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Based on interview, medical record review and hospital document review, hospital staff failed to turn a patient every 2 hours as per physicians order for 1 of 2 patients included in the sample with orders to turn patient every 2 hours and failed to follow up on a wound assessment for one patient. (Patient #4)

The findings are:

Patient #4 was admitted to the hospital's COVID-19 unit on 12/26/20. SM #8 documented a history and physical assessment on 12/26/20 at 2:11 PM to include acute hypoxemic respiratory failure secondary to COVID-19, (Patient #4 tested positive for COVID-19 on 12/21/20), COVID-19 viral pneumonia, possible bacterial pneumonia, Sepsis, Morbid obesity, BMI 66, and OSA (Obstructive Sleep Apnea) on CPAP (Continuous Positive Airway Pressure) at night. SM #8 stated Patient #4 had severe bilateral diffuse pneumonia on chest x-ray and was at high risk for worsening. On 12/28/20, Patient #4 condition deteriorated and the patient was intubated, sedated, and transferred to the intensive care unit (ICU). Patient #4 remained intubated until 1/11/21. After being extubated, Patient #4 was transferred to the progressive care unit (PCU). Patient #4 was discharged to a rehabilitation facility on 1/27/21.

Surveyor review of medical records was conducted on 6/9/21 and 6/10/21 with the assistance of a navigator provided by the hospital.
Review of medical records found the following in part: When first admitted to the hospital on 12/26/20, a nursing assessment at 3:00 PM, found the Patient's skin to be within defined limits (WDL). It was documented that Patient #4 was able to turn self and had a Braden scale of 20. The Braden Scale is a scale made up of six subscales, sensory perception, moisture, activity, mobility, friction, and shear. which measure elements of risk for the development of pressure injuries. Braden scale's total scores rage from 6 to 23, with a score of 15 to 18 presenting a mild risk, 13 to 14 is moderate risk, 10 to 12 is high risk, and 9 or less is very high risk. The hospital's electronic medical record system is set to trigger a wound care consult for a low Braden score.

Patient #4 was sedated and intubated on 12/28/20, and moved to the ICU. Patient #4 was critically ill and was unable to change position without assistance. Review of the medical record found Patient #4 was placed on a CLRT specialty bed. The service manual for the bed provided by Staff Member (SM) #2 contained the following information in part: "The rotation mode provides gentle side-to-side, continuous lateral rotational therapy (CLRT) for the prevention of pulmonary complications related to immobility. Patients can be positioned laterally on the right or left side with varying amounts of turn and pause times to match each individual patient's condition. Pressure relief is provided when the rotation mode is active." On 1/2/21 at 2:28 PM, SM #13, a wound care nurse responded to a consult automatically triggered by a low Braden score. SM #13 documented in part "Patient with low Braden score of 12. Patient is sedated and intubated and is covid + and due to need to limit exposure assessment is provided by bedside nurse" Bedside nurse "States patient has no wounds at this time. Patient is currently on specialty bed and is being turned and heels floated to prevent skin breakdown. Patient is at very high risk for breakdown and will continue to monitor for s/s of such."

Review of flow sheet documentation related to turning or positioning Patient #4 for the first hospital admission (dated 12/26/20 to 1/28/21) found sporadic documentation of turning and/or repositioning of the patient every 2 hours. Documentation of turning the patient would sometimes be every 2 hours but was often 6 hours or more between turns.

A wound care consult was ordered on 1/5/21 by SM #17 and completed by SM #12 on 1/6/21 at 4:02 PM. A pressure and shear injury was found on the left buttock and a deep pressure injury to the right buttock. Wound care note read: "Wound care consult for pressure injury to buttocks. Assess large superficial area with peeling edges from shear and 2 fluid filled blister on left buttock. Cleanse with ns and applied viscopaste followed by mepilex to area. Right buttock noted to have deep purple area, mepilex applied to area for protection. Continue mepilex dressing q 3 days. Patient on pressure reduction mattress taps in place. Turn q 2 hours and float heel." The order for the dressing change, turn patient every 2 hours and float heels was entered on 1/6/21 at 3:40 PM and remained active until discharge on 1/28/21.

