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Based on record review and staff interviews, it has been determined that the hospital failed to meet the Nursing Services Condition of Participation relative to providing the necessary treatment and nursing services, consistent with professional standards of practice, and hospital policy relative to pressure ulcers, medication administration, and intravenous peripheral catheters.

Findings are as follows:

1. The hospital failed to ensure hospital acquired pressure ulcers were evaluated and treated accordingly per hospital policy and standards of practice. (Refer to A-0395)

2. The hospital failed to follow their policies relative to labeling peripheral intravenous catheters. (Refer to A-398)

3. The hospital failed to follow their policies relative to providing education to patients during medication administration. (Refer to A-0405)

Based on record review and staff interviews, it has been determined that the hospital failed to ensure that nursing care provided to each patient is evaluated by the registered nurse upon admission and on an ongoing basis in accordance with hospital policy and standards of nursing practice relative to a patient who developed unstageable wounds (localized deep skin and tissue damage caused by prolonged or severe pressure) after nursing staff neglected to remove a bedpan which had been placed under the patient's buttocks. Additionally, the hospital failed to document the presence of these wounds and evaluate their condition to recommend the appropriate treatment for 1 of 2 patient's with pressure wounds (Patient ID #1).

Findings are as follows:
The hospital's wound care training titled, "Wound Care Orientation 2021" states in part,

" ...Wound Consults

Consults are required for all HAPIs [Hospital Acquired Pressure Injuries] regardless of Stage ...

...Wound Consult - Initial Visit

Wound Care Nurse will:

Assess and measure wounds

Perform the initial dressing change, preferably with RN [Registered Nurse] on duty

Obtain wound care orders

Document in Epic [electronic medical record system] ...

...Wound care

...A pending consult does not eliminate the nurse's responsibility to assess, document and obtain interim orders, especially on weekend and holidays ..."

The hospital's policy titled "Pressure Injury, Assessment, Prevention, and Management" dated 4/27/2022 states in part,

" ...Policy

...B. Pressure injuries are assessed and documented:

...2. on initial finding ...

Procedures ...

...B. Pressure Injury Assessment

...2. Documentation may include the following:

a. Date of initial observation

b. ...location

c. Stage

d. Presence on admission

e. Wound base (color, presence of granulation tissue [new tissue that forms on the surface of the wound during the healing process], slough or necrosis [dead tissue])

f. Measurements including length, width and depth

g. Peri-wound area [surrounding area]

h. Tunneling [channels which extend from the wound, into or through tissue or muscle]/ undermining [depth at the wound edges]

i. Drainage - color, amount, and odor ..."

A community reported complaint submitted to the Rhode Island Department of Health on 6/20/2023 states in part that Patient ID #1 had been left on a bedpan for hours by hospital staff. The complaint further states that after Patient ID #1 was discharged from the hospital, she/he was admitted to a skilled nursing facility with "several unstageable wounds" located on the right and left ischium (lower part of the hip bone) and on the right lower back.

Record review revealed that Patient ID #1 presented to the hospital in May of 2023 due to pain and swelling of his/her right foot and the right lower leg after a callus (a thickened and hardened part of the skin) had been removed from his/her right foot days prior. His/her medical history includes, but is not limited to, diabetes (a condition in which the body has high sugar levels for prolonged periods of time).

While at the hospital, Patient ID #1 was diagnosed with cellulitis (a deep infection of the skin) of his/her right leg and an abscess (an area under the skin filled with infected fluid) on his/her right foot.

Record review of "Clinical Notes" from 5/31/2023 through 6/16/2023 revealed that on 6/14/2023 at 10:31 AM, a nursing note was entered which stated that Patient ID #1 had a "Stage 2" to his/her coccyx and the skin on his/her buttocks was "purple and cracked." Further review of this note indicates that the dressing applied to the coccyx was clean, dry, and intact and barrier cream was applied. However, the record failed to reveal evidence of measurements including length, width and depth, the presence of any tunneling or undermining, or any drainage present.

