HospitalInspections.org

Based on observation, interview, and record review, the hospital failed to meet the requirements of the Condition of Participation of Nursing Services. The RN who was responsible for supervision and evaluation of the nursing care for each patient failed to ensure that care was provided in accordance with accepted standards of nursing practice. This deficient practice was evidenced by the nurses' failure to ensure that 3 of 3 current patients (#3, 4, and 5) with pressure sores received care and services to prevent the development/deterioration of pressure sores.

This deficient practice had the potential to affect 13 current patients admitted to the hospital with pressure sores and any other patient admitted to the hospital identified as high risk for pressure sore development (See findings in tag A-0395).

An Immediate Jeopardy situation was identified on 01/21/21 at 3:50 p.m. due to the hospital nursing staff failing to conduct a complete assessment of pressure sores and failing to notify the physician to obtain orders to treat.

A corrective action plan for removal of the Immediate Jeopardy situation was presented via email and fax on 01/22/21 at 3:45 p.m. The written plan of removal indicated the following actions by the Assessment Team:

1) A "head-to-toe" assessment will be performed for every patient on each designated unit;

2) Immediately provide appropriate care for any identified skin condition concern as set forth in the Lippincott Procedure Manual;

3) Review the skin assessment section in the current nursing shift assessment and identify and report any variance;

4) Accurately document in the EHR the current skin condition assessment;

5) Update the plan of care based upon the findings from the skin assessment;

6) If needed, enter a treatment plan to address any identified skin condition concerns;

7) Verify physician awareness of current skin condition concerns;

8) If it is identified that no documentation of communication was made to the patient's physician, the nurse manager is to immediately notify physician and document such notification;

9) The following data was to be collected on each patient and provided to the Response Team:

a) any identified skin condition concerns;

b) the current skin condition matches what is documented in the patient's chart;

c) nursing or physician documentation related to any identified pressure related skin condition;

d) treatment plans in place for any identified pressure injury; and

10) Comparison of any currently reported pressure injuries with the results of the Team findings.

The assessments of all 202 patients were completed on January 22, 2021 at 2:45 p.m. and appropriate treatment plans were developed.

Beginning Friday, January 22, 2021 and continuing unit implementation of the permanent plan of correction -

New patient admissions - Each patient that is admitted into Willis-Knighton shall have a complete skin assessment performed by a properly trained wound care registered nurse within 24 hours of admission. Treatment plans will be developed for any skin condition concern identified during the complete skin assessment.

Existing patents - On January 26, 2021, "head to toe" skin condition assessment will be required during every bedside shift report between on-going and off-going nurses. Any identified new findings will be promptly sent to the wound care nurses attention for follow up evaluation and treatment plans as well as notification to patient's physician. Nurse managers will be held accountable to ensure the process is being followed.

Weekend/Holiday Coverage - As arrangements have already been put in place for the weekend of January 22-January 24, 2021, a weekend call schedule will be developed on or before January 26, 2021 for future weekends/holidays to ensure proper wound care nurse coverage.

Follow Up Audit Tools - Following the audit performed on January 22, 2021 audit tools will be developed on or before January 26, 2021, focusing on repeating the facility wide skin condition assessment as well as unit specific skin condition assessments. Wound care nurses will follow up on each patient identified as having a pressure injury on the initial or subsequent facility wide skin condition assessments.

Unit Manager Review - A policy will be developed on or before January 25, 2021 requiring unit managers to review the patient EHR to validate the accuracy of each nursing shift's skin assessments, appropriate treatment plan, proper documentation and physician notification.


On 01/25/21 at 9:45 a.m., observations of body audits of random patients #7 and #8 conducted by S3WCC and review of the corresponding wound assessment documentation in the patient records confirmed that all identified areas were documented, treatment plans were developed and the physician was notified of current skin concerns. Interviews with S7RN, S8RN, and S9RN confirmed they were aware of the procedures for skin assessments, documentation and reporting of skin conditions and concerns, and notification of physicians. The inservice list was reviewed.

The Immediate Jeopardy situation was removed on 01/25/21 at 12:15 p.m. The deficient practice continues at condition level.







