes, the patient got up and went to the doorway of his room and yelled out that he needed help. (Pt #5) yelled a few times and no one came, (Pt #5) did not see anyone in the hall or at the nurses station desk. After 2 minutes at the door (Pt #5) went to his/her bathroom and pulled the cord for help. No one responded until after 2 minutes the patient saw someone in the hallway (Pt #5) yelled for her. She came in the room and was not aware of (Pt #5's) calls for help, even though this was not (Pt #5's) nurse she went to get an EKG (electrocardiogram) machine...after this Pt #5's) assigned nurse showed up. She did not know that (Pt #5) had called for help."
Review of the Investigation Summary dated 05/11/2022 revealed, "Upon review, 6E was critically staffed at time of delay. 3 RNs and 1 PCT (Patient Care Technician). Staff were all in patient rooms at the time of the event. This is an unfortunate circumstance related to a lack of resources." Review of the "Contributory Factors" documented was a "Significant lack of Resources" Review of the recommendations documented revealed, "Will continue to elevate a need for more resources."

Review of the Pt #5's complaint investigation showed no documented evidence of who was interviewed, what concerns/issues were addressed, and what interventions were implemented to mitigate the risks of patient safety issues associated with call light response times.

Per interview with Quality Coordinator B on 10/07/2022 at 4:00 pm, there was no additional documentation addressing the investigation into Pt #5's complaint/grievance.

Pt #10:

Review of Pt #10's "Patient Complaint" form dated 7/28/2022 revealed Pt #10 submitted a complaint to the facility regarding "Provider Response Delay Issue." Per Pt #10's complaint, "(Pt #10) was frustrated and anxious about length of time for call lights to be answered/not answered. (Pt #10) was put on a bedpan. (Pt #10) used the call light for help to get off the bedpan/have it removed--(Pt #10) waited over 45 minutes without any response. (Pt #10) ended up sitting on the bedpan for way too long. Now, (Pt #10) doesn't want to eat or drink so that (Pt #10) doesn't have to go to the bathroom."

Review of the "General Investigation Form" completed on 08/5/2022 at 10:17 am revealed that the "Contributory Factors" documented included "...Lack of staff resources/workload..." Review of the Investigation Summary
revealed, "Case reviewed. Staff interviewed. Coaching with staff was performed about expectation around the call light response and follow up time to a patient who was placed on a bedpan..."

Review of the Pt #10's complaint investigation showed no documented evidence of who was interviewed, what concerns/issues were addressed, and what interventions were implemented to mitigate the risks of patient safety issues associated with call light response times.

Per interview with Nurse Manager Q on 10/07/2022 at 4:00 pm, when asked to if there was additional documentation in regards to investigating Pt #10's complaint, Manager Q responded that she/he was unable to provide evidence of who was interviewed, concerns/issues addressed surrounding call light response times, and documentation of the coaching performed with staff. Manager Q stated that hospital staff does not currently track and trend call light response times, Per Manager Q the facility used to track call light response times and forward to managers to review with staff, but this no longer happens.

Based on record review and interview the facility failed to ensure there were sufficient numbers and qualified nursing staff to meet patient care needs; and failed to ensure that nursing staff assess, monitor, and evaluate patient care needs in 6 of 10 medical records reviewed (Pt #1, 2, 3, 4, 5, 10), in a total sample of 10 records reviewed.

Findings include:

Staff failed to ensure there was sufficient numbers of qualified staff to meet patient care needs. See tag A-0392

Staff failed to ensure nurses supervise and evaluate all patient care needs. See tag A-0395

Based on record review and interview the facility failed to ensure there were sufficient numbers and experience of staff to meet patient care needs in 4 of 10 records reviewed (Patient (Pt) #1, 2, 5, 10), in a total sample of 10 medical records reviewed.


