The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

INGALLS MEMORIAL HOSPITAL 1 INGALLS DRIVE HARVEY, IL 60426 July 15, 2020
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on document review and interview, it was determined that for 1 of 4 patients (Pt #1) reviewed for pressure ulcer care, the Hospital failed to ensure that Pt #1 was turned or repositioned every 2 hours, as ordered.

Findings include:

1. On 7/13/2020, Pt #1's clinical record was reviewed and indicated:

-Pt #1's admission assessment dated [DATE] indicated "Braden Score total -15" (high risk for pressure ulcer).

-P#1's history and physical dated 10/8/2019 indicated "admitted & time (10/7/2019 at 3:10 PM)... Pt #1 admitted from inpatient rehab due to fever and acute renal failure. Pt #1 had temp of 102 with unknown cause..."

-Pt #1's physician orders, dated 10/8/2019, included, "...Activity: Reposition every 2 hours..."

Pt #1's surgical consult note, dated 10/9/2019, included, "reason for encounter - sacral wound...surgery was consulted for necrotic sacral wound...sacral wound necrotic without any significant drainage..."

-Pt #1's Wound Care Nurses' notes indicated the following:
- 10/8/2019 -Pt #1 having difficulty with positioning self. Turn every 2 hours and float heels. Unstageable Pressure Injury on sacrum/coccyx- measurement (12.5 length x 4.5 width x 3.4 depth) ...Recommend surgical evaluation for sacral wound and possible debridement ..."
-10/14/2019 - Pt #1 is severely obese and unable to turn self. Pt #1 is incontinent of large amount stool which is in wound bed. Turn every 2 hours. Stage 4 pressure injury - sacrum - measurement (13.5 length x 8 width x 6 depth)
-10/22/2019 - Stage 4 pressure injury -sacrum - measurements (12.5 length x 8 width x 5.8 depth)
-10/28/2019 - Stage 4 pressure injury - sacrum - measurements (12.5 length x 7 width x 2.8 depth)

-Pt #1's operative report, dated 10/11/2019, included "Preoperative diagnosis: Necrotic sacral wound - Excisional debridement of skin and soft tissue from sacral wound (10 x 9 cm) 3 cm depth ..."

-Pt #1's Rounding Flow Sheets dated 10/10/2019 through 10/28/2019 indicated:

-10/10/2019 - 4:15 PM - Pt #1 turned on back and 10:00 PM - Pt #1 moved up in bed
-10/11/2019 - 10:00 PM - Pt #1 moved up in bed
-10/12/2019 - 2:00 AM & 2:00 PM - Pt #1 moved up in bed, 10:00 PM - Pt #1 turned on right side
-10/13/2019 - 2:00 AM - Pt #1 turned on right side, 9:10 AM - Pt #1 turned on left side, 10:00 PM - Pt #1 turned on left side
-10/14/2019 - 2:07 AM - Pt #1 turned on back, 10:00 AM - Pt #1 turned on right side, 2:00 PM - Pt #1 moved up in bed
-10/15/2019 - 2:16 AM - Pt #1 moved up in bed, 10:00 AM - Pt #1 turned on right side, 2:00 PM - Pt #1 turned on left side, 10:00 PM - Pt #1 turned on left side
-10/16/2019 - 2:00 AM - Pt #1 turned on right side
-10/17/2019 - 12:00 AM - Pt #1 turned on left side, 2:13 AM - Pt #1 turned on right side, 5:02 AM - Pt #1 turned on back, 10:00 PM - Pt #1 turned on back
-10/18/2019 - 2:00 AM - Pt #1 turned on left side, 10:00 AM - Pt #1 turned on right side
-10/19/2019 - 10:00 AM - Pt #1 moved up in bed, 2:00 PM - Pt #1 turned on left side, 10:00 PM - Pt #1 turned on left side
-10/20/2019 - 1:59 AM - Pt #1 turned on back, 6:00 AM - Pt #1 moved up in bed, 10:00 AM- Pt #1 turned on left side, 2:00 PM - Pt #1 turned on right side
-10/21/2019 - 10:00 AM - Pt #1 turned on back, 2:00 PM - Pt #1 turned on right side
-10/22/2019 - 8:59 AM - Pt #1 turned on left side, 10:50 AM - Pt #1 turned on back, 12:25 PM - Pt #1 turned on left side, 2:30 PM - Pt #1 turned on right side, 4:20 PM - Pt #1 turned on right side, 6:13 PM - Pt #1 turned on left side, 10:00 PM - Pt #1 turned on left side
-10/23/2019 - 2:00 AM - Pt #1 turned on back, 10:00 AM - Pt #1 turned on back, 2:00 PM - Pt #1 moved up in bed
-10/24/2019 - 2:00 AM - Pt #1 turned on right side, 10:00 PM - Pt #1 turned on left side
-10/25/2019 - 2:00 AM - Pt #1 turned on right side, 10:00 PM - Pt #1 turned on back
-10/26/2019 - 2:00 AM - Pt #1 turned on right side, 10:00 AM - Pt #1 turned on right side
-10/28/2019 - 10:00 AM - Pt #1 turned on right side, 2:00 PM - Pt #1 turned on left side

Pt #1's Rounding Flow Sheets, dated 10/10/2019 through 10/28/2019, lacked documentation of repositioning/turning every 2 hours, as ordered.

2. On 7/14/2020 at 8:45 AM, an interview was conducted with the Manager of Risk Management/Clinical Excellence (E #2). E #2 stated that the Hospital does not have a wound policy or protocol regarding repositioning. E #2 stated that this has been identified as a problem, and the Hospital is in the process of putting a protocol in place.

3. On 7/14/2020 at 9:00 AM, an interview was conducted with the Director of Risk Management (E #3). E #3 stated that there is no policy/protocol for turning patients with pressure ulcers. E #3 stated that the nurses on the units should follow the physicians' orders. E #3 stated that if a patient needs to be turned, they turn the patient.

4. On 7/15/2020 at 1:15 PM, an interview was conducted with the Attending Physician (MD #1). MD #1 stated that Pt #1's order was to reposition Pt #1 every 2 hours. MD #1 stated that staff should always try to reposition a patient every 2 hours when it is ordered. MD #1 stated that Pt #1 was very large and needed help repositioning/turning.

B. Based on document review and interview, it was determined that for 2 of 2 Registered Nurses (E #4 & E #5), the Hospital failed to ensure pressure ulcer assessment and care training was provided.

Findings include:

1. On 7/15/2020, the Hospital was not able to provide a training module for pressure ulcer assessment and care.

2. On 7/15/2020, the Hospital's Competencies 2019 list was reviewed and indicated that pressure ulcer assessment and care was not included in the training.

3. On 7/15/2020, the Registered Nurses' (E #4 & E #5) employee files were reviewed for pressure ulcer assessment and care training. There was no documentation in E #4 or E #5's employee file regarding any pressure ulcer assessment or care training.

4. On 7/15/2020 at 11:30 AM, an interview was conducted with the Nurse Educator (E #7). E #7 stated that annual competencies are completed for each nurse. E #6 stated that pressure ulcer assessment and care was not on the 2019 competencies but will be included in the 2020 competencies for nurses.