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| JEWISH HOSPITAL & ST MARY'S HEALTHCARE | 200 ABRAHAM FLEXNER WAY LOUISVILLE, KY 40202 | Jan. 20, 2012 |
| VIOLATION: NURSING SERVICES | Tag No: A0385 | |
| Based on observations, interviews and record reviews, it was determined the facility failed to meet the Conditions of Participation for Acute Hospitals related to Nursing Services. The facility failed to follow policies and procedures related to pressure ulcer prevention and treatment. The facility failed to provide complete physical assessments for Patients #1, #5, #9, #13 and #14 upon admission, daily, and upon discharge to prevent pressure ulcers resulting in patients #1 and #5 acquiring avoidable pressure ulcers. | ||
| VIOLATION: RN SUPERVISION OF NURSING CARE | Tag No: A0395 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility's policies, it was determined the hospital failed to ensure patient needs were assessed, evaluated, monitored and documented upon admission, and daily as written in the hospital policy for five (5) of fourteen (14) sampled residents related to pressure ulcers (Patients #1, #5, #9, #13, #14) In addition, the facility failed to reposition a patient as indicated in the education provided to staff on 12/16/11-12/23/11 for one (1) of fourteen (14) sampled patients. (#14) The findings include: Review of the policy followed by the GeroPsych unit titled Skin Assessment: Alteration in Skin Integrity, revised 03/2011, applied to Our Lady of Peace and Psychiatric Residential Treatment Facility (PRTF), revealed skin assessment, prevention, and treatment shall be implemented for patients at risk for compromised skin integrity... the procedure indicated, on admission all patients will have head to toe and anterior/posterior examination of the skin. If the patient presents at admission or any time during the stay, with an alteration in skin integrity, a photograph of the skin may be taken. Patients will be reassessed by the nurse if there are any changes in the patients condition that indicated an actual or potential alteration in skin integrity. Documentation should include assessment/reassessment, interventions, and the patients response. Review of the hospital policy titled Wound Care: Pressure Ulcer Prevention and Treatment Guidelines, effective 06/2009, applies to the hospital...indicated the purpose was to provide guidelines...for documenting, assessing, and preventing pressure ulcers... The policy stated every patient will be assessed for pressure ulcer risk upon admission, daily, and per unit specific policy. The procedure stated that on admission to an inpatient facility and every shift, all patients will have a skin assessment. Staff is to notify the wound care clinician for hospital acquired pressure ulcers. Document findings of skin assessment upon admission and at least every shift. Document if there is no alteration in skin integrity. Staff documentation will include: location, wound type, stage, and measurement. Measurements will occur on initial assessment/occurrence, every Wednesday, and document in centimeters (cm). 1. Review of the medical record for Patient #1 revealed the facility admitted the patient to the GeroPsych unit on 10/28/11 and discharged the patient from the unit on 11/11/11. The patient was admitted with a diagnosis of Dementia with behaviors. Review of the admission skin assessment completed on 10/28/11 indicated, "red" to the coccyx/sacral area. There was no other documentation on the skin assessment form that indicated any other skin issues. Review of the nursing narrative for Patient #1 from 10/28/11-11/11/11 revealed: no documentation of a skin assessment; required 2-5 staff for bathing; and activities of daily living (ADL) care needs; used a wheelchair or recliner for mobility; and was incontinent of bowel and bladder. Patient #1 received a whirlpool bath on 11/07/11 with no indication or documentation of a skin assessment. Review of the Nursing Home's Skin Assessment completed by a staff nurse for Patient #1 revealed, a skin assessment completed on 10/19/11 indicated, coccyx/sacral pink and blanchable, right groin pink and blanchable and a scratch on the left lower back. Upon readmission back to the Nursing Home, on 11/11/11 at 3:00 PM, a skin assessment completed by a staff nurse revealed, wounds that included, a deep tissue injury to the right heel measured 3 cm by 6 cm, left lateral malleolus unstageable, measured 1 cm by 0.9 cm, right medial knee unstageable, measured 1 cm by 0.7 cm. Review of the Wound Care Specialist Physician Group progress notes for Patient #1 written on 11/14/11 at the Nursing