HospitalInspections.org

Based on record review and staff interview, the Chief Executive Officer failed to establish a mechanism to ensure that Patient Care Technicians received education on proper bedpan use with patients. This deficiency has the potential to affect all patients.


Findings include...


Based on a written statement provided by Patient #1, he was placed on the bedpan on a day between March 11 and 13, 2017. The patient states that he fell asleep on the bedpan and was "left unattended for several hours...When I woke up I was finally attended to." After shift change, hospital staff came to take him off of the bedpan and remarked, "...You can see the imprint of the bedpan...".


During a face to face interview with Employee #3, Quality, Safety, and Education Nurse, on 10/27/17 at 10:15 AM, she confirmed that the incident did occur, as reported, on 3/11/17. She provided education presented to nursing staff dated 07/12/17 regarding the incident. Employee #3 presented a sign in sheet with the names of the participants. Only nursing staff was included.


A telephone interview was conducted on 11/29/17 at 8:00 AM, with Employee #7, PCT, who placed Patient #1 on the bedpan on the morning of 03/11/17. The surveyor conducted the interview in the presence of Employees #1, 3, and 6. Employee #7 stated that he remembered Patient #1, but did not remember the incident. He went on to say that he recalled the patient needed maximum assistance. When asked about the education or counseling received after the incident, he stated that he received no education or counseling and that the incident was brought to his attention "about two months ago, maybe in August."


The surveyor conducted a telephone interview on 11/29/17 at 3:05 PM, with Employee #8, the oncoming PCT, in the presence of Employees #1, 3, and 6. Employee #8 stated that part of the PCT process at shift change is to conduct a bedside shift report for each patient. She stated that on the morning of the incident, bedside shift report was not performed for Patient #1.


During that same telephone interview, Employee #6, Patient Care Manager (PCM) for 3North East, stated that there was a huddle with all of the PCT's to discuss usage of the bedpan and the length of time that patients should be left on the bedpan. Employees #1, 3, and 6 were unable to provide the documentation of the education or the attendance. When asked how the facility ensured that PCT staff was knowledgeable about risks for impaired skin integrity related to the use of bedpans, Employees #1, 3, and 6 could provide no further insight. They acknowledged the findings.


Based on record review and staff interview, the Chief Executive Officer failed to ensure the quality of care for a patient with a pre-existing pressure ulcer in one of 10 medical records reviewed (Patient #1).


Findings included...


Medstar Washington Hospital Center Policy entitled "Pressure Ulcers, Prevention and Treatment," effective 7/2015, shows that there will be a Wound/Ostomy/Continence Nurse (WOCN) consult for any pressure ulcer that has not improved within one week, or has deteriorated.


Review of the medical record showed that the physician admitted Patient #1 for Unstable Angina and past medical history of Multiple Sclerosis. A nursing assessment dated 03/02/17 at 2:00 PM indicated that Patient #1 had a Stage 2 Pressure Ulcer measuring 1 centimeter (cm) by 1 cm, located on his coccyx. A wound care consult was ordered 03/02/17 at 6:27 PM.


Review of an integumentary assessment dated 03/08/17 at 8:00 AM showed that Patient #1's stage 2 ulcer had increased in size to 3 cm x 3 cm. The record lacked evidence that the patient was assessed by wound care, per policy and physician order.


Based on a written statement provided by Patient #1, he was placed on the bedpan during shift change from night to day, by a Patient Care Technician (PCT), on a day between March 11 and 13, 2017. The patient states that he fell asleep on the bedpan and was left unattended for what was described as several hours. After shift change, hospital staff came to take him off of the bedpan and remarked that she could see the imprint of the bedpan around his buttocks. During a face to face interview with Employee #3, Quality, Safety, and Education, on 10/27/17 at 10:15 AM, she confirmed that the incident did occur as reported by the patient on 03/11/17. There was no evidence in the medical record regarding the incident.


During a telephone interview with Employee #8, PCT, on 11/29/17 at 3:05 PM, she stated that when she performed her rounds after shift report for the day shift on 03/11/17, Patient #1 told her that he was on the bedpan. When she assisted with taking him off of the bedpan, she noticed that he had a circle around his buttocks and notified the nurse.


Review of integumentary nursing assessments dated 03/11/17 to 03/12/17 described the ulcer as flat, pink and red in color, poorly defined with granulation tissue and no exudate. The integumentary assessment dated 03/13/17 at 7:00 AM showed that the wound had a moderate amount of serous exudate, and was healing. The assessment dated 03/13/17 at 8:00 PM revealed that the wound was healing, depressed, and brown, with a moderate amount of serous exudate. There was no documented evidence of physician notification regarding the status of the wound, additional orders for a wound care consult, or communication with the wound care team regarding the change in wound status.


Review of the integumentary assessment dated 03/14/17 at 7:00 AM showed that the wound was a healing stage 2 wound with a moderate amount of strong smelling serous exudate. A subsequent note from that day at 11:00 AM, completed by the Wound Ostomy Care Nurse (WOCN), showed that the wound was depressed, brown and tan, measuring at 6.5cm x 5cm. The wound was unstageable and had a moderate amount of strong smelling seropurulent drainage, 70%necrotic tissue/ moist eschar, and 30 % necrotic tissue/dry eschar.


Further review of the medical record showed that Patient #1 underwent a sacral debridement on 03/17/17; a hematoma evacuation of the sacral wound on 03/20/17; and a sacral debridement on 04/05/17.


