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Based on record review and interview, the Governing Body failed to recognize that the contract for vascular access services had expired and that services were provided by Staff #8 to 2 (Patient #8 and #9) out of 2 patients whose records were reviewed. Additionally, the Governing Body failed to recognize that the service provider did not have current competencies for 1 (Staff #8) out of 2 staff members.

The deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Cross-Refer to Tag: A0083

Based on record review and interview, the Governing Body failed to recognize that the contract for vascular access services had expired and that services were being provided by the contract staff to 2 (#8 and #9) of 2 patients whose records were reviewed. Additonally, the Governing Body failed to recognize that the contract service provider did not have current competencies for 1 (#8) of 2 staff members.

This deficient practice being provided by the individual(s) performing vascular access without current skills and competencies increase the likelihood of increased risk of bleeding, cardiac arrhythmia, blood clots, entrance of air into the vein, injury to an artery or nerve, infection, and/or death.

The deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients requiring vascular access services at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Findings include:

A record review on 5/22/2024 at 11:15 AM, revealed that the service contract for "Vascular Access Services", by the vendor "Institute of Nursing Excellence, Inc." expired on January 14, 2024. Contract Staff #5 and #8, PICC RN, continued to provide services to patients requiring vascular access through 5/22/2024.

In an interview with Staff #3 on 5/22/2024 at 11:15 AM in the conference room. The surveyor asked if there were any other contracted services for vascular access and Staff #3 stated, "No, we just use one service which is the contract that I provided yesterday (5/21/2024)." The surveyor asked Staff #3 if there was a more current contract and Staff #3 stated, "The one I provided was our most current contract."

A review of Patient #8's chart revealed on 5/20/2024 at 5:50 PM, Contract Staff #5 (PICC RN) provided vascular access services through insertion of a PICC Line (Peripherally Inserted Central Catheter) on Patient #8. A PICC is a long catheter that is inserted into a vein in the patient's arm. The tip of the catheter is positioned in a large vein that carries blood into the heart. It is used for long-term use of nutrition, and/or medication.

A review of Patient #9's chart revealed Contract Staff #8 (PICC RN) inserted a PICC Line on Patient #9 on 5/21/2024 at 9:21 AM.

In an interview with Staff #1 on 5/22/2024 at 2:30 PM confirmed that the Vascular Access Service contract on file had expired January 14, 2024. Staff #1 acknowledged that was an oversight for not obtaining an updated contract from the corporate office to ensure the hospital had a current contract. Also, Staff #1 confirmed that the governing body had not been reviewing the competencies of contracted staff, which should have been done for patient safety.

Based on record review, and staff interview, the hospital's nursing staff failed to assess patients in restraints in 4 (#1, #10, #12, #17) of 4 patient records reviewed.


Cross Refer to A 0164 and A 0175

Based on record review, and staff interview the hospital's nursing staff failed to indicate and document the circumstances and patient's condition or symptoms that led to restraint use and the need for restraints for 2 ( #12, #17) of 4 (#s 1, 10, 12, and 17) patient records reviewed.

Findings include:

Patient #12

A review of Patient # 12's medical records revealed that Patient #12 had bilateral wrist restraints applied on 12/27/23, at 1:06 AM. There was no documentation or explanation to indicate the necessity of the restraints. The restraints were removed at 5:00 AM on 12/27/23. There was a gap of 3 hours and 54 minutes without any documented reassessments, interventions, or justification for their initial application.


Patient #17

A review of Patient #17's medical record revealed that Patient # 17 had bilateral wrist restraints applied, but there was no documented date or time for when the restraints were initiated or the indication for the use of restraints. The first documented time was on 4/04/24, at 8:15 PM for a "reevaluation," with subsequent reevaluations every two hours until 4/05/24, at 5:45 AM. After this, the next documented reevaluation occurred on 4/05/24 at 7:00 PM. There was a gap of 13 hours and 15 minutes without any documented restraint reevaluation or interventions. Additionally, there was no documentation to support when the restraints were discontinued.