Home revealed Patient #1 back from the hospital with three (3) noted pressure areas as follows: a 4 cm by 4 cm unstageable pressure ulcer to the right heel with Eschar/blister; positive posterior tibia pulse; an unstageable left lateral ankle 1 cm by 1 cm pressure ulcer; and a right medial knee stage 2, measured 0.7 cm by 0.8 cm. Continued review of the wound care specialist physician group progress notes dated 01/09/12 revealed, the right knee and left ankle were healed, and the right heel was debrided to a level 3, removing eschar measured 2.5 cm by 3.0 cm. Interview with RN #16, on 01/18/12 at 1:50 PM, revealed she was the nurse who discharged Patient #1 from the unit on 11/11/11. RN #16 stated she did not get a chance to do the skin assessment for Patient #1 before the patient was discharged because she had two or three admits and discharges. RN #16 stated she knew the policy indicated to conduct the skin assessment prior to discharge and she did not get around to completing it. Per RN #16, Nurse Manager #4 had previously inserviced and taught her how to do skin assessments. She stated the facility staff were required to document a skin assessment on every patient on every shift. The hospital was unable to provide evidence to validate the training to staff of skin assessment requirements per patient per shift upon surveyor request. Interview with the Nursing Manager #4, on 01/12/12 at 4:40 PM, revealed Patient #1 was a patient on the GeroPsych unit and was discharged on [DATE]. The nursing home the patient was transferred to, and was a patient prior to admission to the GeroPsych unit, called her on the day, or the day after the patient was discharged , to report multiple pressure ulcers were found on the patient. Nursing Manager #4 was able to obtain copies of pictures of the wounds taken at the nursing home on 11/12/11. Continued interview with Nursing Manager #4 revealed she and the Director of Nursing (DON) met with the family on 12/16/11 to discuss concerns regarding the pressure ulcers found on Patient #1. Nursing Manager #4 stated they contacted the wound care nurses to get some education material. A unit meeting/inservice was conducted throughout 12/16/11-12/23/11 that included information for skin care and the prevention of breakdown. She went on to say she showed the pictures of the pressure ulcers found on Patient #1 to the staff during the staff meeting. Staff were instructed to use assistive devices, creams, turn patients every two hours, take slipper socks off, and document skin assessments every shift. Nursing Manager #4 stated she had done normal rounding and did "spot" checks after the inservice was completed to monitor staff and patients, to ensure skin checks were being done; however, had no documentation of patients that had been assessed, or monitored. Interview with the Director of Nursing, on 01/17/12 at 1:30 PM, revealed the facility reviewed the facility policy for pressure ulcer prevention, immediately after the facility was notified by the nursing home, of pressure wounds found on Patient #1 upon discharge from the GeroPsych Unit on 11/11/11. She realized the GeroPsych Unit should be using the hospital policy for pressure ulcer assessment and prevention, including skin assessments every shift with documentation in the narrative notes of the finding or reason the skin assessment was not completed. She believed the patients on the GeroPsych unit were at an increased risk for pressure ulcers related to age, mobility, mental status, and elimination patterns, and therefore, the GeroPsych Unit should use the policy that gave more directive and required more skin assessments. The DON stated the facility completed inservices from 12/16/11-12/23/11 that included pressure ulcer prevention, but did not include the hospital policy Wound Care: Pressure Ulcer Prevention and Treatment Guidelines used by the hospital. The DON state the facility trained on pressure ulcer prevention topics, but did not train staff specifically on the hospital wound care policy. She had rounded on the GeroPsych Unit, speaking to staff, completed skin assessments of patients on the unit while educating staff by demonstration. The DON stated the staff on the GeroPsych Unit were not inserviced on the hospital policy or given any written documentation that explained the new policy and procedure for skin assessments during the inservice of 12/16 -23/11. The DON stated she did not document the completed skin assessments or individual staff inserviced on the GeroPsych Unit. Review of the inservice record completed on 12/16-23/11 on the GeroPsych Unit revealed forty-two (42) staff