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Based on medical record review, observations during staff tracheostomy care, facility policy review, and staff interview, the facility failed to ensure a registered nurse supervised and evaluated the nursing care (A395).

Based on medical record review, observations during staff tracheostomy care, facility policy review, and staff interview, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for three of ten patients reviewed (Patient #2, #5, and #9) and one patient observed receiving tracheostomy care (Patient #11). The facility's census was 504.

Findings include:

1. The facility policy titled, Skin Care and Pressure Injury Assessment and Prevention for Inpatients, effective 06/08/22, was reviewed. The policy defines a pressure injury as a localized injury to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Section 4.5.4.2, titled Tracheostomy devices, instructs staff nurses to check skin with tracheostomy care twice a day. Assess skin around and underneath trach device and trach ties every four hours and more frequently as needed; assess for moisture and redness. If any break in the skin is noted, the policy instructs nurses to inform a physician and consult a wound nurse or unit skin champion for treatment recommendations.

Review of the medical record for Patient #2 revealed the patient had a tracheostomy, was on a ventilator, and had a gastrostomy (G) tube. The patient presented to the facility's Complex Care clinic on 06/16/22 and was discovered to have a 10% weight loss (considered severe malnutrition) since his previous visit, just two months prior. It was noted that the patient's mother reported trouble getting the correct formula at home and substituted with non-nutritional replacement of almond milk and water. The patient was admitted to the Transitional Care Center (TCC) unit at 12:39 PM for management of the patient's nutritional status.

Review of the Body System Assessment flowsheet revealed that on 06/29/22 at 2:30 PM, tracheostomy care was completed and the tracheostomy ties were changed. Redness was noted on the patient's neck and secretions were noted from the stoma (a surgically created hole in the windpipe that provides an alternative airway for breathing). At 7:48 PM, tracheostomy care was completed. Although the tracheostomy ties were not changed, the ties were noted to be clean, dry, and secure. The patient's neck remained reddened with secretions from the stoma at this time. The next trach tie change occurred at 3:56 PM on 06/30/22. An open area to the back of the patient's neck was noted at this time. The medical record lacked documentation a physician, wound nurse, or skin champion was informed of the open area as required by facility policy.

Further review of the Body System Assessment flowsheet for Patient #2 revealed that on 06/28/22 at 3:40 AM, the patient's skin, device, site were unable to be viewed/assessed. At 8:23 AM and 8:49 AM on 06/28/22, a staff nurse continued to note the patient's skin, device, site were unable to be viewed/assessed. At 11:35 AM on 06/28/22 the skin, device, site assessment noted the area was reddened. A comment at this time stated the nurse applied Aquaphor to the patient's neck. The assessments at 1:06 PM, 4:01 PM, and 4:34 PM all noted the skin, device, site were unable to be viewed/assessed. At 8:24 PM on 06/28/22, more than eight hours after the 11:35 AM assessment noted the patient's neck was dry. The skin, device, site assessments at 11:43 PM and at 3:23 AM on 06/29/22 again noted the patient's neck to be dry. The next skin, device, site assessment was not until 2:30 PM on 06/29/22, more than ten hours after the assessment at 3:23 AM. The assessment at this time was "within defined limits." The skin, device, site assessments were completed every four hours as required until 4:42 AM on 07/04/22. The skin, device, site assessment was noted to be within defined limits. The next assessment occurred more than seven hours later, at 12:12 PM on 07/04/22. A skin tear, left of the stoma was noted at this time. An order for a wound/ostomy care consult was placed on 07/04/22 at 12:28 PM as required by facility policy.

Staff E and Staff F were interviewed on 09/14/22 at 1:00 PM. It was confirmed that the medical record lacked documentation a physician or wound nurse was informed of the open area on the back of the patient's neck. A list of the facility skin champions, nurses with advanced wound/skin care education was provided. The staff nurses providing care for the patient when the open area was found were not listed as skin champions.

Staff A was interviewed on 09/26/22 at 8:25 AM. It was confirmed that the medical record lacked documentation an assessment of skin around and underneath the patient's trach device and trach ties occurred every four hours as required by facility policy.

