HospitalInspections.org

Based on observation, interview, record review and policy review, the facility failed to:
- Ensure nursing staff performed consistently the appropriate fall prevention and interventions according to facility policy, to protect 11 current patients, (#5, #34, #14, #19,
#37, #30, #32, #33, #40, #2, and #9) of 13 current patients, who were at high risk for falls and or had a fall history.
- Ensure nursing staff consistently assessed and evaluated nursing care for wounds and/or pressure sores/ulcers (injury to the skin and/or underlying tissue usually over a bony prominence) for one (#10) current of two current patients reviewed and for one (#42) of two discharged patients reviewed.
- Prevent development of a Stage II (partial thickness skin loss involving one to two layers of skin. Usually presents as a blister, abrasion, or shallow crater) pressure sore (injury to the skin and/or underlying tissue usually over a bony prominence, which are staged to show degree of tissue damage) for one (#42) of one discharged patients reviewed with pressure sores.
- Follow their policy regarding use of a skin care clinician for all patients considered a high risk for pressure sores, and the facility could not provide an accurate list of those patients at high risk.
- Address low Albumin (a measurement in the blood that can indicate malnutrition, which can cause poor wound healing ability) levels, even though the patient had poor intake, and a pressure sore, for one current patient (#10) and one discharged patient (#42) reviewed.
- Follow their policy to prevent infection for one of one current post angiogram patient
(#9), which had the potential for infection for all patients who underwent an angiogram.
The failures related to falls had the potential to lead to possible injury and death, and could affect all patients in the facility. The facility identified 159 patients that were a high fall risk.
The patient census for pressure sores was unknown to administration and had the potential to affect all patients allowing them to develop pressure sores, and/or cause unnoticed deterioration of existing pressure sores. The facility census was 361.

The severity and cumulative effect of these systemic failures resulted in the facility remaining out of compliance with 42 CFR 482.23 Condition of Participation: Nursing Services.




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Based on observation, interview, record review and policy review, the facility failed to:
- Ensure nursing staff performed consistently the appropriate fall prevention and interventions according to facility policy, to protect 11 current patients, (#5, #34, #14, #19, #37, #30,
#32, #33, #40, #2, and #9) of 13 current patients, who were at high risk for falls and or had a fall history.
- Ensure nursing staff consistently assessed and evaluated nursing care for wounds and/or pressure sores/ulcers (injury to the skin and/or underlying tissue usually over a bony prominence) for one (#10) current of two current patients reviewed and for one (#42) of two discharged patients reviewed.
- Prevent development of a Stage II (partial thickness skin loss involving one to two layers of skin. Usually presents as a blister, abrasion, or shallow crater) pressure sore (injury to the skin and/or underlying tissue usually over a bony prominence, which are staged to show degree of tissue damage) for one (#42) of one discharged patients reviewed with pressure sores.
- Follow their policy regarding use of a skin care clinician for all patients considered a high risk for pressure sores; the facility could not provide an accurate list of patients at high risk.
- Address low Albumin (a measurement in the blood that can indicate malnutrition, which can cause poor wound healing ability) levels, even though the patient had poor intake, and a pressure sore, for one discharged patient (#42) reviewed.
- Follow their policy to decrease the risk for infection for one current post angiogram patient (#9) of one, which had the potential for infection for all patients who underwent an angiogram.
The failures related to falls had the potential to lead to possible injury and death, and could affect all patients in the facility. The facility identified 159 patients that were a high fall risk.
The patient census for pressure sores was unknown to administration and had the potential to affect all patients allowing them to develop pressure sores, and/or cause unnoticed deterioration of existing pressure sores. The facility census was 361.

Findings included:

1. Record review of the facility's policy titled, "Fall Injury Prevention Policy," dated 07/2016, showed the following:
- Assess/reassess patient to identify those at risk for falling, on admission, and at shift reassessment.
- Appropriate fall interventions should be based on fall risk elements such as, history of falls, confusion, incontinence, urgency/frequency, tethered devices (tubes, cords, etc.), unsteady gait, dizziness, walkers, canes, and impulsive behaviors.
- Preventative measures should include signage (yellow armband) non-slip footwear (yellow), assistance, bed alarms, toileting programs, and sitters.
- Those patients that are a high risk for falls should not get up without assistance.

2. Review of a facility provided document [untitled] showed that the facility had 92 patient falls from 09/21/16 to 12/21/16 (92 day period) that resulted in an average of one patient fall per day.

3. Record review of the facility provided document titled, "Falls-Safety Matters," dated 2016, showed the following:
- The facility has a fall rate three times higher than the National benchmark.;
- Patients that are placed on standard risk for falls will have either blue or gray socks.; and
- Patients that are placed on high risk for falls will have a yellow arm band and yellow socks.

