HospitalInspections.org

Based on review of hospital policy, review of closed medical record, grievance files, and interviews with staff, the hospital failed to ensure a written response per the hospital's specified time frames for 1 of 2 grievance files reviewed. (#4).

The findings include:

Review of policy, titled "Patient Grievance Management Process" with effective date of September 20, 2016, revealed, "...1. All grievances are forwarded to the Office of Patient Experience. 2. The Office of Patient Experience ensures the process and timing of the grievance procedure is followed.....4. Within seven calendar days, the patient or legal representative will be contacted by the Office of Patient Experience to address resolution or notify the patient or representative that further investigation is required. The patient will be informed of an expected follow-up time to address the resolution and will be kept informed of the progress on a weekly basis. All grievances will be resolved as soon as possible, with a goal of resolution within seven calendar days and the recommendation that it take no longer than 30 days...."

Review of closed medical record on 02/06/2018 through 02/08/2018 of 84 year old male (Patient #4) admitted on 10/29/2017 for weakness and shortness of breath on exertion. Past medical history significant for dementia (memory loss condition affecting activities), chronic anemia, heart failure, and diabetes. Further review revealed a grievance letter dated "December 29, 2017," which reads: "I am writing in response to the grievance you filed on November 17, 2017...."

Interview 02/08/2018 at 0900 with AS #1 (Director of Patient Grievance) revealed information from (patient's family member) was not place in "safety zone" (Portal to contain all of the information received from patient's family). Additional interview revealed all information was lost and nothing was documented about conversations. Continued interview revealed the information was not passed on to the team. Further interview revealed final letter was late and did not follow policy.

Interview on 02/07/2018 at 1330 with director of quality revealed the grievance was not completed. "It does not have the initial letter" of notification. Further interview revealed grievance policy was not followed.

Based on medical record review, root cause analysis review, and staff interview, leadership failed to develop a plan to monitor improvement following a hospital acquired pressure injury (Patient #6).

The findings included:

Review of the closed medical record of Patient #6 on 02/06/18 revealed a 32 year old patient with a history of quadriplegia, chronic pain, tracheostomy, and recent intracerebral hemorrhage who was admitted to the hospital on 09/26/2017 for abdominal pain and distension. Review revealed an initial nursing assessment on 09/26/2017 at 2200 which indicated that skin color was appropriate for ethnicity, and skin condition was dry. Review revealed no documentation of any skin discoloration or redness on the sacrum or buttocks on admission or on daily skin assessments until 10/05/2017. Review of a progress note dated 10/05/2017 revealed the rounding physician asked the care nurse to check the patient's skin for a decubitus ulcer (pressure injury). Review revealed a wound nurse consult note dated 10/05/2017 which described a 10cm x 10cm deep tissue injury; a 10cm x 7cm unstageable pressure injury with 3cm tunnels; and a 5cm x 3 cm x 0.1 cm Stage II pressure injury on the patients' buttocks and sacrum. Review revealed the consulting nurse "called primary MD team and notified of presence of HAPI (hospital-acquired pressure injury)." Further review of the medical record revealed the patient required three surgical debridements (a surgical procedure where dead tissue is cut away from a wound) over the course of his hospital stay. Review revealed a CT scan (an imagining study) on 10/20/2017 showed coccygeal osteomyelitis (a bone infection in the tailbone) related to the wound. Review revealed the patient also required a diverting colostomy (a surgical procedure where the bowel is redirected through the abdomen to drain stool into an external pouch) in order to keep the wound clean, which was performed on 11/01/2017. Review revealed the patient was discharged home with home health services on 11/13/2017.

Review on 02/08/2018 of a document entitled "Root Cause Analysis: Pressure Ulcer Delay in Documentation" dated 11/02/2018 revealed that documentation of the condition of the patient's skin did not meet the facility's expectations, which impacted care of the patient. Further review revealed that "documentation is an important communication tool for safe patient care. Documentation was not adequate for this patient's condition." Review revealed action steps related to: ordering specialty beds; staffing acuity; staffing concerns escalation; utilizing just culture for non-compliance of documentation; and reinforcing a two-nurse signoff for skin assessments on admission. Review revealed no action steps related to monitoring skincare documentation.

Request for quality improvement data related to this event revealed documentation of quarterly HAPI prevalence reports (a report of how many patients per unit had a documented hospital-acquired pressure injury).

Additional request for quality improvement data related to the event revealed meeting minutes from a staff meeting on 12/11/2017 on the unit where Patient #6 was located. Review revealed a topic "Pressure Ulcer Prevention" with the following items: "2 Person skin assessments on Admission/Transfer;" "Hospital Wide skin checks quarterly Next one Feb 21st;" "Review the standard practice and process of ordering specialty beds."

Review revealed no other quality improvement data related to the event.

Interview on 02/07/2018 at 1030 with WOCN #1 revealed the nurse was not aware of any quality monitoring related to documentation of skin assessments or skincare interventions besides the quarterly HAPI prevalence reports.

