HospitalInspections.org

Based on observation, interview, and record review the facility failed to uphold all patients' right to receive care in a safe setting:

A patient room with signage "under construction" was left unlocked and accessible to all current patients roomed on the Senior Behavioral Health Unit.

Findings included:

Review of facility policy titled " Patient Bill of Rights," last reviewed 01/2023, showed " .... As a patient at OakBend Medical Center you have the right:... 17. To receive care in a safe setting..."

Observation on 4/19/2024 at 10:15 AM on the Senior Care Unit-, 6th Floor -showed patient room door # 612 with signage posted that read "Under Construction-Work In Progress ." The door was observed to be unlocked and accessible.

Observation inside of the unoccupied room showed the following: 3 mattresses stacked on one bed; another mattress rolled up and located in top of another bed. All 3 mattresses had canvas-type straps: with either loop handles or straps hanging down and accessible . In addition-there was a large 30 gallon trash can observed on a shelf-with what appeared to be large amount of white paper and other debris inside. There were 2 large windows. One side had some type of duct tape or strapping placed across the window. This tape was drooping down across the width of the window.

Interview with Staff -D, at the time of observation , she stated the room should have been locked as there were hazards in the room that could be used for harm.

Observation on 4/19/2024 at 11 AM with the Unit Secretary, she demonstrated that the locking mechanism was not broken on room # 612. When a key was inserted from the hallway into a locked door: if the key was turned to the left and the door was opened: the door would automatically lock when it was shut. If a key was inserted into the locked door from the hallway and turned to the right: the door would NOT lock automatically when shut. Turning the key to the right disabled the self-locking mechanism.

Staff D said Housekeeping was recently in the room; or it could have been one of the workers who may have left the room unsecured. She said all of the unit staff know to turn the key to the left .

Based on record review and interview , facility nursing staff failed to assess patient care needs related to prevention of skin breakdown.

Nursing staff failed to perform and document accurate and consistent patient skin assessments per facility policy and professional standards of nursing practice [ citing Patient ID # 4]

Findings included:

TX00493913

Record review of facility policy titled "Assessment & Reassessment, last revised date 01/23, showed:"A daily head- to- toe patient assessment will be completed at least every 24 hours by an RN, with on-going assessment as patient condition warrants. A licensed nurse will reassess the patient according to unit specific time frames and if a patient has a change in condition.

Record review of professional guidelines established by the American Nurses Association (ANA) titled : "Principals of Nursing Documentation: Guidance for Registered Nurses," 2010, showed:

-Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice;

-The uses of Nursing Documentation include: Communication within the healthcare team. Timely documentation of the following types of information should be maintained in the patient's health record : assessments; order acknowledgement, implementation, and management [*not all inclusive ].

On 4/19/2024 of the medical record of Patient ID # 4 was reviewed with Staff C, Unit Charge Nurse.

Patient ID # 4's medical record showed she was an 80 year old female patient admitted on 2/16/2024 with diagnosis of acute psychosis, depression, and anxiety.

:
2/16/2024 (1657)-Nursing Admission Assessment showed : "bruise: left anterior knee & right anterior thigh. Erythema : lower left chest; groin and sacral ."

Electronic Medical Record : "Skin Lesions:"

-2/17/2024-(00:30): bruise : arm- lower left anterior; arm- lower right anterior
-2/17/2024 (1900): 2 bruises : arm: lower right; arm: lower left.
-2/18/2024-(1930) 6 bruises ( arm: lower left anterior; arm- lower right anterior; and left lower posterior )
-2/19/2024- no skin assessment notes
-2/20/2024- "no lesions noted"
-2/21/2024 (730) : rash x 2
-2/21/24 (1836): " bruising to lower extremities: RIGHT leg: 7 small bruises to lower and 1 (one) to upper. LEFT leg: 3 small bruises to lower and 1 small bruise that is healing. Bruising to upper extremities: Arms: RIGHT: 4 large bruises to upper and lower due to blood draw; LEFT arm: 4 large bruises to upper and lower due to blood draw. Red heat rash on back. Red rash to lower abdomen and perineal areas. Red rash to buttocks."
-2/21/2024 (1915) : pressure ulcer/ wound
-2/22/2024 - no skin assessment notes
-2/23/2024- no skin assessment notes
-2/24/2024 (0007): "no lesions noted."
-2/25/2024- no skin assessment notes
-2/26/2024- no skin assessment notes
-2/27/2024 - (2023): "no lesions noted"
-2/28/2024 - (1950): "no lesions noted"
-2/29/2024- (0730) - rash x 5
-3/1/2024- no skin assessment notes
-3/2/2024 - (0900): "no lesions noted"
-3/3/2024 - (0900): "no lesions noted"
-3/4/2024 - (2000): no skin assessment notes
-3/5/2024 (2013): "no lesions noted"
-3/5/2024 (0:00) rash x 4
-3/6/2024 (9:00): OTHER: left anterior thigh
-3/7/2024 (1900): no skin assessment notes
-3/7/2024 ( 0709: bruise lower left leg-posterior
-
3/08/2024 ( 08:30 ) [-last nursing skin assessment prior to discharge] : LESIONS:
ERYTHEMA : chest lower left; groin; sacral- BRUISE: Knee-left anterior; Thigh- right anterior
~~~~~~~~~~

"SKIN ASSESSMENT" - FULL BODY DIAGRAMS:

-2/17/2024 (0015): Front-facing body diagram: " bruises" -line drawn to lower right arm and lower left arm. red rash -circle drawn around perineal area; "bruise"- line drawn to left knee. Back-facing body diagram: circle drawn around sacral area- "red rash."No descriptive narrative note written.

-2/29/2024 (1604) : Front-facing body diagram: bruise noted to left arm and left knee; 2 bruises noted to right upper thigh and fungal rash to 'perineal area. Back- facing body diagram: 3 bruises notes to right lower arras; 4 bruises noted to left arm; fungal rash to buttocks. "Pt. has fungal rash on buttocks, groin area and bilateral thighs. Pt. has multiple bruises on hands, arms, right thigh, and left knee."

-3/5/2024 (1513) : Front-facing body diagram showed 2 bruises noted by "X" to left arm; 2 bruises noted by "X" to left leg; one bruise noted to left side. 2 bruises noted by "X" to right lower leg. Back-facing body diagram : 3 bruises to right arm; 3 bruises to left arm Purple rash noted to buttocks area. Written narrative read: "pt. has a fungal rash on buttock, groin area and bilateral thighs. Pt has multiple scattered brushing on hands, arms, right thigh, left knee, and posterior left knee."
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During an interview with Staff C, RN Charge Nurse during the record review, she stated the skin assessments reviewed for Patient ID # 4 were not consistent or performed per facility policy. Staff C said that skin assessments should be done every shift. She verified the nursing documentation on 3/3/2024 of "no lesions noted" was not congruent with the "Skin Assessment" [Full Body Diagram ] documented on 3/5/2024. This diagram showed multiple areas of lesions / (bruises) , as well as fungal rash to multiple areas. There was no documented skin assessment on 3/4/2024, as well as multiple other dates.