HospitalInspections.org

Based on a review of facility documentation and staff interviews, the facility failed to ensure nursing staff provided services to each patient as needed, as prescribed or according to hospital policy as physician orders were not carried out, nursing assessments were incomplete and services provided were not accurately documented or performed for 10 of 10 patients.

Findings were:

Facility policy entitled "Safe Patient Management Program," last reviewed 12/18/20, included the following:
"PURPOSE: This policy is to provide guidelines for the safe lifting, transferring, repositioning and moving of patients.
DEFINITIONS: ... Patient handling activities include:
- Repositioning in bed ..."

Facility policy entitled "Guidelines for Skin and Wound Care," effective date 4/13/2012, included the following:
"1. All patients are assessed for potential or actual skin breakdown upon admission and every shift as appropriate. Information from assessment will be entered into Meditech wound screen ...
2. All patients will receive therapeutic interventions aimed at maintaining or restoring the integrity of their skin according to the Nursing assessment. These interventions will be documented in Meditech.
GUIDELINES
1. The Braden Scale is one assessment tool used to help provide information for the caregiver, and to identify the risk of skin integrity alteration ...
5. Patients at intermediate or high risk (below 18) will have interventions instituted based on the nursing assessment. All patients scoring 12 or less on the Braden scale should be placed on a low air-flow bed or surface ..."

Review of Reference #: PC-262 attached to the above policy revealed the following:
"All patients:
All patients have a complete skin assessment on admit, a Braden scale is assigned, and skin condition is documented in Meditech, with photos of any alteration as per policy.
A complete skin reassessment is completed at least q shift, and documented in Meditech ...
[If Braden score < 18, intact skin, add ...Interventions for at risk patients as listed in policy, including:
Monitor mobility, turning, ROM (range of motion) schedule as appropriate...Monitor bony prominences for evidence of skin breakdown, float heels while in bed or chair ..."

A review of the medical record of Patient #1 revealed she was admitted to the hospital on 11/14/19 at 7:05 a.m. via the hospital emergency department. The emergency provider report read as follows:
" ... Patient is a 39-year-old female with history of mental retardation, gastroparesis (a disease in which the stomach cannot empty itself in the normal manner), dysphagia (swallowing difficulties), seizure disorder, and anxiety who presents with a G-tube (a tube placed into the stomach through the abdominal wall) that was pulled out today ..." A history and physical examination performed on 11/14/19 at 9:42 a.m. included the physician note: " ...Turn frequently ..." In addition, a physician's order on 11/14/19 at 9:42 a.m. read as follows: " ...Weigh patient daily ..." Patient #1 was eventually discharged from South Austin Medical Center on 11/20/20. She was repeatedly documented by nursing staff to have been a bedbound patient requiring a 2-person assist for activities of daily living.

Nursing progress notes and/or assessments which addressed the repositioning/turning of Patient #1 were as follows:

11/14/19 9:18 p.m. - " ...Activity: Turn, bedrest..."
11/15/19 7:49 p.m. - " ...Activity: Turn, bedrest ..."
11/15/19 10:55 p.m. - " ...Activity: Turn, bedrest ..."
11/19/19 9:28 a.m. - Nursing - "Turned patient per Q2 turns."

The entries above were the only nursing notes which addressed whether or not the patient was turned during her inpatient stay from 11/14/20 through 11/20/20. The note on 11/19/19 identified the patient was turned every 2 hours. The frequency or time of repositioning was not noted at all in the three assessments made on 11/14/19 and 11/15/19. Thus, it is unclear how often the patient was turned, if at all. In an interview with Staff #1 & 2, Director of Quality and Quality Manager, respectively, during review of the patient record, they stated that checking "turn" on the patient assessment indicated the patient had been repositioned during the shift. When asked how often and when, they stated they did not know.

In addition, despite the physician's order on 11/14/19 for daily weights, there were only two documented patient weights in the record of Patient #1: one on 11/15/19 and one on 11/19/19. The order was in effect for the entire patient stay.

Review of additional patient medical records (Patients #2-10) revealed each of these patients had a deep tissue injury. The skin alteration assessment for each of these patients was inconsistently performed and/or documented throughout their inpatient stays. For example, Patient #2 had an abrasion on his anterior upper back, a bruise on his right lower arm, a stage 2 pressure injury on his coccyx area, excoriation bilaterally on his groin, and pressure injuries bilaterally on his buttocks. For Patient #1, there was no documentation of nursing assessment of his wounds on the 11/1/19 day or night shift despite the nurses having documented that a skin alteration existed and assessment was required. There were multiple other shifts with similar issues.

As another example, Patient #3 was documented as requiring extensive 2-person assist for activities. She was inpatient at the hospital from 8/31/19 through 9/16/19. Her skin assessments were performed only on the night shifts of 9/3/19 and 9/12/19, and on the day shifts of 9/6/19 and 9/16/19, despite evidence that skin assessments were required throughout her stay. As far as repositioning patient #3, on the 9/10/19 night shift, there was no documented evidence the patient was repositioned. There was also no documented evidence on the night shifts of 9/11/19, 9/12/19 and on both the day and night shifts on 9/14/19. On both shifts of 9/9/19, 9/13/19, 9/15/-9/16/19, as well as the day shifts of 9/10/19, 9/11/19, 9/12/19, the patient record included only "turn" as evidence the patient had been repositioned. It was unclear whether the patient had been repositioned every two hours, or on another schedule, or only once during the shift. There was no notation of the time of repositioning. Thus, it was unclear Patient #3 was actually repositioned on those shifts.

In an interview with Staff #1 & 2, Director of Quality and Quality Manager, respectively, during review of the patient records in the offices housing the two individuals, they stated that checking "turn" on the patient assessment indicated the patient had been repositioned during the shift. When asked how often and when, they stated they did not know.

A tour of the nursing unit called "Third Floor Central" with the Director of Quality and the Quality Manager, as well as the third floor nursing manager on the afternoon of 3/3/20 revealed no findings of note. The unit charge nurse stated Patient #12 was a "total care" patient, meaning he needed assistance for activities of daily living. In an interview with Patient #12 stated he was only repositioned when he asked the staff to do it.