2. Staff E was observed providing tracheostomy (trach) care, including trach tie change for Patient #11 on 09/14/22 at 10:00 AM. Staff E was wearing a yellow disposable gown, a surgical mask, goggles, and disposable gloves. Prior to starting the procedure, Staff E was observed picking up a chair and moving it to the corner of the room. Staff E was then observed pulling the bedside table containing supplies closer to herself. Without performing hand hygiene/changing gloves, Staff E completed trach care.

The facility policy for tracheostomy care was reviewed on 9/14/22 at 11:00 AM. According to the policy, hand hygiene is the number one prevention against nosocomial infection. Staff nurses are instructed to change gloves and perform hand hygiene for 20 seconds with soap and water, or use alcohol-based hand sanitizer after gathering supplies.

Staff A, Staff B, and Staff D were interviewed on 09/14/22 at 11:10 AM. It was confirmed that Staff E should have removed gloves, performed hand hygiene, and donned new gloves after touching the chair and bedside table and prior to performing trach care.

3. Review of the medical record for Patient #5 revealed the patient was admitted to the hospital on 07/27/22. Diagnoses included hypoxia and COVID-19. The patient was tracheostomy/ventilator dependent and G-tube dependent. Patient #5 was discharged home on 09/13/22 at 2:16 PM.

Further review of the medical record revealed for 08/31/22 there was no documentation the stoma skin care was completed two times or that the trach ties were changed; 08/31/22 stoma skin care was documented as being completed one time and there was no documentation the trach ties were changed; 09/01/22 stoma skin care documented as being completed one time only; 09/04/22 there was no documentation of the trach ties being changed and no documentation of stoma care being completed a second time; 09/06/22 there was no documentation the stoma skin care was completed a second time; 09/07/22 there was no documentation the trach ties were changed and no documentation stoma care was completed a second time; and on 09/10/22 there was no documentation the trach ties were changed or stoma care being completed a second time.

The facility policy titled, Skin Care and Pressure Injury Assessment and Prevention for Inpatients, effective 06/08/22, was reviewed. Section 4.5.4.5.4, titled Tubes, instructs staff nurses to assess the skin under the bumper of the G-tube for redness, breakdown, edema, and securement of the device is on appropriately every eight hours. If any break in the skin is noted, the policy instructs nurses to inform a physician and consult a wound nurse or unit skin champion for treatment recommendations.

Further review of Patient #5's medical record revealed the following documentation regarding the patient's G-tube site: on 08/31/22 at 3:48 AM documentation revealed unable to view/assess; 09/01/22 at 8:00 AM unable to assess; 11:42 AM unable to assess; 09/08/22 at 8:31 AM reddened (no drainage); 11:51 AM reddened (no drainage); 09/09/22 8:40 AM unable to view/assess; 12:06 PM unable to view/assess; 4:10 PM unable to view/assess and at 8:12 PM within defined limits (WDL); 09/10/22 at 12:18 AM WDL; 4:00 AM WDL; then not again until 8:08 PM WDL; 09/09/22 at 8:40 AM unable to view/assess; 12:06 PM unable to view/assess; 4:10 PM unable to view/assess. Further review of the medical record revealed there was no documentation the physician, wound care nurse, or unit skin champion was notified of the G-tube site being reddened. The patient's G-tube was not assessed every eight hours as required.

This finding was confirmed in an interview with the administrative staff prior to the exit conference on 09/15/22.

4. Review of the medical record for Patient #9 revealed he was admitted to the hospital on 04/08/22. Diagnoses included bacterial tracheitis and Rhino/Enterovirus, atrial tachycardia. The patient had a G-tube, tracheostomy and was on a ventilator.

