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Based on interview and record review, the facility failed to ensure continuous surveillance and analysis of patient acquired pressure ulcers (skin injury) results to the Quality Management and Patient Safety Committee.

As a result the Quality Management and Patient Safety Committee were unable to provide guidance and opportunities for improvement to the Nursing Department related to the prevention of pressure ulcers.

Findings:

On 6/22/21, a record review of the Quality Management and Patient Safety Committee Minutes was conducted.

According to the minutes the following information was noted:

5/29/2020 - "Skin still tracking"
6/6/2020 - "Pressure Injury - CalNoc (Collaborative Alliance for Nursing Outcomes-a nursing quality indicator database), Prevalence study to daily tracking..."
10/2/2020 - "Skin unavailable...skin not being assessed..."
2/19/2021 - Skin data collected and referenced (Total number of patients with pressure ulcers was 39)
"4Q20 - Telemetry 5; MS (Medical Surgical Unit) 6
3Q20 - Telemetry 16 (2 patient with multiple wounds; MS 3
2Q20 - Telemetry 4; MS 1
1Q20 - MS 4"

There was no action plan regarding the data collection and analysis of pressure ulcers on the 2/19/2021 report to the Quality Management and Patient Safety Committee.

On 6/23/21 at 2 PM, a concurrent interview and record review was conducted with the Director of Quality and Risk Management (DQRM). The DQRM verified the information related to pressure ulcers according to the minutes, and recognized there was no action plan related to pressure ulcers on the committee minutes.

On 6/24/21 at 7:33 A.M., an interview was conducting with the Quality Management/Patient Safety Chair, Medical Executive Committee Chair, Chief Nursing Officer, Quality and Risk Management Director, and a Board of Director Member. The information from the Quality Management and Patient Safety Committee Minutes were shared during the interview. When asked about the action plan related to the identified pressure ulcers, the leadership present, recognized there was opportunity for improvement.

Per the facility's Patient Safety Program report, the scope of their patient safety program includes, "all activities within the organization that contributes to the maintenance and improvement of patient safety; reduce risk, prevent adverse and sentinel events; including but not limited to performance improvement ..."
On 6/24/21 at 7:33 A.M., an interview was conducting with the Quality Management/Patient Safety Chair, Medical Executive Committee Chair, Chief Nursing Officer, Quality and Risk Management Director and a Board of Director Member. The information from the Quality management and Patient Safety Committee Minutes were shared during the interview. When asked on the action plan related to the identified pressure ulcer, the leadership present, recognized there was opportunity for improvement.

The facility's Patient Safety Program report, the scope of their patient safety program includes, "all activities within the organization that contributes to the maintenance and improvement of patient safety; reduce risk, prevent adverse and sentinel events; including but not limited to performance improvement..."

Based on interview and record review, the facility failed to ensure Registered Nurses (RNs) supervised and evaluated the nursing care and assessments of 3 of 30 patients (7, 8, 10), per facility policy.

As a result, the patients were placed at increased risk for missed interventions of undetected conditions and delayed treatment of potential life-threatening transfusion reactions.

Findings:

Patient 7 was admitted to the facility on 6/20/21 with a diagnosis of Failure to Thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments. Manifestations of this condition include weight loss, decreased appetite, poor nutrition, and inactivity), per the admission record.

On 6/23/21 at 9:17 A.M. a concurrent interview and record review was conducted with the Charge RN (CRN). According to Patient 7's Progress Notes, dated 6/20/21, a full physical assessment of Patient 7 was documented by Licensed Vocational Nurse (LVN) 2. In addition, LVN 2 documented an assessment of Patient 7's pressure ulcer, indicating, "Stage 2 PU noted on left buttock. No drainage noted. Surrounding skin intact." There was no documentation that the Registered Nurse performed an assessment or supervised and evaluated LVN 2's assessment of Patient 7. The CRN stated it should be documented by the RN in the nurse's note within the assessment.

