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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES was out of compliance.

A-0395 A registered nurse must supervise and evaluate the nursing care for each patient. Based on document review and interviews, the facility failed to ensure skin care assessments and interventions were performed and documented per policy in 2 of 3 medical records reviewed of patients with skin care concerns (Patients #1 and #3).

Based on document review and interviews, the facility failed to ensure skin care assessments and interventions were performed and documented per policy in 2 of 3 medical records reviewed of patients with skin care concerns (Patients #1 and #3).

Findings include:

Facility policies:

According to the Skin Assessment policy, a complete head to toe visual assessment of the skin is to be completed upon admission to the facility, reassessed each shift or reassessed after significant change in condition. Document assessment in the patient care record.

According to the Pressure Injury Prevention and Management policy, all patients will be evaluated for skin breakdown through completion of a skin assessment process. This will occur upon admission, minimum once per shift, following a change in medical condition and/or level of care, and at discharge. Based on the level of skin risk, nursing interventions will be initiated and will be captured on the patient's plan of care.

Reference:

According to the manufacturer's instructions for use for PureWick Female External Catheter, the PureWick Female External Catheter is intended for non-invasive urine output management in female patients. Placement: perform perineal care and assess skin integrity (document per hospital protocol). Maintenance: replace PureWick Female External Catheter at least every 8-12 hours or is soiled with feces or blood. Always assess skin for compromise and perform perineal care prior to placement of a new PureWick Female External Catheter. Recommendations: assess device placement and patient's skin at least every two hours.

1. The facility failed to ensure patients were assessed for skin breakdown in accordance with facility policy to ensure skin issues were addressed.

A. Review of Patient #1's record revealed that the patient arrived at the facility on 12/12/22 for intractable back pain related to surgery on 11/21/22 at another facility for metastatic spinal cancer. According to the Emergency Provider Report documented on 12/12/22 at 11:09 p.m., the patient's spinal incision site had staples in place and appeared to be healing well with no wound dehiscence (a partial or total separation of the wound edges). The provider's note stated there was a very small amount of erythema (redness of the skin) around the incision site but no induration (hardening of the skin) and did not appear consistent with cellulitis (skin infection).

i. The first skin assessment documented by nursing staff on 12/13/22 at 5:36 p.m. showed no evidence of a spinal incision or staples in place. Three days later, on 12/16/22 at 8:00 p.m., nursing documentation first reported a procedural site on the patient's back with staples.

ii. The nursing documentation of assessing the procedural site on the patient's back was inconsistent throughout the patient's stay. For example:

a. From 12/16/22 at 8:00 p.m. until 12/19/22 at 1:38 a.m., there was no evidence of an assessment of Patient #1's incision site. Nursing documentation during this time frame included reporting the dressing was intact or changed, however, there was no evidence nursing staff assessed the wound site for any changes. Also during this time frame, on 12/18/22, the infectious disease provider documented the middle of the wound had some purulent material (consisting of pus) visible. There was no documentation from nursing staff of purulent material during this time frame.

b. From 12/19/22 at 8:00 a.m. until 12/22/22 at 8:00 a.m., there was no evidence of an assessment of Patient #1's incision site. Nursing documentation during this time frame included reporting the dressing was intact, however, there was no evidence nursing staff assessed the wound site for any changes.

c. From 12/24/22 at 9:00 a.m. until 12/27 22 at 8:00 a.m., there was no evidence of an assessment of Patient #1's incision site. Nursing documentation during this time frame included reporting the dressing was intact, however, there was no evidence nursing staff assessed the wound site for any changes. Also during this time frame, on 12/24/22 and 12/25/22, the infectious disease provider documented the spine wound had a moderate, thin brownish drainage. On 12/26/22, the infectious disease provider documented there was serous (clear to yellow) drainage. There was no documentation from nursing staff of drainage from the wound during this time frame.

d. Similar findings of missing spinal incision site assessments by nursing staff occurred between 12/30/22 at 8:00 a.m. until 1/3/23 at 8:00 a.m.

e. On 1/4/23 at 2:43 p.m., a wound care consult note documented serous drainage oozed and with slight pressure more drainage occurred. The staples were documented as being removed on 1/4/23 at 3:19 p.m., six weeks after the patient's procedure.

