HospitalInspections.org

Based on observation, review of policy, and staff interviews, the facility staff failed to follow policy to maintain an intravenous site by failing to change intravenous site in 1 of 2 peripheral sites observed (Patient #14); and by failing to implement interventions to prevent pressure injuries in 1 of 3 pressure injuries reviewed. (Patient #7)

The findings include:

1. Observation of Patient #14 on 10/28/2021 at 1400 revealed a left forearm intravenous site covered with surgical web dressing with a second layer of Coban (self-adherent elastic wrap). Observation revealed the intravenous site was not visualized due to the dressings covering the insertion site. Observation revealed the maintenance IV (intravenous) fluid infusing via the IV pump.

Review of the policy titled "Adult Peripheral Infusion Therapy" with revision dated of 06/2019, revealed "...K. Replacement of Peripheral IV sites: IV sites are changed every 96 hours, when site becomes contaminated, or signs of complications occur. If not completing a routine site change, the clinician will state the reason, ex. pt refused. IV sites may be left in place if asymptomatic with a LIP (Licensed Independent Practitioner) order...H. IV sites are dressed with a transparent semipermeable dressing that is applied directly over the insertion site...Gauze dressings will be changed every 48 hours..."

Review of open medical record of Patient #14 revealed a 46-year-old male admitted on 05/30/2021 with diagnosis of sacral ulcer. Review of IV site documentation revealed #24-gauge angiocath placed in left forearm on 09/30/2021 at 1046, (28 days prior to the observation).

Interview on 10/28/2021 at 1400 with primary RN (RN #1) revealed the review of the medical record revealed the insertion date of the IV was 09/30/2021. Interview revealed the policy was to change the IV site every 96 hours. Interview revealed the physician should be called if patient refuses for the IV to be rotated.

Interview on 10/28/2021 with floor manager #2 revealed the IV should have been rotated and physician should have been notified. Interview revealed the policy for rotating IVs was not followed. Interview revealed the policy for dressing of the IVs every 48 hours was not followed.


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2. Review of the facility policy titled "Pressure Injury Prevention" effective 05/2020 revealed "PURPOSE/SUPPORTING INFORMATION...All patients will have a Braden score (scale for predicting risk of pressure injury) done on admission and every shift thereafter...B. If Braden score is 18 or less, pressure injury prevention practices will be implemented...Nursing to consult WOC (wound ostomy care) for ALL Stage 3, 4, Unstageable, or Deep Tissue Pressure Injuries...A. UNIVERSAL SKIN CARE PRACTICES FOR ALL PATIENTS...11. Turn/reposition patient every 2 hours when in bed and every hour when in chair...B. PREVENTION PRACTICES FOR AT RISK PATIENTS (BRADEN SCORE 18 OR LESS)...4. Elevate the heels using offloading/heel lift boots...7. Protect bony prominences with protective dressings...10. Patients with a Stage 3,4, Unstageable, or Deep Tissue Pressure Injury should be placed on a low air loss mattress..."

Review of a closed medical record on 10/27/2021 revealed Patient #7 was an 83-year-old male admitted to the hospital on 09/28/2020 for a scheduled anterior cervical discectomy and fusion (surgery to decompress the spinal cord and nerve roots). Medical record review revealed Patient #7 had a history of cervical spondylosis with myelopathy (impairment of spinal cord due to degeneration of the neck) and degenerative joint disease. Medical record review failed to reveal documentation of a pressure wound on 09/28/2020 (the day Patient #7 admitted to the facility). Medical record review revealed from 10/02/2020 through 10/20/2020, the nursing staff documented that Patient #7's braden score ranged between 11 and 17 (below the threshold for implementation of pressure injury prevention practices). Medical record review failed to reveal documentation of heel lift boots, protective dressings to Patient #7's bony prominences, or that Patient #7 was lying on a low air loss mattress. Medical record review revealed an "Inpatient Consult to Wound Ostomy Care" was ordered on 10/18/2020 (16 days after first documented Braden score below 18) for a "sacral lesion." Review of the "Wound Ostomy Continence Nurse Consult Note" dated 10/20/2020 at 1111 revealed documentation of a "Coccyx Deep Tissue Pressure Injury...Site Assessment Purple; Red; Yellow...Wound Surface Area 35.96 cm^2; Left heel Deep Tissue Pressure Injury...Site Assessment Red; Purple...; Right heel Deep Tissue Pressure Injury...Site Assessment Purple; Red...; O (observation)...Patient assessed on 4th floor where he has been for this admission...Patient on accumax bed...No wedges or heel lift boots. Bilat heels noted to have deep purple maroon discolorations consistent with deep tissue pressure injuries. Coccyx with large deep purple/maroon discoloration, starting to peel-consistent with evolving deep tissue pressure injury...Current braden 13..." Medical record review revealed Patient #7 discharged to a skilled nursing facility on 10/21/2020.

An interview was requested with Registered Nurse (RN) #3 who was unavailable for interview.

An interview was requested with Nursing Assistant #4 who was unavailable for interview.

An interview was requested with Nursing Assistant #5 who was unavailable for interview.

Interview on 10/28/2021 at 1320 with a WOC nurse (RN #6) revealed a wound ostomy consult was ordered on 10/18/2020 for evaluation and treatment of Patient #7's "sacral lesion." Interview revealed RN #6 assessed Patient #7 on 10/20/2020 (the day prior to discharge). Interview revealed on assessment, Patient #7 had deep tissue pressure injuries to the coccyx, the left heel and the right heel. Interview revealed on assessment, Patient #7 was not on a low air loss bed and did not have wedges or heel lift boots which were used to help prevent pressure wounds. Interview revealed based on the nursing documentation, the staff assisted Patient #7 with turning and repositioning, but it was inconsistent. Interview revealed a WOC consult should have been made sooner.

Interview on 10/28/2021 at 1145 with the current 4th floor nurse manager (RN#8) revealed based on review of Patient #7's medical record, there were some gaps in the documentation of hourly rounding and interventions to prevent pressure ulcers. Interview revealed there was no documentation to support the staff's interventions to protect Patient #7's heels from pressure wounds. Interview revealed based on Patient #7's braden scores, the nursing staff would have been expected to implement the pressure injury prevention interventions per policy.

NC00181719, NC00180637, NC00181748