HospitalInspections.org

Based on interview, record review, call light log review, document review and policy review, the nursing department failed to ensure that call lights were answered in a timely manner for one of one patient (P) (P1); failed to ensure daily bathing was documented per facility policy for seven of 10 patients (P1, P2, P3, P4, P6, P9 and P10) receiving care in this facility; and failed to ensure turning and repositioning was documented per facility policy for 10 of 10 patients (P1, P2, P3, P4, P5, P6, P7, P8, P9, and P10) receiving care in this facility. This failure has the potential to place all patients requiring substantial assistants at risk for skin break down.


Findings Include:


1. Review of P1's medical record showed P1 was admitted 02/24/22 and was discharged 04/02/22 (37 day stay), with an admitting diagnosis: "Acute Respiratory Failure with Hypoxia (inadequate oxygen delivery to the tissues either due to low blood supply or low oxygen content in the blood)."


Review of the facility's call light log for patient or family-initiated calls for P1 from 02/24/22 to 02/28/22 (first five days of admission) revealed the following:

On 02/24/22 at 6:30 PM, P1's call light activated, and the system message indicated "RN [Registered Nurse] Requested." According to the log, it took 26 minutes and 11 seconds for a RN to respond.

On 02/25/22 at 1:24 PM, P1's call light was activated, and the system message indicated "Ready for Bath." P1 waited 40 minutes and 14 seconds.

On 02/25/22 at 2:08 PM, P1's call light was activated, and the system message indicated, "Clean-up." P1 waited 48 minutes and 48 seconds to be cleaned up.

On 02/26/22 at 8:21 AM, P1's call light was activated, and the system message indicated, "Suction." P1 who was on a ventilator waited 34 minutes and 23 seconds to be suctioned.

On 02/26/22 at 3: 24 PM, P1's call light was activated, and the system message indicated, "Bed Pan Assist-On." P1 waited 37 minutes and 25 seconds for nursing staff to respond to assist P1 with toileting.

On 02/28/22 at 6:48 PM, P1's call light was activated, and the system message indicated, "Tele - Leads off/No signal." It took 46 minutes and 42 seconds for staff to respond to telemetry not receiving cardiac readings for P1.

On 07/27/22 at 2:09 PM, during a telephone interview with family member (F1) of P1, F1 stated that on 02/26/22, P1 needed to use the bed pan so F1 pushed the call light. F1 stated, "no one came for over 30 minutes, so I just got P1 on the bedpan, but I could not get P1 off of the bedpan. I needed help. I had to go out to the nurses' station to find a nurse and checked the call light system to ensure it was working. The nurse did confirm the system was working." F1 stated that the staff refused to reposition P1 after toileting, and there were days when P1 "smelled bad" and staff had to be asked to bathe P1.

Review of the hospitals QAPI data titled, "QAPI - Survey Readiness Table - Select Wichita" revealed " Review of the "Call answered in 10 minutes or less" had a goal of 85%, 4th Quarter of 2021 the hospital was at 64%, 1st Quarter of 2022; 62%, April 2022; 52%, May 2022 55%; and June 2022 64%.

During an interview regarding call lights on 07/26/22 1:00 PM, the Director of Nursing (DON) stated, "we are tracking them, and our goal is to stay around 10 minutes for response." The DON stated there are no glaring issues (trends) identified in their call light tracking data. The DON confirmed that the hospital does receive complaints about patients waiting for call lights to be answered, but no trends have been identified. DON stated if staff are providing cares or with other patients, for safety they cannot leave the patient to answer a call light.

During an interview on 07/27/22 at 9:45 AM, a Certified Nursing Assistant (CNA)1 stated, CNAs are usually assigned six to seven patients, but if there is a call in, they may have eight to nine patients. CNA1 stated that some of the RNs "do not answer call lights or assist with cares because they feel it is the CNAs responsibility." CNA1 confirmed, "sometimes the patients do have to wait 30 or more minutes, until I can get there."



2. Review of the hospital's policy titled, "Clinical Services Policy and Procedure" last revised 04/01/22 revealed, the purpose, "To outline clinical routines, guidelines, and protocols of patient care. ...To ensure quality patient care, certain standards of care must be upheld. The following table outlines basic tasks and designates the minimum frequency with which these tasks must be performed to maintain quality care. Two patient identifiers will be used when providing care, treatment, and services ...Hygiene, Routines/Guidelines, Patient bathed/hair combed/shaved as daily, Minimum Frequency: daily ... Activity and Mobility, Bedfast patients turned. Document position (R-repositioned B-back to bed) Document Every 2 hours ..."

