HospitalInspections.org

Based on interview and record review, the facility's registered nurses failed to supervise and evaluate the nursing care for patients that were hospitalized from 02/22/2020 to 07/30/2020, in that:

A. There was no documentation by nursing staff that the plan of treatment for using foam, and/or Aquacel AG, and/or Iodosorb was completed as recommended by the wound care nurse (WCN), citing 5 of 5 patients (Patient #1, Patient #2, Patient #8, Patient #9, and Patient #10).

B. There was no consistent documentation that patients were turned and repositioned every 2 hours as required, citing 3 of 5 patients (Patient #2, Patient #8, and Patient #10).

Findings:

A. 1. Patient #1 was admitted to a medical-surgical floor on 02/22/2020 for encephalopathy with unknown etiology. On 04/08/2020 a wound consultation was conducted by a WCN. The consultation note reflected "Consulted for bilateral elbows...Recommended treatment Iodosorb and foam daily and PRN (as needed) when soiled or dislodged."

2. Patient #2 was admitted to the ICU on 06/16/2020 for Covid-19 infection. Per physician order an initial wound care consult was conducted on 06/23/2020. The WCN noted "Consult...ordered...Reason...Nose..." For nose, WCN recommended protecting the area with foam. Change every 3 days and PRN for soiling/dislodgment.

On 06/24/2020 WCN conducted an initial assessment of the right and left ear lobe. WCN recommended foam every three days or PRN for soiling or dislodgment.

On 06/25/2020 WCN assessed the Left great toe through 3rd and 4th toes, stage I. WCN recommended foam to pressure injuries every 3 days or PRN for soiling or dislodgment.

On 07/09/2020 a follow-up visit was conducted by the WCN. The WCN noted there were pressure ulcers to the left and right ears. WCN recommended foam every 3 days or PRN for soiling and dislodgment.

3. Patient #8 was admitted to the ICU on 06/04/2020 for Covid-19 infection. On 06/26/2020 a consultation of the left cheek was conducted by a WCN. The WCN noted "unable to fully assess the left cheek and will continue placing foam every 3 days and PRN for soiling or dislodgment."

4. Patient #9 was admitted to the ICU on 06/23/2020 for gunshot wound in the abdomen. Per physician's order dated 07/20/2020 a wound consultation was conducted for the trach collar site. WCN recommended Aquacel AG daily and PRN soiling/dislodgment.

5. Patient #10 was admitted to the ICU on 07/14/2020 for acute respiratory failure secondary to Covid-19. Per physician's order, a wound care consultation was conducted on 07/27/2020. The WCN noted the patient's right knee had a dark area and was unable to determine if it was a pressure injury. The WCN recommended foam every 3 days or PRN soiling/dislodging.

During an interview on 08/10/2020 at 2:00 PM in the conference room, Personnel #11 confirmed that there was no documentation by nursing staff that they were doing wound care treatments.

B. Patient #2 was admitted to the ICU on 06/16/2020 for Covid-19 infection. He was intubated on 06/16/2020. On 06/16/2020 at 07:01 the patient was in supine position. The next documentation for repositioning was at 19:01 (12 hours later). The next documentation for repositioning was on 06/17/2020 at 01:00 the patient was in prone position until 07:00 (6 hours). The next documentation for repositioning was at 17:00 (10 hours later). 06/21/2020 the patient was turned to his right side at 07:01. The next documentation for turning/repositioning the patient was at 19:19 (12 hours and 18 minutes later) indicating "Lying left side; Semi-Fowler's; Pillow support." On 06/22/2020 at 19:01 the patient was repositioned for pain comfort. The next documentation for repositioning the patient was on 06/23/2020 at 01:01 (5 hours later).

2. Patient #8 was admitted to the ICU on 06/04/2020 for Covid-19 infection. She was intubated on 06/12/2020. On 06/13/2020 from 03:00 to 07:01 (4 hours) the patient was "Lying left side, prone." On 06/14/2020 23:00 to 06/15/2020 15:00 the patient was in prone position for 16 hours. On 06/16/2020 from 19:00 to 23:00 the patient was in prone position for 4 hours. On 06/18/2020 the patient was not turned/repositioned from 05:00-08:00 (3 hours). On 06/21/2020 the patient was lying left side from 11:05 to 15:00 (3 hours and 55 minutes). On 06/22/2020 the patient was lying left side from 05:01 to 23:00 (17 hours and 59 minutes).

3. Patient #10 was admitted to the ICU on 07/14/2020 for acute respiratory failure secondary to Covid-19. He was intubated on 07/15/2020 at 07:30. On 07/16/2020 at 05:00 the patient was placed in a prone position. The next documentation that the patient was repositioned was at 11:00 (6 hours). On 07/17/2020 the patient was repositioned at 15:00. From 17:20 to 23:00 the patient was in a prone position (5 hours and 40 minutes). The documentation did not indicate the direction of the head. On 07/18/2020 the patient was in a prone position from 01:00 to 07:01 (5 hours and 59 minutes). At 09:12 AM the reposition item in the flowsheet was not filled out.

During an interview on 08/12/2020 at 12:08 PM via phone call, Personnel #6 stated initially the nursing staff were not consistent in turning patients. Now we have turn-teams that consistently turn patients every 2 hours.

In an interview on 08/20/2020 at 12:34 PM via email Personnel #3 was asked if they had identified inconsistent documentation regarding the turning and repositioning of patients every 2 hours as required. Personnel #3 replied that they did. "We have identified there are gaps and work that can be completed on those gaps. We have a report that can be run in EPIC that can track patient turn documentation and percentages. We can begin audits on those reports."