Interview on 02/08/2018 at 1245 with NM #1, the manager of the unit where Patient #6 was located, revealed that reeducation had been done at the unit staff meeting on 12/11/2017. Interview revealed that following the event staff nurses had been encouraged to seek advanced competency in skincare through the Wound Care Associate program (an optional program which offers extra skincare training). Interview revealed there was no formal data available to demonstrate practice changes following re-education. Interview revealed that there was no monitoring of documentation related to skin assessments or skincare interventions.

Interview on 02/08/2018 at 1605 with Administrative Staff (AS) #1 revealed, "We haven't done any official follow-up after the event." Interview revealed the only monitoring related to skincare is the quarterly HAPI prevalence report. Interview revealed the manager of the unit where Patient #6 was located should have followed up on the action plans that were discussed following the event. Interview revealed no such follow-up had been done.

NC00133639

Based on policy and procedure review, medical record review, and staff interview, the facility staff failed to reposition patients per facility policy in 4 of 6 records reviewed (Patients #6, 18, 19, and 21).

The findings included:

Review of facility policies and procedures on 02/06/2018 revealed a procedure document titled "Pressure Injury: Risk Assessment and Prevention." Review revealed that the Braden scale (a 23-point scale used to predict a patient's risk for skin breakdown, where a lower score indicates greater risk) should be used to plan appropriate nursing interventions. Review revealed a Braden score of 9 or less indicates very high risk; 10 to 12 indicates high risk; 13 to 14 indicates moderate risk; and 15 to 18 indicates mild risk. Review revealed factors such as chronic moisture, immobility, and poor nutrition can contribute to pressure injury risk. Review revealed nurses should observe for skin discoloration and areas of redness, which may indicate areas at risk for skin breakdown. Review revealed that early detection of pressure indicates the need for more frequent position changes (regular turning). Review revealed nursing staff should create a schedule for position changes. Review revealed that nursing staff is expected to document a patient's risk score, skin assessment, skin changes, positions and turning intervals.

1. Review of the closed medical record of Patient #6 on 02/06/2018 revealed a 32 year old patient with a history of quadriplegia, chronic pain, tracheostomy, and recent intracerebral hemorrhage who was admitted to the hospital on 09/26/2017 for abdominal pain and distension. Further review revealed an initial Braden score of 12 (high risk for skin breakdown) on admission. Review revealed when nursing staff documents a Braden scale, an information box in the electronic medical record prompts the user to implement appropriate interventions for at-risk patients. Review revealed an area on the electronic medical record labeled "Braden Scale Interventions" for nursing staff to document interventions to reduce risk of skin breakdown. Review revealed no documentation of any interventions coinciding with the Braden score of 12 on admission. Review revealed no available documentation of turning between 09/27/2017 at 1700, when the patient was supine, and 09/28/2017 at 0800 (15 hours later), when the patient was again lying supine. The next available documentation of the patient's positioning was 09/29/2017 at 2000 (36 hours later), when the patient was repositioned to the right. Further review of the positioning flowsheet revealed no evidence of repositioning on 10/01/2017 between 0748 and 2000 (12 hours and 12 minutes); on 10/06/2017 between 0100 and 2142 (20 hours and 42 minutes); or on 10/07/2017 between 0200 and 2030 (18 hours and 30 minutes). Further review revealed on 10/23/2018, patient was sitting in a chair at 2034 with a note in the flowsheet that states "reposition in chair every 20 minutes;" the next evidence of repositioning is documented at 2200 (1 hour and 26 minutes later).

Continued review of the medical record revealed a wound nurse consult note dated 10/05/2017 which described a 10cm x 10cm deep tissue injury; a 10cm x 7cm unstageable pressure injury with 3cm tunnels; and a 5cm x 3 cm x 0.1 cm Stage II pressure injury on the patients' buttocks and sacrum. Review revealed the consulting wound care nurse "called primary MD team and notified of presence of HAPI (hospital-acquired pressure injury)." Review revealed that the patient required three surgical debridements (a surgical procedure to cut dead tissue from the wound) and ongoing hydrotherapy treatment (a type of wound treatment where a jet of water is used to clean dead tissue from a wound). Review revealed a CT scan (an imagining study) on 10/20/2017 showed coccygeal osteomyelitis (a bone infection in the tailbone) related to the wound. Further review of the medical record revealed a surgical note dated 11/01/2017 which stated, "...the ulcer continues to be contaminated by liquid stool, so a diverting loop colostomy (a surgical procedure to redirect the colon through the front of the abdomen so that stool drains into an external pouch) has been recommended to the family." Review revealed the colostomy surgery was performed on 11/01/2017. Review revealed the patient was discharged home with home health services on 11/13/2018.

Interview on 02/07/2018 at 1535 with RN #2, who cared for the patient periodically throughout his hospitalization, revealed that when a patient has a low Braden score or is unable to reposition themselves, "we turn them." Interview revealed that sometimes Patient #6 would refuse turning but "I wouldn't say [he refused] often ...if a patient refuses, you document." Further interview revealed, " ...if it's not documented, it's not done." Further interview revealed that Patient #6 was not able to reposition himself at any point during his admission.

