HospitalInspections.org

Based on document review and interview, the facility staff failed to ensure the ongoing nursing standard of care and assessment, and ensure physician ordered care was provided for two (2) of four (4) patients, Patient #1 and #2.

The findings include:

1. The medical record of Patient #1 was reviewed on 2/11/19 and 2/12/19 with Staff Member # 6 and Staff Member # 7. Patient # 1 was admitted to the facility on 2/8/19 with the diagnosis of Sepsis, urinary tract infection and Stage IV pressure ulcer of the sacral area. Patient # 1 was placed in the room at 7:13 P.M.

On 2/8/19 at 6:57 P.M. the physician placed the following order; Wound Ostomy/ET Nurse Consult (Wound Consult and Implement Skin/Wound/Ostomy Pressure Ulcer Protocol order panel). The Skin/Wound/Ostomy Pressure Ulcer Protocol consist of the following: Incontinence Care every 2 hours, Pressure Injury Prevention: Elevate heels, Pressure Injury Prevention: Turn patient remind/assist...every 2 hours...

A skin assessment was preformed in the Emergency Department on 2/8/19 at 6:19 P.M. and again two (2) hours and forty-two (42) minutes after Patient #1 reached the room on 2/8/19 at 9:59 P.M. There was no wound care documented at 9:59 P.M. Patient #1's wound care and turning/repositioning was documented on 2/9/19 at 9:58 A.M. approximately least twelve (12) hours later. Wound care was documented on 2/9/19 at 9:00 P.M. (twelve hours later). Wound care and turning/repositioning was documented on 2/10/19 at 9:18 A.M. (twelve hours later) and 2/10/19 at 8:57 P.M. approximately eleven (11) hours later.

The Surveyor requested to observed Patient # 1's wounds. On 2/11/19 at 11:35 A.M. The Wound Nurse and Staff Member #8 accompanied the Surveyor to Patient # 1's room. With Patient #1's and Family Member's permission, the wounds were observed. The Wound Nurse stated, "This is the first observation for me of the wounds. I will return later and do my full assessment. We (the wound care team) are not here on the weekends. We work Monday through Friday." Staff Member #3 stated, "They (wound care team) usually gets here around 6:15 A.M. and leaves about 4:00 P.M.

From the time the physician wrote the order for the Wound Care assessment approximately sixty-four (64) hours passed before Patient #1's wound were observed by the Wound Care Nurse.

The findings were reviewed with Staff Member # 2 on 2/12/19 during the exit interview at approximately 11:00 A.M.

2. The medical record review for Patient # 2 on February 11 and 12, 2019 revealed Patient # 2 was admitted to the facility on February 13, 2018 from the Emergency Department (ED). Patient was brought to the ED by family. Patient # 2's admission diagnoses included Acute Renal Failure (ARF), Diarrhea, Hypotension, Chronic Abdominal Pain, Urinary Tract Infection (UTI), Chronic Diastolic Congestive Heart Failure (CHF), Moderate Mitral Regurgitation, Severe Tricuspid Regurgitation, Hypertension (HTN) and Right Knee Pain and Back Pain. The history and physical (H&P) dated February 13, 2018 at 6:03 p.m., reads in part: "Full code - had been dnr (Do Not Resuscitate) as well. Family wants all measures. Pt had told me on previous admission that (he/she) didn't want to be on machines and to allow a natural passing. Will ask palliative to see given frequent admissions. Would recommend against dialysis."

The skin assessment by a staff nurse dated February 14, 2018 at 9:45 p.m. documents Stage 2 pressure ulcers to sacrum.
A wound/ostomy progress note dated February 20, 2018 at 10:15 a.m. lacked documentation of Stage and reads, in part: "Sacrum/Gluteal crease PI (Pressure Injury) POA (Present on Admission), black, pink, macerated, excoriated.
Right medial heel PI POA, SDTI (suspect deep tissue injury) , 3.0 X 3.0 cm, purple burgundy.
Left lateral heel PI POA, SDTI, 4.0 X 4.0 cm, purple burgundy black.
Urine and fecal incontinent.
Bed Surface - VersaCare P500.
Plan/Treatment:
Sacrum/Gluteal crease - Incontinence care/skin care
Offer to toilet if appropriate.
Check for incontinence and treat:
1. Cleanse with disposable wipes and moisture cleanser 2 times daily and as needed.
2. Apply Secura or Calmoseptine moisture barrier ointment to affected area.
3. Use breathable or absorbent under pad. No Diapers.
4. Offload pressure with turning.
Prevalon boots to offload heel pressure.
Continue pressure prevention and moisture management measures."