4. Record review of Patient #5's physical assessment from 12/19/16 to 12/21/16 showed:
- A 50 year old female with cognitive deficit (term used to describe impairment in an individual's mental processes) and confusion.;
- Unsteady gait; and
- Three or more medications in drug classes known to be indicators of fall risk.

During an interview on 12/19/16 at 3:55 PM, Staff R, Register Nurse (RN) stated that she had not performed a fall assessment for Patient #5.

Record review of Patient #5's fall risk assessment dated 12/19/16, at 4:00 PM, was blank.

Record review of Patient #5's medical record on 12/21/16 showed that the fall risk assessment dated 12/19/16, at 4:24 PM, was documented for 7:20 AM. The nurse's failure to perform an assessment in "real time" had the potential for failure to protect, communicate, and implement fall precautions for Patient #5 who was at high risk for falls.

5. Observation on 12/20/16 at 10:00 AM showed Patient #34, walking with a walker in the hallway unassisted. Patient #34 had on yellow socks.

Record review of Patient #34's History and Physical (H&P) showed that she was a 66 year old female admitted on 12/13/16, to the neurology/orthopedic sixth floor for chronic back pain. The patient had intermittent lower extremity weakness and leg pain that worsened when she walked for more than 10 minutes. Review of Patient #34's fall risk assessment dated 12/20/16 at 2:31 PM, showed fall assessment documented as high risk for falls.

During an interview on 12/20/16 at 10:03 AM, Staff Q, RN, nurse manager stated that the yellow socks were an indicator for a patient that was high risk for falls and that the staff should have assisted Patient #34 while she was walking.

6. Observation on 12/20/16 at 9:45 AM showed Patient #14 in her room with no yellow arm band or yellow socks.

Record review of Patient #14's H&P showed a 53 year old female admitted on 12/16/16 to the neurology/orthopedic sixth floor with incarcerated hernia (where the bowel becomes trapped in weak area of the abdominal wall.) Review of Patient #14's on going fall assessments dated 12/16/16 to 12/20/16 showed that the patient had three or more medications in drug classes known to be indicators of fall risk.

7. Observation on 12/20/16 at 2:45 PM showed Patient #19 in his room without a yellow arm band or yellow socks.

Record review of Patient #19's H&P showed that he was 78 year old male admitted on 12/15/16 to the neurology/orthopedic sixth floor, with a recent history of falls. The patient had suffered a neck injury related to a fall and had weakness in both of his arms and legs. Review of Patient #19's fall assessment dated 12/20/16 at 8:30 AM showed that the patient was high risk for falls.

8. Observation on 12/20/16 at 2:50 PM in Patient #37's room, on the six floor rehabilitation unit (an inpatient area devoted to the rehabilitation of patients with various muscular-skeletal, and orthopedic conditions), showed the patient had on gray socks.

Record review of Patient #37's H&P showed that he was a 30 year old male admitted on 12/14/16 with cervical and thoracic fractures (broken bones of the spine in the neck and upper back.) The patient was admitted for activities of daily living and mobility dysfunction, requiring maximum assistance with therapies. Review of Patient #37's fall risk assessment dated 12/19/16 showed that the patient had decreased muscle coordination, unsteady gait, and had been placed on high risk for falls.

The patient was a high risk for falls, and per facility policy should have been wearing yellow socks.

9. Observation on 12/20/16 at 2:40 PM in Patient #30's room, on the six floor rehabilitation unit, showed the patient with one blue sock on the left foot and one yellow sock on the right foot. Signage on the wall showed the patient should have no weight bearing to left lower extremity.

Record review of Patient #30's H&P showed that he was a 60 year old male admitted on 12/05/16 to the six floor rehabilitation unit for activities of daily living and mobility dysfunction related to left ankle fracture post motor vehicle accident. The patient required an assistance device (walker, cane, or crutches) while walking. Review of Patient #30's care plan dated 12/19/16 at 9:44 AM showed fall intervention as standard fall risk

During an interview on 12/20/16 Staff KK, RN stated that all patients admitted to the six floor rehabilitation unit were placed on high fall precautions and given a yellow arm band and yellow socks.

10. Observation on 12/20/16 at 3:00 PM in Patient #32's room, showed Patient #32 with no yellow arm band or yellow socks.

Record review of Patient #32's H&P showed that he was a 31 year old male with an open left femur fracture (a break in the thigh bone) with second degree burns (damage to the skin or deeper tissues caused by fire) admitted to the burn unit. Review of Patient #32's fall interventions dated 12/20/16 at 10:21 AM showed high risk for falls.

11. Observation on 12/20/16 at 3:20 PM in Patient #33's room showed that the patient was wearing yellow socks, (an indication of a patient on high fall risk precautions).

