HospitalInspections.org

Based on interview and record review the facility failed to ensure adverse events for skin pressure injuries are investigated and analyzed for root cause and preventative actions are implemented and monitored for effectiveness per policy in 1 of 2 Patient (Pt) Adverse Events/Incident Reports reviewed involving (Pt #4) in a total sample of 2 incident reports reviewed.

Findings Include:

Per review of policy and procedure titled, "Incident (Patient Safety Event) Reporting/Sentinel Event Management" last reviewed 07/30/2019 revealed, "Incident and sentinel event reporting is an important part of error prevention. (facility) learns from patient safety events to promote system education, initiate process improvement and prevent and mitigate healthcare error."

Per policy a Patient Safety Event is an event, incident, or condition that could have resulted or did result in harm to a patient...Event analysis is warranted in order to identify weaknesses and whether remedial action is indicated. Per policy an Adverse Event is a patient safety event that resulted in harm to a patient.

Per policy Incident Reporting policy, # 5.8 Continued Monitoring of Events, Near misses, or Proactive Assessments revealed the site risk manager, in conjunction with the system Director of Risk Management and the Patient Safety Officer, will work with appropriate departments, units...to continuously monitor the effectiveness of actions in relation to events, near misses, or proactive risk assessment.

Review of Pt #4's adverse event submitted on 09/01/2021 at 3:52 pm, revealed, "New pressure injury noted to left inner buttock." Review of "Manager Action Taken" revealed "Other,(Specify Below)", below this documentation was the "Manager Comments" which revealed , "Skin Champion aware, working on plan." Review Status is listed as "Closed."

Review of of Pt #4's nursing assessments flowsheet revealed Pt #4 had a "Wound Buttock Left interior/Inner Pressure Injury" that was "First Assessed" on 09/01/2021 at 7:47 am (19 days after admission). Per Pt #4's nursing assessment the wound was a "Stage 2" pressure injury.

Per review of Pt #4's adverse events there was no documented evidence of an investigation into this incident including an adverse event analysis of the reasons why Pt #4 developed a Stage 2 pressure injury during hospital stay, and to identify weaknesses and implement remedial action if indicated as per policy.

Per interview with Quality F on 10/20/2021 at 12:44 pm, managers are expected to investigate incidents and take appropriate action.

Per interview with Manager R on 10/20/2021 at 4:00 pm, Manager R reviews Patient Safety Events in MIDAS incident reporting system. Per Manager R, Patient Safety Events should be investigated and the findings should be documented in the incident reporting system. Manager R stated that he/she received Pt #4's adverse event and reviewed it, but did not document the steps he/she took to investigate this adverse event and what actions were implemented.

Based on record review and interview the facility failed to ensure the Registered Nurse (RN) completes nursing wound/skin assessments as per policy and implements and provides nursing interventions to prevent and address skin impairment and breakdown in 2 of 6 records reviewed of patients at risk for skin impairment (Patient (Pt) #1, #4) in a total sample of 10 medical records reviewed, and failed to assess and monitor post procedural vital signs of a patient in 1 of 4 Outpatient Interventional Radiology records reviewed (Pt #3) in a total sample of 10 medical records reviewed.

Findings include:

Staff failed to ensure a RN supervised and evaluated skin and wound assessments and interventions to prevent skin breakdown and impairment in 2 of 10 medical records reviewed . See tag A-0395.

Staff failed to ensure a RN monitors and evaluates patients post procedures in 1 of 10 medical records reviewed See tag A-0395.

The effect of these facility failures resulted in 1 patient developing moisture associated skin damage and 1 patient developing a stage 2 pressure ulcer during hospital admission.

Based on record review and interview the facility failed to ensure the Registered Nurse (RN) completes nursing wound/skin assessments as per policy and implements and provides nursing interventions to prevent and address skin impairment and breakdown in 2 of 6 records reviewed of patients at risk for skin impairment (Patient (Pt) #1, #4) in a total sample of 10 medical records reviewed, and failed to assess and monitor post procedural vital signs of a patient in 1 of 4 Outpatient Interventional Radiology records reviewed (Pt #3) in a total sample of 10 medical records reviewed.