Findings Include:

Review of the facility's "Intermediate Care Criteria Guidelines (Final)" no date, (Guidelines reference the American Association of Critical Care Nurses, Milliman Care Guidelines, Society of Critical Care Medicine--Guidelines on Admission and Discharge for Adult Intermediate Care Units) revealed the following:

-Purpose: Create a standard reference to determine appropriate admission, discharge, and transfer criteria for Critical Care level patients in Intermediate Care Units and create guidance for transition to general care.
-Intensive Care Unit (ICU) Standard Staffing = 1 patient to 1-2 (1:1 or 1:2) Registered Nurse (RN)/Pt Ratio
-Progressive Care Unit (PCU) (Intermediate Care Unit) Standard Staffing = 1 patient to 3-4 (1:3 or 1:4) RN/Pt Ratio
-Criteria to advance to General Care (Medical/Surgical Unit): Discharge from the PCU is indicated when 1 or more of the following are present:
1. No requirement for intermediate care level of nursing
2. Where patient would not require a 1:4 RN/Patient ratio

Review of "Staffing Guidelines" (no date), revealed the following:
Progressive Care Units--7 East, 6 East, 6 West:
-"Standard Ratio-Days"--1:4 RN/Pt ratio
-"Standard Ratio-Nights"--1:5 RN/Pt ratio
-"Stretch Ratio-Days--1:5 RN/Pt ratio
-"Stretch Ratio-Nights--1:6 RN/Pt ratio

Review of "Proactive Hourly Rounding" dated 11/04/2021 revealed, "Hourly rounding is our commitment to visit every patient every hour to ensure we are meeting their personal needs and deliver high quality care. When done consistently, hourly rounding greatly reduces call lights, patient falls, and pressure injuries."

Per email response from Nurse Manager Q on 10/13/2022 at 4:48 pm, Nurse Manager Q stated that the expectation is for the staff to answer the patient call lights within 2 minutes. Per Nurse Manager Q, "This could be either the HUC (Health Unit Coordinator), PCA (Patient Care Assistant), or RN...the call light can be answered remotely at the nurses' station or HUC desk to inquire the nature of the patient's request and then send someone to fulfill the patient's request."

Pt #1:

Per interview with Family A (Pt #1's daughter) on 10/6/2022 beginning at 9:05 am, Family A stated that while Pt #1 was on the 6th and 7th floor, staff did not check on Pt #1 every hour and that it could be 4 hours before staff would come and check on him. Per Family A, the nurses would inform family A that they were short staffed when explaining why it would take so long to answer call lights. Family A stated that Pt #1 had difficulties speaking so when Pt #1 pressed the call light and staff answered, they could not hear him so they would just hang up and no one would come to check on him.

Review of Pt #1's medical record revealed that Pt #1 was admitted to the hospital on 8/31/2022 at 12:40 am with a chief complaint of a fall and shortness of breath; Pt #1 died in the hospital on 09/27/2022 at 2:01 am. Per review of Pt #1's Critical Care History and Physical dated 09/25/2022 at 9:30 pm, Pt #1's "Problem list" included but not limited to; syncope secondary to bradycardia (slow heart rate), Respiratory failure, COPD (chronic obstructive pulmonary disease), Heart failure, Acute Kidney Injury, Hyperkalemia (high potassium), and recent upper GI bleed. Pt #1 was on Fall precautions.

Review of Pt #1's Call Light Report (Pt #1's room on the 7th floor) from 09/12/2022 at 11:38 am to 9/25/2022 at 8:55 pm revealed that staff took more than 2 minutes to respond and cancel the call light in 128 out of 254 calls to staff. The following call light alerts from Pt #1's room took more than 6 minutes for staff to respond:
09/12/2022--call light alert at 3:56 pm, duration 8 minutes and 57 seconds; call light alert at 4:39 pm, duration 12 minutes and 37 minutes; call alert at 11:19 pm, duration 6 minutes and 10 seconds
09/13/2022--call light alert at 1:47 pm, duration 13 minutes and 38 seconds
09/14/2022-- call light alert at 12:52 pm, duration 7 minutes and 34 seconds; call light alert at 8:43 am, duration 8 minutes and 33 seconds; call light alert at 8:59 am, duration 6 minutes and 41 seconds; call light alert at 4:48 pm, duration 9 minutes and 15 seconds; call light alert at 11:19 pm, duration 12 minutes and 29 seconds
09/15/2022--call light alert at 4:45 am, duration 7 minutes; call light alert at 9:00 am, duration 13 minutes and 23 seconds
09/16/2022--call light alert at 9:00 am, duration 8 minutes and 3 seconds
09/17/2022--call light alert at 8:48 am, duration 14 minutes and 18 seconds
09/18/2022--call light alert at 7:37 am, duration 11 minutes and 2 seconds; call light alert at 11:32 am, duration 9 minutes and 35 seconds
09/19/2022--call light alert at 5:01 am, duration 12 minutes and 36 seconds; call light alert at 10:29 pm, duration 11 minutes and 33 seconds
09/20/2022--call light alert at 2:43 am, duration 15 minutes and 23 seconds

Pt #2:

Review of Pt #2's medical record revealed that Pt #2 was admitted to the hospital on 09/05/2022 at 1:10 pm with a chief complaint of shortness of breath; Pt #2 was discharged home on 10/07/2022 at 2:56 pm. Per review of Pt #2's History and Physical dated 09/05/2022 at 4:22 pm, Pt #2's "Principal Problem" was Respiratory failure with hypoxia, Interstitial lung disease, acute on chronic Heart failure, and Hypokalemia (low potassium).