were inserviced. The inservice consisted of the topics skin care, prevention of breakdown, important daily skin care products used for bathing, moisturizing and protection, and how to prevent pressure ulcers that included twelve pictures and descriptions. Interview with Registered Nurse (RN) #1, on 01/12/12 at 4:05 PM, revealed he had worked on the GeroPsych unit since it had opened at the present location. He stated skin assessments are done on admission, but there is no schedule "per say". The Mental Health Worker/Certified Nursing Assistant/ Nursing Assistant (MHW/CNA/NA) would report any new skin issues, at that time a picture will be taken and treatment started. It depended on the patient when skin assessments were done. He did remember Patient #1 and was "shocked" about the pictures. He stated the facility conducted inservices on 12/16-23/12 for pressure ulcer prevention, to be more involved, and to be proactive. Interview with MHW/CNA #3, on 01/12/12 at 4:30 PM, revealed she had worked on the GeroPsych Unit for two years. She did skin assessments "constantly" and told the nurse of any problems. MHW/CNA #3 stated she was familiar with Patient #1 and required two people and sometimes three to care for the patient. MHW/CNA #3 stated the facility inserviced staff on 01/13/12 related to pressure ulcer prevention and to be more vigilant of the patient's skin. 2. Review of the inservice record completed on 12/16-23/11 on the GeroPsych Unit revealed the inservice consisted of: skin care; prevention of breakdown; important daily skin care products used for bathing; moisturizing and protection; and how to prevent pressure ulcers that included twelve pictures and descriptions. Picture #12 stated do not rub reddened areas over bony prominence's. Review of the medical record for Patient #9 revealed the facility admitted the patient on 12/29/11 to the GeroPsych Unit with a diagnosis of Alzheimer's Dementia. A complete head to toe assessment was completed on admission. Review of the nurses narrative notes indicated the patient was restless, and combative with any care needs. Continued review of the nurses notes narrative revealed no skin assessments documented on 12/27-28/11 7 PM-7 AM, and 12/29/11 7 AM-7 PM. On 12/30/11 the notes indicated the patient was cooperative, no aggression, and compliant with medication; however, no documentation of a skin assessment. Continued review of the nurses narrative notes revealed no skin assessment documented on 12/31/11. On 01/01/12 the patient had a skin assessment that indicated, red areas on the right hip, right ankle, outer side of right knee, and a small open area on the coccyx. Pictures were not taken of the pressure areas until 01/04/12. On 01/05/12 interventions were put into place for hip protectors, ankle protectors, and barrier cream. Documentation on 01/07/12 revealed Patient #9 had a 4-5 cm red, blanchable area over the right iliac crest, area massaged to increase circulation. Observation, on 01/12/12 at 4:00 PM, of Patient #9 revealed the patient resting in bed. The patient had a private sitter at all times. The patient was dressed in gray shorts and was incontinent. The patient was restless in the bed. Both internal knees were red. No knee, ankle, or heel protectors were in place. Interview with Nursing Manager #4, on 01/12/12 at 4:00 PM, revealed Patient #9 had a jump suit to prevent friction but did not have it on. She stated she had instructed the staff to keep the patient "greased up". 3. Review of the medical record for Patient #14 revealed the facility admitted the patient to the GeroPsych unit on 01/13/12 with a Diagnosis of Dementia with disturbance in behavior. Review of the admission head to toe skin assessment revealed multiple bruises and a stage I to the coccyx. Review of the nursing notes narrative revealed no skin assessment documented for, 01/13-14/12 2300-0700 shift, 01/16/12 7 AM-7 PM shift, 01/16-17/12 11 PM-7 AM shift, 01/17-18/12 7 PM-7 PM shift. Review of the inservice record completed on 12/16-23/11 on the GeroPsych Unit revealed inservice consisted of: skin care; prevention of breakdown; important daily skin care products used for bathing; moisturizing and protection; and how to prevent pressure ulcers including twelve pictures with descriptions. Picture #6 was a description that stated the individuals position should be changed every two hours when in bed and every one hour when in a chair. Observation, on 01/18/12 at 8:30 AM, revealed Patient #14 sitting up in the recliner chair in the dining room sleeping. Continued observation at 8:45 AM, 9:00 AM, 9:15 AM, 9:30 AM, 10:00 AM, and 10:15 