HospitalInspections.org

Based on record review and interview facility staff failed to ensure the nursing staff are assessing patients, implementing interventions based on patient needs, and evaluating interventions for effectiveness in 3 of 10 medical records reviewed (Patient (Pt #1, 4, 5), in a total sample of 10 patient records reviewed.

Findings Include:

Review of policy and procedure titled, "Interdisciplinary Patient Assessment & Documentation" last reviewed 02/21/2023 revealed the following:
-Data collection/Reassessment is designed to evaluate the patient's response to care and interventions and to determine if a change to the plan of care is warranted.
-The nurse completes date collection for patients in the acute phase at a minimum of 2 times in 24 hours...
-When the plan of care has been developed, the healthcare team implements it. Each discipline documents their interventions and the patient's response to these interventions in the patient's health care record.

Review of the Medical/Surgical units "Required Documentation" guidelines (no date) provided by Nursing Supervisor C, revealed the following:
-On admission: Initiate appropriate Care Plans for the patient.
-Every 12 hours document: Care Plan, Patient (Pt) Education, Mobility, Hygiene, Safe environment, Braden Scale, Psychosocial, Nutrition.
-I & O (input & output) documented by 5:59 AM (Night shift), 1:59 PM (Day shift), 9:59 PM (PM shift)

Review of the Medical/Surgical units "Routine Cares: Tasks and Activities" guidelines (no date) provided by Nursing Supervisor C, revealed that a Pt Bed Bath/Shower should be completed once a day; Oral Care, in the morning and in the evening; Incontinence/Perineal care as needed; and linen changes once per day.

Review of the hospital provided "Braden Scale for Predicting Pressure Ulcer Risk" dated 07/26/12 revealed that patients are at risk for pressure ulcers if the Braden score is
Review of the hospital provided "Pressure Injury Prevention Skin Bundle Components: Think Skin" guidelines (no date) revealed the following:
-Surface Selection: Waffle overlay, low Airloss mattress, chair cushion, preventative foam boarders, pillows, heel boots, pad bony prominence's.
-Keep turning: Reposition every 2 hours, Reposition every 1 hour while sitting in chair, head of bed <=30 degrees...
-Incontinence Management: No incontinence briefs while in bed, Purewick & condom catheter (external catheters), barrier cream.

Review of the manufacturer's Instruction for Use of the "Purewick Male External Catheter (2021)" revealed, "Replace the device at least every 24 hours or if soiled with feces, blood, or semen."

Review of hospital provided "Routine Cares: Safety and Hourly Rounding" guidelines (no date) revealed the following:
Environment Check:
-"The patient's room will be assessed for safety every time you are in the room: Call light within reach, personal items within reach, walkways clear of debris, bed in low position with wheels locked, alarms and equipment are engaged and appropriately set, verify the communication board is up to date."

Pt #1:

Review of Pt #1's History and Physical (H & P) revealed Pt #1 was 91 years old admitted to the hospital on 04/14/2023 at 4:55 PM for Acute Metabolic Encephalopathy (delirium and acute confusional state) with dehydration and Covid-19 positive; Pt #1 was discharged home on 04/18/2023 at 2:49 PM. Per review of the H & P, Pt #1 was "confused to situation and unable to identify his wife; baseline hearing loss and poor vision." Review of Pt #1's past medical history revealed Pt #1 had bilateral Cataracts (clouding of the normally clear lens of the eye)."

Integumentary (skin):

Review of Pt #1's Nursing Flowsheets revealed Pt #1's Braden Scales (pressure ulcer risk) as follows: 04/14/2023 at 9:00 PM--12, 04/15/2023 at 10:30 PM--15, 04/16/2023 at 8:51 AM--16, 04/17/2023 at 1:00 AM--15, 04/17/2023 at 10:37 AM--14, and 04/17/2023 at 11:59 PM--14 (Pressure ulcer risk when
Review of Pt #1's Integumentary Nursing Flowsheets revealed the nurse completed a skin assessment on 04/14/2023 at 9:00 PM and then not again until 04/15/2023 at 10:30 PM (26 1/2 hours later). Per review of Pt #1's Flowsheets, the nurse completed a skin assessment on 04/17/2023 at 11:59 PM; there was no documented evidence of a skin assessment completed on 04/18/2023 prior to Pt #1's discharge at 2:49 PM (14 hours and 50 minutes later) (Per policy should be documented at least every 12 hours).