A record review of the hospital's policy titled "Restraint and Seclusion" Dated: 6/2023, revealed:

"H. Periodically Assessing, Assisting and Monitoring The Patient In Restraint Or Seclusion

...vi) Care is provided at least every 2 hours to include:
*Offer of fluids/nourishment
*Hygiene care as required
*Toileting as required
*Release of extremities and range of motion exercises provided ...

I. Documentation

Each episode of restraint is documented in the patient's medical record, consistent with policies and procedures.
i) Circumstances and patient's condition or symptoms that led to restraint use, description of patient's behavior.
ii) Consideration or failure of alternative interventions.
iii) Rational for the type of interventions selected ...
ix) ...All assessments and monitoring of the patient.
x) Patient's response to the intervention, including the rationale for continued use of the intervention.
xi) Document the time the restraint is released and response of patient to release of restraint and any action taken ..."


On 5/22/2024, at 10:45 AM in the Conference Room, an interview was conducted with Staff #3, the Director of Quality, and Staff #12, Nursing Informatics. It was confirmed during the interview that the charts and restraint log which were reviewed had multiple missed opportunities for documenting restraint initiations, reevaluations, and discontinuations. Staff #3 mentioned that due to the presence of many new nurses, it had been challenging to ensure documentation despite educational efforts. An attempt was made to navigate through the charts to find documentation in other areas, but Staff #12 was unable to locate any. It was also confirmed by Staff #12 that there was a lack of documentation in all of the reviewed charts.

Based on record review, and staff interview the hospital's nursing staff failed to assess patients in restraints in 4 (#1, #10, #12, #17) of 4 patient records reviewed. Also, the hospital's nursing staff failed to follow the hospital policy, "Restraint and Seclusion".

Findings include:

Patient #1

A review of Patient #1's medical records revealed that bilateral wrist restraints were initiated because the patient was attempting to pull out intravenous (IV) lines and had altered mental status. The restraints were initiated on 9/19/2022 at 3:50 PM with documented re-evaluations every two hours. The final re-evaluation was on 9/19/2022 at 11:00 PM. There is no evidence of documentation of a reevaluation, or any interventions documented until 9/20/2022 at 5:00 AM. There was a gap of 6 hours without documented reassessments or interventions.

Patient #10

A review of Patient # 10's medical records revealed Patient # 19 had bilateral wrist restraints initiated on 12/16/2023 at 9:00 AM because the patient required intubation. Intubation is a medical procedure where a tube is placed into a person's airway to help them breathe. This tube ensures that air can get to the lungs. Restraints are used on intubated patients to prevent the patient from pulling the tube out and damaging the esophagus and/or vocal cords. The medical record revealed documentation from 12/16/2023 at 9:00 AM, when the restraints were initiated, and every 2 hours, when a reevaluation was documented, through 12/17/2023 at 7:00 AM.

There was no documentation to indicate when the restraints were discontinued. According to the patient's medical record, the patient was extubated on 12/17/2023 at 3:19 PM. Extubation is the process of removing a tube from someone's airway after it has been used to help them breathe. There is no evidence of documentation after 7:00 AM on 12/17/2023, indicating that the patient was reevaluated or when the restraints were discontinued.

Patient #12

A review of Patient # 12's medical records revealed that Patient #12 had bilateral wrist restraints applied on 12/27/23, at 1:06 AM. There was no documentation or explanation to indicate the necessity of the restraints. The restraints were removed at 5:00 AM on 12/27/23. There was a gap of 3 hours and 54 minutes without any documented reassessments, interventions, or justification for their initial application.


Patient #17

A review of Patient #17's medical record revealed that Patient # 17 had bilateral wrist restraints applied, but there was no documented date or time for when the restraints were initiated or the indication for the use of restraints. The first documented time was on 4/04/24, at 8:15 PM for a "reevaluation," with subsequent reevaluations every two hours until 4/05/24, at 5:45 AM. After this, the next documented reevaluation occurred on 4/05/24 at 7:00 PM. There was a gap of 13 hours and 15 minutes without any documented restraint reevaluation or interventions. Additionally, there was no documentation to support when the restraints were discontinued.