Review of the hospital's policy titled, "Clinical Service Policy and Procedure," dated 10/01/17 revealed, " ...all patients will be cleaned up as soon as possible after soiling ...All patients will be bathed ...."

Review of the hospital's policy titled "Clinical Service Policy and Procedure," subject: "Wound Prevention" last revised 10/01/17 revealed, "All patients admitted will be considered high risk for the development of pressure ulcers ...Individualized plan of care according to patient activity level ...Patients that are bed bound or with limited activity should be repositioned at least every two hours (consider implementing a turn team) ..."


Patient 1

Review of P1's "24-hour Nursing Plan of Care" that revealed, "Self-Care & [and] Mobility Rating Scale" for P1 was a "2" which was defined as needing "Substantial/Maximal Assistance." According to P1's medical record there was no documentation for 19 of the 37-day hospitalization that P1 was bathed on 02/26/22, 02/28/22, 03/01/22, 03/02/22, 03/02/22, 03/04/22, 03/05/22, 3/08/22, 3/10/22, 3/13/22, 3/14/22, 3/18/22, 3/22/22, 3/23/22, 3/26/22, 3/29/22 3/30/22, 3/31/22, and 04/01/22.

Review of P1's "Hourly Rounding," showed there was missing documentation for turning and repositioning of P1 every two hours per hospital policy on 02/28/22, 03/02/22, 3/23/22, 03/24/22, 03/25/22, 03/27/22 and 03/28/22.


Patient 2

Review of P2's medical record showed P2 was admitted on 02/09/22 and discharged on 02/28/22 (19 days) with an admitting diagnosis "Acute Respiratory Failure with Hypoxia." Review of the "24-hour Nursing Plan of Care" revealed, "Self-Care & Mobility Rating Scale" for P2 was a "2" which was defined as needing "Substantial/Maximal Assistance." According to P2's medical record, there was no documentation of a bath for P2 for 11 of the 19-day hospitalization for the dates: 02/09/22, 02/10/22, 02/11/22, 02/13/22, 02/15/22, 02/16/22, 02/18/22, 02/19/22, 02/20/22, 02/23/22 and 02/24/22.

Review of P2's "Hourly Rounding" showed there was missing documentation for turning and repositioning of P2 every two hours per hospital policy on 02/17/22, 02/19/22, 02/20/22, 02/22/22, 02/24/22, 02/26/22 and 02/27/22.


Patient 3

Review of P3's medical record showed P3 was admitted on 02/10/22 and discharged on 02/15/22 (5 Days) with an admitting diagnosis: "Acute Respiratory Failure with Hypoxia." Review of the "24-hour Nursing Plan of Care" revealed, "Self-Care & Mobility Rating Scale" for P3 was a "2" which was defined as needing "Substantial/Maximal Assistance." According to P3's medication record, there was no documentation that P3 received baths for two of the five days stay per the hospital policy on 02/10/22 and 02/12/22.

Review of P3's"Hourly Rounding" showed there was missing documentation for turning and repositioning of P3 every two hours per hospital policy on 02/10/22, 02/12/22 and 02/13/22. On 02/11/22 there was no documentation of turning and repositioning for the entire 24-hour period.


Patient 4

Review of P4's medical record showed P4 was admitted on 07/05/22 and was still a current inpatient with diagnoses: "Right buttock STI [sexually transmitted infection]. Stage III Bilateral [both legs] BKA [below the knee amputation] and mid abdominal wounds." Review of the "24-hour Nursing Plan of Care" revealed, "Self-Care & Mobility Rating Scale" was a "2" which was defined as needing "Substantial/Maximal Assistance." According to P4's medical record, there was no documentation that P4 was bathed on 07/25/22.

Review of P4's "Hourly Rounding" showed there was missing documentation for turning and repositioning of P4 every two hours per hospital policy on 07/20/22, 07/23/22 and 07/25/22.


Patient 5

Review of P5's "24-hour Nursing Plan of Care" showed, "Self-Care & Mobility Rating Scale" for P5 was a "2" which was defined as needing "Substantial/Maximal Assistance." Under the section titled "Hourly Rounding" there was missing documentation for turning and repositioning of P5 every two hours per hospital policy on 07/23/22, 07/24/22, 07/25/22 and 07/26/22.