Review of Pt #1's Mobility Nursing Flowsheets for repositioning every 2 hours, revealed the following:
-Pt #1 was repositioned on 04/14/2023 at 9:44 PM; there was no documented evidence of staff repositioning Pt #1 again until 04/15/2023 at 5:30 AM (7 hours and 46 minutes later).
-Pt #1 was repositioned on 04/15/2023 at 5:30 AM; there was no documented evidence of staff repositioning Pt #1 again until 10:00 PM (16.5 hours later).
-Pt #1 was repositioned on 04/16/2023 at 6:45 AM; there was no documented evidence of staff repositioning Pt #1 again until 04/16/2023 at 9:00 PM (9 hours and 15 minutes).
-Pt #1 was repositioned on 04/16/2023 at 9:00 PM; there was no documented evidence of staff repositioning Pt #1 again until 04/17/2023 at 6:00 PM (21 hours later).
-Pt #1 was repositioned at 04/17/2023 at 11:59 PM; there was no documented evidence of staff repositioning Pt #1 again until 04/18/2023 at 5:00 AM (5 hours later).

Review of Pt #1's Mobility Nursing Flowsheets revealed Pt #1's "Level of Assistance" was documented as "Maximum Assist."

Review of Pt #1's Braden Scale of < 18 and incontinence of urine and stool throughout Pt #1's hospital stay indicated Pt #1 was at risk for pressure ulcers and skin breakdown. Review of Pt #1 nursing Flowsheets and progress notes showed no documented evidence of nursing interventions implemented addressing Pt #1's skin care needs as per the Pressure Injury Prevention Skin Bundle Components: Think Skin" guidelines including, but not limited to; Waffle overlay, low Airloss mattress, chair cushion, preventative foam boarders, reposition every 2 hours, reposition every 1 hour while sitting in chair, barrier cream, and pad bony prominences.

Hygiene:

Review of Pt #1's Hygiene nursing Flowsheets revealed there was no documented evidence of staff performing Hygiene cares including bathing, oral care, and skin care throughout Pt #1's hospital stay (04/14/2023 through 04/18/2023). "Peri care (cleansing of genital and rectal areas)" was documented as being completed on 04/14/2023 at 9:44 PM and 04/18/2023 at 5:00 AM. Per Review of Pt #1's Flowsheets, staff documented that Pt #1 was incontinent of urine and/or stool on 04/16/2023 at 9:00 PM, 04/17/2023 at 9:00 PM, and 04/18/2023 at 7:00 AM, and 9:00 AM; there was no documentation of staff providing Peri care and skin interventions as need.

Safety Environment Checks/Patient rounding:

Review of Pt #1's Safe Environment Nursing Flowsheet (Including, Call light Within Reach, Overbed Table Within Reach, Bed in Lowest Position, Bed Wheels Locked, Side Rails/Bed Safety, and Nonskid Foot Wear) revealed there was no documented evidence of nursing staff addressing "Safe Environment" interventions from 04/14/2023 at 9:45 to 04/15/2023 at 10:30 PM (>24 hours); and from 04/15/2023 at 10:30 PM to 04/17/2023 at 10:37 AM (2 days); Per hospital "Required Documentation" guidelines staff should be ensuring a Safe Environment as evidence by documentation at least every 12 hours.

Dietary Needs:

Review of Pt #1's Nursing Flowsheets for ADL (Activity of Daily Living) Screening dated 04/16/2023 at 3:12 PM, revealed the screening question, "Patient's Vision Adequate to safely complete Daily activities?;" the response was documented as "No". Review of Pt #1's ADL Flowsheet revealed that Pt #1 "Needs Assistance" with "Feeding."

