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Based on record review and interview, the facility failed to include care planning of a wound and the appropriate corresponding nursing interventions for 2 ( #1 and #2) of 16 ( #1 through #16 patients). Also, the facility staff failed to maintain transparent lines of communication between the family caretaker of Patient #2 to enable them to participate in the care planning process.

This deficient practice had the likelihood to affect all patients of the facility.


Findings included:


Patient #1 was admitted 12/15/2022 with a posterior upper leg wound. The nursing documentation referred to the assessment of the suture site, from a recent above the knee amputation. Wound pictures were taken to verify the suture line. Included in the picture was a wound to the posterior upper left leg (not measured by hospital nurses). The wound extending from just behind the knee to the mid posterior thigh in length and the width was mid inner thigh to the mid outer thigh. There was no evidence of an assessment, length, width, depth, color, odor, drainage treatment, dressing, or pain related to this wound being documented. There was no care plan problem created in the patient's nursing care plan and no nursing interventions were established or documented as implemented for facilitating healing and continuity of nursing care.


Patient #2
The social intake documented Patient #2 was a 21-year-old male, who lived at home with his mother and sister. Patient #2 had a lifelong diagnosis of Lennox-Gastaut syndrome and severe mental retardation. He was nonverbal and could not follow directions or make his needs known. The nursing documentation identified in pt #2's medical record may be reviewed in the following assessment of Patient #2's ear wound, when it was initially discovered and entered into the record. Registered Nurse staff #15 documented;

"Date first assessed:05/10/2023-EM 05/10/2023 1617
"Time first assessed 1600-EM, 05/10/2023 1617"
"Preexisting: Acquired this wound during this hospitalization-(sic), 5/10/2023 1617.
"Location: Ear-EM. 05/1-/2023,1617"
"Wound location orientation: Posterior; Right, 05/10/20231617
"Non staged"
"Wound description: Eschar".

There was no documentation the family was made aware of the wound.

When the family visited the patient on 05/14/2023 the family found Patient #2's ear wound and a second wound to the dorsal neck. A review of the nursing documentation failed to reflect an assessment of the patient's neck wound.

Patient #2's nursing care plan was reviewed and revealed the following. Patient #2's right ear wound was documented in the nursing notes as present on 05/10/23. There was no nursing problem addressing the right ear wound in the care plan. There were no nursing interventions recorded in patient #2's care plan to facilitate healing and ensure continuity of nursing care.

This absence of care planning entry was confirmed by Staff #7 on 6/26/2023, who stated, "I don't see any problem entered in the chart regarding the wound to patient #2's ear. There were no interventions for wound care or offloading". There was no documentation that the family was involved in the care planning process until patient #2's mother requested a transfer to another hospital. The chart reflected the physician did not document family involvement until the family requested a transfer.

Based on record review and interview, the facility failed to ensure the consent to treat and Patient Right form was provided to the family for signature for 1 (Patient #2) of 16 patients (#1 through #16) charts reviewed.

This deficient practice had the likelihood to affect all patients of the facility.


Findings included.


Patient #2 was transported to the Emergency Department via EMS (Emergency Medical Services) with seizures, status epilepticus. Patient was unable to support healthy respiratory status. Patient #2 was intubated upon arrival to the ED and sedated to attempt to stop the seizures.

A review of the Consent to Treat and Patient Right forms were reviewed in the EMR (Electronic Medical Record). The Patient Rights form did not have a signature for either the patient or his family representative. The signature line had "Patient unable" written on it. There were no signature witnesses by the facility staff .

The Consent to Treat had a scribbled, illegible mark scrawled across the signature line. Below the signature line was printed, "Signature captured by electronic pad". There were no signatures of witnesses or explanation who signed, if a family member signed, or that the scribble represented the patient signature due to patient was sedated and intubated on arrival.

Patient #2 's mother was interviewed and stated, "I got there real quick after the ambulance arrived at the hospital. I would have signed for his care."

Based on record review and interview, the facility failed to

A. meet the physical needs (repositioning/offloading of head, ears, and neck, assessing left ear wound, changing left ear wound dressing).

B. document awareness of the beginning of deep tissue injury that resulted in an Eschar-covered wound on patient #2's left upper ear.

C. follow the facility's established inpatient Wound Care policy, for two patients (#1 and #2) of 16 patients (#1 through #16) whose records were reviewed.

Refer to tag A0392

Based on record review and interview, the facility failed to

A. meet the physical needs (repositioning/offloading of head, ears, and neck, assessing left ear wound, changing left ear wound dressing).

B. document awareness of the beginning of deep tissue injury that resulted in an Eschar-covered wound on patient #2's left upper ear.

