HospitalInspections.org

Based on policy review, document review, record review and interview, Hospital #1 failed to have an organized nursing which ensured that all patients' needs were met by ongoing assessments; and failed to ensure nursing followed and implemented polices for the prevention and treatment of pressure injuries and to prevent significant weight loss for 1 of 3 (Patient #1) sampled patients with pressure injuries and significant weight loss.

The findings included:

Review of the hospital's policy titled Pressure Injury and Wound Treatment Guidelines revealed all patients should be assessed for skin breakdown on admission, daily and as changes occur; and treatment should begin timely in the prevention and treatment of pressure injuries. The policy stated assessments should occur, physicians should be notified and interventions and assessments documented.

Patient #1 was admitted to the hospital on 6/25/2021 with one (1) sacral pressure ulcer. There was no documentation of an assessment/description of the sacral pressure ulcer. The nursing staff documented the patient was at high risk of developing pressure injuries. There was no documentation of interventions implemented to prevent pressure injuries. On 7/12/2021 nursing documented that Patient #1 had an unstageable pressure injury to the right thigh. There was no documentation of interventions for the unstageable pressure injury. On 7/14/2021 Patient #1 developed a right heel pressure injury and on 7/20/2021 Patient #1 developed a left heel pressure injury. There was no documentation of assessments or interventions after the right and left heel pressure injuries were first discovered. On admission to Hospital #1, Patient #1 weighed 140 pounds (lbs), and at discharge Patient #1 weighed 116 lbs. There was no documentation of dietary or nutrtional interventions for Patient #1's weight during Hospitalization at Hospital #1.
Refer to A395.

Based on policy review, document review, medical record review and interview, Hospital #1 failed to ensure nursing conducted assessments and provided services to prevent and treat pressure injuries and significant weight loss for 1 of 3 (Patient #1) sample patients with pressure injuries and significant weight loss.

The findings included:

1. A review of the Pressure Injury And Wound Treatment Guidelines dated "7/20" revealed, "...Each patient is assessed for potential and actual skin breakdown on admission, daily, and as needed if patient's condition changes. Once assessed, prevention/treatment begins in a timely manner. Obtain order to implement Pressure Injury and Wound Basic Care reference chart as indicated...Skin assessment is performed from head to toe with particular attention to the bony prominences...If a pressure injury is present the staff nurse obtains an order from the physician to implement the appropriate level of treatment...The staff nurse obtains physician's order for Wound/Ostomy Nurse/Physical Therapist consult for patients with a Stage 3 or 4 pressure injury, deep tissue injury or unstageable pressure injury as available and indicated...Documentation...Dates and times...Assessment/skin appearance... Interventions...Nutritional support...Moisture control/incontinence management...Specific location...Size In centimeters, using measuring device... Dressing changes...Drainage...Character/color of wound...Stage...Nutritional support"

A review of the Adult Skin Care Product Reference revealed, "...Implement the appropriate skin protection/prevention guidelines based on RN assessment..."

A review of the Pressure Injury Basic Care Reference Chart (Adult) revealed, "Implement the appropriate pressure injury prevention guidelines based on the patient's Braden Risk Assessment Score [Braden score is a tool used to help determine the risks of a patient developing a pressure injury] ...Obtain Physician order for wound care according to the guidelines below. Nutrition Consult...Encourage PO (oral) intake. Obtain Dietician order and encourage intake of arginine, glutamine, and HMB [Hydroxymethylbutyrate] supplement BID (twice per day). Obtain Dietician order and encourage intake of high calorie, high protein supplement...Stage III (3) & (and) IV (4) or Unstageable...Obtain Physican order: Wound nurse, nutrition, and physical therapy consult..."

