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Based on hospital policy and procedure review, medical record review and staff interview, the nursing staff failed to supervise and evaluate the nursing care by failing to ensure a wound care consult was completed in a timely manner for 1 of 4 wound care patients sampled (Patient # 9) and failed to provide tracheostomy care according to facility policy and procedure and/ or physician order for 1 of 2 sampled patients. (Patient #8 )

The findings include:

1. Review of the hospital policy titled "Scope of Services / Plan for Staffing for Wound Ostomy Nurse" effective date 06/2016 revealed "Scope of Services Provided ...D. Integration and Hours of Operation ...The Wound Ostomy Nurse typically provides services on Monday through Friday basis during normal business hours. Patients may be seen at other designated times on a case-by-case basis. Staffing ...B. Staffing Plan The Wound Ostomy Nurse is available for consultation during typical business hours Monday through Friday. In the absence of the Wound Ostomy Nurse, a Clinical Educator and designated RN's (registered nurse) trained in wound ostomy care may provide care as needed in her absence. The hospital operator is notified of the absence of the Wound Ostomy Nurse and who to notify by beeper for WO (wound ostomy) needs."

Medical record review on 03/08/2017 at 1200 for Patient #9 revealed a 72 year-old male admitted to the hospital on 03/02/2017 with a diagnosis of confusion. Review of History and Physical dated 03/02/2017 at 1409 revealed patient had increased confusion for 2 days. Review revealed the patient also complained of chills and cough. Review revealed patient has past medical history of hypertension, diabetes mellitus, coronary artery disease, hyperlipidemia and stroke. Review of surgical history revealed the patient had a right leg skin graft. Vital signs revealed temperature 99.5, respirations 20, heart rate 116 and blood pressure 178/101 with an oxygen saturation of 97% on 2 liters of oxygen via nasal cannula. Physical exam revealed "bilateral lower extremity edema with area of an ulcer involving the medial aspect of the right leg on the mid-section." Lab results revealed "white cell count 16.9, hemoglobin 16.7, platelet count 194, lactic acid 2.3 and urine, blood and wound cultures pending." Assessment and plan revealed "severe sepsis with lactic acidosis secondary to right lower extremity infected ulcer. Ulcer is draining purulent material with erythematous base. Commence aggressive antibiotic therapy with Vancomycin and Zosyn. Follow blood cultures and wound cultures closely."

Review of record revealed an automatic system order dated 03/03/2017 at 0442 for Skin Care Protocol due to Braden Score less than 18. Review revealed an order dated 03/03/2017 at 1053 for a Consult to Wound Care Nurse for right lower leg wound. Review of record on 03/08/2017 at 1200 revealed no available documentation of a Wound Care Nurse consultation being completed (5 days [3 working days] after wound care consult ordered).

Review of Nursing Integumentary Assessment revealed documentation on 03/02/2017 at 2057 of "Skin Symptoms: Wound to right lower leg, sacrum, and inner buttocks, Temperature: warm, Mucous Membrane Color: Pink; Braden Assessment: Sensory Perception: Slightly limited; Braden Score 14; Incision/Wound (1 venous ulcer Leg Right Posterior...): Description: Necrotic tissue, slough; Drainage: Serosanguineous; Incision/Wound (2 Other: Skin Break Down Chest Right...): Description: Deteriorating, Tenderness within wound; Incision/Wound (3 Stasis ulcer Buttock Other: Inner...): Description: Necrotic tissue, slough, Tenderness within wound; on 03/03/2017 at 0920 of "wound to rt lower leg and buttocks. dry, peeling skin noted to bilat lower legs"; on 03/04/2017 at 0800 of "DDI (dressing, dry, intact) bilateral lower legs"; on 03/05/2017 at 0237 of "no change"; on 03/06/2017 at 1500 and 1930 of "None"; on 03/07/2017 at 0730 of "skin very thick and scaly on lower extremities. overall skin condition poor... and at 1915 of "has wounds on right leg. Wound will see"; and on 03/08/2017 at 0915 of "dressing intact to rt leg".

Interview on 03/08/2017 at 1505 with Administrative Staff #1 revealed the Wound Care Nurse works Monday - Friday during normal business hours. Interview revealed the Wound Care Nurse may be seen at other times on a case-by-case basis. Interview revealed the "Skin Care Protocol" is automatically ordered through the system for Braden Scores less than 18. Interview revealed "5 days is too long for wound consultation to not be done after the order".