AM, revealed the patient still sleeping in the recliner chair. No staff attempted to reposition the patient. At 10:22 AM the patient awoke, crying and hanging legs over the leg rest. Observation, on 01/18/12 at 12:40 PM, of a skin assessment for Patient #14 by RN #18 revealed a stage I to the coccyx. No other skin issues were observed or noted on the patient. Interview, on 01/18/12 at 9:55 AM, with RN #18 revealed she had worked on the GeroPsych Unit over one year. She completed a skin assessment on her patients everyday, of what she could see. If the patients are immobile she would do a head to toe skin assessment. She went on to say she would not document on the narrative nurses notes if the skin assessment was clear. She charted by exception. RN #18 stated there was a renewed interest in skin assessments since a patient developed pressure ulcers on the unit. RN #18 stated she did take care of Patient #1 a few times and did some skin assessments but couldn't say if she looked at the patients heels. The patient was resistive to care and it took 3-4 staff to provide care. Interview with Nursing Manager #4, on 01/20/12 at 1:05 PM, revealed the GeroPsych unit was using the Our Lady of Peace policy for skin assessments until the incident occurred with Patient #1. The hospital policy was more stringent on skin assessments and she and the DON wanted to implement that policy. The hospital policy on skin assessments was not included in the inservice. When asked how often patients are to be repositioned in the bed and chair she stated every two hours. When asked about the inservice provided to the staff on 12/16-23/11 related to picture #6 for patients needing to be repositioned every one hour in the chair, she stated she "didn't notice that". 4. Observation of Patient #5, at the hospital facility, on 01/18/12 at 3:30 PM, revealed the patient was in the room with two staff assisting the patient to stand. The two staff assisted the patient to bed. Additional observation at 3:45 PM revealed the patient was supine (on back) with feet crossed and both heels were lying on the waffle top mattress. The patient had blue hospital footies with non-skid bottoms on both feet. A flat pillow was placed under the patients upper legs. The patient's son was present. Interview, on 01/18/12 at 3:45 PM, with Patient #5 and the patient's son revealed the patient had a reddened area on the coccyx area upon admission; however, there was no problems with the patient's feet. The patient's son revealed he was not aware of the identified pressure areas to the patient's heels and toes. Patient #5 revealed the pressure area to his/her feet were not there upon admission. Record review for Patient #5 revealed the facility admitted the patient on 01/12/12 with diagnoses of Mental Status Changes (MSC) and Urinary Tract Infection (UTI). The skin assessment identified a Stage I pressure on the coccyx area on 01/12/12 at 9:00 PM. No measurements were documented and no picture was taken. Documentation on 01/13/12 revealed the nursing assessment documented a Stage II to coccyx with pink/beefy red wound bed. Compression stockings identified as knee high TEDS was documented on 01/14/12 at 2:00 AM. On 01/16/12 at 4:16 PM documentation revealed a second skin breakdown was identified on the patients left and right heels. A blister was documented to the left and right heels to be red-maroon in color; a blister to the left and right great toes with no drainage and no dressing. No picture was obtained of Patient #5's coccyx area and of the pressure areas identified on the patients feet. No measurements were documented to identify the size of the pressure areas identified. Interviews, on 01/19/12 at 9:00 AM with RN #11, 9:50 AM with RN #12, 11:47 AM with RN #13 and 2:30 PM with RN #19, revealed they had provided care for Patient #5 since the admission on 01/12/12. They stated they were to do a head to toe assessment of patients every shift which included looking at the patient's skin to identify potential pressure areas breakdown. They stated a picture was to be taken of the identified area, measurements were to be documented, and if the area was staged a three (III) or Stage four (IV) they were to put a consult in for the wound nurses. They revealed the patient had TED hose on and they did not remove the stockings to observe the patient's feet. Staff RN #12 at 9:50 AM revealed the patient was much more alert after a couple of days and had complained of his/her toes hurting. She said the nurse aide had checked the patient's pedal pulses and identified the blisters on Patient #5's feet. She stated she was guilty of not pulling