HospitalInspections.org

Based on clinical record review, interviews and hospital document review, the hospital staff failed to a) inform the designated representative of Patient #3 of a change in condition; specifically, the development of pressure injuries requiring treatment and b) request permission before removing Patient #3's full beard. For 1 of 1 patients included in the sample.

The findings included:

Surveyor reviewed medical records on 5/26 and 5/27/2022 with the assistance of a navigator provided by the hospital. Patient #3 at the time of this survey has been an inpatient for 47 days with a complicated hospital course. Patient #3 was a patient in Medical ICU (April 10-19, 2022), Cardiac Care ICU (April 19-May 2, 2022) and was in Medical PCU at the time of survey. Discharge to a specialty facility was anticipated in the next few days. Hospitalists, Critical Care, Cardiology, Pulmonology, Nephrology, Infectious Disease, Palliative, Gastroenterology, Neurology, Wound Care, Speech Therapy, Physical Therapy and Dietary were all involved in the care of this critically ill patient.

Patient #3 had an advanced directive naming a family member as their Health Care Agent (Durable Power of Attorney for Health Care) to make health care decisions for them. A second family member was designated as an Alternate Health Care Agent in the event the first agent was unavailable. The hospital was provided a copy of the document.

a) Review of medical records found the following in part: Patient #3 was admitted to the hospital's medical intensive care unit on 4/10/22 with progressive general weakness, dysphagia, dysphonia, inability to speak and reduced facial movement. Neurology consult (Physician #1) on 4/10/22 at 12:00 AM read in part "There is significant concern for respiratory status, does not appear to be able to clear secretions, intubation is necessary to protect airway and maintain respiration." Patient #3 was intubated, sedated and admitted to the ICU unit.

Admission nursing assessment on 4/10/22, at 8:00 AM, found the Patient's skin to be within defined limits (WDL) except "IAD Incontinence Associated Dermatitis red and dry; documented POA (present on admission) Skin color/characteristics pale; Skin temperature cool; Skin Moisture dry; Skin Elasticity slow return to original state; Skin integrity bruised (ecchymotic); pressure injury; drain/device(s)". It was documented that Patient #3 required "assistance, 2 people" for daily activities and had a Braden scale of 14. Per hospital policy Braden Scale Scores are to be documented every 12 hours. On 4/10/22 at 8:00 PM, Patient #3 was documented to have a Braden Scale of 12. The Braden Scale is a scale made up of six subscales; sensory perception, moisture, activity, mobility, friction, and shear, which measure elements of risk for the development of pressure injuries. A Braden score of 15 to 18 is mild risk, 13 to 14 is moderate risk, 10 to 12 is high risk, and 9 or less is very high risk. The hospital's electronic medical record system is set to trigger a wound care consult for a Braden score of 12 or less. A wound care consult was completed on 4/11/22 by Staff #1 (a wound care nurse). Documentation by Staff #1 included the last documented Braden Scale Score of 12. Wound assessment documented no breakdown on sacrum. Treatment recommendations documented "Patient is on a progressa air bed in ICU and has a TAP patient has no pressure wounds at this time." Plan documented "Continue local wound care as directed. Wound care signing off at this time."

On 5/5/22 at 12:44 PM, a wound care consult was requested by Staff #2, Patient #3 was in the Medical Progressive Care Unit at this time. The last documented Braden Score was 11. Wound care assessments were documented as follow: Patient #3 was evaluated on 5/5/22 and found to have 2 (two) wounds. Wound #1 located on the coccyx/right buttock was approx 8.0 cm x 8.0 cm and unstageable, Wound #2 located or right buttock/ischial was approx 2.0 cm x 2.0 cm as a deep tissue injury. Additionally bilateral heels documented as soft/boggy. Patient #3 was noted to be on a regular bed at that time with TAP (turn and position device used to help turn patient) and floating heels. VersaCare (specialty wound care bed) and off-loading boots were ordered with instructions to place patient on bed as soon as possible. Wound care orders for cleaning and dressing wounds were entered.

In an interview with Patient #3's HCA (Health Care Agent) the surveyor was informed the family member learned of the pressure injuries on 5/2/22 during a visit with Patient #3. The family member stated being present in the room when the nurse was cleaning and changing the patient after an episode of bowel incontinence, stated they were very concerned they had not been told of the development of the pressure wounds. The family member stated they called Staff #3 to discuss their concerns about not being notified and were told by Staff #3 the patient came to the PCU with the pressure injuries and it was thought family would have been told by the Cardiac Care unit prior to the transfer.

