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Based on medical record review, policy review and staff interviews, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient (A395).

Based on medical record review, policy review and staff interviews, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for one of ten patients reviewed (Patient #1). The patient census was 72.

Findings include:

Review of a policy and procedure titled, Verbal, Telephone, Written Order Read-Back Procedure, origination 06/2008, last approved and revised 11/2019, revealed the purpose is to facilitate safe, timely patient care. Reduce errors associated with communicating, interpreting or transcribing verbal and telephone orders for medications, treatments, interventions or other patient care. Verbal communication of orders is limited to emergent situations where written or electronic communication is not feasible. The authorized individual receiving the verbal order must repeat back and confirm the order. The prescriber reviews and authenticates orders on or before the close of the medical record which occurs within thirty days of the date of discharge of the patient.

Review of the policy and procedure titled, Surgical Suites Nursing Care Delivery, last revised 11/22, revealed the team is organized by the registered nurse (RN) assigned as circulator. The surgical patient's care is determined by the nursing process throughout the patient's perioperative nursing experience. The RN retains responsibility and accountability for the surgical patient. An RN is responsible for the assignment and evaluation of care in the operating room. This person is also responsible for the communication of information to not only all areas of the surgery department (outpatient, post anesthesia care unit (PACU), and cardiovascular surgery (CVOR), and interventional services (IVS), but also other health professionals and departments. The RN circulator-scrub-assistant assigned to the surgical patient as circulator is the primary care provider. Additional RN's can also be assigned as scrub or scrub assistant. However, the RN circulator assumes the responsibility for the surgical patient. It is also the circulator's responsibility to maintain communication with the team leader, nurse in charge and or cardiovascular unit (CVU) PACU charge nurse.

Review of an emergency department (ED) note dated 10/17/22 revealed Patient #1 arrived to the ED from the extended care facility (ECF) with an elevated temperature, possible urinary tract infection (UTI), and needing his suprapubic catheter changed. The history of the patient's present illness revealed a history of a suprapubic catheter placement, quadriplegia with a neurogenic bladder, frequent UTI's, metabolic encephalopathy, history of pulmonary embolism and presents today for complaint that he has had eight UTI's in the past year, denies shortness of breath (SOB) or chest pain but just feels sick and feels like he has had a fever and feels his heart racing. This has been going on since earlier today. the SP denies any pain and does take Eliquis (blood thinner) five milligrams (mg) two times a day as a home medication.

Review of the medical decision making revealed straight catheter was unsuccessful, urology was consulted as there is concern for a UTI with bladder distension, and urology will have to place a suprapubic catheter. The patient was admitted to the hospital.

Review of an operative report dated 10/17/22 by the urology surgeon revealed the preoperative diagnosis is urosepsis urinary tension. The operation was urethral cystoscopy, suprapubic cystoscopy, suprapubic to channel dilatation, and 16 French foley catheter placement. The urethral bleeding was minimal. There was no documentation the patient had a dressing of any kind applied to his penis after the suprapubic catheter placement and there was no postoperative recommendation for a dressing of any kind to the patient's penis.

Review of the urology progress notes dated 10/18/22 revealed the suprapubic catheter was in place and the patient denies any discomfort and had dark urine output. Discussed the patient's urologist (surgeon) status post cystoscopy with suprapubic catheter placement on 10/17/22. The surgeon recommends exchange every 30 days and to follow up with primary urologist.

Review of urology progress notes dated 10/19/22, 10/20/22, 10/21/22, 10/23/22 and 10/24/22 revealed no documentation regarding any dressings.

Review of a progress note dated 10/24/22 revealed discharge orders were received to send the patient back to the nursing home and to transport at 1:30 PM. The patient and family were updated.

Review of the discharge documents that were sent with the patient to the nursing home on 10/24/22 did not include any discharge instructions for any kind of dressing to the patient's penis.

Review of a head to toe assessment for the patient on the day of discharge dated 10/24/22 at 4:38 PM revealed under an assessment for incision/wound/skin revealed an area for penile assessment. There was documentation under penile that the dressing was clean and dry and intact. This was the only nursing documentation regarding the dressing.

Review of an ED progress note dated 11/09/22 revealed Patient #1 was sent to the ED for a penile wound by the urologist (surgeon) who placed a suprapubic catheter approximately one month ago. The history of the patient's present illness noted a dressing was placed around the patient's penis due to skin breakdown. He was sent back to the nursing care facility and the bandage was never removed. He now has a dark necrotic tip to the penis. The patient does say he is sensitive and has some pain. He denies any discharge.

Review of a history and physical report dated 11/09/22 revealed that on the patient's previous admission he was found to have a dysfunctional suprapubic catheter. A bandage was taken off today and was noticed to have black discoloration of the glans penis.

