HospitalInspections.org

Based on record review, staff interview and review of the Bylaws of the Medical Staff, Rules and Regulations of the Medical Staff (last revised on April 10, 2018), it has been determined that the hospital's medical staff failed to enforce the rules pertaining to the Bylaws for 1 of 2 patients on the Vanderbilt Unit, (Patient ID # 1).

Findings are as follows:

A. The Medical Staff Rules and Regulations, Section D. Medical Records states, in part:

"3. Progress Notes
a. Pertinent progress notes shall be recorded at the time of evaluation, sufficient to permit continuity of care and transferability. Whenever possible, each of the patient's clinical problems should be clearly identified in the progress notes and correlated with specific orders as well as results of tests and treatments ..."

1. Review of the medical record for Patient ID #1 revealed s/he developed an unstageable pressure ulcer while inpatient in July 2020. Further review of the medical record revealed the progress notes failed to include, at a minimum, evidence of the pressure ulcer, including the correlating treatment order and the results of prescribed treatment.

During surveyor telephone interview with the provider, Staff A, on 8/17/2020 at 9:33 AM, she acknowledged she wrote daily progress notes for Patient ID #1 for the 7 consecutive days prior to his/her discharge and failed to document Patient ID #1's pressure ulcer, ordered treatment, or the results of the treatment she ordered. She further acknowledged that any unstageable wound should be documented in the provider assessment and plan.

During surveyor interview on 8/18/2020 at 1:40 PM with the Director of the Hospitalist/Medicine, she stated she expects all providers to communicate with the nursing staff. She further stated that she would expect an unstageable pressure ulcer to be documented in the daily progress notes.

B. The Medical Staff Rules and Regulations, Section D. Medical Records states, in part:
"5. Discharge Summary
c. The discharge summary should include the reason(s) for admission, the significant findings .... final diagnosis(es), the condition and disposition of the patient at discharge ...or results that require further action."

2. Review of the medical record for Patient ID #1 revealed s/he was discharged to home following a 15 day hospital stay in 2020. The discharge summary failed to include the presence of a pressure ulcer in the final diagnoses, the condition of the pressure ulcer at discharge and any further actions required for the ulcer.

Surveyor interviewed Staff B, the hospitalist responsible for writing the discharge summary for Patient ID #1 on 8/17/2020 at 9:00 AM. Staff B stated that based on his review of the previous progress notes written by Staff A, he was not aware the patient had a pressure ulcer; therefore, he did not include the pressure ulcer as an active problem in the discharge summary. He further stated that subsequent to his summary lacking evidence of the pressure ulcer he did not document further treatments required for the pressure ulcer.

During surveyor interview on 8/18/2020 at 1:40 PM with the Director of the Hospitalist/Medicine, she stated that providers are expected to review the medical record, including patient problem list, history and physical, nurses' notes, and physical therapy/occupational therapy notes prior to writing the patient discharge summary. She acknowledged that if these notes were reviewed by Staff B, he would have been aware of the pressure ulcer, as nursing documentation reflects the staging, care and treatment of the ulcer.

The facility failed to provide evidence that Patient ID #1's progress notes and discharge summary were performed according to the Bylaws of the Medical Staff.

Based on record review and staff interview, it has been determined that the hospital has failed to meet the Condition of Participation relative to Nursing Services for patient ID #1 relative to nursing assessments, nursing documentation and wound care.

Findings are as follows:

1. The hospital failed to provide nursing care in accordance with the hospital policy for Wound Assessment and Reassessment for patient ID #1.

2. The hospital failed to provide nursing care for patient ID #1 in accordance with the hospital policy for Nursing Protocol Orders for Impaired Skin Integrity. (refer to A-395)

3. The hospital failed to ensure that licensed nurses working in the facility adhered to policies and procedures of the hospital. (refer to A-398)

4. The hospital failed to provide adequate numbers of licensed registered nurses and other personnel to provide nursing care to all patients as needed. (refer to A-392)

Based on surveyor review of the Vanderbilt Unit staffing schedule and staff interview, it has been determined that the hospital failed to ensure that patient needs were met by providing adequate numbers of other personnel to meet those needs.

Findings are as follows:

Record review revealed patient ID #1 presented to the hospital for rehabilitation services after recently undergoing a thoracic laminectomy with resection of an epidural lesion. Upon admission, the nursing assessment describes his/her buttocks as having "redness" and Alleyvn (an absorbent foam dressing) was applied. On 7/7/2020 nursing describes the wound area red, light purple, irregular in shape and with having ecchymotic (bruised) areas. A wound consult was ordered. The following day the area was assessed by the wound nurse, Staff G, who documented that the area developed into an unstageable pressure ulcer (a wound that has a top layer that prevents being able to see the underneath damage, if any) to his/her coccyx area (lower back above the buttocks).