A review of the Braden Scale for Predicting Pressure Score Risk revealed, "...Score Interpretation: Score 15-18 = mild risk, Score 13-14 = moderate risk, Score 10-12 = high risk, Score
A review of the Assessment/Reassessment Policy dated "12/20" revealed, "...Collection of the following information initiated upon admission and completed within 2 hours of inpatient admission...vital signs...height and weight (actual)...Collection of the following information initiated upon admission and completed within 12 hours of inpatient admission...nutrition status...skin assessment...A registered nurse (RN) completes a head to toe assessment...at the beginning of each nurses shift...upon receiving a patient transfer from another level of care...Reassessment occurs...at regular intervals (see Addendum 1). Review of Addendum 1 revealed, "...Reassessments...At a minimum, focused reassessments are completed and documented every 8 hours..."

Medical record review revealed Patient #1 was admitted to Hospital #1 on 6/25/2021 with a diagnosis of Failure to Thrive. Patient #1 was admitted with one (1) sacral pressure injury. No further description of the sacral pressure injury was documented upon admission.

Review of Patient #1's Braden scores from 6/26/2021 through 8/13/2021 revealed a range from 15 (mild risk) to 7 (very high risk). There was no documentation of appropriate pressure injury prevention interventions implemented based on Patient #1's Braden Risk Assessment Score. When requested, the hospital was unable to provide a copy of the pressure injury prevention guidelines based on the Braden Risk Assessment Score.

Review of the daily nursing assessments dated 6/25/2021 to 7/11/2021 revealed daily skin assessments were documented as "WDL" (within defined limits) with the exception of one (1) sacral pressure injury.

Review of the Wound Care Consult (WCN) revealed the WCN first assessed the sacral wound on Patient #1 on 7/7/2021 which was eleven days (11) after Patient
#1's admission. The WCN documented the sacral wound measured 5.5 centimeters (cm) in length, 3.0 cm in width, and 0.5 cm in depth. The sacral wound was classified as unstageable with 75% covered with necrotic tissue. The WCN documented the patient's sacral wound would be treated and dressing changed every Monday, Wednesday and Friday.

On 7/12/2021 nursing staff documented Patient #1 was noted to have an unstageable left thigh pressure injury that was obscured by 80% slough or eschar. There was no documentation of order for a Physical Therapy consult, WCN consult or any treatment orders for the unstageable left thigh pressure injury.

On 7/14/2021 the WCN documented Patient #1 had developed a right heel pressure injury which was an intact blister measuring 6 cm in length and 4 cm in width with a Stage 2 partial thickness skin loss and exposed dermis. There were no additional WCN assessments, orders or treatments documented in the medical record for the right heel pressure injury after 7/14/2021.

On 7/20/2021 the WCN documented Patient #1 had developed a left heel pressure injury which was an intact blister measuring 9 cm in length 6 cm in width with a Stage 2 partial thickness skin loss with exposed dermis. There were no additional WCN assessments, orders or treatments documented in the medical record for the left heel pressure injury after 7/20/2021.

Review of the daily nursing assessments from 7/13/2021 through day of discharge on 8/13/2021 revealed no documentation of assessments, skin appearance, size, stage, dressing change, drainage, character/color or any treatments or interventions for Patient #1's unstageable left thigh pressure injury, or the right and left heel pressure injuries. When questioned, Hospital #1 was unable to provide any documentation of assessments or treatments of Patient #1's pressure injuries.

Review of Patient #1's current care plan dated 7/13/2021 revealed, "Problem: Skin Injury Risk Increased. Goal: Skin Health and Integrity...Intervention: Optimize Skin Protection..." There was no documentation of treatments of interventions for the Patient #1's pressure injuries.

3. Review of the hospital's Malnutrition policy and Clinical Documentation Severe Malnutrition Criteria...revealed the Registered Dietician Nutritionist (RDN), "...informs physician/LIP [licensed independent practitioner] when a patient meets the facility criteria for malnutrition [plan of care and interdisciplinary team rounds]...provides and documents nutrition interventions...' The policy states to use the Clinical Documentation Malnutrition Criteria worksheet to identify 2 or more signs and symptoms to validate moderate or severe malnutrition.