off the patient's TED hose. She should have assessed the patient's feet, taken a picture and measurements. Staff RN #13 at 11:47 AM revealed she did not assess every single bony prominence. Staff RN #11 at 9:00 AM revealed she worked as needed (PRN) and she usually did not take measurements of wounds. She stated she was a float nurse and was so busy she did not know where the tools to measure wounds were kept. She stated she did not recall any specific training on wound care and was not aware how the facility monitored. Staff RN #19 at 2:30 PM revealed she may not have assessed Patient #5 head to toe on the backside, but she did assess the front of the patient. She stated the patient had TED hose on and she did not remove them to observe the condition of the patient's feet. She stated she would feel of the patient's feet with the TED hose on. She acknowledged she should have removed the stockings to assess the patients feet. She stated she documented her assessments, but it would depend on how busy she was as to how much detail was included. She stated some nurses would "click" the default button and the computer would repeat what the previous nurse had documented. She said that was OK if there had been no changes in the patients status. Staff Nurses #'s 11, #12, #13, and #19 stated they were busy and did not explain why the facility policy/protocol was not followed. 5. Review of the medical record for Patient #13 revealed the facility admitted the patient to the hospital on [DATE] with diagnoses including History of Toxic Megacolon requiring a Colostomy with Infected Abdominal Wound, and History of Diabetes. Review of the Initial Assessment Part A/B completed by RN #15, on 01/08/12 at 8:00 PM, revealed the patient was admitted with a pressure ulcer and indicated a pressure ulcer documentation form was initiated. Review of the Nursing Flow sheet, on 01/08/12 at 8:00 PM, revealed no additional breakdown, turn every two hours, and assess skin. There was no documentation of where the pressure ulcer was, what stage, no measurements of the wound, and no treatment description. Review of the narrative nurses notes, on 01/09/12 at 9:00 AM, revealed pressure ulcer site, sacral stage I, appearance pink, beefy red, no drainage, foam dressing. Review of the Wound Care Nurse #1 notes' dated 01/09/12 at 10:55 AM revealed the patient was admitted with wounds on the sacral area and the left buttocks that were present on admission. The note went on to say the wounds were difficult to stage because the patient was so thin, the wounds appeared to be very shallow stage III wounds. The wounds were primarily pink with a small amount of yellow tissue on the coccyx. No pictures were taken or measurements completed on admission or by the wound nurse. The Ulcer Documentation form and pictures of the pressure ulcers to the coccyx and sacrum were not completed until 01/19/12 by RN #19. The coccyx wound was described as, unstageable, one centimeter by one centimeter with slough, with rolled edges and surrounding tissue was pink. The other area on the coccyx was documented as a skin tear with no measurements, wound bed pink and surrounding tissue pink. Review of the Skin Assessment for Patient #13 completed on 01/05/12 by the Wound Care Specialist Physician Group at the Nursing Home revealed a sacral Stage III, 1 cm by 1 cm with 100% slough and the right ischial Stage III, 0.5 cm by 0.5 cm with 100% slough. Observation, on 01/19/12 at 10:25 AM, of Patient #13 revealed the patient resting in bed. Awake, alert, pleasant. A tube feeding was infusing and the patient was turned to the left side. Interview with Patient #13, on 01/19/12 at 10:25 AM, revealed the patient felt they received excellent care. He/She stated they offer to turn the patient less often than every two hours and it may take a little time to get the call light answered. Interview with RN #19, on 01/19/12 at 10:30 AM, revealed she had worked at the hospital since June 2011 and stated she had a great orientation. She stated there were no pictures or description of the pressure wounds Patient #13 was admitted with. She stated she was not aware they were not done and should have been done on admission as written in the facility policy. Interview with RN #15, on 01/19/12 at 11:20 AM, revealed she was the nurse who admitted Patient #13 on 01/09/12. She knew the facility policy for patients that were admitted to the hospital with a pressure ulcers, to complete the ulcer documentation form and take pictures, but did not do this for Patient #13 because the patient had a dressing in place. She had put in a consult to wound care; however, had