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Based on observation, interview, and record review, the RN who was responsible for supervision and evaluation of the nursing care for each patient failed to ensure that care was provided in accordance with accepted standards of nursing practice. This deficient practice was evidenced by the nurses failure to ensure that 3 of 3 current patients (#3, #4, and #5) and 1 of 1 discharged patients (#1) with pressure sores received care and services to prevent the development/deterioration of pressure sores by 1) the nursing staff failing to conduct a complete assessment of pressure sores; 2) the wound care team failing to follow the protocol for weekly assessments and treatment of wounds; and 3) the nursing staff failing to notify the physician to obtain orders to treat.

Findings:

Patient #3

Review of the electronic medical record for Patient #3 revealed an admission nursing assessment dated 01/06/21 at 1:33 a.m.

Review of this assessment revealed the patient had a scar to the sacrum, midline and 3 wounds to the abdomen related to a recent abdominal surgery.

Review of the nursing assessment dated 01/10/21 at 7:00 a.m. revealed the patient had the scar to the sacrum, midline and also a wound to the midline coccyx - partial thickness. There was no further documented assessment of the midline coccyx wound, including staging, sizing and characteristics.

Review of the nurses notes dated 01/10/21 at 11:05 a.m. revealed Allevyn dressing placed to sacrum, redness and small area of breakdown noted.

Review of the twice daily head to toe skin assessments from 01/10/21 thru 01/19/21 at 7:00 a.m. revealed they identified the following issues to integumentary: 1) scar to sacrum, midline and 2) coccyx, midline - partial thickness. There was no evidence in the medical record that the coccyx wound was assessed for staging, sizing or characteristics, or that the physician was notified to obtain treatment orders.

Review of a nurses note written by S3WCC dated 01/19/21 at 10:02 a.m. revealed that S3WCC was in the patient's room providing wound care to the patient's abdominal wounds and the patient's wife asked "Will you look at the wound on his bottom?" The note stated that S3WCC was not aware of a pressure injury to the patient's sacrum. S3WCC removed an Allevyn foam dressing from the sacrum and noted a full thickness wound with some necrotic slough to sacrum. Tender to manipulation. The note stated that S3WCC questioned the wife concerning history and the wife stated that the patient has had the wound since he was in the hospital the last time. The note further stated that S3WCC would recommend enzymatic debrider for removal of necrotic tissue to be discussed with physician.

Review of the wound assessment form dated 01/19/21 at 10:02 a.m., completed by S3WCC, revealed a Stage 3 pressure injury to the midline sacrum - full thickness skin loss measuring 1.8 x 2.5 x 0.3cm. The pressure sore had minimum serous exudate with 50% slough.

On 01/20/21 at 10:40 a.m., observation revealed S3WCC performed wound care to the patient's sacral pressure sore. Further observations at that time revealed that the patient also had a second open area to the sacrum. Interview with the patient's wife during this time revealed that the patient has had the pressure sore since December 2020.

On 01/20/21 at 11:00 a.m., interview with S3WCC revealed that she was unaware that the patient had a second pressure sore to the sacrum until she observed it during the above dressing change.

On 01/21/21 at 11:00 a.m., S2RN, IT reviewed the patient's electronic medical record with the surveyor and confirmed that after the pressure sore was identified on 01/10/21, there was no documented evidence that it was assessed or that treatment orders were obtained to treat the pressure sore until 9 days later, on 01/19/21, when it was documented as being necrotic.


Patient #4

Review of the electronic medical record for Patient #4 revealed an admission nursing assessment dated 01/15/21 at 9:36 a.m.

Review of this assessment revealed the patient had a skin tear to the coccyx, midline measuring 2.5 x 0.75cm and "apply absorptive dressing".

Review of the twice daily nursing assessments on 01/16/21 revealed the patient had a skin tear to the coccyx, midline. No further assessments were documented of the coccyx.

Review of the nursing assessment dated 01/17/21 at 9:12 a.m. revealed the coccyx, midline was now a full thickness skin tear. The note further stated "apply absorptive dressing." There was no further assessment of the wound.

Review of the nursing assessment dated 01/17/21 at 8:00 p.m. revealed the patient had a wound to the coccyx, midline. No other assessment of the wound was documented.