Further review of the patient's medical record revealed the following documentation regarding the patient's G-tube site: on 08/29/22 at 8:54 AM unable to view/assess the G-tube; 11:45 AM G-tube assessment reddened; 11:58 AM unable to view/assess; 4:06 PM unable to view/assess, 7:51 PM unable to view/assess; 08/30/22 12:16 AM unable to view/assess; 5:45 AM unable to view/assess; 7:50 AM unable to view/assess; 8:00 PM G-tube site reddened; 08/31/22 7:59 AM unable to assess; then at 6:45 PM unable to view assess; 09/01/22 8:02 AM unable to view/assess; 10:52 AM unable to view/assess; 11:17 AM reddened; 11:55 AM unable to view/assess; 3:00 PM unable to view/assess; 3:31 PM unable to view/assess; 4:03 PM unable to view/assess; 8:04 PM WDL; then no assessment until 09/02/22 at 9:30 AM G-tube site reddened, drainage and granulation tissue; 09/02/22 at 9:30 AM reddened, drainage and granulation tissue; 12:30 PM reddened; 4:00 PM reddened; 7:29 PM reddened; 10:34 PM reddened; 11:33 PM unable to view/assess; 09/03/22 at 4:36 AM unable to view/assess; 8:55 AM unable to view; 10:06 AM reddened; 12:30 PM unable to view/assess; 3:20 PM unable to view/assess; 9:35 PM reddened granulation tissue and bleeding; then not assessed again until 09/05/22 at 8:55 AM G-tube site is bleeding and reddened; 11:55 AM unable to view/assess; and then not assessed again until 09/04/22 at 8:55 AM bleeding and reddened; 11:55 AM unable to view/assess; 3:30 PM unable to view/assess and then at 8:00 PM reddened; 09/05/22 8:50 AM reddened; and then not assessed again until 8:39 PM and G-tube site is reddened; 11:53 PM unable to view/assess; 09/06/22 at 4:27 AM unable to view/assess; 8:05 AM reddened and drainage; 3:53 PM unable to view/assess; 6:52 PM unable to view/assess; 9:00 PM reddened; 09/07/22 at 12:18 AM and 4:38 AM unable to view/assess; 10:42 AM reddened; 11:52 AM unable to view/assess; 9:30 PM reddened; 11:51 PM unable to view/assess; 09/08/22 at 4:20 AM unable to view/assess; then no further documentation until 09/09/22 at 4:46 AM unable to view/assess; 8:30 AM unable to view/assess; 12:08 PM unable to view/assess; 1:08 PM unable to view/assess; 2:35 PM reddened; 4:43 PM, 6:00 PM, and 7:53 PM unable to view/assess; 9:19 PM reddened; 9:49 PM and 11:42 PM unable to view/assess; 09/10/22 at 3:35 AM, 4:05 AM, 6:04 AM, and 6:34 AM unable to view/assess; then not again until 7:54 PM documentation of drainage; 9:30 PM unable to view/assess; 10:00 PM and 11:42 PM unable to view/assess; 09/11/22 at 4:05 AM unable to view/assess; 6:15 AM and 6:45 AM unable to view/assess; 11:48 AM WDL; and 9:00 PM WDL. There was no documentation the physician, wound care nurse, or unit skin champion was notified of the G-tube site being reddened. The patient's G-tube was not assessed every eight hours as required.

Further review of the patient's record revealed on 09/12/22 a new G-tube was placed at 8:30 AM by the advance practice nurse (APN); at 9:30 AM documentation revealed the patient's G-tube site was reddened; then again at 9:25 PM reddened; 11:55 PM unable to view/assess; 09/13/22 at 3:59 AM unable to view/assess; 7:54 AM, 9:02 AM and 9:35 AM unable to view/assess; 10:14 AM reddened; 12:40 PM unable to view/assess; 1:55 PM, 3:07 PM, 3:39 PM, 4:29 PM, 6:22 PM, 6:55 PM unable to view/assess; 8:17 PM reddened; on 09/14/22 at 12:20 AM, 4:12 AM, and 8:46 AM, unable to view/assess; 12:57 PM reddened; and again at 3:28 PM unable to view/ assess. There continued to be no documentation the physician, wound care nurse, or unit skin champion was notified of the G-tube site being reddened.

This finding was shared with the administrative staff prior to the exit conference on 09/15/22.

This deficiency substantiates Substantial Allegation OH00134621.