Findings include:

Per review of policy and procedure titled, "Skin/Wound Care Consults" (no date) revealed that a Wound RN consult can be ordered by a nurse or Medical Doctor (MD). Per policy, a Wound Care RN completes "Head to Toe skin assessments" takes photos and enters miscellaneous nursing orders as needed. Per policy, reasons for RN wound consult includes:
-Moisture or incontinence associated skin issues not improving despite nursing interventions tried.
-Non-healing stage 2 pressure injuries despite nursing interventions tried.
-Assistance with determination of etiology (pressure injury, moisture/incontinence dermatitis, friction/shear)
-Deep tissue injury

Per review of policy and procedure titled, "Nursing Assessment Standards by Patient Venue" Appendix A (No date), a Head to Toe (Comprehensive physical examination of all parameters of all body systems including but not limited to, Integumentary/skin) nursing assessment for medical surgical inpatients will be completed/documented upon admission/arrival to the unit. Per policy, "Head to Toe reassessments will be completed/documented BID (twice a day) at close to regular intervals throughout a 24 hour period." Review of the policy revealed, "Perform/document additional ongoing focused or selected reassessments based on individual needs of the patient, level of care, and/or treatment/interventions provided."

Review of policy and procedure titled, "Skin Integrity: Care and Treatment of the Skin" last reviewed 07/02/2021, revealed the following definitions:
-Moisture Associated Skin Damage: The general term for inflammation of skin or skin erosion caused by prolonged exposure to moisture such as urine, stool, sweat, wound drainage, saliva, or mucous.
-Pressure Injury: A localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer that may be painful. The injury occurs as a result of intense and/or prolonged pressure in combination with shear.

Review of the Skin Integrity policy revealed the following:
-The RN will conduct an integumentary system or skin condition assessment on all patients on admission to determine skin condition, including the presence of skin integrity problems that need to be monitored or treated.
-The RN will assess the risk of pressure injuries using the Braden Scale on admission and daily.
-Prevention or management plan will be implemented for patients at risk or with pressure injuries.
-Assess integumentary system on admission to inpatient units and minimally twice a day in alignment with the Head to Toe and as needed.
-Skin under prevention dressings should be assessed during the integumentary assessment.
-Implement interventions for patient based on pressure injury risk assessment (Braden scale) and integumentary assessment.
-Notify the provider of wounds/skin breakdown and obtain orders for the treatment plan as indicated.
-Assess wound(s) during prescribed dressing change.

Review of facility procedure titled, "Preventing Pressure Injuries in Adults" Dated 09/25/2020 revealed the following:
-Check care plan and treating clinician orders for pressure injury prevention strategies. Note any orders for pressure-relieving devices, skin creams, or specific patient repositioning.
-Perform Head to Toe skin assessment to look for early signs/symptoms of pressure injury at least once per shift.
-If patient cannot independently turn in bed, reposition every 1-2 hours per facility protocol, as ordered, or as tolerated by condition.
-If patient will sit in chair, place padding under patient and encourage frequent, small shifts in movement to promote good blood perfusion of possible pressure points.
-Teach patient/family about pressure injury risk factors and importance of avoiding them.
-Request referrals to wound care specialist as needed.
-Update patient's plan of care and medical record as appropriate, include: date/time care was performed, details of physical assessment, frequency of patient repositioning, skin cleaning, and incontinence care, specify care interventions performed, use of pressure relieving devices, use of prescribed products for skin cleaning and barrier creams.

Pt #1:

Review of Pt #1's medical records revealed Pt #1 was admitted as an inpatient to acute care facility on 07/14/2021 at 2:42 am with a diagnosis of leg pain and shortness of breath, and discharged home on 07/24/2021 at 4:11 pm. Review of Pt #1's History and Physical (H&P) Assessment dated 07/14/2021 at 12:45 pm revealed Pt #1 had Heart failure, Diabetes Mellitus, Morbid Obesity, chronic Lymphedema (localized swelling caused by abnormal accumulation of lymph fluid) with chronic lower extremity pain, acute/chronic abdominal pain with history of Hepatitis C virus Cirrhosis (chronic liver damage), chronic pancreatitis, Hypothyroidism, and Acute Kidney Injury vs. Chronic Kidney Disease. Per H & P, Pt #1 had been bed bound for a year and is cared for by home care and family.