There was no evidence that the physician was notified of the patient's open wound to the coccyx in order to obtain treatment orders.

Review of the wound assessment form dated 01/18/21 at 3:15 p.m., completed by S3WCC, revealed that the patient had a deep tissue pressure injury, persistent non-blanchable discoloration, measuring 3.0 x 3.0 cm, and purple in color. The physician was notified at this time and treatment orders were obtained.

On 01/21/21 at 12:00 p.m., interview with S3WCC confirmed that the patient's wound deteriorated from a skin tear identified on admit to a pressure sore that was identified three days later. S3WCC confirmed that there was no evidence that the physician was notified of the wound until it was assessed by the wound care nurse three days later, and orders for treatment were obtained at that time. S3WCC further stated that hospital's wound care protocol states that nurses can apply absorptive dressings on Stage 1 and Stage 2 wounds without notifying the physician. S3WCC stated that absorptive dressings are to be changed daily. When asked if there was documentation that the nurses were changing the dressing daily to the patient's coccyx, she stated, "No."


Patient #5

Review of the electronic medical record for Patient #5 revealed an admission nursing assessment dated 01/16/21 at 11:45 a.m.

Review of this assessment revealed the patient had a full thickness wound to the left hip, measuring 1.5 x 0.5cm, with a pink, yellow wound bed. The note further stated to "apply absorptive dressing."

Review of the daily nursing assessments dated 01/17/21 thru 01/18/21 at 7:40 a.m. revealed the same above assessment. There was no documentation of any wound treatments.

Review of the wound assessment form dated 01/18/21 at 2:30 p.m., completed by S3WCC, revealed the patient had an unstageable pressure injury: obscured full-thickness skin and tissue loss to the left hip. The pressure sore measured 1.5 x 0.5cm, with a pink/yellow wound bed, 90% slough and minimum exudate. The physician was notified of the pressure sore at this time and treatment orders were obtained.

On 01/20/21 at 2:00 p.m., the patient's electronic medical record was reviewed with S2RN, IT. She confirmed that there was no documented evidence that the physician was notified prior to 01/18/21 to obtain treatment orders for the patient's wound that was identified to the left hip on 01/16/21.


Patient#1

Review of the medical record for Patient #1 revealed an 82 year old female admitted 05/25/20 with diagnoses CVA, dementia, and COVID pneumonia. Review of the discharge summary revealed her respiratory status deteriorated and she required intubation. She improved and downgraded from ICU to stepdown. She was discharged to LTAC on 06/17/20 for continuation of care.

Review of the 05/25/20 Integumentary Assessment conducted upon admission at 8:00 p.m. revealed she had six wound sites:

#1 - non-blanchable erythema to the right ankle;

#2 - non-blanchable erythema to the right foot near the 5th digit;

#3 - a scar to the left breast;

#4 - surgical scars to the abdomen;

#5 - an abrasion to the midline of the back;

#6 - an abrasion to the left knee.

The Braden Skin Risk Assessment score was 9, indicating very high risk for Pressure Ulcer and skin breakdown.

Review of subsequent Integumentary Assessments, completed by the nursing staff each shift (twice daily) revealed new wounds were identified as follows:

On 06/05/20 at 8:00 p.m. -

#7 - left ankle, no wound description;

#8 - right ankle, no wound description.

On 06/12/20 at 7:30 p.m. -

#9 - a bruise on the left heel;

#10 - a bruise on the right heel.

Further review of the Integumentary Assessments documented each shift by the staff nurses revealed no documented changes to the wounds from admission or initial identification until the last assessment on 06/17/20 at 8:00 a.m., the day of discharge. There were no assessments containing descriptions or staging of any of the wounds, other than the site and type. The Braden score on the shift assessments ranged from a low of 8 (very high risk) and a high of 12 (high risk).

Review of the policy for Braden Risk Assessment for Adults revealed it was to be completed on admission, every shift, at discharge and prn (as needed) by the nursing staff to identify individuals admitted who may be at risk for Pressure Ulcer and/or skin breakdown and initiate preventive measures in means of reducing Pressure Ulcer prevalence and incidence.

