HospitalInspections.org

Based on record review and staff interview, the hospital failed to ensure the nursing staff implemented a nursing care plan to meet the patient's needs (A0396).

Based on record review and staff interview, the hospital failed to ensure the nursing staff implemented a nursing care plan to meet the patient's needs for one of ten patients reviewed (Patient #9). The patient census was 518.

Findings include:

Review of the policy and procedure titled, Skin Care Prevention and Treatment, origination date: 06/01/19, last revision date: 01/07/20, revealed the purpose is to outline nursing management for skin and wound care of the patient with potential for and actual alteration in skin integrity. Repositioning every two hours should be provided for those unable to reposition themselves and to document repositioning as it occurs. Further review of the policy and procedure revealed critical care patients pressure injury prevention: if full turns are not possible, attempt small shifts using glide sheet. Reposition and inspect under devices every 12 hours if possible.

Review of the medical record for Patient #9 on 07/21/2020 with the Staff E revealed the patient had a past history of Alzheimer's Disease, diabetes, atrial fibrillation (abnormal heart rhythm), alcoholism and history of a stroke. Patient #9's current diagnoses was a brain bleed. The patient had an emergent crainiectoomy and evacuation of a hematoma.

On 03/06/2020 at 10:00 PM, Patient #9's skin assessment was completed and was within normal limits (WNL). A Braden scale, a tool used in conjunction with the nurse's clinical judgement for assessing the patient's risk for developing a pressure injury, revealed the patient's score was a 12 which indicated high risk for skin breakdown.

Further review of the patient's record revealed interventions were implemented to turn and reposition every two hours, eggcrate for elbows, heels elevated off of the bed, and a pressure redistribution mattress was also implemented. Patient #9 was moved to a low air-loss mattress (used for both the prevention and treatment of pressure wounds, and are well suited to any patients susceptible to these events such as those who are immobilized or lack adequate sensory perception) on 03/09/2020.

Patient #9 had a rectal tube placed on 03/13/2020 for frequent liquid stool incontinence. It was removed on 03/20/2020.

Further review of Patient #9's record revealed the patient developed a pressure ulcer to his/her coccyx on 03/23/2020. This area was defined as a non-stageable, partial thickness wound (wounds that extend into the first two layers of skin, the epidermis or dermis, and do not extend past these layers). Mepilex dressing (a self-adherent, soft silicone foam dressing) was applied. The pressure ulcer measured four centimeters (cm) by 1.5 cm by non-stageable. Patient #9's heels also had pressure areas. The right heel measured two cm by four cm and no depth, and the left heel measured four cm by five cm and no depth. These were both identified as deep tissue pressure injuries. The staff were to continue to elevate the patient's heels. Bilateral heel boots were applied on 03/29/2020.

Review of a physician progress note dated 03/23/2020 and signed by the medical doctor revealed he/she had spoken to Patient #9's power of attorney (POA) and again informed the POA that Patient #9 was now being turned every four hours (the POA previously expressed frustration that the patient was not being turned often enough and was worried about ulcer development). The doctor explained this was being done at this frequency to balance offloading pressure to prevent sores/ulcers and to conserve personal protective equipment (PPE) that is already on shortage and will soon experience surge in requirements.

Review of an email from Staff A on 07/27/2020 at 9:40 AM revealed initially the patient was being turned every two hours. On 03/09/20, 03/11/2020, 03/12/2020, and 03/13/2020 there was documentation the patient was being turned at least every two to four hours prior to being moved to a different floor within the hospital (7NW). Review of the documented turn times while the patient was on 7NW revealed the following: on 03/14/2020, the patient was turned at 12:00 AM, 8:00 AM, 4:00 PM and 8:00 PM; on 03/15/2020, the patient was turned at 9:00 AM, 3:35 PM, 4:46 PM and 9:00 PM; on 03/16/2020, the patient was turned at 9:00 PM; on 03/17/2020, the patient was turned at 11:00 AM and 9:00 PM; on 03/18/2020, the patient was turned at 3:18 PM and 9:33 PM; on 03/19/2020, the patient was turned at 9:00 AM and 10:30 PM; on 03/20/2020, the patient was turned at 10:33 AM and 8:41 PM; on 03/21/2020, the patient was turned at 2:20 AM, 7:50 PM, and 11:22 PM; on 03/22/2020, the patient was turned at 10:00 AM, 5:26 PM; and 8:21 PM; on 03/23/2020, the patient was turned at 9:21 AM, 11:34 AM, 2:00 PM and 5:50 PM; on 03/24/2020, the patient was turned at 9:00 AM, 9:00 PM, and 11:24 PM; on 03/25/2020, the patient was turned at 10:16 AM and 9:00 PM; on 03/26/2020, the patient was turned at 10:57 PM. Review of the documented turn times while the patient was on 9CCP revealed the following; on 03/27/2020, the patient was turned at 8:36 AM, 10:56 AM, and 9:03 PM; on 03/28/2020, the patient was turned at 8:00 PM and 10:00 PM; on 03/29/2020, the patient was turned at 9:00 AM, 9:01 PM, and 11:03 PM; on 03/30/2020, the patient was turned at 12:28 AM, 3:30 AM, 9:00 AM and 10:00 PM; on 03/31/2020, the patient was turned at 12:11 AM and documentation the patient turned his/herself at 9:00 PM; on 04/01/2020, the patient was turned at 9:00 PM. The patient was discharged on 04/02/2020.

This finding was confirmed in an email with Staff A on 07/27/2020 at 10:06 AM and again prior to the exit conference on 07/27/2020.

This deficiency substantiates Substantial Allegation OH00111096.