Per interview with Pt #2 on 10/06/2022 beginning at 1:50 pm, Pt #2 stated that "It takes along time for staff to respond," Pt #2 stated that she/he has waited 30 minutes for someone to answer the call light and then another 15 to 20 minutes before staff come to the room. Per Pt #2, she/he has been told by staff that they are short staffed and that is why it takes a while for staff to answer the call light. Per Pt #2, she/he was diagnosed with C. diff (clostridium difficile--inflammation of the colon caused by bacteria) infection while in the hospital and had frequent episodes of diarrhea. Pt #2 stated that she/he accidentally stooled on herself/himself while waiting for staff to respond to the call light to help Pt #2 to the bathroom; Pt #2 stated that this happened 2 to 3 times while in the hospital. Pt #2 stated, "It's hard when you have to go to the bathroom." Pt #2 stated that staff do not check on Pt #2 hourly.

Review of Pt #2's Call Light Report (Pt #2's room on 6 west) from 9/6/2022 at 6:05 am to 10/03/2022 at 10:21 pm revealed 53 out of 127 calls to nursing staff took more than 2 minutes for staff to respond and cancel the call light. The following call light alerts took more than 6 minutes for staff to respond:
9/06/2022--call light alert at 6:05 am, duration 7 minutes and 12 seconds; Call light alert at 8:30 am, duration 6 minutes and 35 seconds
09/07/2022--call light alert at 7:59 am, duration 6 minutes and 21 seconds
09/09/2022--call light alert at 9:09 pm, duration 6 minutes and 20 seconds
09/10/2022--call light alert at 2:50 pm, duration 6 minutes and 9 seconds; Call light alert at 6:41 pm, duration 6 minutes and 9 seconds
09/11/2022--call light alert at 9:43 pm, duration 7 minutes and 40 seconds
09/13/2022--call light alert at 10:16 pm, duration 8 minutes and 43 seconds
09/17/2022--call light alert at 1:10 pm, duration 7 minutes and 59 seconds
09/20/2022--call light alert at 5:59 pm, duration 7 minutes and 37 seconds; call light alert at 10:04 pm, duration 8 minutes and 55 seconds
09/22/2022--call light alert at 7:03 pm, duration 6 minutes and 7 seconds
09/23/2022--call light alert at 3:42 pm, duration 7 minutes and 32 seconds
09/27/2022--call light alert at 6:48 pm, duration 9 minutes and 57 seconds
09/28/2022-- call light alert at 7:46 am, duration 7 minutes and 23 seconds
10/03/2022-- call light alert at 3:08 pm, duration 6 minutes and 46 seconds; call light alert at 6:16 pm, duration 10 minutes and 33 seconds.

Pt #5:

Per Review of Pt #5's medical record, Pt #5 was admitted to the hospital on 05/01/2022 at 1:01 am with chief complaint of chest pain; Pt #5 was discharged home on 05/05/2022 at 2:00 pm. Review of Pt #5's History and Physical dated 05/01/2022 at 3:30 am, revealed, " ....(Pt #5) with end stage renal disease on dialysis...type 2 diabetes, hypertension presenting with chest pain, shortness of breath, and palpitation." Per history and physical Pt #5's hemoglobin was low (6.8) requiring a blood transfusion.

Review of Pt #5's "Patient Complaint" form dated 5/04/2022 revealed Pt #5 submitted a complaint to the facility regarding "Provider Response Delay Issue." Per Pt #5's complaint "On Monday 5/2 evening patient was experiencing chest pain and fell [sic] out of breath. (Pt #5) used his call light to get his nurse. There was no response to the call light. After 4-5 minutes, the patient got up and went to the doorway of his room and yelled out that he needed help..." Review of the Investigation Summary dated 05/11/2022 revealed, "Upon review, 6E was critically staffed at time of delay. 3 RNs and 1 PCT (Patient Care Technician). Staff were all in patient rooms at the time of the event. This is an unfortunate circumstance related to a lack of resources." Review of the "...recommendations on what needs to be done as a result of this feedback" revealed, "Will continue to elevate a need for more resources."