Interview on 02/07/2018 at 1030 with WOCN (Wound Ostomy Continence Nurse) #1 revealed the nursed remembered the named patient. Interview revealed that a decision tree for skincare interventions is available for nurses, and that the electronic medical record prompts nurses to provide interventions such as turning and special mattresses when a low Braden score is documented. Interview revealed that "Q2 (every two hours) turns should be an expectation," and that even though other interventions such as special mattresses are available, "this doesn't replace turning." Interview revealed that the patient was not placed on a special mattress until after the pressure injury was assessed but that the patient was "paralyzed, he's critically ill, critical thinking would determine he needed an air mattress way sooner." Further interview revealed "the system failed him."

2. Review of an open medical record on 02/08/2018 of patient #18 revealed a 51 year old admitted on 01/19/2018 for treatment of a neck abscess after a dental procedure. Review revealed a Braden score of 13 (moderate risk for skin breakdown) documented on admission with the corresponding Braden intervention "reposition q2h." Review revealed documentation of turns per policy from the time of admission until 01/21/2018 at 0400, at which time the patient refused repositioning. There is no further documentation of repositioning until 01/21/2018 at 0820 (4 hours and 20 minutes later). On 01/24/2018 at 2200, the documentation reflects that the patient was repositioned; no further turning documentation is available until 01/25/2018 at 2145 (23 hours and 45 minutes later). No repositioning documentation is available between 01/26/2018 at 1200 and 01/27/2018 at 0035 (12 hours and 35 minutes). No repositioning documentation is available on 01/29/2018 between 0230 and 2200 (19 hours and 30 minutes). Further review of the medical record reveals a stage II pressure ulcer on the buttocks initially documented on 02/02/2018.

Interview on 02/07/2018 at 1030 with WOCN (Wound Ostomy Continence Nurse) #1 revealed that a decision tree for skincare interventions is available for nurses, and that the electronic medical record prompts nurses to provide interventions, including frequent repositioning, when a low Braden score is documented. Interview revealed that "Q2 (every two hours) turns should be an expectation," and that even though other interventions are available, "this doesn't replace turning."

3. Review of an open medical record on 02/08/2018 of patient #19 revealed a 56 year old who was admitted on 01/29/2018 with decompensated alcoholic cirrhosis, altered mental status and lethargy. Review revealed a Braden score of 10 documented on admission with the corresponding Braden intervention of "reposition q2h (every two hours)". Review revealed a Braden score of 9 recorded on 01/31/2018 at 0745 with the corresponding Braden intervention of "reposition q2h." Review revealed repositioning documentation recorded on 01/31/2018 at 0815; no further turning documentation is available until 01/31 at 2000 (12 hours). Review revealed a Braden score of 15 documented on 02/04/2018 at 0818 with the corresponding Braden intervention of "reposition q2h." Review revealed no turning documentation available on 02/04/2018 between 0818 and 2000 (11 hours and 42 minutes). Further review revealed a wound care consult note dated 02/03/2018 at 1019 which described a deep tissue pressure injury to the right heel and a full thickness wound on the posterior right leg. Review revealed, "Turning and repositioning is still a cornerstone of her skin care plan."

Interview on 02/07/2018 at 1030 with WOCN (Wound Ostomy Continence Nurse) #1 revealed that a decision tree for skincare interventions is available for nurses, and that the electronic medical record prompts nurses to provide interventions, including frequent repositioning, when a low Braden score is documented. Interview revealed that "Q2 (every two hours) turns should be an expectation," and that even though other interventions are available, "this doesn't replace turning."

4. Review of the open medical record on 02/08/2018 of Patient #21 revealed a 91 year old admitted on 01/28/2018 for gall stone pancreatitis. Review revealed an initial Braden score of 20 documented on admission with no corresponding Braden interventions. Further review revealed a Braden score of 13 documented on 01/29/2018 at 1930 with corresponding Braden intervention "reposition q2h." Review of the nursing flow sheet revealed no turning documentation until 01/30/2018 at 2026 (24 hours and 54 minutes later), when the patient was "not compliant with following measures: q2 turns." On 01/30/2018 at 2300, when the patient was documented as "able to turn self." On 02/01/2018 at 2030, a Braden score of 13 was documented with the corresponding intervention "reposition q2h." At that time, patient was "not compliant with following measures: q2 turns." No further repositioning is documented until 02/06/2018 at 2000, at which time the patient is documented as "able to turn self" and has a Braden score of 18. On 02/07/2018, Braden scores were documented as 17 at 0000, 17 at 0400, and 15 at 2000, each with corresponding Braden intervention of "reposition q2h." The patient is repositioned a total of three times on 02/07/2018, at 1345, 1817, and 2000.

Interview on 02/07/2018 at 1535 with RN #2, a nurse who worked on the floor where Patient #21 was located, revealed that when a patient has a low Braden score, "we turn them ...if a patient refuses, you document." Further interview revealed, "...if it's not documented, it's not done."

NC00133639