Review of Pt #1's Nursing Flowsheets for HEENT (Head, Ears, Eyes, Nose, Throat) from 04/14/2023 through 04/18/2023 revealed documentation that Pt #1's Right Eye had "Moderately impaired vision" and the Left Eye had "Severely impaired vision." Per review of the Nursing Flowsheets, there was no documented evidence of nursing staff implementing interventions to address Pt #1's needs related to impaired vision. Per review, the HEENT Nursing Flowsheets do not contain assessments or interventions implemented in regards to Pt #1's impaired hearing as identified in the H & P.

Review of Pt #1's Intake and Output (I & O) Nursing Flowsheet for "Meal Eaten" from 04/14/2023 (admitted to inpatient unit at 4:55 PM) to 04/18/2023 (discharge at 2:49 PM) revealed the following:
04/14/2023: No dinner documented as consumed
04/15/2023: No breakfast or lunch documented as consumed. Dinner consumed did not have "Percentage Meal" documented.
04/16/2023: No breakfast, lunch, or dinner documented as consumed.
04/17/2023: Breakfast did not have "Percentage Meal" documented.
04/18/2023: No Breakfast or lunch documented as consumed.

Review of Pt #1's Nutrition and I & O Flowsheet from 04/14/2023 to 04/18/2023 revealed there was no documented evidence of nursing staff implementing interventions to address and evaluate Pt #1's needs for assistance with feeding and meal set up due to being visually impaired and having an altered mental status.

Per interview with Family A (Pt #1's Daughter) on 05/15/2023 beginning at 9:43 AM, Family A stated that Family B (Pt #1's Wife) found a cold food tray in Pt #1's room; Per Family A, Pt #1 did not know his/her meal was left in the room, and due to being "blind" and confused, Pt #1 would not have been able to see it and retrieve the food to feed him/herself.

External Catheter (Purewick):

Review of Pt #1's Nursing Flowsheets revealed that an External Urinary Catheter (Purewick) was placed 04/14/2023 at 11:00 PM. Per review of the Nursing Flowsheets from 04/14/2023 through 04/18/2023, there was no documented evidence that the Purewick catheter was changed every 24 hours as per manufacturer guidelines.

During interview with Supervisor C, while reviewing Pt #1's medical record on 05/15/2023 beginning at 2:17 PM and on 05/16/2023 beginning at 9:18 AM, Supervisor C stated that staff should complete the Braden skin assessment every shift (12 hour nursing shifts) and if the score is =/< 18, the nurse should implement skin interventions included on the "Pressure Injury Prevention Skin Bundle Components: Think Skin" guidelines. Per Supervisor C, staff should be repositioning Pts every 2 hours who are at risk for skin breakdown based on Braden Scores, and this should be documented in real time. Supervisor C agreed that nursing assessments should be documented as per policy and facility guidelines. Supervisor C stated that there are no policies specific to turning Pts every 2 hours or Hygiene cares, but staff should be following the unit protocol and guidelines. Supervisor C stated that hourly checks are not typically documented in the medical record, but staff should be documenting Safe Environment flow sheets every shift as evidence of the patient safety checks. Supervisor C stated that staff should be following the manufacturer's guidelines for use of the Purewick system, and should be changing the external catheter every 24 hours. Supervisor C stated that staff should be checking the external catheter during the repositioning to ensure it is intact. Per interview, Supervisor C agreed that staff should be documenting breakfast, lunch, and dinner meals and the percentage consumed in real time; and stated that staff should have implemented and documented interventions related to Pt #1's feeding and meal set up needs.


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Review of medical record for Patient #4 revealed that Patient #4 was admitted to the facility on 05/06/2023 for "COPD [chronic obstructive pulmonary disease]/Shortness of Breath" with no anticipated discharge date as of 05/15/2023.

Patient #4's Care Manager's initial Risk Assessment, completed on 05/06/2023 at 3:21 PM, revealed "IDENTIFIED RISKS ...pt [patient] is noted to be 'Hoyer (mechanical lift) dependent' on staff for ADLS [activities of daily living], meds [medications], and tasks ..."

A review of Patient #4's Nursing Flowsheets titled, "Daily Cares/Safety", revealed nursing documentation gaps for repositioning at least once every 2 hours and nursing documentation gaps for hygiene assistance at least once every 24 hours from 5/06/2023 through 05/16/2023.

