HospitalInspections.org

Based on record review and interview, the facility failed to ensure nursing staff:

1. Implemented and carried out physician orders for 1 of 10 patients (ID# 2).

2. Assessed and documented care of patients with female external urinary catheters in 1 of 1 patient (ID# 2).

3. Followed the established process for pressure injury staging in 1 of 1 patient (ID# 1).

Findings included:

1. Medical record for patient ID#2 for showed on an order for oral care to be performed three times daily (TID).
Documented oral care was performed one time each day on 4/18/24 and 4/23/24.

Interview with clinical coordinator staff (ID# 60) on 5/20/24 at 1:30 PM confirmed the above findings.

2. Record review of facility policy titled "Memorial Hermann Health System Clinical Guideline- Female External Urinary Catheter," dated 6/11/2019 showed the following information:

Guideline Purpose
To utilize an external urinary collection system clinically indicated to minimize the utilization of indwelling urinary catheters while reducing the risk of incontinence associated dermatitis (IAD) ...

F. Documentation
2. External catheter placement and skin assessment every 2 hours ...

Medical record review for patient ID# 2 showed the patient had an external urinary catheter in place on 4/20/24 with no documentation during a twelve-hour period.
Interview with clinical coordinator staff (ID# 60) on 5/20/24 at 1:35 PM confirmed the above findings stating that this nurse missed the documentation the entire night shift.


3. Record review of facility policy titled "Memorial Hermann Health System Clinical Guideline- Pressure Injury identification and follow up," dated 12/14/2022 showed the following information:

Guideline Purpose
The purpose of this clinical guideline is to provide a system wide standardized evidence-based and best practice guideline for pressure injury identification, staging, and follow up assessments.

Pressure Injury Staging Process
1. Assess patient for pressure injuries at the time of admission and ongoing throughout hospitalization.
2. If a suspected pressure injury is identified, promptly notify a Qualified Staging Staff member to assess area(s) of concern.
3. If pressure injury is confirmed by staging staff member ...

Medical record for patient ID#1 showed nursing documentation of skin assessment on 7/23/23 of buttocks erythema/intact/dressing intact.
Skin assessment on 7/31/23 showed buttock now pressure injury.

Interview with staff ID# 52 on 5/20/24 at 3:30 pm, she confirmed that the medical record for patient ID# 1 did not contain documentation that followed the approved process for the patient's buttock pressure injury staging. Wound care notes were only for documented foot wound.