HospitalInspections.org

Based on interview and record review, the facility failed to reposition 3 of 30 sampled patients (Patient 2, Patient 3, Patient 6) who presented with pressure injuries (localized skin injury usually over a bony area caused by pressure over that part of the body). This deficient practice can lead to delayed healing and increased discomfort for patients.

Findings:

During a review of the document titled 'Care Activity - Assessments' indicated that on 3/18/2024, Patient 2 was initially assessed to have redness to the medial sacrum (shield-shaped bony structure that is located at the base of the spine). This same document showed that this area was reassessed on 3/20/2024 and this redness had advanced to DTI (deep tissue injury, localized area of discolored intact skin or blood-filled blister due to pressure upon underlying soft tissue).

During a review of the document titled 'Patient Plan of Care - Wound /Skin Management' (Patient 2) this document indicated Pressure Ulcer Precautions to be implemented were: maintain limbs in functional alignment, reposition per protocol, and offloading (reducing pressure over bony areas) body extremities.

During a review of the document titled 'Care Activity -Assessments', this report showed there was no documented repositioning of Patient 2 on 3/18/2024 at 10:00 PM or on 3/19/2024 at 10:00 AM; on 3/20/2024 at 4:30 AM Patient 2 was in a supine (lying face upward) position and also in a supine position on 3/20/2024 at 10:00 AM.

During a review of the document titled 'Care Activity - Assessments' indicated that on 3/13/2024 at 10:00 AM, Patient 3's skin assessment showed a DTI to the left medial right sacrum. This was the same assessment on 3/13/2024 at 7:56 PM. This same report indicated that on 3/13/2024 at 10:00 AM, Patient 3 was in a right lateral position; at 3/13/2024 at 7:56 PM Patient 3 was in a left lateral position.

During a review of the document titled 'Care Activity -Assessments' verified on 3/19/2024 at 10:00 AM, Patient 6's initial skin assessment indicated a 'full thickness loss' (injury beyond the top layers of skin) to the posterior sacrum; the same assessment was displayed on 3/19/2024 at 10:00 PM. This same document showed that on 3/19/2024 at 10:00 AM Patient 6 was in a supine; at 3/19/2024 at 10:00 PM Patient 6 was also in a supine position.

During a review off the document titled 'Department of Policies and Procedures - Skin Integrity' (revised 5/23/2019), this document indicated the nursing team will position the patient so that the skin integrity is maintained. This document stated one of the methods to accomplish this is to reposition the patient at least every 2 hours or as often as the patient can tolerate. This document recited that any refusal or inability of the patient to be repositioned shall be documented.

During a interview on 3/21/2024 at 10:00 AM, the WCN stated that patients with pressure injury or potential for pressure injury should be repositioned every 2 hours, particulary Patients 2, 3, and 6, who had sacral wounds. At that time the WCN said even though they were resting on specialty mattresses, these 3 patients still needed repositioning at least every 2 hours.

Based on observation, interview, and record review the facility failed to date the dressings overlying IV sites (part of body where a thins tube is inserted through which medication or diet is infused) for 2 of 30 sampled patients (Patient 4, Patient 5). This deficient practice may contribute to spread of infection through the IV site.

Findings:

During an observation on 3/19/2024 at 3:05 PM in patient room 326 and accompanied by Charge Nurse 2, there was an IV site on the back of the left hand over which a clear transparent film dressing was placed. There was no marking on the dressing indicating when the dressing had been started/changed.

During an observation on 3/19/2024 at 3:10 PM in patient room 325 and accompanied by Charge Nurse 2, there was an IV site located at the front side of the left arm where the upper and lower arm meet over which a clear transparent dressing was placed. There was no marking on the dressing indicating when the dressing had been started or changed.

During a review of the facility's 'Policy - IV Therapy Protocol', revised 3/2023, this document indicated that IV sites should be assessed every 12 hours and patients should also be also be assessed at the same time. IV sites are to be changed every 96 hours unless otherwise ordered by a physician. This policy stated that IV sites that appear to be infected or infiltrated (when some of the fluid leaks out into the tissues under the skin where the tube has been put into your vein) must be discontinued and this incident is to be reported to a physician. This protocol certified IV site dressings (protective film placed over site to prevent spread of infection) should be replaced every 96 hours or as needed when soiled; the dressing change should be dated and timed.

During an interview on 3/21/2024 at 4:00 PM, the Clinical Educator stated all IV site dressings should be marked with the date and time it was changed; Staff should use a sticker containing the date and time of dressing change but can also use a permanent marker for the same task. At that time, the Clinical Educator said dressings should be changed every 96 hours or when soiled or infiltrated; The Clinical Educator verified that 96 hours coincides with the IV catheter being changed.