During an interview on 05/15/2023 at 3:12 PM, Clinical Nurse Leader E confirmed that Patient #4's Nursing Flowsheets revealed multiple documentation gaps for repositioning every 2 hours and hygiene assistance every 24 hours during admission.

Review of medical record for Patient #5 revealed that Patient #5 was admitted to the facility on 05/04/2023 for "Leg Swelling" and was hospitalized for "infected ulcer of the skin" with an anticipated discharge to home on 05/16/2023.

Patient #5's Care Manager initial Risk Assessment, completed on 05/05/2023 at 9:58 AM, revealed "IDENTIFIED RISKS ...wheelchair ...ADL Screening: Patient Functionally independent? No ...Bathing: Needs assistance ...Toileting: Needs assistance..."

Patient #5's Care Manager's Patient Worksheet completed on 05/16/2023 at 9:17 AM, revealed "Patient is unable to complete self cares ...Pt is wheelchair bound at baseline ..."

Patient #5's Wound Consult completed on 05/12/2023 at 4:26 PM, revealed " ...has a Purewick [external catheter] in place to contain urine ..." and additional Wound Consult on 05/15/2023 at 4:57 PM revealed that patient still had Purewick in place.

A review of the Nursing Flowsheets titled, "Daily Cares/Safety", revealed nursing documentation gaps for repositioning at least once every 2 hours and no nursing documentation for external catheter change at least once every 24 hours from 5/04/2023 through 05/15/2023.

During an interview on 05/15/2023 at 3:48 PM, Clinical Nurse Leader E confirmed that Patient #5's Nursing Flowsheets revealed multiple documentation gaps for repositioning every 2 hours and that nursing staff is not documenting consistently for replacing external catheters every 24 hours along with overall catheter care.

Based on record review and interview facility staff failed to develop nursing care plans based on patient's needs, establish goals, and perform interventions, in 5 of 10 medical records (Patient (Pt) #1, 5, 6, 8, 10), in a total sample of 10 medical records reviewed.

Findings include:

Review of policy and procedure titled, "Interdisciplinary Patient Assessment & Documentation" last reviewed 02/21/2023 revealed the following:
-The plan of care should be developed, when possible, in conjunction with the patient/family. A care plan has individualized patient priorities, expected outcomes with target dates, and appropriate interventions.
-When the plan of care has been developed, the health care team implements it. Each discipline documents their interventions and the patient's response to these interventions in the patient's health record.
-Members of the healthcare team revise the plans and goals for care, treatment, and services, based on the patient's needs.
-The plan of care must be reviewed and/or updated at time of transfer and discharge.
-Evaluation of patient progress towards the attainment of outcome will be reflected in the patient record not less than once each calendar day.

Review of the hospital provided "Braden Scale for Predicting Pressure Ulcer Risk" dated 07/26/12 revealed that patients are at risk for pressure ulcers if the Braden score is
Review of the hospital provided "Pressure Injury Prevention Skin Bundle Components: Think Skin" guidelines (no date) revealed the following:
-Surface Selection: Waffle overlay, low Airloss mattress, chair cushion, preventative foam boarders, pillows, heel boots, pad bony prominence's.
-Keep turning: Reposition every 2 hours, Reposition every 1 hour while sitting in chair, head of bed <= 30 degrees...
-Incontinence Management: No incontinence briefs while in bed, Purewick & condom catheter (external catheters), barrier cream.

Review of Pt #1's Nursing Flowsheets revealed Pt #1's Braden Scales (pressure ulcer risk) as follows: 04/14/2023 at 9:00 PM--12, 04/15/2023 at 10:30 PM--15, 04/16/2023 at 8:51 AM--16, 04/17/2023 at 1:00 AM--15, 04/17/2023 at 10:37 AM--14, and 04/17/2023 at 11:59 PM--14 (Pressure ulcer risk when
Review of Pt #1's Care Plan revealed a nursing diagnosis of "Skin Integrity Impairment Risk" and an expected outcome to "Maintain intact skin and mucosa". The goal does not have an expected target date as per policy.