Interview on 03/08/2017 at 1545 with the WOC RN (Wound/Ostomy Care Registered Nurse) revealed "I have not seen the patient this week". Interview revealed "I did not review the patient's record, but in reviewing now I see the patient had purulent drainage from the leg wound and should have been seen by the end of the work day on 03/06/2017. Interview revealed "I have been involved with wound vac's that have used up my time. Interview revealed the wound care nurse does have back up staff but their hours vary. Interview revealed she works off a wound consult list and prioritizes the patients on the list by degree of need: wound vac, stage III pressure wounds and request from physicians. Interview revealed she reviews the patient's medical record to determine the need if it is not documented on the consult order.






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2. Review on 03/07/2017 of facility's procedure titled "Tracheostomy Care" from the Lippincott Manual, revealed "...
Tracheostomy care should be performed using aseptic technique until the stoma has healed to prevent infection. For recently performed tracheotomies--less than 7 days postoperatively--or unhealed tracheostomies, the site should be assessed at least every 4 hours and the stoma should be cleaned and redressed every 8 hours. Tracheostomy care should be performed at least every shift on a healed tracheostomy....."

Open medical record review of Patient # 8 on 03/08/2017 revealed a 47-year-old male who was admitted to the facility on 02/10/2017 for a diagnosis of pneumonia. Record review revealed the patient had a medical history of quadriplegia (paralysis of all four limbs) and a tracheostomy (a tube which is inserted into the windpipe to enable breathing). Review of the physician order on 02/11/2017 at 1906 revealed an order for "Tracheostomy Care; Frequency; q8h (every 8 hours); Special instructions: Inner cannula non-disposable, must be taken out and cleaned when trach care is performed." Further physician order review revealed on 02/21/2017 at 1435 the Tracheostomy Care order frequency was changed to BID (twice daily). Review of the "Tracheostomy Assessment Flowsheet" Date Range 02/10/2017 00:00- 03/10/2017 1631 EST (Eastern Standard Time) revealed Tracheostomy Care performed and documented at the following times:

02/11/17 at 1834: Extra Trach kit at bedside, Dressing changed, Inner cannula cleansed, Suctioned
02/12/17 at 2245: Extra Trach kit at bedside, Dressing changed, Inner cannula cleansed, Suctioned (28 hours 11 minutes later)
02/13/17 at 2210: Inner cannula cleansed (23 hours 35 minutes later)
02/15/17 at 11:10: Extra Trach kit at bedside, Dressing changed, Inner cannula cleansed, Suctioned (36 hours later)
02/16/17 at 1600: Extra Trach kit at bedside, Inner cannula cleansed, Stoma site cleansed (27 hours 50 minutes later)
02/16/17 at 2326: Extra Trach kit at bedside, Dressing changed, Inner cannula changed (7 hours 26 minutes later)
02/17/17 at 1945: Extra Trach kit at bedside, Dressing changed, Inner cannula cleansed (20 hours 41 minutes later)
02/18/17 at 2258: Extra Trach kit at bedside, Dressing changed, Inner cannula cleansed, Stoma site cleansed (27 hours 13 minutes later)
02/19/17 at 0745: Extra Trach kit at bedside, Dressing changed, Inner cannula cleansed (8 hours 47 minutes later)
02/19/17 at 1600: Extra Trach kit at bedside, Inner cannula cleansed, Stoma site cleansed (8 hours 15 minutes later)
02/20/17 at 0735: Extra Trach kit at bedside, Dressing changed, Inner cannula cleansed, Suctioned (15 hours 35 minutes later)
02/21/17 at 1240: Extra Trach kit at bedside, Dressing changed, Inner cannula cleansed (28 hours 5 minutes later)
02/22/17 at 1538: Extra Trach kit at bedside, Dressing changed, Inner cannula cleansed, Stoma site cleansed (26 hours 58 minutes later)
02/23/17 at 1448: Extra Trach kit at bedside, Inner cannula cleansed, Stoma site cleansed (24 hours 10 minutes later)
02/23/17 at 2015: Extra Trach kit at bedside, Dressing changed, Inner cannula cleansed, Stoma site cleansed (5 hours 27 minutes later)
02/26/17 at 0926: Extra Trach kit at bedside, Inner cannula cleansed (61 hours 26 minutes later)
02/27/17 at 1214: Extra Trach kit at bedside, Inner cannula cleansed, Suction, trachea (26 hours 18 minutes later)
Review revealed no other documentation of care performed until 03/08/17 at 08:15 "Extra trach kit at bedside, other: pt. refused trach care"