Review of the Current Orders Report revealed consults were electronically transmitted to the Wound Care Team related to wounds and/or Braden score on the following dates: 05/25/20 at 11:54 p.m.; 05/26/20 at 3:24 a.m.; 05/26/20 at 9:20 a.m.; 05/29/20 at 1:13 p.m.; 05/30/20 at 9:28 p.m.; 06/01/20 at 3:03 a.m.; 06/04/20 at 7:29 a.m.; 06/12/20 at 10:46 a.m.; 06/17/20 at 8:57 a.m..

Review of the documented assessment notes by the Wound Care Team revealed the following:

An assessment was completed on 05/26/20 at 10:00 a.m. - the sacrum was intact without incident, redness has resolved, spinus process is intact without incident; preventative Allevyn dressing reapplied to sacrum. Patient to be placed on a low air loss surface due to very high risk for skin impairment due to immobility. Patient's right foot and ankle with scarring - no needs to these sites, left open to air.

Review of the Wound Care Team note on 06/04/20 at 11:20 a.m. revealed: Patient is unable to be turned and assessed due to instability and acute care being performed at bedside. WOC staff to follow up at another time for assessment.

The next assessment by the Wound Care Team was on 06/17/20 at 2:30 p.m., on the date of discharge, with a note as follows: patient's bilateral heels with chronic discoloration, discolored area to medial heel appears to be resolved bulla. Sacrum with full thickness injury noted. Surrounded by dusky discoloration.

The documented wound assessment by the Wound Care Team on 06/17/20 at 2:30 p.m. revealed the following:

Site #5 to the sacrum was a Stage 3 pressure injury with full-thickness skin loss measuring 4cmx2.7cmx0.3cm. The wound bed was red and yellow in color with 10% slough.

A new wound was identified as site #6 to the auricle of the right ear - an unstageable pressure injury with obscured full-thickness skin and tissue loss measuring 2cmx1cm with 100% of the wound bed covered in black eschar.

Site #7 to the left heel showed chronic discoloration to the medial heel.

No assessment was documented to the remaining wound sites on the left knee (#6), the left ankle (last identified as site #7), the right ankle (#8), and the right heel (10).

An interview with S3WCC on 01/20/21 at 10:00 a.m. revealed she and one other RN make up the wound care team; they are consulted through the electronic system for wound consults for all patients who score at high risk on the Braden scale or have wounds identified. All high risk patients are supposed to be seen weekly by the wound care team to assess, stage and measure any wounds. She stated that the floor nurses are not allowed to stage the wounds, but can describe the wounds by measurement and characteristics.

An interview with S4RN, ICU nurse on 01/20/21 at 10:35 a.m. confirmed that the wound care team is notified through the electronic record system of the need for wound assessment, or they can call them on the phone. She confirmed that the nurses perform wound care, but do not stage wounds - this is done by the wound care team only.

An interview with S5RN on the COVID unit on 01/21/21 at 10:50 a.m. confirmed that the wound care team is notified through the electronic record system of the need for wound assessment, or they can call them on the phone. She confirmed that the staff nurses perform wound care, but do not stage wounds - this is done by the wound care team only. She further stated that the nursing shift assessments automatically repopulate information based on the prior assessment, and the nurse must change the information that is different. She stated that the wound care team usually comes every 2-3 days to assess changes and perform wound care.

A follow-up interview with S3WCC on 01/21/21 at 11:50 a.m. confirmed that the hospital protocol for wound treatment follows the Lippincott Procedures. All wounds are treated by protocol and without physician orders until they need a medicated dressing applied. There is no treatment documented on a Treatment Record while the protocol is being used; the only documentation would be in the notes nurses or in the treatment plan. She stated that the staff nurses should communicate with the physician about the wounds until they are a Stage 3, at which point the wound care team contacts the physician for specific orders. The orders are then added to a Treatment Record and treatment is documented. She confirmed that patient #1 was not seen by the wound care team for wound assessments as per their protocol, and there were no physician orders for the wounds until 06/17/20, just prior to discharge. She further confirmed there was no documented evidence that the physician was aware of the wounds until they deteriorated on 06/17/20.






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