Review of Pt #1's medical record revealed on 07/14/2021 at 3:20 am, an "Inpatient Consult to RN Wound Care" was ordered due to "right heel pressure injury".

Review of Wound RN assessment progress note dated 07/14/2021 at 10:12 am revealed, "R. (right) Heel w/(with) stage 1 pressure injury; wound base red/non-blanchable & covering skin extremely dry w/large flakes of friable skin present. Pt needs off-loading boots and a mattress pump as neither were seen in pt's room at time of assessment." Per review of RN wound progress notes the Wound RN documented assessing Pt #1's heel pressure injury, but there was no documented evidence of the Wound RN completing a "Head to Toe" assessment to look for early signs/symptoms of pressure injury/skin damage on all areas of Pt #1's skin as per the "Skin/Wound Care Consults" policy and procedure.

Review of Pt #1's medical record revealed on 07/16/2021 at 7:08 pm, a second "Inpatient Consult to RN Wound Care" was ordered due to "Inner thigh abrasions, labia excoriation, posterior knee blisters". RN Documentation in the "Comments" section revealed, "Patient has multiple incontinent loose BM's (bowel movements) due to lactulose (laxative) administration that frequently cover thigh abrasions."

Review of Wound RN assessment progress note dated 07/17/2021 at 11:01 am revealed, "Right heel stg (stage) 1", recommendations (nursing orders) were to apply skin protectant to right heel and Prevalon boots at all times. Review of the Wound RN progress note revealed there was no documented evidence of a Wound RN completing a "Head to Toe" skin assessment and implementing nursing interventions for the skin issues documented in the RN Wound Consult ordered on 07/16/2021 at 7:08 pm (Inner thigh abrasions, labia excoriation, posterior knee blisters).

Review of Wound RN progress note dated 07/24/2021 at 1:33 pm revealed, "RN recheck for right heel, Pt has been incontinent of bowel/bladder, moisture associated derm (dermatitis) noted to buttocks and posterior bilateral thighs. Posterior right knee has open area that appears to have been a blister. Now unroofed." Per review of Wound RN progress notes, the Wound RN implemented skin recommendations (nursing interventions) for Pt #1's posterior knees and posterior thighs/buttocks. Review Pt #1's nursing flowsheet documentation for skin/wound assessments of left and right posterior knee blisters revealed Pt #1's knee wounds were first identified/assessed by Pt #1's RN on 07/15/2021 at 8:31 am. Review of nursing progress note dated 07/15/2021 at 10:45 am revealed that Pt #1 had "skin tears in thighs near female external catheter." Per review of Pt #1's medical record, a Wound RN visited Pt #1 on 07/14/2021 and 07/17/2021, but the Wound RN failed to identify and implement interventions for Pt #1's above skin/wound issues until 07/24/2021 (9 days later).

Interview with Wound RN H on 10/19/2021 at 2:35 pm revealed that a RN Wound Consult can be ordered by the RN if there are skin issues noted during admission assessment or if there is a risk for skin integrity issues. Per RN H the Wound RN should see the patient within 24 hours after a RN Wound Consult is ordered and continue to see the patient at a minimum once per week or more depending on the severity. Per interview with RN H, the Wound Care RN should "look them over" and "turn the patient" to complete a Head to Toe skin assessment with a focus on pressure areas. Per RN H the Wound RN documents the "Recommendations" on the progress note template which informs the RN assigned to the patient on what skin/wound care interventions should be completed and how often.