Review of a urology consult dated 11/10/22 by the urologist revealed the patient was seen in consult today after a phone call to the urologist's office questioning the need for an ACE wrap bandage placed to the patient's penis for urethral bleeding at the time of his cystoscopy and suprapubic tube placement. The patient did have successful placement of the suprapubic tube but just upon entry into the fossa navicularis it was identified the patient had significant bleeding as he was still on blood thinners at the time. The patient's nurses were instructed to remove the ACE wrap approximately two to three hours after his procedure that was done during his last hospitalization here at this hospital. The ACE wrap was removed yesterday and it was identified that the patient had significant necrosis of the glans penis and shaft with what appeared to be the early signs of either necrosis or infection of the shaft and glans penis. The patient is seen at this time for treatment of this situation. The patient is having minimal discomfort but as previously noted is a quadriplegic and does state that he has sensation down below. Other than the feeling of almost an itching type sensation he did not have any significant pain or discomfort during his 24 days at the nursing facility. He is unable to tell me how often he was bathed or how often he was examined in his pelvic and penile region.
Other than that they watched his catheter drain and beyond that does not remember any specific area to his penis or a question of the ACE wrap and why was this in place for such a long time. The physical exam noted the glans penis is firm and darkened with increasing vascularity to the shaft of the penis significantly improved from the pictures that were sent to the urologist's office by the nursing facility yesterday. The assessment/plan is to continue with warm compresses with saline and to continue his antibiotics and potential debridement tomorrow may occur at the shaft of the penis and glans penis in order to hopefully try to preserve as much of the penis as possible.

Review of the operative report dated 11/11/22 at 6:35 PM revealed the patient who previously had bleeding from his urethra over 24 days ago had a tourniquet placed gently over the area of the glans penis for urethral bleeding in an attempt to place a suprapubic tube. The preoperative and postoperative report revealed the operation is extensive debridement of necrotic tissue. The findings were necrosis of the glans penis and partial necrosis of the shaft penis.

Review of a surgical progress note dated 11/18/22 revealed this is a patient who had vascular injury due to the strap bandage that was debrided approximately one week ago. Patient #1 comes at this time for further debridement and grafting with allograft (tissue graft from a donor) to the area of the glans penis and shaft of the penis.

Interview with the operating room (OR) nurse on 11/28/22 at 11:54 AM revealed she was part of the endocysto team and took care of the cystoscopes and was in and out of the OR room on 10/17/22. The patient was still in cysto and was having bleeding from his penis. She stated she called the surgeon on the phone overhead and the surgeon came back in the OR room and looked at the patient. She stated she heard the surgeon say "the only thing we can do is put a wrap on the patient's penis and that he expected the patient to bleed." The OR nurse revealed this was all she heard the surgeon say. She stated the circulating nurse was the one who took the order. "I was not the circulator. If the surgeon would have given me the order I would have documented it and made sure to let someone in post anesthesia care unit (PACU) know. I would have read the order back to the surgeon."

On 11/28/22 at 12:34 PM, the circulating nurse who was working on the day Patient #1 had his suprapubic catheter replaced in October was interviewed. She revealed she did not see the surgeon come back in the OR to look at the patient's penis. She stated that anesthesia and herself took the patient to the post anesthesia care unit (PACU) and from a distance she did see a dressing on the patient's penis. She stated she told the PACU nurse, who was not available for interview at the time of the survey, that the patient had a dressing on his penis "and that is all I told her. We did not look at the dressing together. The surgeon did not give me any orders for the dressing to the patient's penis."

Interview with the patient's urology surgeon on 11/28/22 at 4:25 PM revealed that he put about a one inch ACE wrap that was used for a circumcision and was about a quarter to an inch long to the tip of the patient's penis. The surgeon revealed he was out talking to the patient's family when the OR nurse called him overhead and that he was paged to come back to OR. The surgeon further revealed the end of the patient's penis was bleeding and that was why he put the circumcision wrap to the head of the penis. He gave a verbal order to remove the dressing in one to two hours. He stated it was an order and he did not remember who he gave the verbal order to. The bleeding stopped within two to three minutes. The surgeon revealed on 11/09/22 he received a call from someone at the nursing home who asked what they should do with the dressing on the patient's penis. He said, "what dressing." The surgeon told his medical assistant to relay to the nursing home staff person to remove the dressing and to send the patient to the ED. He stated the nursing home staff person sent him a picture of the patient's penis. He stated, "when I saw the picture it looked like the dressing was removed and the end of the penis was necrotic/gangrenous." The surgeon voluntarily revealed he should have put an addendum on the 10/17/22 post op note that urethral bleeding started and that he applied a dressing the same size used for circumcisions and it was to be removed in one to two hours and that the bleeding had stopped in two to three minutes.

On 11/29/22 at 7:20 AM the registered nurse (RN) who did the patient's head to toe assessment on 10/24/22 was interviewed. She revealed Patient #1's entire penis was covered with a dressing. She stated this was the first time she saw this patient during this stay. She stated she did not see any visible blood to the dressing and there was no order for the dressing. She stated it was normal for the surgeon or the surgeon's nurse practitioner to remove the dressing and not the nursing staff unless there was an order to remove a dressing.

This deficiency represents non-compliance investigated under Substantial Allegation OH00137637.