Patient 8 was admitted to the facility on 6/12/21 with a diagnosis of pneumonia, per the admission record.

On 6/23/21 at 9:35 A.M. a concurrent interview and record review was conducted with the CRN Elena. According to Patient 8's Progress Notes, dated 6/20/21, an admission physical assessment of Patient 8 was documented by LVN 1. There was no documentation that the Registered Nurse performed an assessment or supervised and evaluated LVN 1's assessment of Patient 8. The CRN stated that the RN should document an evaluation of the assessment in the nurse's notes.

Patient 10 was admitted to the facility on 6/12/21 with a diagnosis of right renal mass, per the admission record.

On 6/23/21 at 1:40 P.M., a concurrent interview and record review was conducted with the RN 1 April. According to Patient 10's Progress Notes, dated 6/12/21, an admission physical assessment of Patient 10 was documented by LVN 3. There was no documentation that the Registered Nurse performed and assessment or supervised and evaluated LVN 3's assessment of Patient 8. The CRN stated that the RN should document an evaluation of the assessment in the nurse's notes.

On 6/24/21 at 9:15 A.M., a concurrent interview and record review was conducted with RN 1 April. According to Patient 10's Progress Notes on 6/12/21, LVN 3 documented the administration of a blood transfusion for Patient 10. LVN 3 documented the first 15-minute assessment, indicating, "No s/sx [signs or symptoms] of transfusion reaction. Lung sounds clear bilaterally. Afebrile." There was no documentation that the Registered Nurse had performed the first 15-minute assessment or supervised and evaluated LVN 3's assessment of Patient 10. RN 1 stated, "The documentation should be in the nurse's notes. I don't see it here."

On 6/24/21 at 9;40 A.M., Patient 10's Blood Bank Transfusion Record, dated 6/12/21, was reviewed. The form required two RN signatures for patient verification prior to starting the transfusion. However, there was only one RN signature, under "RN #2" in the section designated for patient verification. LVN 3 signed as "RN #1."

According to the facility's policy, Nursing Scope of Practice, dated 6/19, "The practice of nursing by a Registered Nurse shall mean assuming responsibility and accountability for those nursing actions which include but are not limited to: ...Administering, supervision, delegating, and evaluating nursing activities." In addition, "The practice of nursing by Licensed Vocation Nurse shall mean the assumption of responsibilities and the performing of acts, within the education background of vocational nurse, under the direction of a ...Registered Nurse."

According to the facility's policy, Assessment of Patients, dated 11/19, "Assessments provided by health care professionals are based upon and include: ...Data collected which includes the patient's diagnosis, the treatment setting, the patient's desire for care and response to previous care. This data can be collected by an LVN. Data analyzed to develop a prioritized and interdisciplinary plan of care to address the patient's needs. This analysis must be done by an RN."

According to the facility's policy, Skin Care Management-Pressure Injury Prevention & Management and Wound Care, dated 11/19, "The RN shall assess, LVN to collect data on the patient's skin integrity ..."

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Based on interview, and record review, the hospital failed to:A. Ensure nursing provided wound care and treatment in accordance with acceptable standards of practice for 4 of 30 sampled patients (14, 21, 26, 30).
Nursing failed to:
1. Assess wounds upon admission at the Emergency Department (ED)
2. Take initial measurements of patient's wounds upon admission to the unit
3. Consistently document treatment rendered by staff to Patient's wounds

As a result, there was potential miscommunication amongst staff in providing appropriate care and treatment for Patient's wounds. In addition, the progress or deterioration of the wounds could not be accurately assessed and determined.

B. Implement it's policy and procedure related to the completion of initial discharge assessments for 4 of 30 sampled patients (14,16, 25, 28). This failure had the potential to negatively impact patients' continuity of care after discharge from the hospital.

C.
1. Ensure the staff conducted complete pre and post pain assessment before and after pain medication administration and post-assessment was conducted in a timely manner for 1 of 30 sampled patients (1), and
2. Ensure the staff followed physician orders for pain medication administration for 2 of 30 sampled patients (2,3).