Per interview with Clinical Nurse Specialist (CNS) I and Wound Care Supervisor J on 10/19/2021 at 2:45 pm, CNS I revealed that once a RN Wound Consult is ordered by a RN or Physician, the Wound RN has 24 hours to conduct the assessment on the patient. Per CNS I, the Wound RN should complete a "full skin assessment" and document the assessment and recommendations in the Wound RN progress note. Per CNS I the Wound RN should also specifically address the skin concerns documented on the RN Wound consult order. Per CNS I, the Wound RN should have performed a head to toe on 07/14/2021 and 07/17/2021 and the Wound RN should have addressed the skin issues documented in the RN Wound Consult ordered on 7/16/2021.

Review of nursing progress note dated 07/15/2021 at 10:45 am, revealed the, "Writer notified (physician) regarding patient's skin tears in thighs near female external catheter." Review of the nursing flowsheet for skin/wound assessments revealed from 07/15/2021 through 07/24/2021 (date of discharge) (9 days), there was no documented evidence of skin/wound nursing assessments completed (minimally twice a day as per policy) and interventions implemented/provided for the "skin tears" to Pt #1's thighs.

Review of nursing progress note dated 07/20/2021 at 12:35 pm revealed the RN acknowledged that Pt #1 had "...multiple wounds on her labia and coccyx..." Review of the nursing flowsheet for skin/wound assessments revealed from 07/20/2021 through 07/24/2021 (date of discharge), there was no documented evidence of an initial or ongoing nursing assessments completed (minimally twice a day as per policy) and interventions implemented/provided for "multiple wounds on her labia". Per review of the nursing flowsheet for skin/wound assessments, there was no documented evidence of nursing assessments and interventions completed for Pt #1's "moisture associated dermatitis" (as per Wound RN consult) to the buttocks/coccyx until 07/24/2021 at 1:21 pm (4 days later). Per review of the nursing skin/wound flow sheets, Pt #1's moisture associated dermatitis to the buttocks/coccyx was not documented as present on admission.

Review of Pt #1's Wound Care RN Recommendations on 07/14/2021 at 10:12 am revealed the following nursing interventions for Pt #1's Right Heel Pressure injury, "After cleansing/drying, apply a foam border dressing to pad. Peel back to assess skin under dressing Q (every) shift and re-apply."

Review of Pt #1's nursing skin/wound assessments and interventions for Pt #1's right heel pressure injury revealed on 07/15/2021 the nursing skin/wound assessment was completed once at 8:31 am, and not every shift as per Wound RN. On 07/16/2021 the nursing skin/wound assessments and interventions were not completed on any shift.

Review of Pt #1's Wound Care RN Recommendations on 07/17/2021 at 11:01 am revealed the following nursing interventions updated for Pt #1's Right Heel Pressure Injury, "Skin protectant to right heel...Pt does not want Allevyn foam on heel."

Review of Pt #1's nursing skin/wound assessments and interventions for Pt #1's right heel pressure injury revealed on 07/18/2021 and 07/23/2021 nursing skin/wound assessments/interventions were only documented as completed one time; the nursing skin/wound assessment was not completed every shift as per Wound RN recommendations.

Review of Pt #1's nursing skin/wound flowsheets revealed a Left Knee Skin Fold Blister was "first assessed" on 07/15/2021 at 8:30 am. Review of nursing wound assessments/interventions from 07/15/2021 to 07/24/2021 for Pt #1's Left Knee Skin Fold Blister revealed the following:
-07/15/2021 at 8:30 am the nursing wound assessment revealed "Blister Broken."
-Nursing wound assessments on 07/15/2021 8:30 am; 07/16/2021 at 8:50 am and 3:19 pm; 07/17/2021 at 9:23 am and 5:21 pm; 07/18/2021 at 4:30 pm; 07/19/2021 at 5:04 pm; and 07/21/2021 at 4:18 pm, revealed there was no documented evidence of nursing interventions being implemented and provided (i.e. cleansing with soap and water, topical ointment, or dressing applied).
-Nursing wound assessments on 07/18/2021 at 4:30 pm and 07/23/2021 at 4:12 pm, revealed only one nursing wound assessment was completed (should be minimum twice daily per policy).