Interview with RN # 1 on 03/07/17 at 1430 revealed Trach care is a shared responsibility between respiratory and nursing. Nursing uses the Lippincott Nursing procedure manual as a reference and the manual is available to everyone at all nursing stations.

Interview with RT #1 on 03/07/17 at 1445 revealed there is no written policy for tracheostomy care and care is done as a "as needed" basis. Interview revealed trach care is a shared responsibility with nursing and her practice is usually performing care while going to do treatments.

Interview with Respiratory Care Director on 03/08/17 at 0845 revealed there is no written policy for tracheostomy care. Interview revealed trach care is a shared responsibility with the nursing staff. Interview revealed the care is performed on an "as needed" basis. Interview revealed it is the expectation of all staff to follow the physician orders. Interview confirmed the staff did not follow physician order nor guidelines the facility uses in providing tracheostomy care.

Based on medical record review, review of DHSR correspondence, and staff interview the facility staff failed to ensure a patient was referred/discharged to an appropriate licensed facility to meet the patient's need for 1 of 1 sampled patients (Patient #12) with a discharge referral.

The findings include:

Medical record review on 03/08/2017 for Patient #12 revealed a 65 year-old female who presented to the Emergency Department via law enforcement on 12/28/2016 with a chief complaint of "flight of ideas" and "medication non-compliance". Review of the Admission History and Physical documented 12/29/2016 at 1410 revealed " ...she (patient) was recently released from (Hospital Name A) and has been unsteady on her feet and been acting confused. ...her behaviors are related to her taking Seroquel ...'looked up the side effects of this particular medication and the side effects are exactly how she is acting'. ... pt has not slept in the past 2 days. ...pt was seen by her pain doctor and her PCP (primary care provider), (Dr. Name) yesterday and her PCP stated that pt 'needs to get the medication out of her system'. He (ex-husband) does not contract for pt's safety due to her increased confusion and feels she is a danger to self... Pt lives with her ex-husband. She can return to the home."

Review of psychiatry notes revealed the patient has 2+ LE (lower extremity) edema and TSH (thyroid stimulating hormone) has elevated since last admission, this indicates medication non-compliance, question patients ability to care for herself. Will need further investigation into living situation and a family meeting, pt. may need ALF (assisted living facility) to prevent frequent hospitalizations. Plan: Medication management, Psychoeducation and SW (social worker) referral."

Review of medical record on 03/08/2017 revealed a multidisciplinary treatment team plan documented on 12/28/2016 with delusional and hallucination problems identified on the initial assessment. Review revealed an admitting diagnosis of Unspecified Bipolar Disorder. Further review revealed documentation of "Discharge/Continuing Care plan" that included "patient education needs: medication, diagnosis/disease process and coping skills; discharge criteria: tolerates medications without severe side effects and free of suicidal ideations/thoughts; and initial discharge plan: living arrangement - multi-specialty unit". Review revealed the treatment plan was discussed with the patient and she was in agreement.

Review of provider progress notes dated 01/03/2017 at 1135 revealed "Basic Information: "I can't do this anymore I hope they accept me at the new place. ...Impression and Plan - Progress/Update: ...Patient reportedly had a meeting with group home this AM and thought the meeting went well. ... Estimated Date of Discharge: 1/4/17 Pending Placement." Review of Social Worker's Discharge Summary Plan dated 01/04/2017 revealed follow-up appointment made with (Name Clinic) for 01/19/2017 at 10:00 am and follow-up appointment with (Name Family Medicine) to be made by facility manager after discharge from hospital. Further review revealed "Diagnosis: Bipolar Disorder, unspecified; Level of Care: Outpatient; Discharge Destination: Residential Placement." Continued review revealed a brief discharge summary note which read "Pt mood is stable; Pt denies SI/HI. Pt participated in group sessions to aid in the tx (treatment) process. Pt is strongly urged to follow inpatient tx with all aftercare appointments to include medication management, therapy and medical care. Pt to also follow all instructions on prescriptions as written by the physicians. Pt to discharge to (Name) Residential, via manager, (Name and telephone number)."