As a result, there was a potential the patients' pain was not relieved.

Findings:

A.
1. Patient 14 was admitted to the hospital on 6/18/21 with diagnoses that included shortness of breath per the hospital's Face Sheet.

On 6/23/21 at 10:30 A.M., a concurrent record review and interview with the Director of Critical Care Services (DCCS) was conducted. Per the ED physician's notes dated 6/18/21, Patient 1 had severe bilateral groin cellulitis (a deep infection of the skin caused by bacteria) with wet wounds; right groin had a large wet wound. There was no documentation from nursing of any assessments and description of Patient 1's wounds. The DCCS stated the nurses noted the wounds upon admission at the ED and had to complete a skin section of the ED assessment form. The DCCS confirmed there was no documentation related to the wounds on the assessment form.

On 6/23/21 at 1:45 P.M., a record review was conducted. A document titled Patient Progress Notes dated 6/19/21 indicated Patient 1 was now transferred to the telemetry floor (unit with continuous monitoring), the initial assessment form was reviewed; Patient 1 had multiple wounds: a stage 2 on the upper back , a stage 2 on sacrum/coccyx(tailbone), unstageable pressure wound on the left lateral heel and right ankle, a draining wound between 2nd and 3rd left toe, a left breast skin tear, left lower abdominal fold skin tear, and a left inner groin skin tear. There were no wound measurements and description of these wounds.

On 6/23/21 at 1:55 P.M., Charge Nurse (CN) 1 stated it was important to measure and describe the wounds upon admission to the unit to determine improvement or worsening during the patient's hospitalization. CN 1 also stated the references for nurses to describe or stage wounds was from a binder with laminated pictures of wounds and from a treatment cream vendor. When asked what nationally recognized standards or resources were used for staff education to treat and to stage wounds, CN 1 did not have an answer.

On 6/23/21 at 2:30 P.M., a concurrent record review and interview with the CN 1 was conducted. A document titled Treatment Flowsheet dated 6/20/21 through 6/22/21, both morning shift and night shift sections were blank, Patient Progress Notes dated 6/20/21 through 6/22/21, both morning shift and night shift, indicated inconsistencies in nursing staff documentation of treatments rendered to Patient 1's wounds. The CN confirmed and stated treatment rendered should be documented and completed.

On 6/24/21 at 9 A.M., LN 14 was interviewed. LN 14 stated she was not able to take measurements of Patient 14's and confirmed incomplete and inconsistent documentaion in Patient 14's treatment flowsheet.

2. Patient 26 was admitted to the facility on 6/16/21 with diagnosis which included congestive heart failure per the facility Face Sheet.

On 6/23/21 at 10:12 A.M., a concurrent interview and record review with charge nurse (CN 1) was conducted. CN 1 stated Patient 26 had stage II (two) pressure injury on admission. The following skin assessments were completed by various license nurses (LNs):
6/18/21- blank, no documentation of pressure ulcer
6/19/21- blank, no documentation of pressure ulcer
6/20/21 - blank, no documentation of pressure ulcer
6/21/21- blank, no documentation of pressure ulcer
6/22/21- redness to sacral
6/23/21 - deep tissue injury

CN 1 stated this portion of the skin assessment, "Should be filled out." CN 1 stated it was important to document the stage and location of the wound, "So we can see if the wound is getting better or worse." CN 1 also stated the documentation were inconsistent. CN 1 further stated she was not sure if Patient 26 had deep tissue injury. CN 1 acknowledged the inconsistency of documentation did not represent the true picture of Patient 26 skin condition.

A review of facility policy and procedure titled, Skin Management- Pressure Injury prevention & (and) Management and Wound Care, dated 4/21, was conducted. This policy indicated, "...Documentation: Documentation must be done each shift, document on Nursing Flow Sheet and/or Skin Care Documentation Record..."