Review of the Braden Scale skin risk assessment/intervention tool revealed the following:
-Score of <12 are at high risk. Staff should frequently reposition, protect heels, and use pressure-reducing support for these patients, place foam wedges for 30 degree lateral positioning.

Review of Pt #1's medical record revealed from 07/14/2021 through 07/24/2021 Pt #1's skin risk assessments using the Braden Scale ranged from 9 to 12, placing Pt #1 at "high risk" for skin impairment/breakdown.

Review of the Physical Therapy progress notes dated 07/21/2021 at 10:20 am revealed, "At baseline, (Pt #1) is bed bound, requiring total assistance with all cares." Per Physical Therapy notes Pt #1 had "Severe gross weakness".

Review of RN Plan of Care note dated 07/14/2021 at 11:29 am revealed, "Patient being turned every 2 hours."

Per interview with Quality Coordinator BB on 10/14/2021 at 9:20 am, staff should be documenting repositioning every two hours in the "Mobility" section of the nursing flowsheets.

Review of the "Mobility" nursing flowsheets from 07/15/2021 through 07/24/2021 revealed there was no documented evidence of Pt #1 being repositioned at least every 2 hours on the following dates and time frames;
-07/15/2021 from 8:31 am to 4:00 pm (7 1/2 hours).
-07/15/2021 from 4:00 pm to 07/16/2021 at 1:20 am (more than 9 hours).
-07/15/2021 from 11:31 am to 07/17/2021 at 3:00 pm (more than 2 days).
-07/19/2021 from 9:17 am to 5:24 pm (more than 8 hours).
-07/19/2021 from 5:24 pm to 07/20/2021 at 2:00 pm ( more than 1 day).
-07/21/2021 from 12:37 am to 11:30 pm (23 hours).
-07/23/2021 from 9:17 am to 2:30 pm (more than 5 hours).

Per review of nursing progress note dated 07/22/2021 at 7:06 am, "(Pt #1) is refusing all cares, turns, and help from staff." Review of "Mobility" nursing flowsheet and nursing progress notes revealed no documented evidence that Pt #1 refused repositioning for the dates and times listed above.

Per review of Pt #1's History and Physical (H&P) dated 07/30/2021 at 2:41 pm, Pt #1 was readmitted as an inpatient to an acute care satellite location on 07/30/2021 at 2:15 pm (6 days after discharge from main hospital). Review of the H&P revealed, "(Pt #1) states that (Pt #1) had a home wound care nurse that saw (Pt #1) at home 2 days ago, recommended that (Pt #1) gets evaluated in the ED (emergency department) for extensive sacral wounds that would be difficult to manage as an outpatient." Per H&P Pt #1 lives at home with husband who is Pt #1's main caretaker. Review of the H&P Physical Exam of the Skin revealed, "Extensive wounds in the buttock area in the posterior side with an area of cellulitis in the posterior right extremity. Purulent drainage noted."

Review of Pt #1's H&P Assessment and Plan revealed that Pt #1 presented with "Stage 2 Pressure Ulcers with surrounding Cellulitis 2/2 (secondary to) immobility from Morbid Obesity." Per H&P, Wound Care MD (medical doctor) consulted.

Per review of Pt #1's Inpatient MD Wound Care Consult Note dated 08/02/2021 at 8:46 am, Pt #1's Diagnoses were as follows:
-Pressure ulcer of the lower extremity, stage Deep Tissue Injury right heel.
-Obesity
-Friction, sheer, and moisture associated skin damage buttocks and posterior legs
-Fungal dermatitis

Review of Pt #1's Wound Care Consult orders revealed, "Frequent turning/repositioning at least every 2 hours, gel chair cushion and prevalon boots at all time while in bed."

Per review of Pt #1's MD Wound Care orders dated 08/02/2021 at 3:31 pm for Pt #1's moisture associated skin damage, "Wash with soap and water. Pat dry. Sprinkle a layer of Remedy Antifungal powder over area to be treated. Gently brush off excess powder using a 4 x 4 gauze. Spray No Sting Barrier film over powder. Allow barrier film to dry. Interdry to folds. Repeat x 2 Perform 3x/daily (3 times)..."

