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Based on medical record review, interview and policy review, the facility failed to ensure a registered nurse supervised and evaluated the nursing care (A395).

Based on medical record review, interview and policy review, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for one of 10 patients reviewed (Patient #6). The census was 349.

Findings include:

Patient #6's medical record was reviewed. Review of the internal medicine history and physical dated 07/15/22 revealed she was admitted to the hospital on 07/15/22 at 11:54 AM. The chief complaint was shortness of breath (SOB), fatigue, and positive for COVID-19. This patient was with a primary history of SOB, status post percutaneous endoscopic gastrostomy (PEG) tube insertion, acute kidney injury, and electrolyte imbalance. The patient claims she has additionally suffered multiple episodes of diarrhea over the last three days and appreciates a decreased oral intake. The physical exam by the physician on admission revealed the patient's skin was warm, dry, with no bruising or rash. There was no documentation of any skin breakdown.

On 07/18/22 a Stage 1 area (observable, pressure-related alteration of intact skin with non-blanchable redness of a localized area usually over a bony prominence) to her coccyx was documented on the flowsheet. The flowsheet revealed Mepilex (a foam dressing to help protect the wound that has silver in it to help prevent infection) was applied to the coccyx area.

On 07/18/22 at 4:32 PM the physician ordered a wound care consult.

Review of the wound care consult dated 07/19/22 revealed the patient's coccyx area was cleansed with normal saline, there was no drainage and the Mepilex dressing was in place. The documentation revealed the patient's sacrum is red with a small blister, Stage 2 (open wound that expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin). The recommendation by the wound care nurse is to turn every two hours, apply Venelex (ointment that's used on the skin to cover wounds. It can also help to get rid of smells and might relieve pain from the wound) three times a day and as needed to stimulate capillaries and therefore increase tissue perfusion. The status will be determined on re-evaluation. Call wound care if it worsens and waffle seat cushion if up in chair.

Further review of Patient #6's medical record revealed the following was documented on the flowsheet for 07/25/22: at 12:00 AM it was documented the patient was in the semi-fowlers position (on their back on a bed, with the head of the bed elevated between 30-45 degrees); at 7:00 AM it was documented she was in the semi-fowlers position; at 8:00 AM she was in semi-fowlers; at 10:00 AM she was in semi-fowlers; at 11:00 AM she was in semi-fowlers; at 1:00 PM it was documented she was sitting in the chair; at 3:00 PM she was put back in bed in semi-fowlers; at 4:42 PM it was documented she was in semi-fowlers; at 5:00 PM she was in semi-fowlers; at 6:29 PM she was in semi-fowlers; at 8:30 PM it was documented she was on her right side in bed; the patient stated that someone cleaned her up and bathed her; peri care was provided.

Review of the inpatient wound and ostomy consult note dated 07/26/22 revealed the registered nurse reports the patient's peri area is more reddened and that the external catheter is not 100 percent effective. The reason for the consult was re-evaluation of the coccyx wound. The blister is now unroofed. The recommendations on the wound and ostomy consult note dated 07/26/22 revealed number (1) dressing/treatment: coccyx and perineum, cleanse well, pat dry, apply Critic-Aid Clear Moisture Barrier (purple cap), used to protect the skin from unwanted moisture and prevent skin breakdown and protects sensitive skin areas during routine incontinence care. Perform twice daily and as needed after toileting. No cover dressing. Turn every two hours, LAL mattress. Air inflated seat cushion when up to chair. Call wound care if worsens. Recommend that the patient follow up at the hospital wound and ostomy care clinic upon discharge for ongoing wound management. Continue pressure ulcer prevention and interventions.

Review of the flowsheet for 07/26/22 revealed the following documentation: at 7:00 AM she was in semi-fowlers; 8:00 AM the patient was in semi-fowlers; at 9:00 AM she was in semi-fowlers; at 10:00 AM she was on her left side; at 11:00 AM she was in semi-fowlers; at 12:00 PM she was in semi-fowlers; at 1:00 PM she was in semi-fowlers; at 3:00 PM she was in semi-fowlers; at 4:00 PM she was in semi-fowlers with a pillow beneath each hip; at 5:00 PM she was sitting in bed; at 6:00 PM she was in semi-fowlers with a pillow beneath each hip; at 8:50 PM she was in semi-fowlers; at 11:00 PM she was in semi-fowlers. There was no documentation that hygiene or peri-care was performed this day.