Review of Pt #5's Call Light Report (Pt #5's room on 6 east) from 5/01/2022 at 5:39 am to 05/05/2022 at 1:36 pm revealed that 17 out of 46 calls to nursing staff took more than 2 minutes for nursing staff to respond and cancel the call light. The following call light alerts took more than 6 minutes for staff to respond:
5/01/2022--call light alert at 5:45 am, duration 10 minutes and 1 second
5/02/2022--call light alert at 6:37 am, duration 6 minutes and 39 seconds; Call light alert at 10:40 am, duration 8 minutes and 26 seconds; Call light alert at 6:58 pm, duration 13 minutes and 16 seconds; Call light alert at 8:10 pm, duration 9 minutes and 19 seconds
5/03/2022--call light alert at 1:24 pm, duration 6 minutes and 43 seconds
5/04/2022--call light alert at 7:31 am, duration 6 minutes and 46 seconds; Call light alert at 8:10 am, duration 13 minutes and 43 seconds

Pt #10:

Per review of Pt #10's medical record, Pt #10 was admitted to the hospital on 7/25/2022 at 5:14 pm and discharged home on 07/29/2022 at 3:04 pm. Per Pt #10's History and Physical dated 07/25/2022 at 5:24 pm, Pt #10 had Tachyarrhythmia (fast irregular heart rhythm) with Atrial Flutter/fibrillation requiring pacemaker insertion.

Review of Pt #10's "Patient Complaint" form dated 7/28/2022 revealed Pt #10 submitted a complaint to the facility regarding "Provider Response Delay Issue." Per Pt #10's complaint, "Patient was frustrated and anxious about length of time for call lights to be answered/not answered..." Review of the "General Investigation Form" completed on 08/5/2022 at 10:17 am revealed that the "Contributory Factors" documented included "...Lack of staff resources/workload..."

Review of Pt #10's Call Light Report (Pt #10's room on 6 west ) from 7/25/2022 at 7:19 pm to 07/29/2022 at 12:41 pm revealed that 9 out of 24 calls to nursing staff took more than 2 minutes for nursing staff to respond and cancel the call light. The following call light alerts took more than 5 minutes for staff to respond:
7/25/2022--call light alert at 7:50 pm, duration 5 minutes and 58 seconds.
7/26/2022--call light alert at 9:41 am, duration 8 minutes and 58 seconds; Call light alert at 6:53 pm, duration 5 minutes and 47 seconds; Call light alert at 8:21 pm, duration 8 minutes and 41 seconds.
7/28/2022--call light alert at 3:47 pm, duration 5 minutes and 28 seconds.

Review of the nursing assignments for 6 west on 07/26/2022 from 7:00 pm to 11:00 pm revealed there were 4 RNs on the schedule; 2 RNs with a 1:6 RN/Pt ratio, and 2 RNs with a 1:5 RN/Pt ratio. The charge RN was assigned 5 patients.

Per interview with RN I (Charge RN 6 West) on 10/06/2022 at 12:10 pm, RN I stated that the unit is short staff and that it was hard to meet all of the patient care needs on the PCU unit when the nurse is assigned 5 and 6 patients. Per RN I there have been times when day shift nurses are assigned 6 patients. RN I stated, "It's hard to give patients the care they deserve due to staffing issues." RN I stated she/he does not feel patients are safe with the current "stretch" staffing ratios. RN I stated that staff rarely get a lunch break due to the heavy patient load and critically ill patient population.

Per interview with RN J (6 West) on 10/06/2022 at 12:49 pm, RN J stated that she/he has had up to 6 patients during the day shift. Per RN J she/he feels concerned about patient safety and staffing issues. RN J stated that she/he does not typically get a lunch break due to no lunch staffing coverage. RN J does not feel she/he is able to meet all the patient care needs with the current patient to nurse ratios.

Per interview with RN K (6 West) on 10/06/2022 at 1:00 pm, RN K stated that she/he has had up to 6 patients on the PCU unit on 1st shift. RN K stated that there was not adequate staffing to meet all the needs of the patients. Per RN K she/he does not usually get lunch breaks due to staffing concerns. Per RN K, it is hard to complete hourly rounding due to the increased patient to nurse ratio and the high acuity level on the PCU.

