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Based on record review and interview, staff failed develop a comprehensive action plan to address adverse events in 1 of 2 adverse events reviewed (Patient (Pt) #1), in a total sample of 2 adverse events reviewed.

Findings Include:

Review of policy and procedure #3079 titled, "...Patient Safety Event Reporting and Investigation" last reviewed 11/09/2023 revealed the following:
-Reached the individual Safety Event Classification 4: "...Event reached patient; mild and transient anxiety or pain or physical discomfort, but without the need for additional treatment other than monitoring (such as observation; physical examination..."
-"Any safety event, error or unusual occurrence involving patients...must be reported upon discovery."
-"The objectives of the policy are to:...identify opportunities to improve the quality and safety of care and mitigate/minimize hazards and risk and/or future events."

Review of Pt #1's medical record revealed Pt #1 was admitted to the hospital on 08/13/2023 at 9:02 PM post cardiac arrest and cardiogenic shock; Pt #1 was a current inpatient at the time of survey. Per Pt #1's medical record, Pt #1 had a history of type 2 diabetes.

Review of Pt #1's hygiene nursing flowsheet revealed Registered Nurse (RN) G documented trimming Pt #1's fingernails on 11/29/2023 at 4:00 AM (3rd shift).

Review of Pt #1's adverse event report dated 12/01/2023 at 4:35 PM revealed, "(Pt #1's) sister (A) called RN (Registered Nurse) on 11/29 at 1615 (4:15 PM) (1st shift RN) to ask about small cut on left index finger and thumb. RN noted small cut that may have been caused by nail cutter. Sister (A) asked how this happened and RN told her she did not know. No active bleeding noted, dried blood present...Sister (A) called unit on 11/30 and wanted to speak to director of the unit. Manager (C) present during call and Sister (A) accused...staff of intentionally injuring patient...Manager (C) called night RN (G) who stated that she had cut (Pt #1's) nails during the night as she has done before to protect skin on palm since patient clenches his fists. (RN G) did note that skin was broken and cleansed area and applied a Band-Aid to index finger." Review of the adverse event report revealed the incident was investigated for caregiver misconduct, but there was no plan of action to prevent future incidents occurring from untrained staff trimming patient's nails.

Review of Pt #1's Internal Medicine Daily Progress Noted dated 12/01/2023 at 8:54 AM revealed, "...Left index finger with small wound to tip of the finger with dried blood. faint erythema (redness), no drainage...Right thumb with small wound to the tip of the finger with dried blood. No erythema or drainage..."

Per interview with Associate Chief Nursing Officer (CNO) B on 01/04/2024 at 1:49 PM, nursing staff (RNs) should not be clipping any patient's nails; Per CNO B, there is an Advanced Practice Nurse who can do this if needed.

Per interview with Nurse Manager C on 01/04/2024 at 2:00 PM, Manager C stated that RN G was informed that "staff really should not be cutting patients nails, especially a diabetic patient." Manager C stated that she/he was not aware who could trim patient's nails if needed. Manager C stated that she/he was not aware that there is an Advanced Practice Nurse who can do this as per CNO B stated. Per Manager C, there is currently no process/procedure in place addressing nail trimming and no action plans have been implemented in response to this adverse event, to ensure all staff are educated on who can trim patient's nails.

Per interview with RN G on 01/08/2024 beginning at 9:45 AM, RN G stated that Pt #1 was always flexing his/her hands into chest so RN G trimmed Pt #1's index fingernail and accidentally cut the nail too short; RN G stated that she/he went "a tiny bit too deep." RN G did not recall trimming the thumb nail too short. RN G stated that she/he did not think "there was any reason to notify the physician" and did not complete an adverse event report. Per RN G, there was no unit guideline on who was supposed to trim patient nails. RN G denied having training on trimming patient's nails.