Review of the medical record failed to provide evidence Patient #3's HCA was informed of the change in the patient. The family member stated Patient #3 had a family member at the hospital every day and made frequent phone calls to the unit as well. This statement was confirmed by Staff #3 and #4.

b) Patient #3 received a tracheotomy on 4/29/22 due to not being able to be weaned from the ventilator and needing a more permanent airway than the endotracheal tube. Patient #3 was transferred to the PCU on 5/3/22. On 5/8/22 on nightshift, Staff #13 removed/shaved all the patient's facial hair (full beard and moustache). When family arrived to find the patient clean shaven they were upset this had been done without their knowledge or the Patient's consent. During a telephone interview with the Patient's HCA the surveyor was informed the patient had not been clean shaven in 65 years and expressed concern that the Patient was not able to communicate their wishes and the family member was not consulted. The family member (Health Care Agent) stated to the surveyor, " (Patient #3) would not have wanted the beard to be shaved." The family member stated having been asked about shaving Patient #3 previously and stated staff were told to only shave the neck up to the jaw line. (Date and time of discussion was not provided to the surveyor). In an interview with Staff #4 on 5/26/22, Staff #4 reported speaking to the Staff #13 about the event and stated the nurse was concerned the beard was irritating and possibly contaminating the tracheostomy. It is noted Patient #3 was receiving antibiotic treatment for possible tracheitis (an infection of the trachea). The medical record did not contain documentation the beard was contributing to the infection or placing the patient at increased risk. This was not an emergency situation requiring immediate action. On 5/9/22 at 5:10 AM, Staff #13 documented speaking with the patient's family member and explaining the reason for shaving the facial hair of the patient. Documentation stated the family member accepting of explanation.

Review of the medical record failed to provide evidence the family or the patient was consulted prior to removing the patient's beard or evidence that religious, cultural or spiritual beliefs related to the presence of a beard were considered prior to removing the beard.

Review of hospital document "Patient Rights and Responsibilities" given to patient's on admission found the following in part: "...you may expect to receive considerate and respectful care. We will honor your rights to be informed and to be involved in making decisions about your care....You have the right to receive considerate, respectful, compassionate and appropriate clinical care...You have a right to know about your illness and proposed treatment and to participate in the development of your plan of care...You have the right to make informed decisions about your care, including the right to know why you need an operation or treatment".

Review of hospital policy "Patient Rights and Responsibilities" updated 11-21 found the following in part: "In recognition of the patient's personal dignity, values, and beliefs, the patient is to receive considerate, respectful care at all times and in all circumstances."... "The right to make reasonable informed decisions involving his/her care, treatment and services"... "to the degree possible the patient will receive a clear, concise explanation of: a. his/her condition."

In a meeting with Staff #7, #5, #4 and #3 the morning of 5/26/22, the failure to inform the Health Care Agent of a pressure injury acquired by the Patient after admission and the failure to discuss and obtain consent before shaving the patient's beard was discussed. It was agreed the family was not informed of the pressure injuries, and was not consulted before removing the patient's beard and given the opportunity to consent or refuse based on information provided. The surveyor asked staff to consider if this had been a patient with long hair, would they have cut it without permission? There was no reply.

The above findings were shared with staff at the time of discovery and reviewed with the leadership team prior to exit on 5/27/22.

Based on interview, medical record review and hospital document review, hospital staff failed to fully implement interventions (per hospital policy) developed to prevent the development of pressure injuries. For 1 of 1 patients included in the sample with a pressure injury.

The findings are:

Surveyor review of medical records was conducted on 5/26 and 5/27/2022 with the assistance of a navigator provided by the hospital. Patient #3 at the time of this survey has been an inpatient for 47 days with a complicated hospital course. Patient #3 was a patient in Medical ICU (4/10-19), Cardiac Care ICU (4/19-5/2) and is in Medical PCU at present time. Discharge to a specialty facility is anticipated in the next few days. Hospitalists, Critical Care, Cardiology, Pulmonology, Nephrology, Infectious Disease, Palliative, Gastroenterology, Neurology, Wound Care, Speech Therapy, Physical Therapy and Dietary were all involved in the care of this critically ill patient.