Per interview with RN E (Interim Manager on 6 West) on 10/06/2022 at 1:20 pm, RN E stated that with "stretch" staffing, RNs can be assigned up to 6 patients on the day shift and up to 7 patients on the night shift. RN E stated that she/he does not feel staff can meet all the patient care needs in the PCU with the current patient to nurse ratios. Per RN E staff do not typically take their lunch breaks due to the lack of lunch coverage.

Per interview with RN L (Charge RN 7 West) on 10/06/2022 at 2:18 pm, RN L stated that as Charge RN L she/he has been assigned up to 6 patients and also be responsible for staffing, bed management, admission and discharges, and be a resource to other staff. RN L stated that she/he does not feel that all patient care needs can be met with the current staffing levels. RN L stated that she/he does not typically take a lunch break related to staffing shortage and lack of lunch coverage.

Per interview with Director C (ICU/Interim PCU director), Director D (New PCU director), and Director G (staffing office) on 10/06/2022 beginning at 4:00 pm, the hospital is currently experiencing a RN staff shortage. Per Director C, the 7th and 6th floor are Progressive Care Units and are considered a step down unit from the ICU. Director C stated that ideally they would like to keep RN staffing at 1:4 RN/Pt ratio during day shift, and at 1:5 RN/Pt ratio during the night shift. However, due to a RN staffing shortage, Director C stated that the facility has implemented "Stretch" staffing, so the PCU RN/Pt ratio is currently set at 1:5 RN/Pt ratios during days and 1:6 RN/Pt ratio during the night shift. Per Director C, he/she has not seen the PCU RN/Pt ratios go more than 1:5 during the day shift. Director C stated the charge nurse should not have more than 4 patients assigned to him/her during the Day shift.

Per interview with Quality Manager B on 10/07/2022 beginning at 4:05 pm, the facility does not have a policy and procedure or professionally accepted standards of practice for "stretch" staffing guidelines to ensure patients are kept safe during this increased patient to nurse ratio.

Staff Experience:

Review of Charge Nurse Competency Checklist, included but was not limited to, the following competencies:
-Coordinates patient assignments considering acuity, staff grid/matrix, staffing mix, unit based competence, continuity of care, and productivity standards.
-Coordinates workflow of the unit (change of shift report, meals, meetings, care coordination rounds).
-Manages admissions, transfers, and discharges. Collaborates with other units as needed.
-Coordinate emergent care on unit (fire drills, codes, rapid response calls).
-Supervises activities of support personnel

Per interview with RN N on 10/07/2022 at 10:40 am, RN N stated that she/he has been assigned to work as Charge RN despite having no training or competency check list completed. RN N stated that there was no standard acuity protocol in place for making patient assignments so she just "asked around" to see if staff thought there patient assignments were appropriate.

Per interview with Quality Manager B on 10/07/2022 at 4:07 pm, RN M, RN N, RN S work as Charge RNs but do not have documented evidence of completing the Charge RN education and competency check list. Per Quality Manager B, staff should have this education and competency check list completed before working as a Charge RN.

Based on record review and interview the facility failed to ensure that nursing staff assess, monitor and evaluate patient care needs in 5 of 10 medical records reviewed (Pt #1, 2, 3, 4, 5) in a total sample of 10 records reviewed.


Findings Include:

Review of "Med Surg (Medical/Surgical) Shift Charting Responsibilities-Epic (electronic medical records system)" no date, revealed the following:
-Vital signs with pulse oximetry every shift (Blood Pressure (BP), heart rate (HR), Respiratory Rate (RR), Temp, and Pulse oximetry (PO)).
-Weight and weight method daily if ordered.
-Intake and Output should be done by 5:59 am, 1:59 pm, and 9:59 pm to count for your shift
-Document completion of Hygiene (bathing, oral, catheter care) and Nutrition (meals) every shift; document CHG (chlorhexidine gluconate) Bath with central lines.

Review of policy and procedure titled, "Management of Skin Breakdown" last revised 10/10/2022 revealed, "If Wound Care RN consult has been completed, complete wound care as ordered per recommendations."

