HospitalInspections.org

.
Based on document review and interview, the facility became aware of a patient elopement and implemented corrective actions to be completed by 01/15/2024; however, as at 02/08/2024, the facility had not fully implemented the corrective actions.

Findings include:

Review of the facility's corrective actions to a patient elopement dated 12/04/2023 revealed the facility would educate staff on the organization's policies for levels of observation, elopement risk assessment, and reassessment by 01/15/2024.

Review of staff training document dated 01/24/2024, revealed staff members that have not been educated included 42% of Agency Nurses, 27% of Emergency Department (ED) staff, and 22% of staff categorized by the facility as "Other."

During an interview on 2/5/2024 at approximately 11:30 AM, Staff K (Clinical Risk Manager) confirmed that staff training had not been completed. Staff K stated that ED staff members who have yet to be trained are actively working because the ED is undergoing construction, and there was a change in leadership, which limited the opportunity for staff training.
.

.
Based on medical record (MR) review, document review, and interview, in four (4) of five (5) MRs reviewed, nursing staff failed to:

a) Perform consistent skin assessment and reassessment of patients at risk of skin impairment and refer patients for timely wound and nutritional consultation as per policy and procedure on Prevention and management of pressure injury (Patient #s 1, 3, 4, and 5).
b) Consistently assess and document the care of a patient (Patient #1) with Arteriovenous (AV) Fistula and avoid blood pressure measurement on the site as per facility's policy and procedure.

Findings:

a) The facility's policy and procedure (P&P) titled, "Pressure Injury Prevention and Intervention" dated 9/2021, stated, "All patients admitted to the inpatient unit will have their skin assessed on admission, and every shift throughout the hospital stay using the Braden Scale [Scale for predicting pressure injury risk]. Additionally, the RN (Registered Nurse) will assess the patient's skin when transferring to another level of care... Evidence-based protocols will guide the practice for early recognition, prevention, and treatment of pressure injury (PI). The RN's will use the Braden Scale to determine the patient's risk for PI. Patients with a Braden Score of 18 and less are at high risk for PI and the RN will initiate PI prevention measures."

Review of Patient #1's MR identified: Patient #1 was evaluated in the Emergency Department (ED) on 11/20/2023 and admitted for inpatient care.

Review of nursing skin documentation for Patient #1 from 11/20/2023 to 12/4/2023 identified the following:

On 11/20/2023 at 1:00 PM, an initial skin assessment by the ED nurse documented, Wound on Perineum - "Moisture associated skin damage (open, moist, redness)." At 1:57 PM, ED nurse documented, Wound is on Coccyx - Pressure Injury Stage: Deep Tissue (A pressure-related injury to subcutaneous tissues under intact skin).

Nursing admission assessment on telemetry unit dated 11/20/2023 at 11:30 PM indicated the patient's skin was intact and no abnormalities were noted.

On 11/21/2023 at 12:30AM, Nursing Clinical Note documented, "Skin is noted to be intact."

Nursing Clinical Notes on 11/25/2023 at 10:55 AM and 6:55 PM revealed a Stage II Pressure Ulcer to Coccyx, and redness to perineal area.

On 11/27/2023 at 2:34 PM, wound care consultant, indicated Patient #1 has a Deep Tissue Pressure Injury (DTPI) [Full-thickness ulcers with a wound base that is covered with slough] on sacrum which was present on admission and has now evolved to an unstageable pressure injury; wound dimension - 5.0 centimeters (cm), by 7.0 cm).

The skin description by nursing staff in the telemetry unit on 11/20/2023 at 11:30 PM and 11/21/2023 at 12:30 AM, indicated an intact skin. This information was not consistent with an earlier skin assessment by the ED nurse on 11/20/2023 at 1:57 PM that documented a skin injury to the patient's coccyx.

There was no documented evidence of a timely recognition, and treatment of the patient's pressure injury in the inpatient unit until 11/25/2023 at 10:55 AM, when nursing documentation revealed a stage II pressure ulcer to coccyx, and redness to the patient's perineal area.

There was no documentation found which indicated the patient was evaluated by a wound consultant prior to their assessment on 11/27/2023 which was approximately six (6) days after her admission.

On 11/20/2023 at 10:07 PM, the Provider noted orders to turn and position the patient every two (2) hours, or more frequently as needed (PRN) on alternating sides to offload bony prominences.

Review of Nursing Flow Sheets and nursing notes for Patient #1 identified turning and positioning were not documented every 2 hours from 11/21/2023 to 12/4/2023.

During interview of Staff C (Wound Care Specialist) on 2/1/2024 at 11:45AM and 2/6/24 at 10:45 AM, Staff C confirmed she did not see patient #1 prior to 11/27/23.

b) The facility's policy and procedure (P&P) titled, "Assessment and Management of Patients with Arteriovenous (AV) Fistula or Graft," Date Reviewed: January 2024, stated, "Nursing staff responsibility - Physical assessment: all patients presenting to the institution require a baseline assessment at admission completed by a registered nurse. Patients presenting to the facility with AV access will have the following documented in their records. Site of AV access; assessment for bleeding, swelling, or discoloration at the access site.... Assess for fistula thrill, differentiate thrill from pulsating fistulas... and avoid peripheral venous access, phlebotomy, or blood pressure measurements on the side of the fistula/graft."

Head-to-toe assessment of patient #1 documented by nursing staff on 11/20/23 at 11:30 AM lacked assessment of AV Fistula site per facility policy and procedure.

Review of Patient #1's flow sheets for vital signs from 11/20/2023 to 12/5/2023 identified blood pressure measurements were taken on the patient's left arm, the site of her AV Fistula on 11/20/2023, 11/24/2023, 11/27/2023, and on 11/28/2023.

