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Based on interview, medical record review and policy review, the facility failed to ensure the registered nurse evaluated the nursing care for one of 30 medical records reviewed (Patient #10). This could affect all patients receiving services from the facility. The facility census was 647.

Findings include:

Review of the policy and procedure titled, Premier Nursing Services Skin Integrity Maintenance Program Pressure Ulcer Prevention Program and Pressure Ulcer Prevention Program Initiations (PUPPI), effective 12/12/19, revealed patients identified within this scope will receive a pressure injury risk assessment score upon admission. For those patients determined to be at risk, action-based interventions related to the prevention of pressure injuries, and/or to the treatment of those already present, will be implemented and documented along with patient and/or family education related to these measures. Staff were to notify the attending provider of all suspected and actual pressure injuries. It is recommended to notify the appropriate wound service for Stage 3, 4, unstageable and deep tissue injuries. Efforts should be made to utilize repositioning or lifting devices and/or pressure redistribute surfaces to effectively redistribute and offload pressure.

Review of a policy and procedure titled, MVH Nursing Services Wound Care Management and Treatment Ostomy, Draining Wound and Incontinence Care revealed if the nurse identifies the patient has a hospital acquired wound, the nurse will discuss the status of all hospital acquired wounds to the licensed independent practioner (LIP) to ensure orders and appropriate communication are addressed. The LIP will provide orders for wound care and an incident report will be submitted for a hospital acquired wound. When changing the dressing, assessment should include the following: location, length, width done weekly and presence, location and extent of undermining or tunneling.

Review Patient #10's medical record revealed he/she was transferred from another hospital to this provider on 04/17/2020. The patient was admitted to the COVID-19 intensive care unit (ICU) on the ninth floor, room 920 and then eventually transferred to SE 7 Advanced Care Cardiology. The admitting diagnosis was respiratory failure (septic shock) secondary to COVID-19 and pneumonia. Other diagnoses included chronic kidney disease and converted to dialysis, atrial fibrillation and on Eloquis (blood thinner), history of chronic lymphomatic anemia, atrophic left kidney with right renal stenosis, coronary disease and status post CABG (coronary artery bypass graft) and deep vein thrombosis prophylaxis.

The initial nursing assessment dated 04/17/2020 revealed the patient's Braden score was a "10" (a total score of 10 to 12 is moderate risk for skin breakdown). The patient did not have a pressure ulcer on admission.

A medical staff note dated 04/26/2020 revealed the patient had multiple loose bowel movements and to screen for C. difficile (bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon). The lab results came back negative for C. difficile.

Interventions were put in place to prevent skin breakdown including turning and repositioning, waffle boots, passive and active range of motion, perineal care, daily toileting, daily and as needed skin care, optimization of nutrition, friction and shear precautions, pressure reduction devices, and foam dressing with silicone border applied.

Interview with Staff A by email on 09/28/2020 at 4:34 PM revealed there was documentation throughout the patient's hospitalization to support that the patient had been turned and repositioned every two hours until he/she was extubated on 04/30/2020. At that time the patient was able to turn independently in bed. There was an exception to the every two hour repositioning as evidence by instability of the patient's blood pressure. When this occurred, the patient was not repositioned or turned. Passive and active range of motion, waffle boots and other preventative measures continued.

A phone conference was made on 09/29/2020 at 1:36 PM with Staff ZZ, AA, BB, V, A, and VV to discuss the patient's record. During the phone conference interview, Staff ZZ disclosed that a pressure ulcer that developed on Patient #10's sacral area was not present on admission. Staff ZZ stated that on 04/27/2020 Staff Y documented Patient #10 had a deep tissue injury. Foam dressing was applied with a silicone border and changed two times daily.

