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Based on policy review, medical record review, observation during tours, and staff interview, the nursing staff failed to evaluate and supervise the delivery of patient care by (A) failing to follow hospital policy for care and maintenance of Intravenous infusions for 5 of 6 patients (#9, 12, 13, 14, & 15) and (B) failing to follow policy for skin assessment and pressure ulcer prevention for 3 of 5 patient's (#2, 4, & 5).

The findings include:

(A.) Review of the hospital policy, "Documentation IV (Intravenous) Therapy", dated 04/2013, revealed "...Assessments of the IV (intravenous) site are documented at the initiation of the IV therapy and ongoing assessments are documented at the time of any IV intervention (changing of tubings and dressings, restarting the IV, etc.).. Labeling: ... B. Labeling on all dressings (peripheral and central) should include gauge and length of cannula, date and time of insertion, and identification of the individual who inserted the cannula...C... Place a colored CHANGE sticker on all bags of fluid running at KVO (keep vein open) rate... E. Labeling of administration sets should contain date and time of initiation and expiration (use colored change stickers)... Medical Record: ...C. Documentation shall include but shall not be limited to: cannula gauge and length, insertion site, and date and time of insertion; identification of the individual who inserted the cannula..."
1. Open medical record review for Patient (Pt) #12 on 04/17/2014 revealed a 71 year old female who presented to the Emergency Department (ED) on 04/16/2014 with a chief complaint of back pain. Record review revealed she was admitted with a diagnosis of renal failure and hyperkalemia (high potassium).
Review of the Physician's Orders dated 04/16/14 at 1357 revealed "IV (Intravenous) Access, Saline Lock". Continued review of orders dated 04/16/2014 at 1430 revealed "NS (Normal Saline) 0.9% 1,000ml (milliliters) IV, at 100ml per hour".
Observation during tour on 04/17/2014 at 0850 of Pt #12 revealed a primary IV of 1000ml NS infusing. Observation of the IV tubing revealed no label on the IV tubing administration set with a colored change sticker and no date and time of initiation and expiration. Observation of the IV insertion site revealed no documentation of the gauge and length of cannula, date and time of insertion, and identification of the individual who inserted the cannula.
Interview with the Nursing Administrative Staff #1, during the tour on 04/17/2014 revealed the IV insertion site is to be labeled with the date and time of insertion and the name of the person who inserted. The tubing is to be labeled with a color coded sticker the date and time the tubing is scheduled to be changed." Continued interview revealed "this IV site should be labeled with the date and time it was started and who started the IV but it is not. There is no sticker on the IV tubing and there should be". Review of the medical record for patient #12 by the Nursing Administrative Staff #1 revealed "this IV was started in the ED but there is no documentation by the ED nurse or the unit nurse when this IV was started" (18 hours and 20 minutes after physician order). Interview confirmed the facility nursing staff failed to follow the hospital's policy for care and maintenance of the IV.
2. Open medical record review for Pt #15 on 04/17/2014 revealed a 66 year old female who presented to the Emergency Department (ED) on 04/16/2014 then admitted with a diagnosis of syncope episodes, neurogenic (nerve) versus cardiogenic (heart).
Review of the Physician's Orders dated 04/16/14 at 1842 revealed "IV Access, Saline Lock". Continued review of orders dated 04/17/2014 at 0800 revealed "D (dextrose) 5% 1/2NS, 1000ml IV, at 100ml per hour ".
Observation during nursing unit tour on 04/17/2014 at 0850 of Pt. #15 revealed a primary IV infusing. Observation of the IV tubing revealed no labeling of the IV tubing administration set with a colored change sticker and no date and time of initiation and expiration. Observation of the IV insertion site revealed no documentation of the gauge and length of cannula, date and time of insertion, and identification of the individual who inserted the cannula.