Pt #1:

Review of Pt #1's medical record revealed that Pt #1 was admitted to the hospital on 8/31/2022 at 12:40 am with a chief complaint of a fall and shortness of breath; Pt #1 died in the hospital on 09/27/2022 at 2:01 am. Per review of Pt #1's Critical Care History and Physical dated 09/25/2022 at 9:30 pm, Pt #1's "Problem list" included but not limited to; syncope secondary to bradycardia (slow heart rate), Respiratory failure, COPD (chronic obstructive pulmonary disease), Heart failure, Acute Kidney Injury, Hyperkalemia (high potassium), and recent upper GI bleed. Pt #1 was on Fall precautions.

Review of Pt #1's medical records revealed the following orders:
-Intake and Output orders for every shift (6:00 am, 2:00 pm, 10:00 pm) dated 09/01/2022 at 12:45 am to 09/14/22 at 7:37 pm.
-Intake and Output orders for every shift dated 09/14/2022 at 2:32 pm to 09/25/2022 at 9:43 pm.
-Daily weights, order dated 09/01/2022 at 12:45 am to 09/25/2022 at 9:43 pm.
-Vital Signs (Blood Pressure, heart rate, pulse oxygenation, temperature, pain assessment) at least every 4 hours, order dated 09/01/2022 at 12:45 am to 09/25/2022 at 9:43 pm.

Review of Pt #1's Intake and Output nursing flowsheets dated from 09/07/2022 to 09/25/2022 revealed there was no documented evidence of nursing staff monitoring Pt #1's "Meal eaten" and "Percent meal eaten" on the following dates and meals:
-09/13/2022: Breakfast and lunch meals
-09/12/2022, 09/18/2022, 09/23/2022, 09/24/2022: Breakfast, lunch, and dinner meals
-09/07/2022, 09/09/2022, 09/10/2022, 09/11/2022: Dinner meal
-09/08/2022: Lunch and dinner meals
-09/20/2022: Breakfast
-09/19/2022: Breakfast and dinner

Review of Pt #1's Dietician Nutrition progress noted dated 09/20/2022 at 10:35 am revealed, "Difficult to assess adequacy of PO (oral) intake based on documentation, 75 % x 1 meal documented over the past 5 days."

Review of Pt #1's nursing flowsheets from 09/06/2022 through 09/25/2022 revealed that there was no documented evidence of staff obtaining a daily weight on the following days;
-09/10/2022, 09/11/2022, 09/12/2022, 09/16/2022, 09/18/2022, 09/19/2022, 09/20/2022, 09/22/2022, and 09/23/2022 and 09/25/2022.

Review of Pt #1's Vital Signs (VS) Flowsheets dated 09/07/2022 through 09/21/2022 revealed that there was no documented evidence of VSs (including BP, HR, RR, PO, and Temperature) being assessed every 4 hours as per physician orders, on the following dates and times:
-On 09/07/2022 between 3:50 pm and 11:00 pm (7 hours and 10 minutes).
-On 09/10/2022 between 2:23 pm and 8:18 pm (5 hours and 55 minutes).
-On 09/10/2022 between 11:49 pm and 8:10 am (8 hours and 21 minutes).
-On 09/12/2022 between 7:00 am and 5:55 pm (10 hours and 55 minutes).
-On 09/12/2022 between 5:55 pm and 11:29 pm (5 hours and 34 minutes).
-On 09/12/2022 to 09/13/2022 between 11:29 pm and 7:30 am (8 hours and 1 minute).
-On 09/13/2022 between 7:30 am and 3:12 pm (7 hours and 42 minutes).
-On 09/14/2022 between 7:00 am and 3:00 pm (8 hours).
-On 09/15/2022 to 09/16/2022 there between 11:45 pm and 7:46 am (8 hours and 1 minute).
-On 09/16/2022 between 7:46 am and 2:01 pm (6 hours and 15 minutes).
-On 09/18/2022 between 9:00 am and 3:45 pm (6 hours and 45 minutes).
-On 09/19/2022 between 9:23 pm and 7:18 am ( 9 hours and 55 minutes).
-On 09/19/2022 there was no documented evidence of nursing staff assessing Pt #1's BP between 7:18 am to 8:57 pm (13 hours and 45 minutes).
-On 09/19/2022 to 09/20/2022 between 11:35 pm and 7:27 am (7 hours 52 minutes).
-On 09/21/2022 to 09/22/2022 between 11:47 pm and 8:00 am (8 hours and 13 minutes).