Record review for Patient #1 revealed upon admission on 6/25/2021 the patient weighed 140 lbs. There was no documentation of any other weights for Patient #1 while hospitalized at Hospital #1. Review of Patient #1's history revealed the patient had a history of severe malnutrition with muscle wasting and fat loss.

On admission 6/25/2021 Patient #1's Albumin level was 3.4 (normal levels 3.4-5.0).

On 6/28/2021 a RD nutritional consult note revealed plans for Patient #1 to receive a Percutaneous Endoscopic Gastrostomy tube (PEG tube - a tube inserted into the stomach to supply nutrition to a patient) on 6/29/2021. The RD documented the patient weighed 140 lbs and had a Body Mass Index (BMI) of 23.3 (BMI - determines if your weight is healthy according to your height with normal being 18.5 - 24.9). The RD estimated Patient #1 needed 51 - 64 grams of protein daily.

On 6/29/2021 after Patient #1 received the PEG tube, the RD recommended that Patient #1 receive 80 grams of protein via the PEG at 60 milliliters (mls) a hour (hr).

On 7/7/2021 the RD documented to add a Therapeutic Nutrition Powder twice a day for Patient #1's for wound healing. The RD wrote the patient had a Stage 3 sacral pressure injury and weighed 140 lbs. There was no documentation Patient #1 was administered the Therapeutic Nutrition Powder twice daily.

On 7/14/2021 the RD documented, "...Continue [Name Brand Therapeutic Nutrition Powder] Bid [two times per day] for wound healing...Last...Recorded Weights...140...Skin: Unstageable sacral PU [Pressure Ulcer]... Dietary nutrition supplements...Give [Name Brand Therapeutic Nutrition Powder] per feeding tube...7/3/2021 Albumin 1.9 (L)[Low - normal 3.4 - 5.0]..." There was no documentation Patient #1 was administered the Therapeutic Nutrition Powder twice daily.

On 7/20/2021 the RD documented, "...Continue [Name Brand Therapeutic Nutrition Powder] Bid [two times per day] for wound healing (...5g prot)...Last...Recorded Weights...140...Skin: Stage III [3] sacral PU, Stage II [2] heel PI [Pressure Injury]... Dietary nutrition supplements...Give [Name Brand Therapeutic Nutrition Powder] per feeding tube... 7/16/2021...Albumin 1.4 (L)..." There was no documentation Patient #1 had been administered the Therapeutic Nutrition Powder twice daily.

On 7/26/2021 revealed, "...Nutrition consult to switch to low potassium formula per [Named Physician]...Unstageable sacrum wound, stage II [2] thigh wound, stage II [2] right heel wound, DTI [Deep Tissue Injury] to left heel...Patient is receiving [Name Brand Therapeutic Nutrition Powder] BID for wound healing. Will continue to monitor...Wt [Weight] Readings from last 3 Encounters: 6/25/21 140 lbs, 6/7/21 140 lbs, 22/20/19 140 lbs...Will adjust current tube feeding regimen...[Named Formula] bolus at 4 cans/day...Provides...76 g protein + [Name Brand Therapeutic Nutrition Powder] BID...Dietary nutrition supplements...Give [Name Brand Therapeutic Nutrition Powder] per feeding tube..." There was no documentation Patient #1 had been administered the Therapeutic Nutrition Powder twice daily.

On 7/30/2021 the RD documented, "...PLAN: [Named Formula], 5 cartons per day...[Name Brand Therapeutic Nutrition Powder] twice a day for wound healing...Skin: Stage II[2] pressure ulcer L thigh, R heel...unstageable sacrum, DTI L heel...Goal: met..." There was no documentation Patient #1 had been administered the Therapeutic Nutrition Powder twice daily.

On 8/4/2021 the RD documented, "...PLAN: Will resume [Name Brand Therapeutic Nutrition Powder] BID once restocked in facility, Patient needs updated weight...Lab Results...Albumin 1.0 (L) [Low] 8/1/2021...Goal: met..." There was no documentation the Therapeutic Nutrition Powder was restocked and administered to Patient #1 twice daily. There was no documentation Patient #1 was re-weighed.