Record review of consult orders revealed an "Inpatient Consult to Wound Care Nurse" dated 6/15/2023 at 8:05 AM for Patient ID #1. The consult order revealed that the reason for the consult was for treatment recommendations related to pressure injuries of the heel and buttocks. Further review revealed that the wound nurse, Employee B, visited the patient on 6/15/2023, but failed to assess Patient ID #1's buttocks as requested on the wound consult order.

Patient ID #1 was subsequently discharged on 6/16/2023 and an "Inter-Agency Referral Report" completed at discharge revealed a nursing note dated 6/16/2023 at 4:06 PM which states that Patient ID #1 had a "purple ring" on his/her buttocks and blisters on his/her gluteal crease (a fold that marks the upper limit of the thigh from the lower limit of the buttock).

Review of a "Skin/Wound Note" dated 6/17/2023 at 12:19 AM for Patient ID #1 completed at the skilled nursing facility where the patient was admitted, states that Patient ID #1 arrived with a "discolored oval ring" which measured 7 by 5.5 inches and 2 lacerations, one on each side of his/her buttock folds. Additionally, the note further states that the hospital nurse who gave report to the skilled nursing facility upon hospital discharge stated that while at the hospital Patient ID #1 requested to use the bedpan, it was found that she/he still had a bedpan in place while in the hospital. The note did not indicate the length of time the patient was on the bed pan. This note further indicates that the patient's coccyx (tailbone area) would be evaluated by wound specialists.

Review of a document titled, "Initial Wound Evaluation and Management Summary" dated 6/19/2023 completed by VOHRA Wound Physicians at the skilled nursing facility, revealed that Patient ID #1 had the following pressure injuries not present when initially admitted to the hospital:

- Unstageable (pressure injury consisting of skin and tissue loss in which the extent of tissue damage within the wound cannot be confirmed) DTI (deep tissue injury) to the left ischium measuring 3.5 centimeters in length and 4 centimeters wide

- Unstageable DTI to the right ischium measuring 9 centimeters in length and 3 centimeters wide

- Unstageable DTI of the right lower back measuring 2 centimeters in length and 1 centimeter wide

Further review of the Initial Wound Evaluation and Management Summary completed by VOHRA Wound Physicians completed at the skilled nursing facility upon the patient's hospital discharge revealed that all 3 unstageable deep tissue injuries were caused by pressure applied to the skin. Additionally, the note indicates that the unstageable DTI of the left ischium was due to the patient being left on a bedpan for an extended period of time.

During a surveyor interview on 6/30/2023 at 11:32 AM with the Nurse Manager, she revealed that on 6/14/2023 it was a nursing assistant during the evening shift who discovered that Patient ID #1 had a bedpan under him/her after she/he requested to be placed on it. The Nurse Manager revealed that the nurse assigned to Patient ID #1 in the evening, was unable to identify who placed Patient ID #1 on the bedpan which resulted in skin breakdown after she/he was forgotten to be removed. In addition, the Nurse Manager indicated that dayshift staff on 6/14/2023 were also unable to recall who placed Patient ID #1 on the bedpan and forgot to remove him/her off it.

During a surveyor interview on 6/30/2023 at 2:14 PM with the Wound Care Manager, she was unable to provide evidence that Employee B assessed and recommended treatments for Patient ID #1's buttock wounds. She indicated that Employee B, did not recognize that there was an additional area to be evaluated other than the patient's heel and indicated that there is no policy that describes the process of how the wound nurse ensures all wound consults are reviewed. When asked by the surveyor for evidence of communication between the nurse on duty on 6/15/2023 and Employee B regarding the wound consult request for the patient's heel and buttocks, the Wound Care Manager stated that Employee B indicated she did not remember.