Review of Pt #1's Wound Care RN T consultation progress note dated 09/12/2022 at 12:23 pm revealed that Pt #1 was at risk for skin breakdown due to moisture and the recommendations was to "Cleanse abdominal/inguinal folds with soap and water, pat dry with towel...Apply antifungal powder BID (twice daily) and place InterDry in folds..." Per Wound Care progress notes, Preventative Measures documented included but was not limited too, "Repositioning every 2 hours while in bed and every hour while in chair, mostly side to side."

Review of Pt #1's Daily Cares/Safety flowsheets from 09/06/2022 through 09/25/2022 revealed that there was no documented evidence of hygiene (including bath and oral care) provided/offered to patient during the following dates and times:
-09/06/2022, 09/12/2022, 09/15/2022, 09/16/2022, 09/17/2022, 09/18,2022, 09/19/2022, 09/20/2022, 09/21/2022, 09/22/2022, 09/23/2022--(No Oral care)
-09/06/2022, 09/07/2022, 09/09/2022, 09/10/2022, 09/11/2022, 09/12/2022, 09/13/2022, 09/14/2022, 09/15/2022, 09/16/2022, 09/17/2022, 09/18,2022, 09/19/2022, 09/20/2022, 09/21/2022, 09/22/2022, 09/23/2022, 09/24/2022 and 09/25/2022--(No Bathing)

Review of Pt #1's Daily Cares/Safey flowsheets from 09/12/2022 to 09/25/2022 showed no documented evidence of the nursing staff cleansing abdominal/inguinal folds with soap and water and applying antifungal powder twice daily as per Wound Care orders.

Review of Pt #1's flowsheets revealed Pt #1 had a Hemodialysis Catheter (central line) placed on 09/22/2022 at 8:23 am (per policy patients should have daily CHG bath documented with central lines).

Review of Pt #1s Mobility flowsheets from 09/13/2022 to 09/19/2022 revealed there is no documented evidence that staff addressed Pt #1 repositioning at least every 2 hours while in bed and every hour while in the chair on the following dates and times:
-09/13/2022 between 9:00 am and 4:14 pm (7 hours and 14 minutes) (in chair)
-09/14/2022 between 10:00 am and 5:00 pm (7 hours) (in chair)
-09/15/2022 between 12:00 am and 09/16/2022 at 12:00 am (24 hours) in
-09/16/2022 between 8:30 am and 3:30 pm (7 hours) (in chair)
-09/17/2022 between 3:30 pm and 11:49 pm (8 hours and 19 minutes) (in chair)
-09/18/2022 between 3:30 pm and 11:21 pm (7 hours and 51 minutes) (in chair)
-09/18/2022 to 09/19/2022 between 11:21 pm and 8:00 am (8 hours and 39 minutes) (in bed)
-09/19/2022 between 8:00 am and 2:00 pm (6 hours) (in chair)

Review of Wound Care RN T progress noted dated 09/20/2022 at 11:43 am revealed, "Buttock: scattered partial thickness skin breakdown noted bilaterally, likely related to shearing and moisture." "Coccyx: Stage II hospital acquired pressure injury measuring 1 x 0.5 (cm) x 0.1 cm (centimeters)." Per Wound Care note, "Patient (Pt #1) reports spending a lot of time up in the chair (did sleep in it last night)."

Pt #2:
Review of Pt #2's medical record revealed that Pt #2 was admitted to the hospital on 09/05/2022 at 1:10 pm with a chief complaint of shortness of breath; Pt #2 was discharged home on 10/07/2022 at 2:56 pm. Per review of Pt #2's History and Physical dated 09/05/2022 at 4:22 pm, Pt #2's "Principal Problem" was Respiratory failure with hypoxia, Interstitial lung disease, acute on chronic Heart failure, and Hypokalemia (low potassium).

Review of Pt #2's medical records revealed orders for strict intake and output and daily weights dated 09/05/2022 to 10/07/2022.

Review of Pt #2's nursing flowsheets revealed that there was no documented evidence of nursing staff assessing Pt #2's weight on the following days:
-09/15/2022, 09/16, 09/19, 09/20, 09/21, 09/25, 09/25, 09/28, and 09/29.