C. follow the facility's established inpatient Wound Care policy, for two patients (#1 and #2) of 16 patients (#1 through #16) whose records were reviewed.


This deficient practice had the likelihood to affect all patients of the facility.

Findings included:

A review of the facility's policy titled, "Wound Care -Inpatient #7085-0006" revealed the following:

"Purpose: to Specify criteria that will initiate a referral to the In-patient Wound Care Team.

Policy: The Inpatient Wound Care Team members are accessible to all health care system staff to assist with wound care needs of all patients and to provide wound care education to all clinical health system employees.

Procedure:
1. A consult to the Inpatient Wound Care Team is automatically generated by the electronic record for all Braden Score < 13. Any patient admitted to the health care system who has an existing wound or by request (i.e. Family, Nursing, Physical therapy, etc.) should be referred for consult to Inpatient Wound Care.
2. ALL referrals are entered into EMR, Consult Wound Care.
3. The Inpatient Wound Care Team consult will occur 24-48 hours of receipt of referral.
4. The patient's primary nurse will implement nursing interventions, depending upon the patient's level of identified risk (see Braden Scale Prevention), prior to being seen by an Inpatient Wound Care RN.
5. The Inpatient Wound Care Team's assessment of each patient will include:
5.1 Review of History and Physical
5.2 Targeted medical record review
6. The Inpatient Wound Care Team will recommend individualized Braden Scale interventions.
7. The Inpatient Wound Care Team will develop interventions based upon current evidence-based guidelines, and when appropriate, address etiology; factors that may affect healing, topical therapy, pain management; patient and caregiver education; and date gained from serial assessments of deterioration or failure to progress toward healing.
8. Follow up assessments should be performed at least weekly.
9. Care plan notes will be updated when the patient is seen by a member of the Inpatient Wound Care Team.
(It must be noted, the above policy does not refer to the physician at any point. Within the State, RN's must not function outside their scope of practice and a physician must be the involved).AA"

A.

Patient #2

Upon admission, 05/01/2023, to the acute hospital, patient #2 was assessed by staff #18, the receiving Registered Nurse (RN), and documentation indicated, "No skin breakdown". Upon patient #2's ED intubation and sedation, he became bed-confined and unable to meet his own needs. Patient #2 was 100% dependent on the facility's nursing staff for care and comfort. Documentation identified in patient #2's MR confirmed RN's consistently documented position changes to avoid skin breakdown of patient #2's heels and buttock. A thorough review of patient #2's EMR failed to identify evidence of documentation that included patient #2's upper body (Head, neck, and ears) for symptoms of pressure-related skin breakdown included in every 2-hour repositioning of patient #2.

Observed in the wound care photograph of patient #2's right ear, was a white netting affixed over his head. Staff #7 was asked why was netting applied over his head. Staff #7 replied, "He likely had electrodes placed in his hair/scalp and they were trying to keep them in place for an EEG (Electroencephalogram)". The order for an EEG was confirmed.

Staff did realize that netting can cause pressure to the head and ears. The weight of a human head is 5-11 pounds of pressure, enough to cause reduced blood flow to the cartilage of the human ear. If the netting had moved over the top of patient #2's right ear or behind it during repositioning
and remained in place for 2 hours, the netting was sufficient to cause reduced blood flow. Pt #2 was intubated and sedated. He was unable to move or reposition his head/ear for comfort. The nursing staff failed to meet the physical needs of a sedated patient.




B.
Patient #2

On 06/26/2023 in the conference room, the EMR was again reviewed to identify the daily shift nurses, skin assessment. The assessment consistently documented, "repositioned every 2 hours, skin clean dry and intact". With the assistance of staff #7 and #1, both reviewed the EMR for patient #2. Both staff #7 and #1 stated, "We didn't find any documentation" (that indicated staff awareness of the wound to the left ear until Wound Care Nurses pictured the left ear with eschar-covered tissue on 05/10/2023). The EMR did not contain documentation of any staff RN being aware tissue injury had begun on patient #2's left ear until 05/10/2023, 10 days after admission.

EMR documentation may be read below for pt. #2:

"Date First Assessed: 05/10/23 -EM, 05/10/23 1617
Time First Assessed: 1600 -EM, 05/10/23 1617
Acquired this wound during this hospitalization, 05/10/23 1617.
Location: Ear -EM, 05/10/23 1617 Wound Location Orientation: Posterior; Right, 05/10/23 1617 Non-staged Wound Description:
Eschar -EM, 05/10/23 1617"


The definition and characteristics of Eschar/slough may be found at, "ncbi.nlm.nih.gov" (National Center for Biotechnology Information, National Library of Medicine, National Institute of Health, Government). Refer to the information below:

"Assessing wounds: The size of the wound should be assessed at first presentation and regularly thereafter.
Necrotic tissue: The wound may be covered with necrotic tissue (non-viable tissue due to reduced blood supply), SLOUGH (dead tissue, usually cream or yellow in color), or ESCHAR (dry, black hard necrotic tissue".
The NPUAP (National Pressure Ulcer Advisory Council) statement on Eschar reads, "Eschar represents an unstageable Pressure injury".