3. Patient 30 was admitted to the facility on 6/11/21 with diagnosis shortness of breath per the facility Face Sheet.

On 6/23/21 at 3 P.M., a concurrent interview and review of Patient 30's Photographic Wound Documentation with CN 1 was conducted. Patient 30 had multiple photographs of wounds on admission. These photographs did not include wound location and wound size.
CN 1 stated when patient had wounds on admission, photographs of the wounds would have been taken which included the wound location and wound size. CN 1 further stated it was important to know where the wound was and the size of the wound, "So we can see how it is progressing." CN 1 acknowledged Patient 30's photographs of his wounds were incomplete.

A review of facility policy and procedure titled, Skin Management- Pressure Injury prevention & (and) Management and Wound Care, dated 4/21, was conducted. This policy indicated, "...A photograph shall be taken on admission... Photo labeling should include these items: ...Date/Time taken, Location of Pressure Injury, First initial, last name and title of photographer..."

4. Patient 21 is a 87 year old male admitted to the facility on 6 /4/21. Patient 21's initial skin assessment on 6/4/21, was not done. There was documentation wound: right foot ulcers on tip of toes, healed pressure injury on coccyx, excoriation of peri area and sacrum. On 6/5/21, there is documentation all five toes and stage one on sacral coccyx.
the documentation of patient 21's skin was inconsistent on:
6/4/21, "...right toes and healed coccyx..."
6/5/21, "...left toes stage one coccyx..."
6/6/21, "...healing stage one..."
6/7/21, "...right foot ulcers..."
6/8/21, "...Right foot "healing"
6/9/21, "...right foot open skin stage one coccyx..."
6/10/21, "...intact redness to buttocks sacral decub stage one..."
6/18/21, "...scrotal redness healing stage one sacral..."
6/19/21, "...wound /pressure ulcer DTI (deep tissue injury)..."
6/20/21, "...deep tissue injury..."
6/21/21, "...DTI..."
6/22/21, "...wound /pressure ulcer scrotal swelling deep tissue injury..."
6/23/21, "...DTI sacral wound /pressure ulcer skin tear..."

On 6/23/21, there were still open areas with scabs on patient 21's right toes. From the documentation it was unclear which foot had the injury and which toes were affected.

The photographs should have been taken initially on 6/4/21, and on Wednesdays and Sundays for a total of 7 photographs to document the progression of the wounds on the toes and sacral area. The only photographs taken of patient 21's wounds were done on 6/13/21, only the toes, 6/19/21 sacral area and 6/22/21 sacral area.

There was no documentation of any care provided. No description of the wounds, or changes either good or bad to the wounds. There was no documentation found of dressing changes done for Patient 21's toes, sacral area or the skin tear.

There was no systemic plan to identify, categorized, track, and treat wounds that patients had prior to admission, acquired during their hospital admission, wounds that healed or worsened during the hospital admission.

B.
1. Patient 14 was admitted to the hospital on 6/18/21 with diagnoses that included shortness of breath per the hospital's Face Sheet.

On 6/23/21 at 3:50 P.M., a concurrent record review and interview was conducted with the Case Manager 14 (CM 14). There was no initial discharge assessment completed for Patient 14. CM 14 stated all patients received an initial discharge assessment at admission to obtain some information- where they came from, family dynamics, agencies to follow up, caregiver support, and equipment used. CM 14 confirmed Patient 14 did not have a completed initial assessment done at the beginning of hospital admission. CM 14 further stated he did not fill out the form which was essential for the continuity of the care of Patient 14.

2. Patient 21 was a 87 year old male admitted to the facility on 6/4/21. Patient 21 had a discharge plan dated 6/14/21, 6/16/21, and 6/18/21, All three discharge plans indicated patient was to be discharged home with family. On 6/18/21, Patient 21 had a drastic change of condition and was taken to the ICU. There was no changes or no update to the discharge plan to indicate the patient discharging to home with family may no longer be an option.