Based on record review and interview, staff failed to perform wound assessments and interventions in 1 of 10 patient medical records reviewed (Patient (Pt) #1); and failed to perform pain assessments and reassessments as per policy in 1 of 10 medical records reviewed (Pt #1), in a total sample of 10 medical records reviewed.

Findings Include:

Review of policy and procedure #1728 titled, "Nursing Skin and Wound Assessment and Management" last reviewed 10/03/2023 revealed the following:
1. "A head-to-toe skin assessment will be conducted as follows:...1. Every shift."
2. A focused wound assessment will be completed for any wound identified in the basic skin assessment...2. With every dressing change...a. With each dressing change, the wound will be observed for developments that may indicate the need for a change in treatment (e.g., wound improvement, wound deterioration, more or less exudate, sign of infection or other complications)...3. Upon discovery..."

Review of policy and procedure #1902 titled, "Patient Care Services Pain Management Policy" last reviewed 07/13/2023 revealed the following:
1. "Patient will be screened and assessed for pain by using the appropriate pain scale according to the patient's age, condition..."
2. "Assessment and reassessment of pain will be documented in the medical record."
3. "To ensure patient safety and care efficiency, pain reassessment will occur prior to and following every intervention..."

Review of Pt #1's medical record revealed Pt #1 was admitted to the hospital on 08/13/2023 at 9:02 PM post cardiac arrest and cardiogenic shock; Pt #1 was a current inpatient at the time of survey. Per Pt #1's medical record, Pt #1 had a history of type 2 diabetes.

Review of Pt #1's nursing flowsheets revealed the following:
On 09/23/2024:
-At 6:41 AM, Pt #1 was given Oxycodone 5 mg (milligrams) (narcotic for pain) via Pt #1's gastric tube; there was no reassessment of Pt #1's pain following the intervention as per policy.
-At 12:01 PM, Pt #1 was given Oxycodone 5 mg, there was no assessment of Pt #1's pain.
-At 4:34 PM, Pt #1 was given Oxycodone 5 mg, there was no assessment of Pt #1's pain.
On 09/24/2024:
-At 6:13 AM, Pt #1 was given Oxycodone 5 mg, Pt #1's pain was not reassessed until 8:00 AM (1 hour and 47 minutes later).
-At 10:24 AM, Pt #1 was given Oxycodone 5 mg, there was no assessment of Pt #1's pain.
-At 2:26 PM, Pt #1 was given Oxycodone 5 mg, there was no assessment of Pt #1's pain.

Per interview with Clinical Nurse Specialist (CNS) D, while reviewing Pt #1's medical record, CNS D stated that nursing staff should be performing a pain assessment prior to, and an hour after administering oral pain medications.

Review of Pt #1's hygiene nursing flowsheet revealed Registered Nurse (RN) G documented trimming Pt #1's fingernails on 11/29/2023 at 4:00 AM.

Review of Pt #1's Internal Medicine Daily Progress Noted dated 12/01/2023 at 8:54 AM revealed, "...Left index finger with small wound to tip of the finger with dried blood. faint erythema (redness), no drainage...Right thumb with small wound to the tip of the finger with dried blood. No erythema or drainage..."

Per interview with RN G on 01/08/2024 beginning at 9:45 AM, RN G stated that she/he trimmed Pt #1's index fingernail too short and the finger tip was red; RN G stated that she/he accidentally went "a tiny bit too deep." RN G stated that she/he placed a Band-Aid over the fingertip. RN G did not recall trimming the thumb nail too short.

Review of Pt #1's medical record revealed there was no documented evidence of RN G performing an initial focused wound assessment addressing the injury to Pt #1's finger tips after trimming Pt #1's nails.

Per interview with CNS D, while reviewing Pt #1's medical record, CNS D confirmed there was no documented evidence of a nursing assessment of Pt #1's fingernail wounds until 12/02/2023 (3 days later). CNS stated that RN G should have opened a wound assessment and documented an assessment and interventions.