Record review of Patient #33's H&P showed that he was a 19 year old male admitted to the Third Floor medical unit. Review of Patient #33's care plan dated 12/20/16 at 11:57 AM showed standard fall precautions.

12. Observation on 12/20/16 at 3:15 PM in the Patient #40's room showed the patient was not wearing any socks and was setting up in a chair.

Record review of Patient #40's H&P showed the following:
- Patient was a 77 year old female admitted on 12/12/16 for respiratory distress (difficulty in breathing) on the third floor medical.
- Fall assessment on 12/20/16 indicated that the patient was on standard precautions; and
- The care plan dated 12/20/16 at 11:39 AM showed that interventions for fall precautions were in place with non skid socks.

The nursing staff failed to ensure the patient had non-skid socks on per the facility's policy.

13. Record review of Patient #2's H&P dated 12/19/16, showed he was admitted to the intensive care unit (ICU-a unit where the more critically ill patient is cared for) on that date. He was unresponsive with a systemic infection.

Record review of the patient's admission nursing assessment dated 12/19/16, showed he was a high fall risk related to being incontinent, having decreased muscle tone, having medical equipment attached, and because he had fallen prior to admission (11/2016).

Record review of the patient's care plan dated 12/19/16 showed he was a standard risk rather than a high fall risk; therefore, not having the appropriate interventions to address his high risk for falls.

14. Observation on 12/19/16 at 2:22 PM on the Cardiac Care floor, showed that Patient #9 had no fall prevention interventions in place per the the facility policy. The patient had a walker in his room.

Record review of current Patient #9's medical record showed the following:
- H&P dated 12/12/16, showed that the patient was an 89 year old male that had a gastrointestinal bleed, aortic stenosis (narrowing of the valve in the large blood vessel branched off of the heart), paropxysmal atrial fibrillation (sudden recurrence of an irregular and rapid heart that caused poor blood flow), diverticulitis (inflammation in the digestive tract which caused a change in bowel habits), seizure disorder (excessive activity in the brain which caused uncontrolled jerking movements), chronic kidney disease, coronary artery disease, hypertension, hypothyroidism and depression.
- Nursing assessments dated 12/13/16, 12/17/16, 12/18/16 and 12/19/16 showed that the patient was placed on standard fall precautions and 12/14/16, 12/15/16 and 12/16/16 patient was placed on high fall risk precautions.
- Patient's care plan dated 12/13/16 - 12/18/16 showed no fall preventions listed and on 12/19/16 and 12/20/16 showed standard fall precautions in place.

During an interview on 12/20/16 at 4:08 PM, Staff GG, RN, stated that the patient should have had non-skid socks on.

During an interview on 12/20/16 at 4:26 PM, Staff II, Nurse Manager for Four North and Four West, stated that nursing should have placed non-skid socks on all patients that were a fall risk.

During an interview on 12/21/16 at at 9:43 AM, Staff C, Chief Nursing Officer (CNO), stated that she was ultimately responsible for all patient care. She stated that patients with a high fall risk should have a care plan that matched that high fall risk assessment because the interventions were different than the care plan for a standard fall risk. Staff C also stated that both the yellow wrist band and yellow non-slip socks were identifiers of a high fall risk and both should be on the patient at all times.

15. Record review of the facility's policy titled, "Pressure Ulcers: Management and Treatment of the Patient at risk for and with existing Pressure Ulcers," dated 03/2014 showed the following:
- Risk factors increase the patient's susceptibility to pressure sores and include: immobility, moisture, incontinence, and poor nutrition.
- The nurse is to notify the skin care clinician for any patients considered a high risk for pressure sores (a Braden score of 13 or less. A Braden score is a scoring tool used to identify risk for development of pressure sores).
- Document location, drainage, and size.
- Measure the pressure sore on admission, upon initial identification and weekly thereafter.

16.Observation and concurrent interview on 12/20/16 at 10:30 AM, showed Staff DD, RN, performed a dressing change per physician orders and noticed there was no date on old dressing. Staff DD stated that the surgery staff probably changed it last and stated that there wasn't a wound care team.

Record review of current Patient #10's H&P dated 12/18/16, showed a 33 year old male on Four West, with a past medical history of a gunshot wound, which left him a quadriplegic (partial or total paralysis of all limbs and torso). Patient presented with Systemic inflammatory response syndrome (SIRS, a serious condition related to inflammation, organ dysfunction, and organ failure), sepsis (life threatening condition when the body's response to infection injures its own tissues and organs), sacral pressure sore, colostomy and an indwelling suprapubic (inserted through a hole in the belly to drain urine from the bladder) catheter.

Record review of the patient's care plan showed pressure sores should have been:
- Measured and documented by length, width and depth in centimeters every shift (12 hours):
- Documented location every shift; and
- Assessed and documented color, odor and inflammation every shift.