A record review of the hospital's policy titled "Restraint and Seclusion" Dated: 6/2023, revealed:

"H. Periodically Assessing, Assisting and Monitoring The Patient In Restraint Or Seclusion

...vi) Care is provided at least every 2 hours to include:
*Offer of fluids/nourishment
*Hygiene care as required
*Toileting as required
*Release of extremities and range of motion exercises provided ...

I. Documentation

Each episode of restraint is documented in the patient's medical record, consistent with policies and procedures.
i) Circumstances and patient's condition or symptoms that led to restraint use, description of patient's behavior.
ii) Consideration or failure of alternative interventions.
iii) Rational for the type of interventions selected ...
ix) ...All assessments and monitoring of the patient.
x) Patient's response to the intervention, including the rationale for continued use of the intervention.
xi) Document the time the restraint is released and response of patient to release of restraint and any action taken ..."


On 5/22/2024, at 10:45 AM in the Conference Room, an interview was conducted with Staff #3, the Director of Quality, and Staff #12, Nursing Informatics. It was confirmed during the interview that the charts and restraint log which were reviewed had multiple missed opportunities for documenting restraint initiations, reevaluations, and discontinuations. Staff #3 mentioned that due to the presence of many new nurses, it had been challenging to ensure documentation despite educational efforts. An attempt was made to navigate through the charts to find documentation in other areas, but Staff #12 was unable to locate any. It was also confirmed by Staff #12 that there was a lack of documentation in all of the reviewed charts.

Based on record review and interview the facility failed to ensure the nursing staff provided skin and wound care assessments and interventions for 4 of 4 (Patient's #1, #3, #6, and #7). Also, the nursing staff failed to notify the Physician and obtain treatment orders for wounds identified on 4 of 4 (Patients #1, #3, #6 and #7). In addition, the nursing staff failed to follow the hospital policy "SKIN INTEGRITY PROGRAM: PRESSURE ULCER PREVENTION AND ALTERATION IN SKIN INTEGRITY MANAGEMENT."

These deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.


On the morning of 5/23/2024 a review of 4 medical records (MR) identified patients that had skin breakdown/wounds. The medical records that were reviewed were from the month of September 2022, and the months of January through May 2024.

Patient #1 was admitted on 09/13/2022 to the facility. Patient #1 was alert, oriented and mobile with limited assistance. Patient #1's initial skin assessment that was recorded by the Registered Nurse revealed no skin breakdown. Further review of the record revealed a photograph dated 09/23/2022 of Patient #1's bilateral buttock with redness and purple discoloration. There was no documentation by the Registered Nurses after the date of the photograph (9/23/2022). There was no evidence that skin assessments had been completed. Also, there was no evidence the physician had been notified for wound care treatment/orders. Patient #1's nursing care plan was reviewed and there was no acknowledgment that Patient #1 had skin breakdown/a wound.

Further review of Patient #1's medical record revealed that on 09/21/2022 a consent for "Exploratory Laparotomy, possible bowel resection, possible ostomy" was obtained and surgery was performed. A review of Patient #1's record after surgery and admitted to the nursing unit found no documentation the Registered Nurses had assessed the abdominal surgical site. Further review of the post surgical medical record for Patient #1 revealed there were no orders provided by the surgeon to assess and treat the surgical incision site; nor was there physician orders for dressing changes.

A review of the medical record reveled the surgeon placed a VAC (Vacuum assisted closure device) two (2) days prior to discharge. The medical record revealed a registered nurse documented a telephone notification to the surgeon that Patient #1 was being discharge and the "VAC" was still in place. The Registered Nurse documented a telephone notification of the surgeon saying "Remove it". There was no documentation of the telephone order to remove the VAC prior to Patient #1's discharge, and there was no order for placing a surgical dressing over the incision site after the wound 'VAC" had been removed.