Review of Pt #2's Intake and Output nursing flowsheets from 09/17/2022 to 10/06/2022 revealed that there was no documented evidence of nursing staff assessing Pt #2's urine output on all shifts/required times (6:00, 2:00 pm, and/or 10:00 pm) on the following days:
-09/21/2022, 09/22, 09/24, 09/26/, 10/01, 10/03, 10/04, 10/05.

Review of Pt #2's Intake and Output nursing flowsheets dated from 09/17/2022 to 09/30/2022 revealed that there was no documented evidence of nursing staff monitoring Pt #2's "Meal eaten" and "Percent meal eaten" on the following dates and meals:
-09/18/2022, 09/19, 09/20, 09/22, 09/26, 09/25, 09/24, and 09/30 (breakfast, lunch, and dinner)
-09/21/2022 (Lunch)
-09/28/2022 and 09/29 (breakfast and dinner)
-09/27/2022 (breakfast and lunch)

Review of Pt #2's Daily Cares/Safety Flowsheets from 09/10/2022 through 09/23/2022 revealed that there was no documented evidence of hygiene (including bath and/or oral care) provided/offered to patient during the following dates and times:
-09/23/2022, 09/22, 09/21, 09/20, 09/19, 09/18, 09/17, 09/16, 09/15, 09/14, 09/13, 09/12, 09/11--(no bathing)
-09/20,2022, 09/19, 09/17, 09/13/2022--(no oral care)

Pt #3:

Review of Pt #3's medical record revealed Pt #3 was admitted to the hospital on 07/09/2022 at 3:20 am with a complaints of shortness of breath; Pt #3 was discharged on 07/15/2022 at 2:20 pm.

Review of Pt #3's medical records revealed orders for strict Intake and Output and daily weights dated 07/09/2022 through 07/15/2022.

Review of Pt #3's flowsheets dated 07/09/2022 to 07/15/2022 revealed no documented evidence of nursing staff assessing Pt #3's weight on 07/10/2022 and 07/11/2022.

Review of Pt #3's Intake and Output flowsheets dated 07/09/2022 to 07/15/2022 revealed urine output was not documented at all times and/or required shifts on 07/12/2022 (morning) and 07/14/2022 (evening).

Review of Pt #3's Daily Cares/Safety flowsheets revealed there was no documented evidence of staff offering/providing hygiene cares, including but not limited to, bathing and oral hygiene on 07/09/2022, 07/10, 07/11, 07/12--(no bathing); and 07/09/2022, 07/10, 07/11, 07/12--(no oral care).

Pt #4:

Review of Pt #4's medical record revealed Pt #4 was admitted to the hospital on 06/11/2022 at 1:04 pm for End Stage Renal Disease and Atrial flutter; Pt #4 was discharged on 06/22/2022 at 1:00 pm.

Review of Pt #4's medical records revealed orders for daily weights from 06/15/2022 to 06/22/2022.

Review of Pt #4's nursing flowsheets revealed that there were no documented evidence of nursing staff assessing Pt #4's weight on 06/16/2022, 06/17, 06/21, and 06/22.

Review of Pt #4's Intake and Output nursing flowsheets from 06/11/2022 to 06/22/2022, revealed there was no documented evidence of nursing staff monitoring Pt #4's "Meal eaten" and "Percent meal eaten" on the following dates and meals:
-06/15/2022 and 06/19 (no breakfast, lunch, dinner)
-06/16/2022 and 06/22 (no breakfast and lunch)
-06/17/2022 and 06/21 (no dinner)
-06/18/2022 (no breakfast)
-06/20/2022 (no lunch and dinner)

Pt #5:

Per Review of Pt #5's medical record, Pt #5 was admitted to the hospital on 05/01/2022 at 1:01 am with chief complaint of chest pain; Pt #5 was discharged home on 05/05/2022 at 2:00 pm.

Review of Pt #5's Daily Cares/Safety flowsheets from 05/01/2022 through 05/05/2022 revealed there was no documented evidence of nursing staff offering/providing hygiene cares, including but not limited to, bathing and oral care throughout Pt #5's hospital stay.

Per interview with Quality Coordinator R on 10/10/2022 beginning at 9:00 am during medical record review, Quality Coordinator R confirmed and agreed with the above findings for Pt #1, 2, 3, 4, and 5. Per Quality Coordinator B staff should be documenting repositioning every 2 hours/1hour under mobility in the nursing flowsheets.

Per interview with Quality Manager B on 10/10/2022 beginning at 12:00 pm, Manager B stated that hygiene cares should be documented on each nursing shift.