3. Patient 16 was admitted to the hospital on 6/13/21 with diagnoses that included alcohol withdrawal and ambulatory dysfunction (abnormal gait) per the hospital's Face Sheet.

On 6/24/21 at 9:35 A.M., a concurrent record review and interview was conducted with the Charge Nurse (CN 1). There was no initial discharge assessment completed for Patient 16. A document titled Case Management Discharge Planning Assessment dated 6/24/21 indicated Patient 16 lived in a van outside of sister's home and is not able to return...will need to remain hospitalized until fully stable for discharge to his van. CN 1 stated the initial assessment should have been completed to have obtained more information related to this patient's living situation. CN 1 confirmed this note was completed 11 days after admission.

4. Patient 25 was admitted to the facility on 6/13/21 with diagnosis which included small bowel obstruction per the facility History and Physical dated 6/13/21.

On 6/23/21 at 9:04 A.M., a concurrent interview and record review with charge nurse (CN 1) was conducted. CN 1 stated discharge planning should have started on admission. CN 1 further stated also stated licensed nurse (LN 1) would initiated in the care plan and case manager (CM 2) would also fill out a discharge planning assessment form. CN 1 further stated, it was important to know the plan for discharge, "to have better transition of care."

On 6/23/21 at 1:40 P.M., a concurrent interview and record review with CM 2 was conducted. CM 2 stated her responsibilities which included, "Get discharge planning going." CM 2 also stated she would gather information from the patient and documented on the form titled, Case management Discharge Planning Assessment. CM 2 further stated this form was completed during the, "Initial meeting or assessment and incorporate patient's preference for after care." CM 2 stated the purpose of completing the discharge planning assessment was, "To make sure we have the proper and safe discharge." CM 2 acknowledged, "Haven't done it" for Patient 25.

5. Patient 28 was admitted to the facility on 6/20/21 with diagnosis of dypsnea (difficulty breathing) per the facility Face Sheet.

On 6/23/21 at 10:42 A.M., a concurrent interview and record review with charge nurse (CN 1) was conducted. CN 1 stated discharge planning process started on admission. CN 1 also stated licensed nurse (LN) would initiate in the care plan and case manager (CM 2) would also fill out a discharge planning assessment form. CN 1 further stated, it was important to know the plan for discharge, "to have better transition of care." CN 1 acknowledged there was no documented evidence that discharge planning was done for Patient 28.

On 6/23/21 at 1:40 P.M., a concurrent interview and record review with CM 2 was conducted. CM 2 stated her responsibilities which included, "Get discharge planning going." CM 2 also stated she would gather information from the patient and documented on the form titled, Case management Discharge Planning Assessment. CM 2 further stated this form was completed during the, "Initial meeting or assessment and incorporate patient's preference for after care." CM 2 further stated this process starts first or second day after admission but maybe later depending on the patient's condition. CM 2 stated, "All new admission should have one." CM 2 was not able to find documented evidence that this was done for Patient 28. CM 2 stated, "Hasn't been done."

A review of facility's policy and procedure titled, Case Management Screening Assessment for Discharge Planning, dated 6/19, was conducted. This policy which indicated, "... Discharge planning begins when the patients enters the acute care setting to provide for continuity of care and appropriate and timely post-discharge care. Case Managers will respond to all referrals within 72 hours..."



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C.
1. Patient 1 was admitted to the facility on 6/11/21 with diagnoses which included pancreatitis (inflammmation of the pancreas) per the facility's face sheet.

a. On 6/23/21 a joint review of records was conducted with Registered Nurse (RN) 1 and the Director of Rehabilitation Services (DRS). Patient 1's medication administration record (MAR) on 6/12/21 indicated Patient 1 was given acetaminophen (a type of pain medication) orally at 4:59 P.M. for a pain level of 7 (on a numeric pain rating scale of 0-10: 0 for no pain and 10 for worst possible pain). Per the flowsheet, Patient's 1 pain level was re-assessed approximately three hours later at 8:01 P.M. The Pasero Opioid-induced Sedation Scale (POSS- a type of sedation level assessment scale) was not documented as done at this time. There was also no documentation the POSS on 6/17/21 at 9:21 A.M. after Patient 1 was administered Hydrocodone (a type of pain medication) was done.