A consult to wound care was ordered by SM #18 on 1/19/21 at 9:09 AM. SM #12 (a wound care nurse) documented at 1:44 PM a wound assessment with the following note: "Patient is covid + and due need to limit exposure assessment provided by bedside nurse. Nurse reports no change in pressure injury and continues to use viscopaste to area. Patient continues to be Turn q 2hours, float heels. Patient currently on pressure reduction surface with TAPs in place." After the assessment by the wound care nurse on 1/6/21, there is no evidence of further assessment by the wound care nurse prior to discharge. Out of three wound care visits documented during the first hospital stay, two of those assessments were completed by a bedside nurse.

On 6/10/21, at 2:52 PM, SM #12 (a wound care nurse) was interviewed. When asked about wound assessments and dressing changes, SM #12 confirmed that it often is the primary nurse that changes the dressings and because of COVID 19 the primary nurse sometimes assesses the wound. SM #12 was asked if the nurse still needed to turn a patient who is on a CLRT bed or did the CLRT bed replace turning. SM #12 stated that the CLRT bed did not replace turning the patient.

On 6/11/21, at 11:30 AM, SM #6 (wound care manager) was interviewed. SM #6 confirmed that the CLRT bed does not take the place of turning the patient. SM #6 was asked about dressing changes and confirmed that most dressing changes are completed by the primary nurse, unless it was something new or the wound appearance had changed. The surveyor shared with SM #6 that 13 days elapsed between visits to Patient #4, and that the assessment on 1/19/21 was not completed by SM #12 but by the primary nurse. SM #6 was asked what the expectation was for how often the wound care nurse should visit a patient after the initial assessment. SM #6 stated a wound care nurse would be expected to visit at least once a week for a hospitalized patient. SM #6 was asked if the wound care nurse sees the patient before discharge, SM #6 stated "don't usually do a discharge note unless it is a wound vac". SM #6 was asked if the primary nurses received training in wound care other than what they received as a registered nurse. SM #6 stated the wound care nurses would always show the primary nurse how to change a dressing if it was something new.

The surveyor's finding of sporadic documentation of turning Patient #4 was shared with SM #2 (chief nursing officer) on 6/9/21. SM #2 stressed to the surveyor that the hospital staff charts by exception and so would not have been required to document turning the patient as that was what would be expected. The surveyor asked for the policy that would outline the process of charting by exception and received the hospital policy titled " Patient Initial Assessment and Reassessment ". Review of the policy found the following in part " Documentation in the medical record may use within defined limits (WDL) or, based on body system, 'deviation from WDL ' to document physical assessment findings. 1. Refer to age-appropriate WDL criteria. 2. Only assessment findings that do not fit the definition of WDL require detailed documentation. " Review of hospital document " Nursing Documentation within Defined Limits (WDL) for adults (18 + years) " found the following guidelines for skin assessment: *Skin is WDL if skin is warm, dry and intact, without ulcers, redness, signs of trauma or excoriation *Mucous membranes are pink, moist and hydrated *Skin color unblemished, no mottling and appropriate for ethnicity *Skin turgor without tenting or tightness, *No itching, tenderness or pain with skin or scalp *No edema, phlebitis, necrosis or ulceration." The surveyor's interpretation of the policy and the document " Nursing Documentation within Defined Limits (WDL) for adults (18 + years) is the following: The policy spoke to nursing assessments and documentation of nursing assessments of body systems and did not speak to the documentation of nursing interventions and/or physicians orders. A nursing intervention, or in this case a physicians order, to turn a patient every two hours is not a part of a body system assessment. With sporadic documentation of turning the patient every two hours there is no evidence this intervention was carried out. It was noted by the surveyor that the inconsistency in documentation may be a lack of understanding by nurses of what information should be charted in relation to turn orders. The surveyor asked to be provided with additional policies or procedures to guide staff in how to document by exception and what could be documented this way. No additional information was provided.

On 1/30/21, Patient #4 returned to the hospital for" an infected decubitus ulcer of the buttock" , as documented by the attending physician. On 2/1/21, Patient #4 received debridement of the left buttock decubitus wound. On 2/4/21, Patient #4 had a second surgical debridement to the left buttock wound involving muscle layer and wound vac placement. Patient #4 remained hospitalized until 2/21/21 when the patient was discharged to a rehabilitation facility.

Review of medical record for 1/30/21 admission, found Patient #4 was able to turn self with trapeze bar and was being encouraged by physical and occupational therapy to move more. Surgical team encouraged patient to off load the left buttock as much as possible. Wound care nurses documented on Patient #4 on nearly a daily basis, completing assessments and changing the wound dressing.

The above findings were shared with SM #2 and the management team prior to exit on 6/11/21.