not left a note or message in regards to the pressure ulcer to the coccyx, or not having measurements or pictures completed. RN #15 stated the patient came at shift change and the nurse from day shift helped with the admission. She stated it had been a long time since she had been inserviced regarding wounds, or pressure, and had not received any alerts or information from risk, safety or Friday Facts regarding skin care notices. Interview with RN #17, on 01/20/12 at 10:00 AM, revealed she had taken care of Patient #13 on 01/08-09/12. She remembered the patient came at shift change and she stayed over to help the night nurse do the admit. Although she was aware of the policy for assessment and pictures, she did the database, asked questions but did not do a medication reconciliation or any physical assessment. She told RN #15 she had not completed an assessment of any kind for Patient #13. RN #17 stated if the patient had come on her shift she would have done a complete assessment, removed the dressing, and taken pictures. She stated measurements should be done every Wednesday and documented in the nurse notes. She went on to say the unit was "bombarded" at the time the patient was admitted . RN #17 stated she was last inserviced in November 2011 for annual competencies and did not recall any alerts or notifications of a problem with wounds, skin or pressure ulcers recently. Interview with Wound Care Nurse #1, on 01/19/12 at 4:00 PM, related to the Wound Assessment documented by her on Patient #13, on 01/09/12 at 10:55 AM, revealed she usually checked the chart for pictures and documentation but did not remember if she had for this patient. Regarding the documented observation of the wound, by Wound Care Nurse #1 for Patient #13, revealed she stated it was "technically" unstagable because if it was debrided, it would be a stage III or IV. Interview with Nurse Manager #5, on 01/19/12 at 11:00 AM, revealed she had worked at the hospital ten years. The nurse assigned to the patient was responsible for the admission. She stated she was aware of the policy and indicated when a patient is admitted with a pressure ulcer, the nurse should have followed with pictures and completed the pressure ulcer documentation form. Patient #13 did not have the assessments or pictures in the medical record. It was important to follow the policy to ensure the wounds are documented upon arrival and to ensure they are properly treated and monitored. Quality Risk was responsible to do audits to ensure the proper forms and assessment were completed for patients in the hospital. Nursing Manager #5 stated the last inservice on wounds or skin assessments was about a year and a half ago. She had no alerts on skin, wound or pressure ulcers lately. She stated the last notice from Quality Risk and Safety was December 2011 regarding contact precautions and in November 2011 regarding patients going outside. She went on to say the Unit Managers had several monthly meetings and there had been no mention of skin issues, or pressure ulcer concerns. Interview with Nurse Manager #4, on 01/20/12 at 1:05 PM, regarding the training on the GeroPsych Unit she stated she had added interventions, showed pictures of Patient #1's wounds, went over the hospital policy on skin assessments, but was not auditing enough to ensure daily charting had been completed correctly. They just conducted another inservice on 01/13/12 on documentation of skin assessments. She was more focused on patients who were admitted with pressure ulcers then on monitoring those without pressure ulcers. She had reported the incident with Patient #1 in the morning huddle meeting where all the unit managers attend and filled out an incident report that went to Risk Management. Interview with the Director of Nursing, on 01/20/12 at 1:45 PM, revealed the hospital needs to get the Policy and Procedures to match up related to skin assessments and wound assessments. The facility was not doing such a good job on documentation of skin assessments. That was important so the facility could know what the patient was admitted with or if there were any changes. They have completed skin audits and chart audits but not on a formal tool. There was no potential for other areas of the hospital to develop pressure ulcers if the staff were following policy and procedure. She did not think about the other units in the hospital and was just focused on the GeroPsych unit. She notified safety and Risk Management of the incident with Patient #1. She stated QA and Risk only do audits for pressure wounds quarterly. |
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