Interview with the Nursing Administrative Staff #1 during the tour on 04/17/2014 revealed the IV insertion sites are to be labeled with the date and time of insertion and the name of the person who inserted. The IV tubing is to be labeled with a color coded sticker and date and time of when the next tubing change is due. Continued interview revealed "this IV site should be labeled with the date and time it was started and who started the IV but it is not. There is no sticker on the IV tubing and there should be". Review of the medical record for patient #15 by the Nursing Administrative Staff #1 revealed "this IV was started in the ED but there is no documentation by the ED nurse or the unit nurse when this IV was started" (14 hours and 8 minutes after physician order). Interview confirmed the facility nursing staff failed to follow the hospital's policy for care and maintenance of the IV.
3. Open medical record review for Pt #9 on 04/17/2014 revealed a 56 year old female admitted on 03/27/2014 with a diagnosis of UTI (urinary tract infection) and severe hypokalemia (low potassium), and dehydration.
Review of the Physician's Orders dated 03/27/2014 at 1211 revealed "IV Access, Saline Lock". Continued review of orders dated 03/27/2014 at 1400 revealed "NS 0.9% 1,000ml IV, NS Bolus."
Observation during nursing unit tour on 04/17/2014 at 0850 of Pt. #9 revealed a primary IV of 1000ml NS infusing. Observation of the IV tubing revealed no labeling of the IV tubing administration set with a colored change sticker and no date and time of initiation and expiration.
Interview during the tour on 04/17/2014 at 0850 with the Registered Nurse (RN #1) revealed "Primary IV tubing are to be changed every 72 hours and a secondary IV tubing is changed every 24 hours." Continued interview revealed a color coded sticker indicating the day the IV tubing is due to be changed is applied to the tubing with each IV start and each new tubing change. This tubing is not stickered and it should be." Interview confirmed the facility nursing staff failed to follow the hospital's policy for care and maintenance of the IV.
4. Open medical record review for Pt #13 on 04/17/2014 revealed an 83 year old female presented to the Emergency Department (ED) on 04/14/2014 then admitted with a diagnosis of Right hip fracture.
Review of the Physician's Orders dated 04/14/14 at 2230 revealed "IV NS 0.9% 1,000ml IV, at 50ml per hour ".
Observation during nursing unit tour on 04/17/2014 at 0850 of Pt. #13 revealed a primary IV of 500ml NS infusing. Observation of the IV insertion site revealed no documentation of the gauge and length of cannula, date and time of insertion, and identification of the individual who inserted the cannula.
Interview with the Nursing Administrative Staff #1 during the tour on 04/17/2014 revealed the IV insertion sites and dressing are to be labeled with the date and time of insertion and the name of the person who inserted the IV. Continued interview revealed "this patient's (#13) IV site should be labeled and it is not." Review of the medical record for patient #13 by the Nursing Administrative Staff #1 revealed "this IV was started in the ED but there is no documentation by the ED nurse or the unit nurse when this IV was started or when the tubing is due to be changed" (2 days, 10 hours and 20 minutes after physician order). Interview confirmed the facility nursing staff failed to follow the hospital's policy for care and maintenance.
5. Open medical record review for Pt #14 on 04/17/2014 revealed a 92 year old female presented to the Emergency Department (ED) on 04/15/2014 with a chief complaint of decreased appetite and generalized weakness. Record review revealed she was admitted with a diagnosis of delirium, dehydration and acute kidney injury.
Review of the Physician's Orders dated 04/15/2014 at 1800 revealed "NS 0.9% 500ml IV".
Observation during nursing unit tour on 04/17/2014 at 0850 of Pt. #14 revealed a primary IV of 500ml NS infusing. Observation of the IV tubing revealed no labeling of the IV tubing administration set with a colored change sticker and no date and time of initiation and expiration.
Interview during the tour on 04/17/2014 at 1400 with Nursing Administrative Staff #1 revealed a color coded sticker indicating the day the IV tubing is due to be changed is applied at initial start of the IV and with each new tubing change. Continued interview revealed "there is no sticker on the IV tubing and there should be". Interview confirmed the facility nursing staff failed to follow the hospital's policy for care and maintenance of the IV.