Further interview with Staff ZZ on 09/29/2020 revealed on 05/04/2020 documentation showed Patient #10 had a Stage 3 pressure ulcer to his/her sacral area and that there should have been a change in treatment. Staff ZZ also confirmed there were no measurements of the wound. According to the policy and procedure the registered nurse (RN) on duty should have notified the attending provider and measured the wound. Nursing documentation revealed that Staff XX did not notify the clinical nurse practioner (CNP) until 05/05/2020. A referral to the wound care team was made on 05/05/2020 but the patient was not seen until 05/08/2020, three days later. The area measured 3.4 centimeters (cm) by 1.4 cm. Staff ZZ further revealed the referral on 05/05/2020 did not indicate the deep tissue injury had deteriorated and needed additional attention. The wound care team would not have known the current treatment was not enough and that they needed to prioritize the referral. Ideally the RN should have indicated the pressure ulcer was now a Stage 3.

Interview with Staff A in an email on 09/30/2020 at 9:11 AM confirmed Patient #10's medical record did not include measurements of the Stage 3 pressure ulcer on 05/04/2020. Staff A verified the the wound should have been measured on 05/04/2020.

Interview with Staff A on 09/30/2020 at 2:54 PM revealed there was no incident report submitted for the hospital acquired wound when one was requested by the surveyor.

Based on observation, staff interview, and policy review, the facility failed to properly implement methods for preventing the spread of COVID-19. (A0749).

Based on observation, staff interview, and policy review, the facility failed to properly implement methods for preventing the spread of COVID-19. The active census was 647.

Findings include:

Review of the Emergency Department's COVID-19 Visitor Restrictions and Guidelines, effective 05/19/20, revealed all employees, staff, and visitors will be screened for symptoms and exposure history. Visitors will be asked to leave the facility if they have had symptoms in the past 24 hours or exposures within the last fourteen days.

1. A tour of the Miami Valley Emergency Room South was conducted on 09/22/2020 at 9:08 AM. Observation revealed a Registered Nurse was assigned at the entrance to screen all visitors for COVID-19 prior to entering the emergency department. Upon entrance the surveyor was not screened for COVID-19 symptoms and/or recent exposures. An interview was conducted with Staff T on 09/22/2020 at 10:02 AM who reported he/she was to screen all visitors entering the facility and was supposed to screen the surveyor upon entering according to policy and procedure.


28999

2. Observations related to COVID-19 screening at the facility's women's center were made over two days, 09/21/2020 and 09/22/2020. While sitting in the lobby of the Berry Women's Center on 09/21/2020 at 11:40 AM, this surveyor observed a masked visitor walk into the building through glass double-doors and approach a staff member sitting behind the information desk in the lobby. The visitor stated the name of the patient he/she was going to visit and was immediately directed to the bank of elevators on the staff member's left. The visitor walked to the elevators, pushed the button to call the elevator, and then entered the elevator. The visitor was not screened for COVID-19 prior to entering the elevator.

A police officer was also observed to walk through the entrance of the women's center and through the lobby. The police officer's facial covering was positioned around his/her neck leaving his/her nose, mouth, and chin exposed. The police officer walked past this surveyor and past the information desk to the elevators, and pushed the button to call the elevator. The police officer was not screened for COVID-19 prior to entering the elevator nor did he/she pull the mask up to cover his/her nose and mouth prior to entering the elevator. This surveyor was escorted to the elevators by Staff Y, the manager of Labor and Delivery. This surveyor received no screening for COVID-19 prior to entering the elevator. There was also no screening for this surveyor as this surveyor and Staff Y walked past the nurses' station in the Labor and Delivery department. This surveyor's temperature was not assessed, no questions about potential exposure to COVID-19 or symptoms were asked by staff members for the rest of the day.

On 09/22/2020 at approximately 9:00 AM, this surveyor entered the lobby of the facility's women's center. Again, there was no screening for COVID-19 prior to entering the elevator. Two masked visitors were on the elevator with this surveyor. This surveyor was buzzed into the locked door on the second floor of the women's center. Approximately seven staff members were observed behind the nurses' station of Labor and Delivery, but no screening for COVID-19 was conducted by any as required by facility policy.

This lack of screening for COVID-19, as required by facility policy, was confirmed with Staff U, Staff Y, and Staff Z on 09/22/2020 at 5:50 PM.

This substantiates Substantial Allegation OH00115132.