Patient #3 was admitted 05/20/2024 with a wound present on buttock, sacrum/coccyx, right hip, bilateral chest, left toes, and behind the left knee. Patient #3 admission weight was 274 pounds. There was no physician's order for a low air loss or bariatric bed. A review of the medical record revealed photographs dated at admission of Patient #3's wounds. There was no documentation by the Registered Nurses after the date of the photograph. Further review of the medical record revealed no skin assessment had been completed and no evidence the physician had been notified for wound care treatment/orders. For the duration of Patient #3's admission to the hospital there was no documentation of assessment for skin integrity. Also, Patient #3's nursing care plan was reviewed and there no acknowledgment that patient #3 had skin breakdown on buttock, sacrum/coccyx, right hip, bilateral chest, left toes, and behind the left knee.

Patient #6 was admitted 02/27/2024 from a long term care facility with an tunneling pressure wound on the coccyx. There was a photograph of the wound the date of admission. There was no documentation by the Registered Nurse after the date of the photograph. Further review of the medical record reveled no skin assessment had been completed. There was no evidence the physician had been notified for wound care treatment/orders. For the duration of patient #6's admission to the facility there was no documentation of assessment for skin integrity. Also, Patient #6's nursing care plan was reviewed and there no acknowledgment that patient #6 had a wound on the coccyx. Patient #6 was discharged 03/16/2024.

Patient #7 was admitted 01/13/2024. Patient #7 was admitted with a wound on the right heel, coccyx, and left great toe. A photograph for each of patient #7's wounds was found in the medical record. There was no documentation by the Registered Nurse after the date of the photograph on admission. Further review of the medical record reveled no skin assessments had been completed. There was no evidence the physician had been notified for wound care treatment/orders. For the duration of Patient #7's admission to the facility there was no documentation of assessment for skin integrity. Also, Patient #7's nursing care plan was reviewed and there no acknowledgment that patient #7 had skin breakdown on the right heel, coccyx, and right great toe. Patient #6 was discharged 02/07/2024.

The informatics Registered Nurse (Staff #12) assisted the surveyor with the navigation of the electronic medical record for chart reviews. Staff #12 stated, "I can't find any nurses assessments, wound care/treatments or care plans for patient's #1, #3,
#6, or #7".


A review of the medical record for patient's #1, #3, #6, and #7 revealed the nursing staff failed to document the description of the wound. (Color, drainage, odor, length, width, depth, pain) There was no nursing documentation in the medical record regarding wound or wound care, other than the photograph.

In an interview on 05/22/2024 with Staff #3, Quality Director stated, "We don't have a wound care nurse right now. We don't ask our nurses to measure length, width, and depth. The nursing staff have not been trained to measure length, width, and depth of wounds."

A review of the nursing files for Staff #5, #7, #9, and #10 revealed that the nurses caring for patients #1, #3, #6 and #7 (wound care patients) had no training/competencies for wound care presence in there personnel files.


A review of the facility's policy titled, "SKIN INTEGRITY PROGRAM: PRESSURE ULCER PREVENTION AND ALTERATION IN SKIN INTEGRITY MANAGEMENT" dated reviewed 6/2022 revealed the following:

"I. PURPOSE
A. To define an interdisciplinary program that offers a comprehensive approach to the prevention of pressure ulcers and the management of alterations in skin integrity.
B. Through the use of algorithms, clinical decision-making will be made more efficient with standards of care being implemented consistently across the hospital.
C. Identification of patient needs in order to prevent pressure ulcers and healthy skin will be driven by skin assessments in a methodical manner in all levels of care within the facility.
D. Any acquired pressure ulcers will be reported and then care will be provided according to the policy and procedure included in this plan.
E. Education of staff related to pressure ulcer prevention and management of pressure ulcers will be mandatory for all clinical departments.
F. Patients, family, and others concerned will be educated as to risk of pressure ulcer development, methods to prevent ulcers, and the necessary management of pressure ulcers or wounds that are present.
G. Only nursing staff specifically trained in wound assessment will stage wounds.

POLICY
This policy applies to all hospital departments including inpatient and outpatient, as appropriate.