Record review of the Patient #10's nursing assessment showed the following documentation:
- 12/18/16 at 3:27 AM, wound on coccyx, no measurements and no notes;
- 12/18/16 at 8:00 AM, wound on coccyx, no measurements and no notes;
- 12/19/16 at 8:29 AM, no wounds noted;
- 12/19/16 at 12:00 PM, no wounds noted;
- 12/19/16 at 7:04 PM, no wounds noted; and
- 12/20/16 at 12:00 AM, wound on coccyx, no measurements and no notes.

Record review of Patient #10's surgical note dated 12/19/16 showed that the sacral pressure sore's center area was a 2 cm opening with mild tunneling of approximately 4-5 cm and mildly foul smelling. The surgical note showed no measurement of length, width and depth.

During an interview on 12/20/16 at 10:50 AM, Staff DD, RN, stated that she thought that someone from surgery documented and measured the pressure sore and this is why she didn't document on Patient #10's pressure sore.

During an interview on 12/20/16 at 4:26 PM, Staff II, Nurse Manager for Four North and Four West, stated that she expected all nurses to measure and document all pressure sores on admission and with any dressing change.

17. Record review of discharged Patient #42's H&P dated 09/18/16, showed he was admitted to the ICU on that date with a diagnosis of diabetes (a disease when the body cannot rid itself of excess glucose/sugar in the blood and requires insulin to control; can increase risk for development of wounds, and also cause poor healing ability related to poor blood circulation). The patient had no pressure sores. The patient's albumin level was low at 3.4 g./dl.

Record review of the patient's admission nursing assessment dated 09/18/16, showed the following:
- He was placed on bedrest (decreased mobility is a risk factor for pressure sores).
- The patient was incontinent of urine (cannot control urination, moisture can also increase risk for pressure sores).
- He was identified as a medium risk for development of pressure sores at 3:35 PM, and a high risk at 8:00 PM.
- His skin was moist.
- He was not placed on a specialty mattress to prevent pressure sore development.

Record review of the patient's ongoing nursing shift assessments from 09/21/16 through 10/08/16 showed on 09/21/16 the patient was considered a high risk for development of pressure sores. His nutritional status was very poor (increased risk for pressure sores) as indicated by poor intake. He was not on a specialty mattress. He was still ordered to be on bedrest. As of 09/21/16, he had developed a Stage II pressure sore on his bilateral buttocks. Staff failed to measure and/or describe the Stage II pressure sore on the patient's buttocks from its development through the patient's discharge on 10/08/16.

Record review of a physician's progress note dated 09/22/16, showed no identification of the Stage II pressure sore on the patient's buttocks.

Record review of Nurses Notes showed the following:
- On 09/26/16, the patient had a poor appetite.
- On 10/07/16, the patient had a very poor appetite.
- On 10/08/16, the patient had a poor appetite.

Record review of an albumin level dated 10/02/16, showed it had decreased to 2.3 g./dl.

Record review of dietary assessments, from admission through discharge, showed no mention of the facility-acquired Stage II pressure sore, and no mention of the low albumin.

During an interview on 12/21/16 at 9:43 AM, Staff C, CNO, stated that the facility had not had a wound care team/clinician or nurse since her hire in 09/2016. Staff C had not read the pressure sore policy and was not sure if staff were to measure pressure sores. Staff C stated that she was aware that pressure sores was an area that needed attention/focus going forward.

18. Record review of the facility's policy titled, "Diagnostic Angiogram (a catheter inserted into a large vessel in the upper thigh (groin area) or arm and guided through the arteries of the heart to look for blockage) Post," dated 8/05/16 showed that after patients had an angiogram procedure the pressure dressing should be removed within 24 hours.

19. Record review on Four North of Patient #9's nursing assessments dated 12/14/16, 12/15/16 and 12/16/16 showed that the patient had a right inguinal (groin) puncture site with a gauze dressing post angiogram.

Observation on 12/19/16 at 2:22 PM, showed Patient #9's right groin puncture site to be without infection even though the dressing was left on for three days against the facility's protocol.

During an interview on 12/21/16 at 9:10 AM, Staff OO, Nurse Manager Four North, stated that the dressing that was placed following an angiogram should be removed after 24 hours.

During an interview on 12/21/16 at 9:25 AM, Staff PP, RN, Four North, stated that the dressing on an angiogram site was normally left in place for 24 hours. She stated that leaving the dressing on the site for more than 24 hours increased the potential for infection.

During an interview on 12/20/16 at 4:26 PM, Staff II, Nurse Manager for Four North and Four West, stated that the dressings on post cardiac catheterization (angiogram) patients should have been removed within 24 hours.






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