Review of Pt #1's Nursing skin/wound assessment/interventions flowsheet for the "Wound Buttock; Skin fold Incontinence Associated Dermatitis" revealed on 08/03/2021 at 5:00 pm, and 08/04/2021 at 8:00 am, there was no documented evidence that the nurse applied Antifungal powder and No Sting Barrier film as per Wound Care orders.

Review of the "Mobility" nursing flowsheets from 07/30/2021 through 08/08/2021 revealed there was no documented evidence of Pt #1 being repositioned at least every 2 hours on the following dates and time frames;
-08/01/2021 from 6:00 am to 6:00 pm (12 hours).
-08/02/2021 from 5:30 pm to 11:00 pm (5 1/2 hours).
-08/03/2021 from 1:00 pm to 5:00 pm (4 hours).

Per interview with Director of Quality D and Quality C on 10/19/2021 during Pt #1's medical record review from 9:30 am to 12:00 pm, Wound RN should be doing a head to toe during assessments to identify other skin areas of concern. Per Quality C and Director D the nurse should be performing comprehensive skin and wound assessment and skin/wound care interventions on each shift and evidence of this should be documented in the skin/wound nursing flowsheets. Per Quality C the nurse should perform skin/wound interventions as recommended by the RN Wound consult or MD Wound care consult orders.

Pt #4

Review of Pt #4's medical record revealed that Pt #4 was 74 years old and admitted as an inpatient on 08/13/2021 at 9:27 pm with the diagnosis of Covid-19, fever, dizziness, and headache. Pt #4 was discharged on 09/05/2021 at 1:45 pm.

Review of Pt #4 nursing skin assessments flowsheets revealed nurses documented "Buttocks Red" and/or "Buttocks Pink" on 08/13/2021 at 10:51 pm; 08/14/2021 at 9:50 am and 4:15 pm; and 08/15/2021 at 5:10 am and 8:08 am. Per review of skin assessment flowsheets there was no documented evidence that the nursing staff implemented/provided interventions to address Pt #4's red/pink buttocks.

Review of Pt #4's medical record revealed on 08/16/2021 at 3:37 pm a nurse requested an "Inpatient Consult to RN Wound Care" for "Buttocks excoriation (erosion of skin tissue)."

Review of Wound RN progress note dated 08/17/2021 at 2:18 pm revealed "...(Pt #4) with sacrum excoriation has pump on bed, bilateral heels and elbows intact. no redness will need prevalon boots to help protect heels." Per Wound RN orders, nursing staff should wash the sacrum area with soap and water daily and as needed and apply Antifungal powder twice daily and as needed. Per Wound RN progress notes Pt #4 needs "Aggressive off-loading with frequent turning/reposition at least every 2 hours, gel chair cushion..."

Review of Pt #4's nursing assessments for "Wound Sacrum Midline/Middle Moisture Associated Skin Damage" from 08/17/2021 to 08/28/2021, revealed that there was no documented evidence that nursing staff completed wound interventions as per RN Wound care orders (cleansed with soap and water and/or applied Antifungal powder twice daily) on the following dates;
-08/17/2021; 08/18/2021; 08/19/2021; 08/20/2021; 08/22/2021; 08/23/2021; 08/25/2021; 08/26/2021; and 08/27/2021.

Review of Wound RN progress note dated 08/28/2021 at 10:30 am revealed, "(Pt #4) crying out when cleansing coccyx/sacrum skin. At time of assessment skin was moist & inflamed w/small area of slough deep in fold." Wound RN progress notes revealed, "After Cleansing/drying thoroughly, apply Remedy Antifungal Powder topped with Calazime Zinc barrier cream applied TID (three time daily) and PRN (as needed). Assure to wash & dry prior to every application."