Review of medical records found the following in part: Patient #3 was admitted to the hospital's medical intensive care unit on 4/10/22 with progressive general weakness, dysphagia, pysphonia, inability to speak and reduced facial movement. Neurology consult (Physician #1) on 4/10/22 at 12:00 AM reads in part "There is significant concern for respiratory status, does not appear to be able to clear secretions, intubation is necessary to protect airway and maintain respiration." Patient #3 was intubated, sedated and admitted to the ICU unit.

Admission nursing assessment on 4/10/22, at 8:00 AM, found the Patient's skin to be within defined limits (WDL) except "IAD Incontinence Associated Dermatitis red and dry;documented POA (present on admission) Skin color/characteristics pale; Skin temperature cool; Skin Moisture dry; Skin Elasticity slow return to original state; Skin integrity bruised (ecchymotic);pressure injury; drain/device(s)". It was documented that Patient #3 required "assistance, 2 people" for all ADLs (Actitvities of Daily Living) and had a Braden scale of 14. On 4/10/22 at 8:00 PM, Patient #3 was documented to have a Braden Scale of 12. The Braden Scale is a scale made up of six subscales, sensory perception, moisture, activity, mobility, friction, and shear, which measure elements of risk for the development of pressure injuries. A Braden score of 15 to 18 is mild risk, 13 to 14 is moderate risk, 10 to 12 is high risk, and 9 or less is very high risk. The hospital's electronic medical record system is set to trigger a wound care consult for a Braden score of 12 or less. However, clinical staff may request an evaluation by a wound care nurse. A wound care consult was ordered on 4/10/22 by Physician #1 and completed on 4/11/22 by Staff #1 (a wound care nurse). Documentation by Staff #1 included the last documented Braden Scale Score of 12. Wound assessment documented no breakdown on sacrum. Treatment recommendations documented "Patient is on a progressa air bed in ICU and has a TAP patient has no pressure wounds at this time." Plan documented "Continue local wound care as directed. Wound care signing off at this time."

Review of hospital policy "Wounds - Prevention and Treatment of Pressure Injuries" effective 03/2022 revealed the following in part, "Interventions for Prevention of Pressure Injuries by Braden Subsection Guideline: For a Braden score of Moderate Risk 13-14, implement nursing interventions; For a Braden Score of High Risk 10-12, implement nursing interventions and consult wound care team or wound specialist". As noted above, a consult with wound care was requested and completed. Nursing interventions are listed by the skin assessment subsection, with guidelines given for scores below 3 for moisture, activity, and sensory perception. And scores below 2 for nutrition and friction or shear. Patient #3 was critically ill and was unable to change position without assistance and scored a 1 for activity and 2 for mobility, interventions listed for both subsets includes but is not limited to "Turn and/or reposition at least every 2 hours." Also noted under interventions for High Risk 10-12 Braden Score was the statement in bold "low air loss beds do not substitute for turning schedule".

On 5/5/22 at 12:44 PM, a wound care consult was requested by Staff #2, Patient #3 was in the Medical Progressive Care Unit at this time. The last documented Braden Score was 11. Wound care assessments were documented as follow: Patient #3 was evaluated on 5/5/22 and found to have 2 (two) wounds. Wound #1 located on the coccyx/right buttock was approx 8.0 cm x 8.0 cm and unstageable, Wound #2 located or right buttock/ischial was approx 2.0 cm x 2.0 cm as a deep tissue injury. Additionally bilateral heels documented as soft/boggy. Patient #3 was noted to be on a regular bed at that time with TAP (turn and position device used to help turn patient) and floating heels. VersaCare (specialty wound care bed) and off-loading boots ordered with instructions to place patient on bed as soon as possible. Wound care orders for cleaning and dressing wounds were entered. Staff #6, (wound care nurse) documented on 5/10/22, a follow-up visit with Patient #3. No changes were made to treatments/interventions and the wound measurements had not changed. Staff #5 documented a follow-up visit with Patient #3 on 5/16/22, during "Multi-disciplinary Wound Care Team Rounds". Wound #2 was noted at that time to be Stage 2. Skin treatment changed at this time due to yeast appearance of incontinence acquired dermatitis around rectum. No other changes were noted. On 5/16/22, Physician #3 (a member of the wound care team) evaluated Patient #3 and documented in part "Buttock/sacral pressure injury which are stable and appear to be improving and perirectal IAD. No necrosis/infection requiring debridement". On 5/25/22, Patient #3 was evaluated during "Multi-disciplinary Wound Care Team Rounds" with Wound #1 reduced in size to 6/8 cm x 6.0 cm and Wound #2 documented as resolved. Noted "Coccyx wound may need bedside debridement next week".