Review of the flowsheet for 07/27/22 revealed the following documentation: at 8:00 AM she was in semi-fowlers and refused to be repositioned; at 9:00 AM she was in semi-fowlers; at 10:00 AM she was in semi-fowlers and refused to be re-positioned; at 12:00 PM she was sitting in the chair; at 2:00 PM she was sitting in the chair; at 3:00 PM she was back in bed in semi-fowlers; at 4:00 PM she was in semi-fowlers; at 4:30 PM she was supine in bed; at 6:00 PM she was in semi-fowlers with a pillow beneath each hip; at 7:00 PM she was in semi-fowlers; at 10:00 PM she was in semi-fowlers; at 11:00 PM she was in semi fowlers. There was no documentation that hygiene or peri care was performed this day.

Review of the flowsheet for 07/28/22 revealed the following documentation: at 3:00 AM she was in semi-fowlers; at 7:00 AM she was in semi-fowlers; 9:00 AM she was boosted in the bed; at 11:00 AM she was in semi-fowlers; at 1:00 PM she was up in the chair; at 3:00 PM she was in bed in semi-fowlers; at 5:00 PM she was in semi-fowlers; at 7:00 PM she was on her right side in bed; at 8:00 PM she was on her right side; at 9:00 PM she was on her right side; at 10:00 PM there was a pillow beneath her left hip on her back towards the right side; at 11:00 PM she was supine in bed.

Review of a wound consult dated 07/29/22 revealed the reason for the consult was re-evaluation of the coccyx wound requested by the patient's daughter and husband. The measurements were 3.5 centimeters (cm) x 1.5 cm x 0.1 cm. The wound was cleansed with normal saline, scant amount of serous drainage, clean, dry intact, Mepilex dressing, and Stage 2. The peri-wound skin color is blanchable with redness. It was documented that the wound remains stable at a Stage 2 and is small in surface area. The wound nurse encouraged the patient to reposition side to side every two hours or more frequently to allow perfusion to this area, which is healing. She verbalized understanding. She is on a LAL mattress. The patient also has a fungal rash to the peri-anal area and Critic Aid Antifungal was applied. The wound nurse explained the cause of fungal rash and treatment to spouse and daughter. They verbalized understanding. The recommendations were to cover wound with Mepilex Border Sacrum dressing, change every three days and as needed if soiled or loose. Twice a day and as needed, wash peri area and buttocks with bath wipes, then apply Critic-Aid Clear AF (tube with green lid in clean supply room). Reconsult wound nurse if condition worsens. Continue pressure injury prevention interventions.

Review of the flowsheet for 07/29/22 revealed the following documentation: at 12:00 AM the patient was supine and refused to be repositioned; at 1:00 AM refused turning; at 2:00 AM refused repositioning; at 3:00 AM refused to be repositioned; at 4:00 AM refused to be repositioned; at 5:00 AM she was laying on her left side; at 6:00 AM she was laying on her left side and refused to be repositioned; at 7:00 AM she was on her left side; at 9:00 AM she was on her left side; at 11:00 AM she was on her right side; at 1:00 PM she was in semi-fowlers; at 3:00 PM she was in semi-fowlers; at 6:00 PM she was in semi-fowlers; at 7:00 PM she was in semi-fowlers; at 8:00 PM she was boosted in bed; at 9:00 PM she was on her right side; at 11:00 PM she was on her right side.

