HospitalInspections.org

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Based on record review and interview, the facility failed to ensure that a patient received daily inpatient skin assessments (Item #1) and bodily re-positioning in the emergency department (Item #2) to prevent pressure injury occurrence.

Failure to ensure performance of skin assessments and bodily re-positioning created risk for physical harm and medical complications related to the occurrence of skin breakdown.

Findings included:

Item #1 - Daily Inpatient Skin Assessments

1. a. Record review of facility policy titled, "Comprehensive Skin Assessment," no # ; reviewed 02/2017, stated to assess the patient's skin thoroughly for signs of impairment . . . discoloration, skin breakdown to assist in early discovery of abnormal findings for the most comprehensive and effective patient care. It stated to perform the assessment daily and more often with patients at increased risk (bed bound, patients with physical limitations, and patients with Braden scores of 18 or less).

b. Record review of facility policy titled, "Pressure Injury (Ulcer) Risk Assessment," no policy #; reviewed 08/2017, stated that the Braden Scale was to be completed . . . daily and with changes patient condition. It stated to implement appropriate prevention strategies for identified risks and document in the medical record. During those time periods, the patient reported severe to moderate pain levels from fractures, especially with movement in bed. Pain levels interfered with routine daily patient care, including required assessment.

2. a. Review of the medical record for Patient #1 indicated that he had a traumatic fall and fractured both upper legs and one lower leg. Prior to the fall, he was physically disabled and wheelchair-dependent. The medical record showed that upon admission (11/01/18) his Braden Score was 11 (higher risk for skin breakdown). Braden Scores recorded between 11/01/18 and 11/13/18 were all below 16 (higher risk).

b. From 11/02/18 to 11/10/18 (9 consecutive days), the record indicated that there were no Braden Scores recorded for the following 5 of 9 days in November: 2nd, 5th, 7th, 9th and 10th. Facility staff identified that the patient had a large wound on the buttocks on 11/08/18 and a specialized wound assessment occurred that day.

3. a. On 02/15/18 at 12:30 PM, the investigator confirmed the above medical record finding with a wound care nurse (Staff #1).

Item #2 - Bodily Re-positioning of Patients in the Emergency Department

1. a. Review of the medical record for Patient #1 indicated that he had a traumatic fall and fractured both upper legs and one lower leg. He was transported to the facility's Emergency Department (ED) and received care there on 11/01/18 from 12:30 AM - 3:00 PM, 14.5 hours. A nursing note at the beginning of the stay indicated that he was positioned supine [on back]. The patient was cleared from spine precautions [required immobilization on his back until determined to be safe for spine movement] by 3:30 AM and his cervical collar was removed at 4:30 AM.

b. Patient #1 was in the emergency room for 10.5 more hours after the cervical collar was removed. The record did not indicate that he was re-positioned in any manner by nursing staff during that time.

2. Record review of facility policy and procedure titled, "Emergency Services ED Documentation Standards," no policy #; reviewed 06/2017, showed nursing care documentation guidelines. In one section, it stated that nursing annotations would be made a minimum of every 2 hours and will include documentation of patient contact. It did not include specific information about patient contact for re-positioning.

3. On 02/28/19 at 12:30 PM, the investigator interviewed the Nurse Manager of the Emergency Department (Staff #2) about the above finding in the medical record. He acknowledged it and indicated that ED staff did not notate the positioning of patients in the medical record, including patients with prolonged stays. Additionally he stated that staff did not record the type of mattress patients are placed upon for the ED stay. When asked if the facility had standards of practice for the ED nursing for staff reference, he replied that they did not.
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Based on interview and record review, the facility failed to implement a system(s) for members of a specialized manual patient handling team, supervised by nursing, to document their direct patient care.

Failure to ensure documentation of patient handling created risk for patient harm while rendering direct patient care and for lack of continuity among team members about the specific actions associated with that care.

Findings included:

1. a. Review of facility policy titled, "Safe Patient Handling and Movement,", Policy #85.11; reviewed 08/2017, indicated that the purpose of the policy was to protect staff from patient handling injuries while ensuring patients are cared for safely, with dignity and respect. "Staff" were expected to assess the potential for risk of injury as well as psychological readiness. It encouraged staff to speak up if they had safety concerns. It also identified several Manager/Supervisor and Clinical Care Provider responsibilities and included information about use of equipment.

1.b. Record review of a document titled "HMC Hospital Assistant Orientation Checklist," no Policy #; version 07/25/2006, showed that it did not include documenting patient care or basic re-positioning of patients, including patients in pain.

2. On 02/28/19 at 1:00 PM, the investigator interviewed the Nurse Manager of the Lift Team (Staff #3). He identified that Lift Team members did not document their direct patient contact in the medical record. Additionally, he stated that there were not procedures specific to Lift Team routine hands-on patient activities/functions and related documentation. He described their actions as extensions of the nursing staff.

3. Review of the medical record on Patient #1 showed that the patient "refused" to be turned 10 times from 11/02/19 to 11/04/19. The documentation did not include the rationale for the refusal. Additionally, over those dates and the next 4 days, the record did not contain information which team members provided/attempted to provide hands-on care for re-positioning.
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