During a face to face interview on 10/27/17 at 10:48 AM, Employee #12, WOCN, she stated that some of the consults are generated by the system when the nurse enters certain information. She went on to say that based on the volume of the consults, they don't address every consult generated by the system. She stated that an increase in drainage or size would show that the wound was not healing. Employee #12 acknowledged the above findings.

Based on record review and staff interview, the facility failed to protect patient's right to care in a safe setting as evidenced by the worsening of a community acquired pressure ulcer for one patient (Patient #1); and failed to ensure Patient Care Technician staff were educated on the proper use of bedpans to prevent alterations in skin integrity for at risk patients.


The findings included ...


Medstar Washington Hospital Center Policy entitled "Pressure Ulcers, Prevention and Treatment," effective 7/2015, shows that the Wound/Ostomy/Continence Nurse (WOCN) will be consulted for any pressure ulcer that has not improved within 1 week or has deteriorated.


Review of the medical record showed that the physician admitted Patient #1 for Unstable Angina and past medical history of Multiple Sclerosis. A nursing assessment dated 03/02/17 at 2:00 PM indicated that Patient #1 had a Stage 2 Pressure Ulcer measuring 1 centimeter (cm) by 1 cm, located on his coccyx. A wound care consult was ordered 03/02/17 at 6:27 PM.


Review of an integumentary assessment dated 03/08/17 at 8:00 AM showed that Patient #1's stage 2 ulcer had increased in size to 3 cm x 3 cm. The record lacked evidence that the patient was assessed by wound care, per policy and physician order.


Based on a written statement provided by Patient #1 on 08/09/17, he was placed on the bedpan during shift change from night to day, by a Patient Care Technician (PCT), on a day between March 11 and 13, 2017. The patient states that he fell asleep on the bedpan and was left unattended for several hours. After shift change, hospital staff came to take him off of the bedpan and remarked that she could see the imprint of the bedpan around his buttocks. Over the next three days, Patient #1's pressure ulcer evolved to an unstageable ulcer requiring multiple debridement procedures. During a face to face interview with Employee #3, Quality, Safety, and Education, on 10/27/17 at 10:15 AM, she confirmed that the incident did occur as reported by the patient on 03/11/17. There was no evidence in the medical record regarding the incident.


During a telephone interview with Employee #8, PCT, on 11/29/17 at 3:05 PM, she stated that when she performed her rounds after shift report for the day shift on 03/11/17, Patient #1 told her that he was on the bedpan. When she assisted with taking him off of the bedpan, she noticed that he had a circle around his buttocks and notified the nurse.


Review of integumentary nursing assessments dated 03/11/17 to 03/12/17, described the ulcer as flat, pink and red in color, poorly defined with granulation tissue and no exudate. The integumentary assessment dated 03/13/17 at 7:00 AM showed that the wound had a moderate amount of serous exudate, and was healing. The assessment dated 03/13/17 at 8:00 PM revealed that the wound was healing, depressed, and brown with a moderate amount of serous exudate. There was no documented evidence of physician notification regarding the status of the wound, additional orders for a wound care consult, or communication with the wound care team regarding the change in wound status.


Review of the integumentary assessment dated 03/14/17 at 7:00 AM showed that the wound was a healing stage 2 wound with a moderate amount of strong smelling serous exudate. A subsequent note from that day at 11:00 AM, completed by the WOCN, showed that the wound was depressed, brown and tan, measuring at 6.5cm x 5cm. The wound was unstageable and had a moderate amount of strong smelling seropurulent drainage, with 70%necrotic tissue/ moist eschar, and 30 % necrotic tissue/dry eschar.


Further review of the medical record showed that Patient #1 underwent a sacral debridement on 03/17/17; a hematoma evacuation of the sacral wound on 03/20/17; and a sacral debridement on 04/05/17.


During a face to face interview on 10/27/17 at 10:48 AM, Employee #12, WOCN, she stated that some of the consults are generated by the system when the nurse enters certain information. She went on to say that based on the volume of the consults, they don't address every consult generated by the system. She stated that an increase in drainage or size would show that the wound was not healing. Employee #12 acknowledged the above findings.



During a face to face interview with Employee #3, Quality, Safety, and Education, on 10/27/17 at 10:15 AM, confirmed that the incident did occur, as reported, on 3/11/17. She provided education presented to nursing staff dated 07/12/17 staff regarding the incident. Employee #3 presented a sign in sheet with the names of the participants. The staff included nursing staff only.


A telephone interview was conducted on 11/29/17 at 8:00 AM, with Employee #7, PCT, who placed Patient #1 on the bedpan. The surveyor conducted the interview in the presence of Employees #1, 3, and 6. Employee #7 stated that he remembered Patient #1, but did not remember the incident. He went on to say that he recalled the patient needed maximum assistance. When asked about the education or counseling received after the incident, he stated that he received no education or counseling and that the incident was brought to his attention "about two months
ago."


The surveyor conducted a telephone interview on 11/29/17 at 3:05 PM, with Employee #8, the oncoming PCT, in the presence of Employees #1, 3, and 6. Employee #8 stated that part of the PCT process at shift change is to conduct a bedside shift report for each patient. She stated that on the morning of the incident, bedside shift report was not performed for Patient #1.


During that same telephone interview, Employee #6, Patient Care Manager (PCM) for 3North east, stated that there was a huddle with all of the PCT's to discuss usage of the bedpan and the length of time that patients should be left on the bedpan. Employees #1, 3, and 6 were unable to provide the documentation of the education or the attendance. When asked how the facility ensured that PCT staff was knowledgeable about risks for impaired skin integrity related to the use of bedpans, Employees #1, 3, and 6 could provide no further insight. They acknowledged the findings.