(B.) Review of the hospital's policy "Assessments/Reassessments (Newborn, Pediatric, Adult Inpatient)" dated 04/2013 revealed "...Assessments are conducted at least once each shift...Procedures: A. All patients admitted to an inpatient care area, shall have a full assessment to include: all body systems...Medical-Surgical: Time Frame: 8 hrs..."
Review of the hospital's policy "Pressure Wound Prevention & Treatment Protocol" dated 02/2013 revealed "...A thorough assessment of the skin area will be made on admission by the admitting nurse and every shift throughout hospitalization. All patients will be assessed for skin breakdown potential based on the Braden Scale. Prevention measures will be initiated for any patient with a prevailing potential for skin breakdown (Braden score < (less than) 13. These are: A. If unable to turn self, the patient will be turned and repositioned every 2 hours...Barrier products will be used on all incontinent patients...heel protectors will be utilized and heels will be elevated off of bed at all times...therapeutic mattresses will be provided as ordered by the physician...2. All decubitus ulcers will be staged and the appropriate treatment assigned as outlines in the pressue wound treatment protocol and/or other appropriate pressure wound treatment orders...PRESSURE WOUND TREATMENT PROTOCOL:...3. All pressure wounds will be stage and the appropriate treatment option assigned per physican order from the following: Option A (Stage 1): Red, unbroken, and/or denuded areas exposed to incontinence, including those that are difficult to dress, (i.e. perineal tissue)...Option B (Stage 2): Shallow, broken, or sheared areas with denuded tissue, abrasions, or blisters, with pink or red wound bed..."
Review of the hospital's policy "Decubuti Documentation" dated 04/2013 revealed "a patient will be assessed on admission to (name of facility) by a registered nurse (RN). A complete head to toe assessment shall be performed including the integumentary (skin) system. 1. Any wounds shall be noted. 2. The location, stage and appearance of all decubuti will be recorded on the decubutis tab of the electronic medical record....5. all decubutis wounds shall be measured on a weekly basis and on discharge from the facility..."
1. Open medical record review on 04/16/2014 for Patient #4 revealed a 50 year old male admitted on 04/09/2014 at 1350 with diagnosis of CVA (cerebral vascular accident). Review of the physcian's History and Physical dated 04/09/2014 at 1651 revealed "...came in with right sided weakness that started last night. He had inability to walk at that point and right hand weakness..."
Review of the Nurse's Admission Assessment dated 04/09/2014 at 1612 revealed "Integumentary: Skin: Signs/Symptoms: noted scab wound to rt. (right) inner leg 2 cm (centimeters) by 2 cm, scar to rt. foot and abd (abdomen) outer ankle 2.5 cm by 0.5cm. Braden Scale: Sensory Perception - 4 (no impairment); Moisture - 4 (rarely Moist); Activity - 2 (chair fast); Mobility - 3 (Slightly Limited); Nutrition - 3 (adequate); Friction & Shear - 3 (No Apparent Problem); Total (Braden) Score 19 of 23 (low risk). Musculoskeletal: Mobility: Bedrest...right leg: weak..."
Review of the Physician's Orders dated 04/11/2014 at 1209 revealed "Please start santyl (enzyymatic debrider ointment) to right calf and ankle ulcers daily."
Review of the Nurse's Assessment "Decubitus Assessment" revealed no documented assessment and measurment of a right inner leg, calf or ankle wound or decubitis on 04/09/2014, 04/10/2014, 04/11/2014.
Review of the Nurse's Decubitus Assessment dated 04/12/2014 at 1032 revealed Santyl dressing applied to Right medial ankle and Right Lower leg for a Stage II Decubitus. (22 hours (hrs) and 23 minutes (mins) after physician order).
Interview on 04/16/2014 at 1155 with RN #2 revealed "the nurses shift assessment documentation on 04/09/2014 at 2025, 04/10/2014 at 2035, 04/11/2014 at 2000, and 04/12/2014 at 1032 says the patient's (pt #4) skin assessment is normal but obviously this is an incorrect assessment since the patient had a Stage II pressure ulcer on his leg and foot. There is no decubitus assessment documented on these days and it should have been documented under the decubitus tab of the medical record." Interview confirmed the nursing staff failed to follow the hospital's policy for skin assessment and pressure ulcer prevention.