Review of physician's Discharge Summary dated 01/04/2017 at 1521 revealed "Hospital Course...A family meeting was planned with social worker and the patient's ex-husband and it was determined that the patient needed a higher level of care other than discharge to home. Discharge Plan: The patient will be going to (The Name Clinic)." Review of discharge instructions revealed "Discharge Diagnosis: Auditory hallucinations; Bipolar disorder; Psychosis ...Follow up: With: (Name Family Medicine) Comments: Facility manager to schedule an appointment With: (Name Clinic)...When: 1/19/2017 10:00 Medication List Fill New Prescriptions: Cleocin, Gabapentin, Dyazide, Levothroid, Magnesium oxide, Protonix, Seroquel Discontinue These Medications: Doxycycline, Furosemide, Lorazepam."

Review of the medical record for Patient #12 revealed the hospital providers and staff identified further investigation would be needed to determine living situations and the possibility of placement into an Assisted Living Facility to prevent frequent hospitalizations. Review revealed patient #12 was discharged from Hospital A to a multi-unit residential facility on 01/04/2017.

Telephone interview on 03/10/2017 at 1237 with Social Worker (SW) #1 revealed she was the social worker that worked with the patient and prepared the discharge treatment plan for the patient. Interview revealed the patient was given two different lists of facilities to choose a location for discharge. Interview revealed the discharge facility was chosen from the DHHS website of approved facilities. Interview revealed the criteria for choosing an appropriate facility for the patient included independence and help support when needed. Interview revealed the patient was contacted 72 hours after discharge by one of our social workers to follow-up on how the patient was transitioning to her new surroundings. Interview revealed the patient was happy and thriving. Interview revealed the patient stated "she hoped to get a roommate soon". Interview revealed the decision to discharge to a multi-specialty housing unit was made by the patient and staff after patient stated "she did not want to return home".

Interview on 03/08/2017 at 1720 with SW #1 revealed the treatment team rounds daily to determine discharge and location. Interview revealed the patient had a lot of physical decline, leg edema, on this admission. Interview revealed there was a phone call with the ex-husband and as a result, the facility staff removed the patient's permission to talk with her ex-husband. Further interview revealed the discharge plan was discussed with the patient and she was given a choice to go back home or to a multi-specialty residential home. Interview revealed "I felt it was a safe discharge." Interview revealed the patient was excited to go to her new home. Further interview revealed the ex-husband was told that we did not have permission to share information about the patient with him. Interview revealed the ex-husband did attend meetings. During last meeting with patient and ex-husband, patient requested security to be present.

Interview on 03/08/2017 at 1745 with Nurse Practitioner (NP) #2 revealed she was the provider that discharged the patient. Interview revealed the patient was stable for discharge to the residential facility. Interview revealed the patient was capable of making her own decisions. Further interview revealed a family meeting was held with the patient and ex-husband present to discuss patient's care and discharge. Interview revealed the ex-husband became very verbal in the meeting, cursing at the NP and the NP left the room. Interview revealed "the ex-husband gave them a list of places in Raleigh that he wanted the patient transferred to."

In summary, hospital staff failed to ensure Patient #12 was discharged from the inpatient behavioral health unit to an appropriate facility. Review of correspondence from the Division of Health Service Regulation, Adult Care Licensure Section dated March 23, 2017, revealed Patient #12 was discharged to a residential facility that was operating as an unlicensed Adult Care Home.

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Based on hospital policy and procedure review, medical record review and staff interview, the nursing staff and respiratory staff failed to provide tracheostomy care according to facility policy and procedure and/ or physician order for 1 of 2 sampled patients. (Patient #8 )

The findings include:

Review on 03/07/2017 of facility's procedure titled "Tracheostomy Care" from the Lippincott Manual, revealed "...
Tracheostomy care should be performed using aseptic technique until the stoma has healed to prevent infection. For recently performed tracheotomies--less than 7 days postoperatively--or unhealed tracheostomies, the site should be assessed at least every 4 hours and the stoma should be cleaned and redressed every 8 hours. Tracheostomy care should be performed at least every shift on a healed tracheostomy....."