Review of Pt #4's nursing assessments for "Wound Sacrum Midline/Middle Moisture Associated Skin Damage" from 08/28/2021 to 09/01/2021, revealed that there was no documented evidence that nursing staff completed wound interventions as per RN Wound care orders (cleansing with soap and water and/or applied Antifungal powder and zinc barrier cream three times daily) on 08/29/2021 at 8:30 am and 9:03 pm, and 08/30/2021 4:05 pm. Per review, nursing skin assessments/interventions were not completed 3 times daily on 08/28/2021,08/29/2021, and 08/30/2021.

Review of the "Mobility" nursing flowsheets from 08/16/2021 through 09/01/2021 revealed there was no documented evidence of Pt #4 being repositioned at least every 2 hours as per RN Wound care orders on the following dates and times :
-08/17/2021 from 12:00 pm to 5:00 pm (5 hours)
-08/18/2021 from 7:05 am to 4:30 pm (approximately (approx) 9 1/2 hours)
-08/20/2021 from 11:45 am to 8:27 pm (approx 8 hours 45 minutes); 8:27 pm to 1:10 am (approx 4 1/2 hours)
-08/21/2021 from 1:10 am to 10:30 am (approx 9 hours); 12:13 pm to 3:43 pm (approx 3 1/2 hours); 6:15 pm to 10:29 (approx 4 hours)
-08/22/2021 from 10:28 pm to 5:36 am (approx 7 hours); 8:23 pm to 6:23 am (approx 10 hours)
-08/23/2021 no documented evidence of Pt #3 being repositioned all day
-08/24/2021 from 8:10 pm to 4:15 am (approx 8 hours)
-8/25/2021 from 10:12 am to 3:29 pm (approx 5 hours)
-08/26/2021 from 9:00 am to 6:20 pm (approx 9 hours)
-08/27/2021 from 11:00 am to 5:57 pm (approx 7 hours); from 8:22 pm to 08/28/2021 to 12:45 pm (approx 17 hours)
-08/28/2021 from 8:29 pm to 08/29/2021 at 8:00 am (approx 12 hours)
-08/30/2021 from 10:00 am to 8/31/2021 at 1:23 am (approx 15 hours)
-08/31/2021 from 3:30 pm to 09/01/2021 at 12:00 am (8 1/2 hours)

Review of of Pt #4's nursing assessments flowsheet revealed Pt #4 had a "Wound Buttock Left interior/Inner Pressure Injury" that was "First Assessed" on 09/01/2021 at 7:47 am (19 days after admission). Per Pt #4's nursing assessment the wound was a "Stage 2" pressure injury.

Per interview with RN Manager E on 10/19/2021 at 1:10 pm, RN E stated that staff should be documenting when patients are repositioned in the nursing flowsheets under mobility. RN E stated that staff are expected to document nursing interventions and complete a comprehensive skin/wound assessment at a minimum every shift and/or as required by Wound care consult.

Pt #3:

Review of Pt #3's medical record revealed Pt #3 was admitted as an outpatient on 07/23/2021 at 9:30 am for a CT (computed topography) guided needle biopsy of an abdominal biopsy. Pt #3 received Moderate Sedation during biopsy.

Review of nursing progress noted dated 07/23/2021 at 10:18 am, revealed Pt #3 requires "Bedrest for 2 hours, until 12:20 (pm)."

Review of Pt #3's procedure report revealed the CT started at 9:34 am and ended at 10:16 am. Per review of Pt #3's Flowsheet Data there was no documented evidence of vital signs being monitored after 10:15 am. Review of Pt #3 Discharge nursing note dated 07/23/2021 at 12:40 pm revealed, "Patient is awake and alert to baseline level of consciousness at pre-procedural level.

Per interview with RN Supervisor K on 10/20/2021 at 10:32 am, Patients are observed in a recovery area for 2 hours post procedure. Per RN K, Vital signs should be completed at least every 15 minutes for an hour and every 30 minutes for 1 hour. Per interview with RN K, he/she was unable to find vital signs documented while Pt #3 was in recovery. Per RN K vital signs are automatically taken by the monitor while a patient is in the recovery area; however, the RN must validate the vitals signs that are taken in order for vital signs to be saved to the EPIC medical record.