A wound/ostomy progress note dated February 27, 2018 at 11:30 a.m. reads in part "Sacrum/Gluteal Crease PI POA, US (Unstageable), 14.0 X 8.0 X 0.1 cm, yellow slough, pink, excoriated.
Right medial heel PI POA, SDTI (suspect deep tissue injury) , 3.0 X 3.0 cm, purple burgundy.
Left lateral heel PI POA, SDTI, 4.0 X 4.0 cm, purple burgundy black.
Urine and fecal incontinent.
Bed Surface - VersaCare P500.
Plan/Treatment:
Sacrum/Gluteal crease - Incontinence care/skin care
Offer to toilet if appropriate.
Check for incontinence and treat:
1. Cleanse with disposable wipes and moisture cleanser 2 times daily and as needed.
2. Apply Secura or Calmoseptine moisture barrier ointment to affected area.
3. Use breathable or absorbent under pad. No Diapers.
4. Offload pressure with turning.
Prevalon boots to offload heel pressure.
Continue pressure prevention and moisture management measures."

An interview with Staff Member # 5 revealed the "incontinence care/skin care" is standard nursing interventions and does not require a physician's order."

The facility's procedure titled "Skin Integrity Risk (Braden Scale)" provided by Staff Member # 5 on February 11, 2019 at 12:05 p.m., reads in part: "Consult WOCN/ET (Wound Ostomy Continence Nurse/Enterostomal Therapy) for multiple Stage 2 pressure injuries."
The facility's "Nursing Pressure Injury Prevention Orders" provided by Staff Member # 5 on February 11, 2019 at 12:05 p.m., reads in part: "Interventions for incontinence/skin care. Every 2 hours. Offer toileting if appropriate. Check for incontinence and treat. 1. Cleanse with comfort shield wipes or moisture cleanser. 2. Apply moister barrier cream/ointment to affected area if comfort shield is not used. 3. Use breathable or absorbent under pad. Avoid plastic backed diapers while in bed. Use breathable pads with low air loss beds.
Interventions for Pressure injury prevention. To reduce/redistribute pressure: Turn every 2 hours and PRN. May use pillows, air filled chair cushion, or foam wedge for positioning. Avoid back lying on both standard and speciality beds."

Nursing documentation provided by Staff Member # 7 on February 12, 2019 at 10:40 a.m. revealed the nursing staff documented turning and repositioning as follows:
February 14, 2018 at 9:45 p.m.
February 15, 2018 at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 7:40 p.m.
February 16, 2018 at 9:37 p.m.
February 17, 2018 at 6:30 a.m., 8:54 a.m., and 6:14 p.m.
February 18, 2018 at 10:53 p.m.
February 19, 2018 at 6:02 a.m., 10:00 a.m., 6:04 p.m., and 8:00 p.m.
February 20, 2018 at 9:15 p.m.
February 21, 2018 at 9:30 a.m. and 9; 13 p.m.
February 22, 2018 at 10:00 a.m.
February 23, 2018 at 8:00 a.m. and 9:29 a.m.
February 24, 2018 at 7:40 a.m. and 8:15 p.m.
February 25, 2018 at 7:31 a.m., 12:21 p.m. and 8:17 p.m.
February 26, 2018 at 8:00 a.m. and 11:03 p.m.
The facility nursing staff failed to turn and reposition and provide incontinent care for Patient # 2 every 2 hours per pressure injury prevention interventions.

The findings were discussed with Staff Members # 1, #2, #3, #11 and #12 during the exit interview on February 12, 2019 at 11:00 a.m.