Pt #1's Care Plan interventions are listed as "Assess skin risk daily and w/(with) change in patient condition" and "Perform skin care prevention measures considering risk." There is no documented evidence in Pt #1's medical record of staff implementing specific individualized skin interventions addressing Pt #1's risk for impaired skin integrity and evaluating Pt #1's progress to goal daily as per policy.


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Review of medical record for Patient #5 revealed that Patient #5 was admitted to the facility on 05/04/2023 for "Leg Swelling." A nursing care plan for "Blood Pressure Alteration, Clinical Nutrition, Fall Risk, Fluid Volume Alteration, Hyperthermia, Infection, Knowledge Deficit, Noncompliance of Safety Precautions, Nutrition Alteration, Skin Integrity Impairment " was initiated on 05/05/2023 with goals "PO [oral intake] intake greater than 75% of protein on trays and Juven [nutritional supplement] during hospital stay, Maintain freedom from fall injury, Maintain freedom from fall injury considering secondary dx [diagnosis], Maintain Freedom from fall injury considering use of amb [ambulatory] aid, Maintain freedom from fall in/use [sic] of their equipment, Maintain freedom from fall injury considering gait risk, Maintain freedom from fall injury considering mental status, Be free of complications such as irreversible brain or neurological damage or seizure activity, acute renal failure, cardiac failure, respiratory infection or failure, and/or thromboembolic [blood clot] conditions, Improved nutritional status, Maintain weight, Maintain intact skin and mucosa [soft tissue], Open skin areas healing." There was no evidence in Patient #5's medical record of interventions to help Patient #5 meet the care plan goals.

Review of medical record for Patient #6 revealed that Patient #6 was admitted to the facility on 05/01/2023 for "Partial small bowel obstruction versus postop ileus [lack of intestinal movement after surgery]" and was discharged from the facility on 05/14/2023. A nursing care plan for "Pain, Altered nutrition, less than body requirements" was initiated on 05/02/2023 with goals "Improve patient pain intensity rating to mild/no pain, Patient maintains adequate nutrition and hydration." There was no evidence in Patient #6's medical record of interventions to help Patient #6 meet the care plan goals prior to discharge.

Review of medical record for Patient #8 revealed that Patient #8 was admitted to the facility on 03/29/2023 for "Melena [blood in bowel movements]" and discharged from the facility on 04/01/2023. A nursing care plan for "Fall Risk, Skin Integrity Impairment Risk" was initiated on 03/31/2023 with goals "Maintain freedom from fall injury, Maintain intact skin and mucosa." There was no evidence in Patient #8's medical record of interventions to help Patient #8 meet the care plan goals prior to discharge.

Review of medical record for Patient #9 revealed that Patient #9 was admitted to the facility on 04/29/2023 for "Abdominal Pain, Acute Appendicitis [inflamed Appendix]" and discharged from the facility on 05/01/2023. A nursing care plan for "Pain, Hemodynamic Status, Inadequate Airway Clearance, Mobility, Alteration in gastrointestinal function, Alteration in urinary elimination" was initiated on 04/30/2023 with goals "Satisfied with pain management, tolerates PO opioids/analgesi [analgesics], Patient's vital signs are stable, Patient will achieve/maintain normal respiratory rate/effort, Early mobility is achieved, Maintains or returns to baseline bowel function, Minimal or absence of nausea and vomiting, Maintains adequate nutritional intake, Absence of urinary retention." There was no evidence in Patient #9's medical record of interventions to help Patient #9 meet the care plan goals prior to discharge.

Review of medical record for Patient #10 revealed that Patient #10 was admitted to the facility on 04/28/2023 for "Infection associated with internal right hip prosthesis" and discharged from the facility on 05/01/2023. A nursing care plan for "Fall Risk, Pain, Skin Integrity Alteration" was initiated on 04/29/2023 with goals "Maintain freedom from fall injury, Satisfied with pain management, tolerates PO opioids/analgesi, Incisions, wounds, or drain sites healing without S/S [signs/symptoms] of infection." There was no evidence in Patient #10's medical record of interventions to help Patient #10 meet the care plan goals prior to discharge.

During an interview on 05/16/2023 at 11:56 AM, Clinical Nurse Leader E stated, "Interventions are not listed for each problem, and is not consistent listed under the problem description."