Review of flow sheet documentation related to turning or positioning Patient # 3 prior to the development of pressure injuries first documented by wound care team on 5/5/22, found documentation of turning and/or repositioning the patient every 2 hours missing for periods of 4 to 12 hours on 6 of the 25 days.

The morning of 5/26/22 during the review of the medical record, the surveyor was able to confirm with Staff #5 that a specialty bed or turning system does not replace the nursing intervention of turning the patient. The involvement of multiple body systems placed Patient #3 at increased risk for the development of pressure injuries and increased the possibility that any lapse in protocol can result in a pressure injury.

The above findings were shared with Staff #7, #5, #4 and #3 at the time of discovery and reviewed on 5/27/22 with the leadership team.

Based on observation, interview and document review hospital staff failed to adhere to hospital policy on infection control for transmission based precautions.

The findings are:

As part of a complaint investigation related to allegations of infection control practice, the surveyor toured the hospital making observations of general infection control practices and patient care. While conducting observations on 5/26/22 at approximately 1:50 PM on 9S ICU, the surveyor noted the following breaks in infection control practice:

Patients in rooms #3, 4, 5, 6 and 8 were on "Special enhanced Contact and Droplet precautions" for COVID-19. Signs were located on the doors entering the room, the signs listed the required protective gear.

Staff #14, was observed leaving Room #4 after removing the isolation gown and gloves in the room. No hand hygiene was performed. Staff #14 removed the N95 mask, puts on a surgical mask, touched their glasses then went to sink to wash hands.

Staff #16 was observed wearing gown, respirator and gloves while assisting with patient care in Room #5. Staff #16 was not wearing goggles or face shield. When Staff #16 was questioned about the lack of eye protection, they replied "I didn't know I had to". Staff #16 was provided with eye protection by staff.

Staff #15 was noted to enter Room #8 wearing mask, gloves and goggles. Staff #15 did not wear a gown when entering room. Staff #15 exited Room #8 removed gloves, removed N95, donned surgical mask then performed hand hygiene.

Staff #17 (a lab technician) was noted to enter Room #8 wearing gown, gloves, N95 mask and prescription glasses. Staff #17 did not wear goggles or face shield.

The surveyor noted an isolation cart containing PPE (personal protective equipment) against the wall between Room 8 and Room 9. The top of the cart held open boxes of gloves and masks. Directly beside the cart was a storage bag for clean gowns. A used surgical mask was present on the top of the cart. The mask remained on the cart until the surveyor questioned Staff #3 about its presence there. Staff #3 stated it "should not be there" and on picking up the mask stated "it's definitely used".

Review of hospital policy "Hand Hygiene" effective 6-2021, found the following in part: "C. Indications for Hand Hygiene when performing patient care: 7. Clean hands after: e. Removing gloves, gloves are not a substitute for hand cleaning. F. Other aspects of hand hygiene: 3. Isolation Rooms: a. Hand hygiene should be performed immediately prior to donning PPE when entering an isolation room and immediately after doffing PPE when exiting. i. Remember - the gloves and the front of the gown, mask, and goggles are contaminated. Perform hand hygiene after doffing gloves, before touching 'clean' areas such as your face, eye protection straps, and after doffing PPE."

Review of hospital policy "Transmission-based (Isolation) Precautions" effective 4-2022 found the following in part: "Remove gloves promptly after use, and before touching items or surfaces, before going to another patient"... "Perform hand hygiene immediately after removal of gloves to avoid transfer of microorganisms to other patients or environments"... "Appendix E: Type of Isolation Precautions: Special enhanced Contact and Droplet Precautions required *Hand Hygiene *Gown *Respirator (N95, PAPR, P100) *Face shield or goggles *Gloves *Keep door closed *Visitation will be limited"

The above findings were shared with Staff #7 and Staff #8 on 5/26/22 at the end of day and reviewed during a meeting with the Infection Prevention Team on 5/27/22 at 9:30 AM. Education files were reviewed for the employees observed breaking infection control protocols and training was up to date.

The above findings were reviewed with hospital leadership prior to exit on 5/27/22.