During interview of Staff F (3rd year medical resident) on 2/7/2024 at 10:40 AM, Staff F acknowledged findings and stated: "no one should be drawing blood from AV fistula arm or taking blood pressure at the site."

During telephone interview of Staff M (Chief Patient Experience Officer) on 2/7/2024 at 9:52 AM in the presence of Staff K (Assistant Director Clinical Risk Management), staff acknowledged findings.


Review of Patient #3's medical record revealed the following:

The patient was admitted on 1/11/2024 to the Surgical Intensive Care Unit.

On 1/12/2024 at 2:18 AM, nursing documented Braden Score is 16 indicating mild risk for pressure injury (10-12 is high risk; 13-14 is moderate risk and 15-18 is mild risk); "Skin is intact".

On 1/17/24 at 1:00 AM, nurse documented: Pressure Injury to Coccyx - Stage II measuring 0.7 cm x 1.0 cm, dry, excoriated, wound surface area 0.7 cm.

Review of nursing flow sheet from 1/17/2024 to 2/7/2024 identified the Braden Score ranged from 10 to 19 (mild to high risk for pressure injury).

On 1/25/2024 at 5:07 PM, wound care specialist documented an assessment and provided recommendations for wound management.

The was no documented evidence of a timely referral of the patient to wound care specialist until eight (8) days after the patient was identified with pressure injury.

On 1/26/24 at 4:53 PM, nurse documented the patient was received from the operating room status post left AKA (above knee amputation) on vent, patient with a stage III pressure injury to sacrum with slough.

On 2/1/2024 at 8:58 PM, nurse assessment revealed an unstageable sacrum pressure injury.

On 2/5/24 at 7:41 AM, nurse indicated a stage III pressure injury with yellow slough and an order for Santyl (Ointment used for removal of damaged skin to allow for wound healing) was requested and obtained from the physician.

There was no documentation found that indicated the patient's pressure injury was timely identified. The pressure injury to the patient's sacrum was first identified as a stage II pressure injury, six (6) days after her admission.

On 2/8/24 at 7:47 AM, vascular surgery progress note indicated the patient was evaluated and a wound vacuum was ordered but was not installed due to non-availability of the machine.

The MR lacks documented evidence that nursing staff referred the patient for dietary consultation.

During interview of Staff C (Wound Care specialist) on 2/8/2024 at 1:45 PM, Staff C was asked how the nurses communicate or make a referral to her regarding a patient with pressure injury and how quickly she responds to wound consultation. Staff C stated: Nurses can call, text, or send an email, and usually, the patient is seen the same day. Once a pressure injury is identified, the nurses are to document in the medical record, notify the physician, and make referrals to the wound care nurse and the dietician.

This finding was acknowledged by Staff K (Assistant Director Clinical Risk Management) who was present during the interview.


Review of Patient #4's MR revealed the patient was admitted on 6/1/2023.

Skin assessment by the ED nurse on 6/1/2023 at 7:29 AM indicated skin was intact, warm, and dry. Braden Score 16 (Mild risk for Pressure injury).

Review of nursing skin assessments from 6/1/2023 to 6/10/2023 revealed the patient's skin was intact and the patient's Braden Score ranged from 11 to 15 (Mild to high risk for pressure injury).

Review of Nursing Flow Sheets dated from 6/2/2023 to 6/10/23 revealed nurses documented the patient's skin was "WDL."

On 6/11/2023 at 6:00 AM, nursing note indicated the patient has a stage III pressure injury on the sacral area.

There was no documented evidence of timely identification and management of the patient's pressure injury. Upon identification of the pressure injury on 6/11/2023, the description of the pressure injury was not documented.

On 6/12/2023, the patient was discharged to a Nursing Home with a stage III pressure injury to the sacral region.

During interview of Staff L (Nurse Educator) on 2/5/2024 at 12:15PM, Staff L confirmed pressure injury was hospital acquired.


Review of Patient #5's medical record identified the following:

The patient was admitted on 1/4/2024.

Nurse's skin assessment in the ED on 1/4/2024 at 11:01 PM documented skin was intact warm and dry, WDL. Braden Score 13 (Moderate risk).

On 1/12/2024 at 3:35 PM, the Physician documented an order for nutritional consultation.

There was no documented evidence that the Patient #5 received nutritional consultation as per physician order on 1/12/2024 and up to 2/8/2024 when the surveyor reviewed the patient's medical record.

Nurse assessment on 1/17/2024 at 8:14 AM, noted an unstageable pressure injury to the patient's sacrum.

Review of Flow Sheets from 1/4/2024 to 1/21/2024 identified the patient's Braden Score ranged from 13 to 18 (Mild to moderate risk).

Nursing assessment of the patient's risk for pressure injury (Braden Score) was rated moderate even after an unstageable pressure injury (when a stage of pressure injury cannot be determined) was identified on 1/17/2024.

On 1/22/2024 at 11:00 PM, nursing note indicated the patient was discharged to a Skilled Nursing Facility.

There was no documented evidence of a timely recognition and treatment of the patient's pressure injury until 1/19/2024 when the pressure injury was identified as unstageable to sacrum.

There was no documentation found which indicated the patient was evaluated by a wound consultant prior to their assessment on 1/19/2024, approximately seven (7) days after her admission. In addition, there was no documented evidence that the patient was assessed by a nutritionist prior to the patient's discharge.

During interview with the Staff L (Nurse Educator) on 2/8/2024 at 12:00 PM, Staff L confirmed the findings.