Interview on 04/16/2014 at 1225 with LPN #1 revealed "I completed the skin assessment on the 11th and 12th for this patient. I documented he had a normal skin assessment but I did this wrong. I documented my assessment prior to assessing the patient's legs. I shouldn't have documented a normal assessment since he had wound on his leg. The assessment is wrong. I documented normal without doing my assessment. I did change his dressing but I did not document that either and I should have. The policy says we should measure and document all decubitus in the decubitus tab and I did not do that." Interview confirmed the nursing staff failed to follow the hospital's policy for skin assessment and pressure ulcer prevention.

Interview on 04/16/2014 at 1255 with RN#3 revealed "I do recall (name of patient #4). I cared for him on the 9th and 10th. His skin assessment was intact, dry, and warm. Wounds and pressure ulcers should be documented here under the decubitus screen. But I don't recall him (pt #4) having a wound or any decubitus. That wasn't reported to me in our shift report. He did not have a dressing and I do not recall wounds. I see now he had a Stage II when he was admitted but I do not recall that." Interview confirmed the nursing staff failed to follow the hospital's policy for skin assessment and pressure ulcer prevention.

2. Closed medical record review on 04/16/2014 of Pt #2 revealed a 48 year old male admitted on 10/04/2013 at 1817 with a diagnosis of complication related to Lung Cancer.

Review of the Nurse's Integumentary (Skin) Assessment revealed on 10/06/2013 at 0910 skin is intact, dry and normal with a Braden score of 18. Continued review revealed the next documented skin assessment on 10/07/2013 at 0730 (22 hrs and 20 mins from last documented assessment). Continued review revealed on 10/07/2013 at 1910 a documented skin assessment "intact, dry, warm, and normal". Continued review revealed the next documented skin assessment on 10/08/2013 at 1900 (23 hrs and 50 mins from last assessment). Continued review revealed the next documented skin assessment on 10/10/2013 at 0730 (36 hrs and 30 mins from last documented assessment).

Interview on 04/16/2014 at 1140 with RN #2 revealed "skin assessments should be done and documented every shift and it is not done for this patient (#2)". Interview confirmed the nursing staff failed to follow the hospital's policy for skin assessment and pressure ulcer prevention.

3. Closed medical record review on 04/15/2014 for patient #5 revealed a 57 year old female presented to the Emergency Department (ED) on 07/28/2013 at 1437 with a chief complaint of difficulty breathing, shortness of breath and weakness. Continued review revealed a Past Medical History of Down's Syndrome and Hyperglycemia.

Review of the ED Physician's Physical Assessment dated 07/28/2013 at 1510 revealed "...Physical Exam:...Skin: color normal, no rash, warm, dry, intact. Extremities: no pedal edema, nontender, normal ROM (range of motion) ..."

Review of the ED Nurse's Documentation dated 07/28/2013 at 1752 revealed no documented Integumentary (skin) assessment. Review of the ED Nurse's Progress Notes revealed no documented skin assessment or Braden Scale Total Score.

Review of the Nurse's Admission Assessment "Activities of Daily Living (ADL's) dated 07/28/2013 at 1930 revealed "Grooming - Total; Feeding: Total Feed; Toileting - Incontinent (uncontrollable urination), brief (diaper)." Continued review of the Nursing Admission Integumentary (skin) Assessment dated 07/28/2013 at 2332 revealed "...Skin - Intact, dry, cool; Sign/Symptoms (of skin breakdown) - Other: pt has several scabbed areas on legs ...Mobility: Bed Rest ...". Continued review revealed no documented Braden Scale Total Score.

Continued review of the Nurse's Integumentary Assessment dated 07/29/2013 at 0720 revealed "Skin - dry and warm; Signs/Symptoms - redness (Stage I). Braden Scale Total Score is 14. Skin Protection in Place: N/A (not applicable) ..." Continued review revealed no documented Skin Care Preventive Measures implemented per hospital policy. Review of the Decubitus tab of the electronic medical record revealed no documented decubitus assessment per hospital policy.

Continued review of the Nurse's Integumentary Assessment dated 07/29/2013 at 1940 revealed Skin is dry, warm, and intact (no documentation of redness-Stage I decubitus). The total Braden Score is "13" (high risk for skin breakdown). The documented Pressure Wound Prevention measures implemented were "pressure relief mattress and repositioned." Review of the Decubitus tab of the electronic medical record revealed no documented decubitus assessment

Review of the Nurse's documentation "Positioning" (turning) Pt #5 dated 07/29/2013 at 2400 revealed "positioning: left (side)". Continued review revealed documentation of repositioning/turning on 07/29/2013 at 0600. Continued review revealed the next documented repositioning on 07/29/2013 at 2000 (14 hours from last documented repositioning/turning).

Continued review dated 07/30/2013 at 0740 revealed "Skin - dry, warm ... Signs/Symptoms - Redness (Stage I decubitus); Group Note: BOTH LOWER EXT (extremities) W (with)/ SCABBED, OLD SORES, NO DRAINAGE FROM SORES NOTED. ENDIT (barrier) CREAM APPLIED TO BOTH BUTTOCKS, COCCYX, AND GROINS. Braden Scale for Risk: Total Score 12 (high risk)." Review of the Decubitus tab of the electronic medical record revealed no documented decubitus assessment.