B. Review of patient #3's record revealed the patient had a PureWick device (external female catheter) placed for voiding. According to the manufacturer's instructions for use for the PureWick Female External Catheter, the patient's skin should have been assessed at least every two hours. Also, the PureWick catheter was instructed to be replaced at least every 8-12 hours. Review of the medical record revealed inconsistencies with skin assessments and care while the PureWick device was in place. For example:

i. On 2/3/23 at 4:38 a.m., the patient's urine output was documented from the source of a PureWick device. Skin assessments were documented at 9:43 a.m. and 8:00 p.m. There was no evidence of skin assessments occurring in two hour increments between 9:43 a.m. and 8:00 p.m. In addition, there was no evidence of the catheter being replaced until approximately 23 hours later, on 2/4/23 at 8:00 a.m.

ii. On 2/4/23 at 5:55 p.m., urine output from the PureWick was documented in Patient #3's medical record. At 11:06 p.m., perineal care was provided to the patient. There was no further documentation of skin assessments or perineal care until 2/5/23 at 9:00 a.m.

iii. On 2/16/23 at 8:00 p.m., the medical record revealed Patient #3's PureWick was in place and had been applied on 2/4/23. The PureWick site was not assessed again until 2/17/23 at 9:37 a.m.

iv. Similar findings of a lack of skin assessments and care at the PureWick site were found between 2/17/23 at 09:37 a.m. to 2/21/23 at 6:12 p.m., at which time the PureWick was discontinued.

There was no evidence in the record the patient's skin was assessed every 2 hours while the PureWick was in use, nor was there evidence the catheter device was changed every 8-12 hours per the manufacturer's instructions.

C. Interviews revealed facility processes regarding skin care and assessments were not followed while Patients #1 and #3 received care at the facility.

i. On 3/22/23 at 10:25 a.m., an interview was conducted with wound nurse (RN #2). RN #2 stated staff was expected to assess patients' skin at least each shift and notify the provider of any changes or concerns. RN #2 stated staples or sutures typically remained in a patient for 7-10 days and could be removed by an RN with a provider's order.

ii. On 3/22/23 at 11:38 a.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated she worked on the medical-oncology unit. RN #1 stated anytime a patient had a wound or incision concern, she would request a wound consult. RN #1 further stated a wound care consult could be ordered by the nurse if there was a concern for skin breakdown or wound concern. During the interview, Patient #1 was discussed with RN #1. RN #1 stated she remembered assessing Patient #1's incision because she had to change the dressing over the incision due to the patient's incontinence. RN #1 stated she recalled Patient #1's incision to have had a lot of drainage, which she reported to the provider. RN #1 stated she did not recall seeing staples in the incision and would have documented if she had seen them. RN #1 stated it was typically up to the physician to determine how long staples stayed in an incision, however, prolonged staples were at risk to cause an infection.

iii. On 3/22/23 at 11:55 a.m. an interview was conducted with nursing director (Director) #3. Patient #1 was discussed with Director #3. Director #3 stated the providers overseeing the patient's care at the facility should have consulted with the original surgeon on how to care for the patient's incision. Director #3 stated if there were concerns with the incision during the patient's stay, she would expect the RN to report these concerns to the provider. Director #3 stated she was unsure what the risk would be if staples were left in an incision site for a prolonged amount of time. After reviewing the medical record for Patient #1, Director #3 verified there was a lack of documentation about the patient's staples in the patient's incision site. Director #3 stated it was rare for a patient to have staples on the unit and that patients were usually discharged after a few days.

iv. On 3/22/23 at 12:25 p.m., an interview was conducted with medical provider (Provider) #4. Patient #1 was discussed with Provider #4. Provider #4 stated due to the patient's cancer, the patient had poor wound healing from the procedure. Provider #4 explained the infectious disease (ID) team was following the patient due to the concern for a potential infection at the incision site. Provider #4 stated he expected RN staff to assess the incision and provide care to the incision. Provider #4 stated he provided care of Patient #1 later in her stay and was unsure as to why the staples were still in place. Provider #4 stated the staples were probably left in longer than they should have been. Provider #4 stated if staples were left in too long, there was a risk of the incision site becoming infected.

v. On 3/22/23 at 3:46 p.m., a second interview was conducted with Director #3. Director #3 explained the PureWick was a female catheter device used for patients who were unable to ambulate in order to prevent skin moisture and breakdown and for documenting accurate urinary output measurements. Director #3 stated the PureWick device was for single use, and needed to be changed if the patient had a bowel movement. Director #3 stated the PureWick placement and skin site should have been assessed every shift and potentially assessed more frequently due to patients' frequent position changes. Director #3 stated if the PureWick and skin site were not assessed there was a risk of the device leaking which could have caused a moisture related injury.

Director #3's interview stating the skin site should have been assessed at least every shift was in contrast with the PureWick manufacturer's instructions for use which recommended to assess the skin site at least every two hours.