The nursing staff was unaware deep tissue injury had begun prior to eschar covering patient #2's right ear.

C. Patient #1

Patient #1 was admitted on 12/15/2022 with complaints of nausea, vomiting, and diarrhea. Patient #1 had been seen on the day of admission in the office by the vascular surgeon for a follow-up of Left above-the-knee amputation. The patient's electronic medical record (EMR) was reviewed with the assistance of Staff #7, the EMR Supervisor, and the Program Manager.

The EMR documented the recent visit to the vascular surgeon, who indicated to the family, "The suture line looked healthy, and the sutures had been removed. The small openings in the skin from the incision would heal on their own".

The nursing documentation referred to the assessment of the suture site. Wound pictures were taken to verify the suture line. Included in the picture was a wound to the posterior upper left leg. The wound extended from just behind the knee to the mid posterior thigh in length and the width was mid inner thigh to the mid outer thigh (not measured by hospital nurses). The picture showed the wound tissue to have a red wound bed. The edges of the wound were "Punched out" (raised with a deep rim, as opposed to smooth flush granulating tissue near the healing edges of a wound). This picture surprised Staff #7, who stated, "Wow, from the documentation, I wasn't expecting that".

Nursing documentation from the staff nurses did not include an assessment of the posterior thigh wound. There was no description of this wound documented. The method of cleansing this wound, or the type of dressing included as part of the treatment was not documented. Staff failed to follow the facility policy for wound assessment and care.


Patient #2

On 06/26/2023 with the assistance of Staff #7, the EMR review indicated Pt #2 was admitted 5/1/2023. The first entry establishing neuro ICU nursing awareness of pt. 2's wound was 5/10/2023. On 5/10/2023 RN #15 recorded in his documentation, "Pt has redness, and scabs on the skull directly behind the ear and on his-(sic)", the EMR documentation failed to capture the end of the sentence. Staff #17 entered the following entry into the EMR, "Authorized by Dr #17, per protocol, no co-sign required". Staff #7 explained the authorization was for a wound care consult. The above assessment, by staff RN #17 was the only documentation of pt. #2's wound, other than photographs of the wound that were identified in the EMR.

The EMR reflected 5/13/2023, that Physician #17 ordered Mupirocin Dressing changes BID and as needed. The wound care policy failed to indicate whose responsibility wound care dressing changes fell to. Staff #7 was asked who was responsible to ensure the dressing change was done. Staff #7 replied, "If it is a simple dressing change, the floor nurses would do it. If it was a specialty dressing change, such as a replacement of a VAC (Vacuum Assisted Closure device) the wound Care nurses would be responsible for that". The EMR indicated the order was, "Mupirocin to wound BID (2 times a day) and as needed". Staff #7 stated, "That is a simple dressing change order."

Pt. #2's EMR consistently recorded "UTA" each day. Staff #7 was asked what "UTA" represented. Staff #7 replied, "Unable to assess". When staff #7 was asked why the nurse who was tasked with a BID dressing change was unable to assess. Staff #7 replied, "I'm not sure unless the wound was always covered and not visible to the nurse". "UTA" indicated the Registered Nurse failed to document the removal of the dressing and assessment of the wound. On 5/13/2023 at 0555, staff Neuro ICU nurse #21 documented "dressing changed". On 5/13/2023 at 0626, Staff Neuro ICU nurse #19 documented a dressing change. On 5/16/2023 staff Neuro ICU, #19 documented a Dressing change, and on 5/17/2023 staff Neuro ICU nurse #20 documented "Wound care provided". There was no further documentation identified for the assessment of patient #2's right ear wound.
The Registered Nursing staff failed to follow the facility policy for wound assessment and wound care dressing changes.

Based on observation, document review, and interview the hospital failed to:

A. ensure a policy and/or process was in place for the safe and secure storage of radioactive dye (Intravenous Contrast) in 1 (Radiology) of 2 departments (Radiology and Emergency) observed.

B. follow the manufacturing guidelines for use on multidose bottles of IV Contrast.

C. ensure the IV Contrast was stored at temperature ranges recommended by the manufacturer in 2 (Radiology and Emergency) of 2 departments observed.