On 8/10/2021 the RD documented "...[Name Brand Therapeutic Nutrition Powder] BID Provides...5 g of protein...Tube feeds stopped yesterday due to diarrhea. Rectal tube in place...Skin: Stage II[2] pressure ulcer L thigh, R heel...unstageable sacrum, DTI L heel...PLAN...[Name Brand Therapeutic Nutrition Powder] BID: Provides...5 g of protein... Diet Orders...Give [Name Brand Therapeutic Nutrition Powder] per feeding tube: yes...Estimated PRO [Protein] Needs: 80-96 g/day...Goal: Met..." There was no documentation Patient #1 had received the Therapeutic Nutrition Powder.

There was no documentation Patient #1 received any of the Name Brand Therapeutic Nutrition Powder during Hospital #1's admission from 6/25/2021 through 8/13/2021.


4. On 8/13/2021 Patient #1 was discharged to Hospital #2 at 3:22 PM.

Review of the History and Physical for Patient #1 at Hospital #2 dated 8/13/2021 at 4:12 PM revealed, "...Admission Diagnoses: pressure injury sacral infected stage 4...Pressure injury of heel, stage 2, Pressure injury of sacral region, stage 3...Pressure injury of left thigh, stage 2...Assessment And Plan...Stage IV [4] Sacral Decubitus Ulcer...PT [Physical Therapy] wound care...Multiple pressure injuries..."

Patient #1's weight upon admission to Hospital #2 directly from Hospital #1 on 8/13/2021 was 116 lbs.
Patient #1 had lost 24 lbs in 49 days which resulted in a severe and significant weight loss of 17.14% during admission to Hospital #1.

Review of a RD Nutrition Consult from Hospital #2 dated 8/16/2021 revealed, "...Recommendations adjusted today d/t [due to] updated weight obtained...monitor tolerance, this formula may be more easily tolerated...Rec' [recommend] adding [Name Brand Therapeutic Nutrition Powder] BID to promote wound healing...Diagnosis: Present on Admission: Failure to thrive in adult, Severe protein-calorie malnutrition...Available weights since 6/25 [Hospital #1]: 140 lb - 6/25...116 lb - 8/13 [Hospital #2] admission...Lab Results...Albumin 1.6 (L) 08/16/2021..."

Review of a PT progress note at Hospital #2 dated 8/18/2021 revealed, "...Pressure Injury Sacrum...Stage 4 [four]...9.5 cm length x 8.7 cm width x 1.5 cm depth with 2 cm undermining...50% necrotic tissue...Other Thigh Left...Unstageable...1.5 cm length, 3.5 cm width, 0.4 cm depth...80% necrotic tissue..."

Review of Hospital #2's WCN note dated 8/18/2021 revealed, "...[Patient #1] current skin/wound condition appears to be skin failure at end of life, but with the addition of enteral feedings, that has been slowed/haulted [halted]..."

5. In an interview with Hospital #1's WCN on 8/26/2021 beginning at 10:14 AM, the WCN was asked if the Braden score drives the skin prevention interventions and the WCN stated, "The Braden score is a helper, you have to use your eyes and your critical thinking skills" The WCN was asked about Patient #1 after the 6/25/2021 admission. The WCN stated, "[Patient #1] came back on the 26th [June] and I saw her a week or 2 later...One thing about a patient with dark skin, we won't see a pressure injury like a DTI, purple red- it can be a problem. This patient was failure to thrive, no nutrition, the family doesn't really know the causes of a pressure injury, moisture, turning etc. The family needs to be educated...The wound consult date was 7/4/2021 and I saw [Patient #1] on 7/7/2021. I took a picture of the sacrum. It was unstageable because it was necrotic tissue in greater than 50% of the wound bed. I wrote wound care orders..."
Hospital #1's WCN was asked about the documentation regarding Patient #1's wounds and the WCN stated, "We do expect documentation, we could have been better..."
Hospital #1's WCN was asked if a tube feeding would provide adequate nutrition and the WCN stated, "My experience as a nurse, it is individual. [Patient #1] is a failure to thrive, sometimes it doesn't work. Look at labs, look at nutrition. [Patient #1] had renal problems, sodium is off, lots of stuff is off, CBC's [Complete Blood Count] numbers are low because they carry oxygen for wound healing..."