Review of the unit staffing schedule with the Clinical Manager of Rehabilitative Services for dates 7/1/2020 through 7/8/2020 revealed the schedule lacked sufficient staffing on one or more shift for 7 of 8 days from Patient ID #1's admission until the pressure ulcer was assessed by the wound nurse as an unstageable pressure ulcer.

During this 8 day time frame on the Vanderbilt Unit the staffing schedule review revealed a deficit of 8 CNA's on day shift, a deficit of 1 RN and 2 CNA's evening shift and a deficit of 7 CNA's on the night shift.

During an interview with staff nurses on the rehabilitation unit on 8/18/2020 ap 1:40 PM, Staff C and Staff D (RN's) both stated the unit "struggles" with having appropriate CNA coverage for census and acuity.

During an interview with the Clinical Manager of Rehabilitative Services on 8/17/2020 at 10:30 AM, she acknowledged there are identified staffing deficits on all shifts based on the volume and acuity of the patients on the unit.

During an interview with the Chief Nursing Officer on 8/17/2020 at 10:55 AM, she acknowledged that she was aware of the minimal staffing on the rehab unit and revealed the challenges the hospital has been faced with in attempt to fill the staff vacancies.

Based on record review and staff interview, it has been determined that the hospital failed to evaluate the care for Patient ID #1 in accordance with accepted standards of nursing practice and hospital policy as to the patient's response to nursing interventions.

Surveyor review of the Patient ID #1's record revealed his/her coccyx area was assessed by the wound nurse on 7/8/2020. She described the wound as an "unstageable pressure ulcer" and measured the ulcer as 6.4cm x 5.3cm x 0.1cm.

Review of the nursing flowsheets from 7/10, 7/11, 7/14 and 7/15/2020 reveal the pressure ulcer staging was incorrectly identified despite the asssessment and documentation by the wound nurse.

During surveyor interview with Staff E, a wound nurse, on 8/14/2020 at 12:30 PM, she described a stage 2 pressure ulcer as an "abrasion" and described an unstageable pressure ulcer as a wound that has a "thick cap" over it which prevents the nurse from assessing the damage underneath. Staff E further stated that a stage 2 wound cannot become unstageable within hours, and that an unstageable wound cannot become a stage 2 wound within days.

Based on record review and staff interview, it has been determined that the hospital failed to ensure nursing care was provided in accordance with the hospital's policies and procedures for 1 of 2 patients (patient ID #1) with a pressure ulcer.

Findings are as follows:

A. Review of the "Nursing Protocol Orders for Impaired Skin Integrity", last revised in December 2016, states in part,

"II. POLICY
2. Patients identified at increased risk for skin breakdown or with actual impairment in skin integrity must have an integumentary focused reassessment performed by an RN at a minimum of two times every 24 hours: At least one time between 0701 and 1900, and at least one time between 1901 and 0700 ..."


B. Review of the " Wound Assessment and Reassessment" policy, last revised in March 2018, states in part,

"III. PROCEDURE
3. Reassessment. Patients identified at increased risk for breakdown ..., or with actual impairment in skin integrity, must have an integumentary focused reassessment performed at a minimum of two times every 24 hours, per Lifespan policy: Nursing Protocol Orders for Impaired Skin Integrity."

Record review revealed patient ID #1 presented to the hospital on 6/30/2020 for rehabilitation services after recently undergoing a thoracic laminectomy with resection of an epidural lesion. On 7/6/2020 nursing documentation reflects Patient ID #1 was noted to have a Stage 2 pressure ulcer (a shallow open area with slight loss of skin; may look like a fluid filled blister) on his/her coccyx area (area at the bottom of the spine) which was treated with nursing intervention. On 7/7/2020 a wound consult was ordered by nursing for evaluation of the area. On 7/8/2020 the wound nurse assessed the area and described it as an unstageable pressure ulcer requiring Santyl (a medicine that removes dead skin to promote healing of the sore) and a dressing (cover for the area).

Further review of the nursing documentation and skin assessment flow sheets, which includes the assessment of any wounds, revealed that from admission to discharge there were thirty-one (31) opportunities for skin assessment flowsheet documentation for Patient ID #1. Of those, 6 of the 31 failed to have any skin assessments documented, and 8 of the 31 had incomplete skin assessments.

In conclusion. 15/31 nursing skin assessments were either absent or incomplete.

During an interview with the site Risk Manager on 8/14/2020 at 9:15 AM, she acknowledged that there were deficits in documentation and assessment of the integumentary system for Patient ID #1.

During an interview on 8/17/2020 at 1:30 PM, Staff F, a hospital nurse educator, stated that the focused assessment is completed on the nursing flow sheets and acknowledged there were multiple integumentary focused assessment areas left blank for Patient ID #1.