Based on record review and staff interviews, it was determined that the hospital failed to ensure hospital policies were followed relative to labeling the Peripheral Intravenous Catheters (a thin, flexible tube inserted into a vein that healthcare providers use to draw blood and administer treatments) dressing with the insertion date and catheter gauge after insertion for 4 of 5 patients reviewed, Patient ID #s 2, 3, 4, and 5.

Findings are as follows:

The hospital's policy titled Peripheral Intravenous (PIV) Catheters effective 4/28/2021 states in part,

" ...Label PIV dressing with insertion date and catheter gauge [size of the catheter] ..."

During a surveyor interview on 6/28/2023 at approximately 12:00 PM with Patient ID #2, she/he was observed with a peripheral intravenous (PIV) catheter near the left wrist. The dressing applied over the PIV catheter was not labeled with the insertion date and catheter gauge per hospital policy.

During a surveyor interview on 6/28/2023 at approximately 12:44 PM with Patient ID #3, she/he was observed with a PIV catheter near the right wrist. The dressing applied over the PIV catheter was not labeled with the insertion date and catheter gauge per hospital policy.

During a surveyor interview on 6/29/2023 at approximately 11:51 AM with Patient ID #4, she/he was observed with a PIV catheter on the inner middle surface of the right arm. The dressing applied over the PIV catheter was not labeled with the insertion date and catheter gauge per hospital policy.

During a surveyor interview on 6/29/2023 at approximately 12:05 PM with Patient ID #5, she/he was observed with a PIV catheter on the inner middle surface of the left arm. The dressing applied over the PIV catheter was not labeled with the insertion date and catheter gauge per hospital policy.

During a surveyor interview on 6/28/2023 at 12:27 PM with the Nurse Manager, she indicated that the PIV catheters should be dated.

Based on policy review, record review and staff interview, it has been determined that the hospital failed to provide patient education regarding new medication in accordance with hospital policies and procedures for 1 of 4 patients who were observed during medication administration, Patient ID #3.

Findings are as follows:

The hospital's policy titled, "Medication Administration" effective 1/27/2023 states in part,

" ...Before administering a new medication, the patient or family is informed about any potential clinically significant adverse drug reactions or other concerns regarding administration of a new medication ..."

Record review revealed that Patient ID #3 presented to the hospital in June of 2023 with increased shortness of breath. His/her medical history includes, but is not limited to, Leukemia (blood cancer).

During a medication administration observation on 6/28/2023 at 12:36 PM, Employee A, Registered Nurse, was observed preparing ciprofloxacin (antibiotic) 500 milligrams to administer orally to Patient ID #3. During the observation, Employee A informed Patient ID #3 that the physician had ordered this medication, and Employee A administered the medication without informing the patient about any clinically significant adverse reactions or other concerns.

During a surveyor interview with Employee A in the presence of the Lead Regulatory Specialist following the above-mentioned observation, this surveyor asked Employee A why Patient ID #3 received ciprofloxacin and she stated she did not know. This surveyor requested to see Patient ID #3's record with Employee A to identify the reason why Patient ID #3 received this medication. Upon review with Employee A, it was identified that Patient ID #3 received ciprofloxacin as prophylaxis (treatment or actions taken to prevent disease) for leukemia. Employee A indicated that the physician had already discussed this medication with Patient ID #3.

During a surveyor interview with Patient ID #3 following the interview with Employee A, this surveyor asked Patient ID #3 why she/he received ciprofloxacin to which she/he stated, "I think it's for diarrhea." When asked if the physician had discussed this medication with him/her, Patient ID #3 stated that the physician had not. When asked if the nurse explained what the medication was for or any other details about the medication, Patient ID #3 indicated that Employee A had not.

During a surveyor interview on 6/28/2023 at 12:50 PM with the Nurse Manager regarding the the above-mentioned observations and interviews, she indicated that it is the expectation that the nurse explains the name of the medication, how much the patient is receiving, why the patient is taking it, and explain the medication's side effects.