A The Braden Assessment tool will be completed within 24 hours of admission in all levels
of care. Interventions are planned and implemented based on level of risk assessed.

B. Ongoing Braden Assessments will be completed each shift for all inpatients, and
patients placed in observation, including a "head to toe" skin assessment to promptly
identify alterations in skin integrity, areas of redness, nutritional needs, mobility issues or
any other condition placing the patient at risk.

C. Skin assessments will be documented in the EMR with completion of the Anatomical
Man designating all alterations in skin integrity.

D. Apply necessary algorithms to provide the best possible care for the patient in order to
prevent pressure ulcers or manage present wounds. Algorithms include nutrition
guidance for the compromised patient, specialty bed use for the prevention of pressure
ulcers, skin care products to protect fragile or at risk skin, and wound care products best
utilized based on the clinical condition and presentation. Indications may exist for the
use of the wound VAC (vacuum assisted closure) per physician order. All measures are
closely assessed for effectiveness as shown in the algorithm or per physician orders.

E. Thorough documentation of all skin conditions, including wounds, alterations in skin
integrity, or ecchymosis or bruising, will be part of the admission assessment. All
conditions as stated present upon admission will be photographed with pictures retained
in the medical record.

F. The results of the thorough skin assessment and any interventions performed will be
discussed during Bedside Shift Report to ensure continuum of care from shift to shift.

G. For all hospital acquired pressure ulcers, pressure ulcers present upon admission,
and/or those ulcers present upon admission that fail to improve, an incident report is
completed through the ERS (Event Reporting System) managed by the Risk
Management process. Photographs of all skin conditions will be photographed with
pictures kept as part of the medical record.

H. As appropriate, each patient will out-of-bed for meals 2-3 times per day. Nursing staff
will strongly encourage and assist all patients to be in a chair for meals. Those that are
ambulatory are encouraged to walk at least twice a day. Leadership will monitor for
compliance with this action.

I. All patients with alterations in skin integrity will be reported to the charge nurse/director
and discussed during Safety Huddles."


An interview with Staff #3 on the morning 05/22/2024 acknowledged that due to the presence of many new nurses, it had been challenging to ensure documentation despite educational efforts.

Based on record review and interview, the facility failed to ensure the nursing staff implemented nursing care plans for alteration of skin integrity for 4 (#1, #3, #6, and #7) of 4 patients for the month of September 2022 and April through May 2024. Also, the facility staff failed to follow the hospital policy, "Plan for the Provision of Patient Care, Treatment, and Services".

On 5/23/2024 in the conference room the medical records were electronically reviewed for patients #1, #3, #6, and #7. Each of the 4 patients were identified from their medical record as having wounds. A review of the medical record for these 4 patients (#1, #3, #6, and #7) had no documentation in the nursing care plan for wound care, wound treatment or nursing interventions to reduce the worsening of the wounds.

A review of the hospital's policy titled, "Plan for the Provision of Patient Care, Treatment, and Services" with a revision date of 06/2018 revealed,

