HospitalInspections.org

Based on record review, observation and interview the facility failed to ensure that a Registered Nurse supervised the care of 2 (Patient #1 and #2) out of 3 sampled patients to ensure repositioning and perineal Foley catheter care.

The findings include:

1. Patient #1 was admitted to the hospital on 2/5/19, had a Foley catheter inserted at 2:40 a.m., and had a diagnosis of closed fracture of neck of the right femur.
On 2/7/19 the patient was found in bed, at approximately 8:15 a.m., sitting on a bed pan.

Record review revealed the bedpan caused a pressure injury to deep tissue of the contiguous region involving back, buttock and hip. The area was initially purple; but lightened to red, with the epidermis intact, as documented by the ARNP on 2/7/19 at 12:52 p.m.

Interview of the nursing staff, assigned to the patient on the 12 hour night shift (from Wednesday 2/6/19 at 7:00 p.m. to Thursday 2/7/19 at 7:00 a.m.) revealed that certified nursing assistant (CNA) Staff A and RN Staff B were unaware that the patient was sitting on a bed pan. Both staff denied placing the patient on a bedpan per hospital interview records.

Upon interview on 3/21/19 at 5:20 a.m., CNA Staff A stated that she did not reposition or provide perineal care (Foley catheter care) to Patient #1 during the 12 hour shift on 2/6/19 through 2/7/19. She said "We were very busy that night. I did not reposition the patient because she was complaining of pain. At one point, early in the shift, I pulled the patient to the middle of the bed with the help of another CNA." When asked, she said she did not place the patient on a bed pan, saw the patient about 4 times (from the hallway) during the night and reported to the registered nurse (RN) that the patient was in pain. She said she emptied the Foley catheter urinary drainage bag near the end of the shift.

RN Staff B was unavailable for interview.

Review of Patient #1's medical record revealed that no perineal care (Foley catheter care) was documented as being administered during the patient's entire hospital stay (2/5/19 to 2/8/19). Repositioning was documented one time at 1800 (6:00 p.m.) on 2/5/19 for this patient status post a hip fracture.

Hospital Policy and Procedure entitled "Catheter Associated Urinary Tract Infection Prevention", dated February 2018 (revised) states "3.8 Inspect urinary meatus for drainage or encrustation. 3.10 Cleanse the outside of the catheter and around the meatus daily and PRN (as necessary) after bowel movements with soap and water."

2. Patient #2 was admitted to the hospital on 3/15/19, had a Foley catheter inserted on 3/18/19 at 12:30 p.m., and had a diagnosis of a right hip fracture. The patient was observed at 11:50 a.m., on 3/20/19 sitting in an upright position in a reclining chair. She was observed receiving IV fluids and had a urinary drainage bag connected to a Foley catheter. The urinary drainage bag was observed to be touching the floor. Upon interview at this time, the hospital Risk Manager acknowledged that the urinary drainage (collection) bag was touching the floor.

Hospital Policy and Procedure entitled "Catheter Associated Urinary Tract Infection Prevention", dated February 2018 (revised), states "3.5 Keep collection bag below the level of the bladder at all times. Do not allow bag to touch the floor."

Review of Patient #2's medical record revealed that no perineal care (Foley catheter care) was documented as being administered during the patient's entire hospital stay (3/15/19 through 3/20/19) and repositioning of the patient, status post a hip fracture, was documented one time at 1500 (3:00 p.m.) on 3/15/19.