Review of the flowsheet for 07/30/22 revealed the following documentation: at 12:00 AM the patient was in semi-fowlers and refused to be repositioned; at 1:00 AM she was in semi-fowlers; at 2:00 AM she was in semi-fowlers; at 3:00 AM she was on her right side; at 4:00 AM she was in semi-fowlers; at 5:00 AM she was in semi-fowlers; at 6:00 AM she was in semi-fowlers; at 7:00 AM she was in semi-fowlers; at 8:00 AM she was in semi-fowlers; at 11:00 AM she was sitting in the chair; at 3:00 PM she was back in bed in semi-fowlers; at 8:30 PM she was in semi-fowlers; and at 10:00 PM she was in semi-fowlers.

Review of the flowsheets in the patient's medical record revealed on the following dates the patient was a two person assist for turning: 07/25/22, 07/26/22, 07/27/22, 07/28/22, and 07/29/22.

Further review of the flowsheets during the patient's admission from 07/15/22 through 08/02/22 revealed the patient at times had a Purewick external catheter for bladder incontinence, but there was documentation throughout that the patient was incontinent of bladder and bowel.

Further review of the medical record revealed a Braden score skin assessment on 07/15/22 of a 19 which is considered no risk for skin breakdown. The patient did have a low airloss (LAL) mattress on her bed which is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown. The patient was assessed as having no sensory perception impairment, rarely moist, walks occasionally, slightly limited mobility, adequate nutrition, and no problem with friction and shear. On 07/19/22 at 8:32 AM the Braden score was 12 and determined to be a high risk for skin breakdown; 07/19/22 at 8:00 PM the Braden score is 14 and determined to be moderate risk for skin breakdown; 07/20/22 at 9:00 AM the Braden score was 12 and a high risk for skin breakdown; 07/21/22 at 8:45 AM the Braden score was 19 and is no risk; 07/21/22 at 7:00 PM the Braden score is 19 and no risk for skin breakdown; 07/22/22 at 3:00 AM the Braden score is 19 and no risk for skin breakdown; 07/22/22 at 9:00 AM the Braden score is 23 and no risk for skin breakdown; 07/22/22 at 7:00 PM the Braden score is 23 and no risk for skin breakdown; 07/23/22 at midnight is 17 and is a mild risk for skin breakdown; 07/23/22 at 9:38 AM the Braden score is 15 and is mild risk for skin breakdown; 07/24/22 at 8:50 AM the Braden score is 15 and is mild risk for skin breakdown; 07/24/22 at 3:00 PM the Braden score is 15 and mild risk for skin breakdown; 07/24/22 at 8:30 PM the Braden score is 15 and mild risk for skin breakdown; 07/25/22 at 8:00 AM the Braden score is 15 and is mild risk for skin breakdown; 07/25/22 at 8:30 PM the Braden score is 13 and is moderate risk for skin breakdown; 07/26/22 at 8:00 AM the Braden score is 13 and is moderate risk for skin breakdown; 07/26/22 at 8:50 PM the Braden score is 13 and is moderate risk; 07/27/22 at 8:59 AM the Braden score is a 9 and is considered a severe risk for skin breakdown.

Review of the policy and procedure titled, Pressure Injury Prediction, Prevention and Treatment, revised on 11/21, revealed interventions for pressure injury prevention and Stage 1 or 2 pressure injuries to include repositioning. Patients are considered at risk of pressure injury development if their Braden score is less than or equal to a score of 18.

There was no consistency to the Braden scores based on the information in the patient's record.

Additionally, there was no documentation that the patient was bathed between 07/22/22 at 12:30 PM and 07/29/22 at 4:25 AM.

Interview with Staff B on 10/26/23 at 1:40 PM revealed the hospital received a 150 page typed grievance from the patient's daughter a year after the patient was discharged. The concern was the patient's nutrition, wound care and communication with family. The family was upset because the patient had a sacral wound and said it was from the patient not being turned.

Interview with Staff A on 10/26/23 at 3:15 PM confirmed that on 07/26/22 there was no documentation of peri-care or bathing and on 07/27/22 there was no documentation of peri-care or hygiene. Staff A also confirmed there were recommendations to turn the patient every two hours and this was not done.

This deficiency represents non-compliance investigated under Substantial Allegation OH00146408.