"INTRODUCTION: The Plan for the Provision of Patient Care Services at Navarro Regional Hospital and RHC is designed to support improvement and innovation in clinical practice, in response to the needs of our patients, based on our mission, vision, values...
C. Admission Assessment Process:
1. Each patient's need for care, treatment, and service is assessed by individuals of appropriate disciplines throughout the organization at the time of admission and continues throughout his/her contact within the system. Patient care, treatment and service are an interdisciplinary function utilizing licensed professionals who practice within a defined scope consistent with Texas law....
D. Initial Assessment:
1. The initial assessment/screening is performed to determine the need for care, the type of
care to be provided and the need for further assessment. Assessment is an essential
component of patient care provided at Navarro Regional Hospital and RHC. Each patient's
need for care, whether an inpatient or an outpatient, is assessed by qualified professionals.
These needs are reassessed throughout the patient's contact with Navarro Regional
Hospital and RHC. The scope and content of screening, assessment, and reassessment
information may be obtained with the patient's consent, from the patient's family, and the
patient's other care providers, as well as information conveyed on any medical jewelry and
is collected based on the physician's orders, patient history and diagnosis. Factors that
may influence the patient's assessment include the setting in which the patient seeks
care/treatment/services and the patient's emergent needs. Assessing the status and
identifying the needs of the patient are the basis for determining the care to be provided.
Such assessments include appropriate screening, observation and examination
procedures with regard to the patient's physical, psychological and social status, as well as
considering the patient's nutritional, functional, spiritual and educational needs.
2. The patient assessment is age-specific (neo-natal, infant, toddler, pre-school, school age,
adolescent, young adult, adult and geriatric) and will consider aspects of educational,
social, cultural and daily activities of the patient.
3. A member of the Medical Staff shall be responsible for the medical care and treatment for
each patient. A medical history and physical examination is completed 24 hours of
inpatient admission.
4. The process components of the assessment activity include:
a) Collecting data about the patient's health history; physical, functional, and psychosocial
status; and needs as appropriate to the setting and circumstances.
b) Analyzing data to determine the approach to meet patient needs for care, treatment
and services;
c) Making care, treatment and service decisions based on information developed about
the patient's needs and his or her response to care, treatment, and services.
5. The performed assessment results in either the identification of appropriate care needs
and/or the need for further assessment. When the patient's care needs are not within the
services provided by Navarro Regional Hospital and RHC, appropriate referrals or
transfers are performed.
6. A Registered Nurse will perform the admission physical assessment and will be initiated
within the time frame identified for the specific unit. The nursing staff member escorting the
patient to his/her room will notify the RN immediately of any condition or problem requiring
attention. The Registered Nurse will incorporate and analyze the data also collected during
the admission phase to identify patient needs and problems and initiate a plan of care.
7. Initial assessment includes:
a) Physical status (skin assessment)
b) Psychological status
c) Social status
d) Nutritional screening
e) Functional screening (rehabilitation)
f) Pain assessment
g) List of current patient medications, food and drug allergies, and patient's perception of
prescribed medication effectiveness
h) Need for discharge planning
i) Educational needs assessment
j) Safety Needs assessment ( such as fall risk and skin integrity)
k) End of Life care if admitted with terminal condition; Social/spiritual/cultural needs
I) Resuscitative status (DNR or chemical code only)
8. In addition to the physical, cognitive, behavioral, emotional and psychosocial status, the
assessment is geared to identify factors or barriers that may prohibit the patient from
reaching the goals such as:
a) Symptoms that might be associated with a disease, condition or treatment (such as
pain, nausea, or dyspnea)
b) Social barriers including cultural and language barriers
c) Social and environmental factors
d) Physical disabilities
e) Vision and hearing impairments and disabilities
f) Developmental disabilities
g) Communicative disorders
h) Cognitive disorders
i) Emotional, behavioral and mental disorders
j) Substance abuse, dependence and other addictive behaviors
k) Patient's perception of the effectiveness of and side effects related to medications
9. Time Frames:
a. Time frames for completing the initial assessment/screening may differ according to
setting, unit or service. The depth and frequency of the assessment or screening
depends on the patient's needs, program goals and the care, treatment and services
provided. Assessment and screening activities vary between settings as defined by
the leadership of the hospital. Documentation occurs according to the time frames
identified in each setting to meet the patient's identified needs and to reassess to
determine if these needs are being met.
b. The nursing admission assessment is completed according to the time frame set up for
the unit. The problems/needs of the patient are identified for the patient with
care/treatment/services planning initiated within those given times and also in
conjunction with the Practitioners orders. Prioritization of patient problems/needs
occurs with the initiation of the care planning process and is ongoing throughout the
patient's stay with collaborative interdisciplinary plan of care..."


An interview with Staff #12 (Informatics Registered Nurse) on the morning of 5/22/2024 who facilitated the electronic medical record review and confirmed there were no care plans addressing wounds. Staff #12 stated, "I can't find any nursing care plan entry for any wound so far." Also, the nursing staff failed to follow the hospital policy.