In an interview with Hospital #1's Clinical Nutrition Manager (CNM) on 9/1/2021 beginning at 9:00 AM, the CNM was asked about the nutrition of Patient #1 the CNM stated Patient #1 was first seen on 6/29/2021 for a PEG tube feeding. The CNM stated Patient #1 "did fine" except for the potassium levels.
The CNM was asked if labs were important in a diagnosis of Severe Protein Calorie Malnutrition and CNM stated, "we assess labs, and diagnosis to help determine needs. Weight plays a significant part in it...Nutrition wise, she was getting adequate plus more. We were exceeding Patient #1's estimated needs...we try to avoid using labs, Albumin, Pre Albumin, are all hematology...We cannot get a diagnosis based solely on labs...I do feel Patient #1's nutrition was adequately managed during her stay [at Hospital #1]...[Name Brand Therapeutic Nutrition Powder] has arginine for wound healing, there is not much protein in it maybe 1 gram per package. It can be ordered by the dietitian and it is not documented on the MAR [Medication Administration Record]. We ask the nurses if they have given it or we can see it in the room [packages in the room]. It is not caloric and it is not part of a wound care protocol. They are recommendations we feel that can assist..."
The Clinical Nutrition Manager was asked when patients should be weighed. The Clinical Nutrition Manager stated, "I would like to see weights on every patient when they change beds, room or have a change in status..."

In an interview with Patient #1's Power of Attorney (POA) on 9/1/2021 at 1:05 PM the POA was asked if Patient #1 had a sacral pressure injury when Patient #1 was admitted to Hospital #1 on 6/25/2021 and the POA stated, "Yes, I believe so."
The POA stated when in the room with Patient #1, the nurse would show Patient #1's wounds to the POA and that there were no dressings put on the patient's sacral and unstageable right thigh wounds. The POA provided the surveyor with copies of the pictures.
The POA was asked if Patient #1 received the Name Brand Therapeutic Powder and the POA stated, "Nobody ever gave [Patient #1] any [Name Brand Therapeutic Nutrition Powder] while I was there. The nurses would come in and give the medicine in the feeding tube and throw the package of [Name Brand Therapeutic Nutrition Powder] over by the sink or some other counter". The POA stated, "there were always packages laying around and I know it was never given while I was there."

Based on facility algorithm procedure, record review, observation and interview, the hospital failed to have an active hospital-wide infection prevention and control program to reduce the development and transmission.

The findings included:

Review of the Emergency Department (ED) "Patient Covid-19 Surveillance" algorithm procedure policy provided by the Director of Risk Management revealed under the section titled, "Personal Protective Equipment (PPE) Reference Chart COVID-19 Pandemic" that all Emergency Department Direct Patient Contact Staff and all Emergency Department Support Staff should wear an N95 Respirator, and a Face Shield or Goggles. All Emergency Department Direct Patient Contact are also required to wear a gown and gloves.

During observations of the ED on 8/30/2021 and 9/1/2021 some of the hospital's ED nursing staff were observed not following the COVID 19 ED policies for the prevention and transmission of the COVID 19 infection. The ED nursing staff were interviewed and were aware of the COVID 19 policies. Two (2) ED physicians were interviewed and one (1) ED Physicians was aware of the hospital's ED COVID 19 policies. The hospital's Respiratory Therapy Department had received a complaint about the nursing staff in the hospital's ED but failed to follow-up on the complaint.

Refer to A749.