Patient 6

Review of P6's medical record, showed P6 was admitted on 06/30/22 and was still a current inpatient with admitting diagnoses: "Acute hypercapnic respiratory failure [AHRF], Pulmonary nodular amyloidosis [PNA], and S/P [status post] Fall from standing." Review of the "24-hour Nursing Plan of Care" revealed, "Self-Care & Mobility Rating Scale" for P6 was a "2" which was defined as needing "Substantial/Maximal Assistance." According to P6's medical record, there was no documentation of a bath for P6 per hospital policy for 07/26/22.

Review of P6's "Hourly Rounding" showed there was missing documentation for turning and repositioning of P6 every two hours per hospital policy on 07/22/22 and 07/23/22.


Patient 7

Review of P7's medical record showed P7 was admitted on 06/21/22 and was still a current inpatient with admitting diagnosis of failure to thrive. Review of the "24-hour Nursing Plan of Care" revealed, "Self-Care & Mobility Rating Scale" for P7 was a "2" defined as needing "Substantial/Maximal Assistance." Under the section titled "Hourly Rounding" there was missing documentation for turning and repositioning of P7 every two hours per hospital policy on 07/22/22 and 07/26/22


Patient 8

Review of P8's medical record showed P8 was admitted on 07/23/22 and is a current inpatient with admitting diagnoses: "Acute on Chronic Hypoxic Respiratory Failure secondary to Hemimedullary (lateral and medial medullary infarctions in the brain) Stroke & COVID PNA [pulmonary nodular amyloidosis]." Review of the "24-hour Nursing Plan of Care" revealed, "Self-Care & Mobility Rating Scale" for P8 was a "2" which was defined as needing "Substantial/Maximal Assistance." Under the section titled "Hourly Rounding" there was missing documentation for turning and repositioning of P8 every two hours per hospital policy on 07/24/22 and 07/26/22.


Patient 9

Review of P9's medical record showed P9 was admitted on 07/13/22 and was still a current inpatient with admitting diagnosis: "Respiratory Failure Unspecified w/ Hypoxia or Hypercapnia (excessive carbon dioxide in the bloodstream)." Review of the "24-hour Nursing Plan of Care" revealed, "Self-Care & Mobility Rating Scale" for P9 was a "2" which was defined as needing "Substantial/Maximal Assistance." According to P9's medical record, there was no documentation of a bath for P9 per hospital policy for 07/21/22, 07/23/22 and 07/24/22.

Review of P9's "Hourly Rounding" showed there was missing documentation for turning and repositioning of P9 every two hours per hospital policy on 07/20/22, 07/21/22, 07/23/22, 07/24/22 and 07/26/22.


Patient 10

Review of P10's medical record showed P10 was admitted on 07/20/22 and was still a current inpatient with admitting diagnoses: paraplegic since 2003 due to MVA [motor vehicle accident] and left ischial [the lower part of your pelvis] decubitus ulcer." Review of the "24-hour Nursing Plan of Care" revealed, "Self-Care & Mobility Rating Scale" for P10 was a "2" which was defined as needing "Substantial/Maximal Assistance." According to P10's medical record, there was no documentation that P10 was bathed per hospital policy on 07/21/22.

Review of P10's "Hourly Rounding" showed there was missing documentation for turning and repositioning of P10 every two hours per hospital policy on 07/21/22, 07/22/22, 07/23/22 and 07/25/22.


During an interview on 07/27/22 at 9:45 AM, CNA1 stated that CNAs do occasionally miss giving baths during the day."

During an interview of 07/27/22 at 9:50 AM, RN1 stated RNs do try to help sometimes but it is the CNAs job to complete patient care (bathing, toileting, turning and repositioning).

During an interview of 07/27/22 at 2:00 PM, the DON confirmed that bathing documentation was missing for P1, P2, P3, P4, P6, P9 and P10 and that turning, and positioning documentation was missing for Patients P1, P2, P3, P4, P5, P6, P7, P8, P9 and P10. The DON confirmed if the hospital has a call in, the CNAs would split up the workload and would have up to nine patients during a 12-hour shift. DON stated if the RNs have time, RNs should be helping patient care assignments if needed. DON stated it is the RNs responsibility for all care provided by nursing staff, and RNs are responsible for follow up on CNAs assigned cares to ensure the care was completed and documented.


Review of the hospitals QAPI data titled, "QAPI - Survey Readiness Table - Select Wichita" revealed under the "Q2 hourly turning documented" had a goal of 90%. First Quarter 2022 the hospital was at 72%, April 2022 was 69%, May 2022 was 63% and June 2022 was 80%. A note written in the comments section "Expect Turn Team to impact this number."