Review of the Nurse's documentation "Positioning" dated 07/30/2013 at 03:00 revealed "positioning: left (side)". Continued review revealed the next documented repositioning/turning on 07/30/2013 at 0800 (5 hours from last documented turn).

Continued review of the Nurse's Integumentary Assessment dated 08/01/2013 at 0800 revealed "Skin - Intact, dry and warm; Signs/Symptoms (of skin breakdown) - none." (No documentation of Stage I). Continued review revealed Braden Scale Total Score of 11 (high risk). Continued review revealed no documented prevention measures. Review of the Decubitus tab of the electronic medical record revealed no documented decubitus assessment.

Continued review of the Nurse's Integumentary Assessment dated 08/02/2013 at 0710 revealed "Sign/Symptoms: Redness, sore, bruises ...Redness noted to both groins, and bilateral buttocks/hips. Scabbed, healed sores scattered over both lower legs. Scattered bruises noted to both arms ...Braden Scale for Risk Total Score: 10 (high risk) ..." Continue review revealed no documented prevention measures. Review of the Decubitus tab of the electronic medical record revealed no documented decubitus assessment.

Review of the Nurse's documentation of patient "Positioning" (turning) dated 08/02/2013 at 1700 revealed "positioning: left (side)". Continued review revealed the next documented repositioning/turning on 08/02/2013 at 2250 (5 hours and 50 minutes from last documented turn). Continued review revealed on 08/13/2013 at 1807 "positioning: left (side)". Continued review revealed the next documented repositioning/turning on 08/14/2013 at 0800 (13 hours and 53 minutes from last documented turn).

Continued review of the Nurse's Integumentary Assessment dated 08/05/2013 at 0801 revealed "Skin protection in Place: N/A (not applicable); Sign/Symptoms: None (no documentation of Stage I decubitus); Braden Scale for Risk Total Score: 12 (high risk). Review revealed no documented prevention measures. Continued review of the Integumentary Assessment revealed the next documented assessment on 08/06/2013 at 0751 (23 hours and 50 minutes from last documented assessment)

Continued review of the Nurse's Integumentary Assessment dated 08/08/2013 at 2350 revealed "Skin - intact; Skin Protection in place: N/A; Signs/Symptoms (of skin breakdown) - None" (no documentation of Stage I decubitus). Review of the Decubitus tab of the electronic medical record revealed no documented decubitus assessment

Review of the Nurse's Decubitus tab of the electronic medical record revealed only two (2) documented decubitus assessments: 1) On 08/14/2013 at 0845 revealed "Location: Coccyx (tailbone)...Signs and Symptoms: Redness and Heat; Stage of Decubitus - Stage 1 Decubitus ..." (16 days and 1hrs and 25 mins from first documented redeness-Stage I) 2) On 08/15/2013 at 0830 a Stage 1 Decubitus with Redness located on the Coccyx. (no documentation of the Stage I decubitus assessment every shift in the decubitus tab of the electronic medical record).

Interview on 04/15/2014 at 1235 with Nursing Administration #1 revealed integumentary assessments are to be completed and documented upon admission and once every shift by nursing for all patients. Continued interview revealed Pressure Wound Protocol is to be implemented for any patient with an existing wound or pressure ulcer and any patient with a "Braden Score less than 13". Continued interview revealed patient's at risk for skin breakdown are to be turned every 2 hours and all prevention measures documented in the medical record. Continued interview revealed "a Stage I decubiti is redness of an area with no break in the skin." Interview confirmed the nursing staff failed to follow the hospital's policy for skin assessment and pressure ulcer prevention.

Interview on 04/15/2014 at 1430 revealed "there are discrepancies in the nurse's documentation. Some are documenting red skin or Stage I (ulcer) and other's are not. A stage I is red skin with no break in the skin. It should be treated as a decubitus and the decubitus tab should be used for documentation. There are times the patient was not turned every 2 hours." Interview confirmed the nursing staff failed to follow the hospital's policy for skin assessment and pressure ulcer prevention.

Interview on 04/16/2014 at 1040 with the RN#4 revealed a Stage I decubitus is when the "skin is pink and red but not broken". Continued interview revealed "the Nurse should document under the decubitus section (tab) every shift the decubitus assessment along with care of the skin and any interventions". Interview confirmed the nursing staff failed to follow the hospital's policy for skin assessment and pressure ulcer prevention.

NC00094799