Open medical record review of Patient # 8 on 03/08/2017 revealed a 47-year-old male who was admitted to the facility on 02/10/2017 for a diagnosis of pneumonia. Record review revealed the patient had a medical history of quadriplegia (paralysis of all four limbs) and a tracheostomy (a tube which is inserted into the windpipe to enable breathing). Review of the physician order on 02/11/2017 at 1906 revealed an order for "Tracheostomy Care; Frequency; q8h (every 8 hours); Special instructions: Inner cannula non-disposable, must be taken out and cleaned when trach care is performed." Further physician order review revealed on 02/21/2017 at 1435 the Tracheostomy Care order frequency was changed to BID (twice daily). Review of the "Tracheostomy Assessment Flowsheet" Date Range 02/10/2017 00:00- 03/10/2017 1631 EST (Eastern Standard Time) revealed Tracheostomy Care performed and documented at the following times:

02/11/17 at 1834: Extra Trach kit at bedside, Dressing changed, Inner cannula cleansed, Suctioned
02/12/17 at 2245: Extra Trach kit at bedside, Dressing changed, Inner cannula cleansed, Suctioned (28 hours 11 minutes later)
02/13/17 at 2210: Inner cannula cleansed (23 hours 35 minutes later)
02/15/17 at 11:10: Extra Trach kit at bedside, Dressing changed, Inner cannula cleansed, Suctioned (36 hours later)
02/16/17 at 1600: Extra Trach kit at bedside, Inner cannula cleansed, Stoma site cleansed (27 hours 50 minutes later)
02/16/17 at 2326: Extra Trach kit at bedside, Dressing changed, Inner cannula changed (7 hours 26 minutes later)
02/17/17 at 1945: Extra Trach kit at bedside, Dressing changed, Inner cannula cleansed (20 hours 41 minutes later)
02/18/17 at 2258: Extra Trach kit at bedside, Dressing changed, Inner cannula cleansed, Stoma site cleansed (27 hours 13 minutes later)
02/19/17 at 0745: Extra Trach kit at bedside, Dressing changed, Inner cannula cleansed (8 hours 47 minutes later)
02/19/17 at 1600: Extra Trach kit at bedside, Inner cannula cleansed, Stoma site cleansed (8 hours 15 minutes later)
02/20/17 at 0735: Extra Trach kit at bedside, Dressing changed, Inner cannula cleansed, Suctioned (15 hours 35 minutes later)
02/21/17 at 1240: Extra Trach kit at bedside, Dressing changed, Inner cannula cleansed (28 hours 5 minutes later)
02/22/17 at 1538: Extra Trach kit at bedside, Dressing changed, Inner cannula cleansed, Stoma site cleansed (26 hours 58 minutes later)
02/23/17 at 1448: Extra Trach kit at bedside, Inner cannula cleansed, Stoma site cleansed (24 hours 10 minutes later)
02/23/17 at 2015: Extra Trach kit at bedside, Dressing changed, Inner cannula cleansed, Stoma site cleansed (5 hours 27 minutes later)
02/26/17 at 0926: Extra Trach kit at bedside, Inner cannula cleansed (61 hours 26 minutes later)
02/27/17 at 1214: Extra Trach kit at bedside, Inner cannula cleansed, Suction, trachea (26 hours 18 minutes later)
Review revealed no other documentation of care performed until 03/08/17 at 08:15 "Extra trach kit at bedside, other: pt. refused trach care"

Interview with RN # 1 on 03/07/17 at 1430 revealed Trach care is a shared responsibility between respiratory and nursing. Nursing uses the Lippincott Nursing procedure manual as a reference and the manual is available to everyone at all nursing stations.

Interview with RT #1 on 03/07/17 at 1445 revealed there is no written policy for tracheostomy care and care is done as a "as needed" basis. Interview revealed trach care is a shared responsibility with nursing and her practice is usually performing care while going to do treatments.

Interview with Respiratory Care Director on 03/08/17 at 0845 revealed there is no written policy for tracheostomy care. Interview revealed trach care is a shared responsibility with the nursing staff. Interview revealed the care is performed on an "as needed" basis. Interview revealed it is the expectation of all staff to follow the physician orders. Interview confirmed the staff did not follow physician order nor guidelines the facility uses in providing tracheostomy care.