Based on the hospital's COVID algorithm policy procedure, observation, record review and interview, the Emergency Department (ED) staff failed to follow the hospital's polices for the prevention and transmission of COVID 19 during 2 of 2 (8/30/2021 and 9/1/2021) days of observations of the ED.

The findings included:

1. Review of the Emergency Department (ED) "Patient Covid-19 Surveillance" algorithm procedure policy provided by the Director of Risk Management revealed under the section titled, "Personal Protective Equipment (PPE) Reference Chart COVID-19 Pandemic" that all Emergency Department Direct Patient Contact Staff and all Emergency Department Support Staff should wear an N95 Respirator, and a Face Shield or Goggles. All Emergency Department Direct Patient Contact are also required to wear a gown and gloves.

2. During the ED entrance interview on 8/30/2021 at 2:40 PM the Director of Risk Management stated to tour the ED the surveyor needed to wear a fitted N95 and a face shield to which the surveyor complied with.

Observations during the ED tour on 8/30/2021 beginning at 3:00 PM with the Director of Risk Management and the ED Head Nurse revealed the following:
a. Emergency Medical Service (EMS) was bringing RP #1 into Room #48. The hospital's female staff member standing at the patient's bedside was not wearing a face shield or goggles.
b. Patient #1 was observed in Room #34. A female nursing staff member was standing at the patient's bedside and was not wearing a face shield or goggles.

Observations on 9/1/2021 beginning at 10:20 AM of the hospital's ED accompanied by the Director of Risk Management and the ED Director revealed RN #1 was in Room #8 placing socks on RP #2's feet. RN #1 was only wearing a surgical type mask and gloves. RN #1 was not wearing an N95, face shield or goggles,or a gown.

3. In an interview on 9/1/2021 at 10:40 AM in the ED, RN #2 was asked what PPE should be worn in the ED and RN #2 stated nursing staff had to wear an N95 mask, goggles and gloves around all patients in the ED.

In an interview on 9/1/2021 at 10:45 AM in the ED, RN #1 was asked what PPE should be worn in the ED and RN #1 stated nursing staff should wear a mask, face shield and gloves for any patient presenting to the ED.

In an interview on 9/1/2021 at 10:55 AM in the ED, RN #3 was asked what PPE should be worn in the ED and RN #3 stated nursing staff should wear an N95, eye wear and gloves with all patients.

In an interview on 9/1/2021 at 10:58 AM in the ED, RN #4 was asked what PPE should be worn in the ED and RN #4 stated nursing staff should wear an N95 mask, goggles and gloves if there was patient contact.

In an interview on 9/1/2021 at 11:03 AM in the ED, Physician #1 was asked what PPE should be worn in the ED and Physician #1 stated for known or suspected Covid-19, wear eye protection/shield, N95 mask gown, and gloves. Physician #1 stated that they wear double gloves, a surgical mask over the N95 and wipe down the workstation.

In an interview on 9/1/2021 at 11:10 AM in the ED, Physician #2 was asked what PPE should be worn in the ED and Physician #2 stated wear an N95, glasses and gloves for any patient coming into the ED. Physician #2 stated for known or suspected Covid-19 patients, "wear the same, wear the same for any patient and a gown".

In an interview on 9/1/2021 at 11:51 AM the Director of Risk Management stated they have not received any complaints related to PPE use, nor had the Patient Advocate received any complaints.

In an interview on 9/1/2021 at 12:52 PM the Operations Manager for Respiratory Therapy (OMRT) stated they had received a complaint related to staff not wearing appropriate PPE in the ED. The OMRT was asked if they reported the complaint to anyone, the OMRT stated "No."

In an interview on 9/1/2021 at 1:20 PM the Director of Respiratory Therapy (DRT) was asked if they had received complaints regarding inappropriate PPE use. The DRT stated they did receive a complaint regarding PPE on the previous Friday (8/27/2021). The DRT stated they asked the person reporting the complaint to send them an email with the information. The DRT stated they had not yet reported the complaint to anyone to address the PPE use.