b. On 6/23/21 a joint review of records was conducted with RN 1 and the DRS. Patient 1's MAR on 6/12/21 indicated Patient 1 was given acetaminophen (a type of pain medication) orally at 4:59 P.M. for a pain level of 7 (of 0-10: 0 for no pain and 10 for worst possible pain). The physician orders dated 6/11/21 indicated acetaminophen was to be administered "for mild pain(1-3)..."

On 6/23/21 at 2:04 P.M., a concurrent interview and record review with the DRN was conducted. The DRN stated Patient 1's pain level of 7 is not considered mild. A joint review of the policy and procedure titled Pain Management Guidelines revised 11/19 with the DRN "G. Tools for pain assessment:..0-10 Numeric Pain Rating Scale...7-10 worst possible pain..." The physician orders dated 6/11/21 indicated acetaminophen was to be administered "for mild pain (1-3) and morphine for severe pain. There was no documentation why acetaminophen was administered to Patient 1 instead of morphine ordered for severe pain.

2.. Patient 2 was admitted to the facility on 6/21/21 with diagnoses which included ureteral stone (a stone in the tubing for urine flow) per the facility's face sheet.

On 6/23/21 a review of records was conducted with RN 1 and the DRS. Patient 2's MAR on 6/23/21 indicated Patient 1 was given morphine (a type of pain medication) intravenously (IV- through a tube inserted through a vein) at 1:11 A.M. Per the flowsheet, Patient 2's pain was reassessed approximately 1 hour later at 2:05 A.M.

On 6/23/21 at 1:46 P.M., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated when patients complain of pain, the pain level had to be reassessed and documented within 30 minutes for IV drugs and within one hour for oral drugs.

On 6/23/21 at 2:04 P.M., an interview with the Director of Nursing (DRN) was conducted. The DRN stated patients' pain level had to be reassessed for effectiveness within one hour for oral drugs and within 30 minutes for IV drugs.

On 6/23/21 at 2:38 P.M., an interview with the Director of Pharmacy (DOP) was conducted. The DOP stated pain level needed to be reassessed within 30 minutes after IV pain drugs and within one hour after oral pain drugs were administered to patients. The DOP also stated POSS assessment was conducted during pain level reassessment.

Per the facility's policy and procedure titled Pain Management Guidelines revised 11/19, "...H. Pain Re-assessment: All patients will be re-assessed for pain level and sedation level by using Pasero Opiod-induced Sedation Scale (POSS) thirty to sixty minutes after pain relieving interventions. Medications administered by IV...will be reassessed within 30 minutes and medications given orally will be reassessed within 60 minutes."

3. Patient 3 was admitted to the facility on 6/11/21 with diagnoses which included active tuberculosis (a type of lung infection) per the facility's flow sheet.

On 6/24/21 a review of records was conducted with RN 1 and the DRS. Patient 3's MAR indicated Patient 3 was administered acetaminophen on 6/13/21 at 7:49 A.M., 6/14/21 at 10:17 A.M., and on 6/20/21 at 5:33 P.M. There was no documentation Patient 3's pain level and the POSS were assessed before and after administration of acetaminophen.

On 6/24/21 at 10:30 A.M., an interview with RN 2 was conducted. RN 2 stated Patient 3's pain level and POSS should have been reassessed after administration of pain medications. RN 2 stated she must have "forgotten" to document it and "if you didn't document it, it didn't happen.". RN 2 also stated pain level and POSS reassessment were conducted and documented within 30 minutes after IV pain drugs and within one hour after oral pain drugs were given to patients.

Per the policy and procedure titled Nursing Scope of Practice revised 1/19 "...1.1.2...the administration of medications...ordered by...a physician..."