Cross Refer to Tag A 0535

Based on observation, document review, and interview the hospital failed to:

A. ensure a policy and/or process was in place for the safe and secure storage of radioactive dye (Intravenous Contrast) in 1 (Radiology) of 2 departments observed (Radiology and Emergency).

B. follow the manufacturing guidelines for use on multi use bottles of IV Contrast.

C. ensure the IV Contrast was stored at temperature ranges recommended by the manufacturer in 2 (Radiology and Emergency) of 2 departments observed.

Findings:

A. A tour was conducted in the Radiology Department on 6/27/2023 at 9:30 AM with Staff#3 and #8. In the main Radiology Department, it was observed that multidose IV Contrast bottles were stored in an unlocked cabinet in CT room one. Radiology Staff#3 reported that the cabinet was able to be locked but was kept unlocked while radiology staff were on site. Radiology room one was observed unattended while patient family members were standing in the radiology department hallway between room one and room two.



B. An observation tour of the ED (Emergency Department) was conducted on 06/26/2023 at 1030 AM with ED staff #2. It was reported by ED staff #2 that the department had a new Computed Tomography (CT) machine. When entering the CT room in the ED, a bottle of IV Contrast connected to a liter bag of normal saline was observed hanging from a pole that was connected to the CT machine. Upon further observation of the contrast, it was noted there was no date or time documented on the bottle confirming when the bottle was opened as recommended by the manufacturer. The CT machine was ready to receive a new patient.

An interview was conducted with staff #8 on 06/26/2023 at 10:40 AM. Staff # 8 was asked if the facility had a policy regarding labeling and monitoring the IV contrast bottles. Radiology staff#8 reported that the facility follows manufacturing guidelines for the multidose IV Contrast bottles. Radiology staff #8 confirmed that the IV Contrast bottles should be discarded 10 hours after opening. Radiology staff # 8 was unable to provide a date or time when the IV Contrast bottle was opened.

A tour of the main Radiology department was conducted between 11:00 AM and 12:00 PM with Radiology Staff #3 and Staff #5. Two CT machines were observed in the main radiology department. In room one, a multidose bottle of IV contrast connected to a pole, in preparation for patient use. The IV contrast bottle and one-liter normal saline bag was noted to have an expiration date and time written on the label. The time written on the bottle was noted to be past the expiration time. Radiology Staff #3 confirmed the bottle was expired according to the manufacturer guidelines.

An interview was conducted with Staff #3 on 06/26/2023 at 1140 AM. Staff#3 was asked what the departments process was for labeling and monitoring the multidose IV contrast bottles. Staff #3 replied that all staff are to follow manufacturing guidelines and discard the bottles 10 hours after opening.

An observation of CT Room #2 revealed a multidose bottle of IV contrast hanging on the pole connected to the CT machine. The bottle had a date and time of opening written on the label. Radiology Staff #3 could not provide a reason why the IV Contrast and normal saline were labeled with an opening date and time. Radiology Staff#3 confirmed that the labels should reflect the date and time of expiration, 10 hours after opening per manufacturing guidelines.

C. During a tour on 06/27/2023 of the Radiology Department and the ED CT rooms revealed the following:

CT Room #1 in the main Radiology Department, a metal cabinet was noted to be storing multiple bottles of multidose IV Contrast in an unlocked cabinet. There was a thermometer inside the cabinet but there was no temperature log for the room or the cabinet to ensure the IV contrast was stored according to the manufactures recommended temperature guidelines of 68-77 degrees Fahrenheit. Staff#3 confirmed CT room #2 and the CT room in the ED did not have a temperature log either.

A review of the manufacturing guidelines for (IV Contrast) was as follows:

"A maximum use time of 10 hours from initial closure entry is permitted to complete fluid transfer. Any unused ISOVUE injection must be discarded 10 hours after initial puncture of the Imaging Bulk Package. After the container closure is punctured, if the integrity of the Imaging Bulk Package and the delivery system cannot be assured through direct continuous supervision, the Imaging Bulk Package and all associated disposables for the automated contrast injection system, contrast management system, or contrast media transfer set should be discarded. Storage temperature of the ISOVUE Imaging Bulk Package container after the closure has been entered should not exceed 25 degrees Celsius (77 degrees Fahrenheit); however, it is desirable that the contents be warmed to body temperature prior to injection. Store at 20-25 degrees Celsius (68-77 degrees Fahrenheit). Protect from light."


An interview was conducted with Staff#3 and Staff#5 on 06/26/2023 after 12:00 PM. Staff#3 and #5 confirmed there was no policy available for review for the storage and use of multidose bottles of IV Contrast.