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.

Based on staff interview, review of facility's policies and review of one (1) of three (3) medical records (Patient # 1) review, nursing services failed to identify, implement and revise the nursing care plan and to contact the physician for orders to revise the nursing care plan.

Findings Include:

Medical record review on 12/17/2020 at 2:00 p.m. revealed, "Arrival of Patient # 1, means of arrival: car, on 10/18/2020 at 5:20 p.m., point of origin: home/work/self; chief complaint: wound infection. Visit diagnoses: Cellulitis of left lower extremity, Chronic? no; Sepsis, due to unspecified whether acute organ function present (HHC), Chronic? no; PAD (peripheral artery disease) (HHC), Chronic? yes".

Registered Nurse (RN) job description review on 12/17/2020 at 3:00 p.m. revealed RN job responsibilities included, "Assess the patient, develop a plan of care, evaluate the plan of care ...and completing assigned goals".

Medical record review of Patient # 1 on 12/18/2020 at 9:30 a.m. revealed Emergency Department (ED) RN assessment documentation of skin on 10/18/2020 at 7:27 p.m., "Skin WDL: all; WDL except ...wound bilateral lower extremities".

During interview with ED RN on 12/18/2020 at 9:30 a.m., asked if she did an overall assessment of Patient # 1. She confirmed that on the ED assessment, she did not do a complete assessment, she only assessed the areas related to Patient # 1's complaint in the ED.

Medical record revealed no documentation of a skin assessment until 10/28/2020 of a Pressure Injury Sacral Wound and Patient #1 did not receive a Wound nurse consultation/order until 11/17/2020 at 9:11 a.m. or a physician's order for wound care and treatment until 11/17/2020 at 11:48 a.m.

Review of the facility policies revealed that nursing staff failed to assess and reassess Patient #1 as indicated in the facility's Assessment/Reassessment Policy Purpose: ..."To establish assessment/reassessment time frames and processes to help determine the care, treatment and services that will meet the patient's initial and continuing needs. To outline pressure injury and wound treatment interventions utilized and to identify wounds and treatment of wounds ..." as stated in the facility's Pressure Injury and Wound Treatment Guidelines Policy.

The facility's Hygiene Log revealed no documented evidence of Patient #1 receiving a daily bath from date of admission on 10/18/2020 at 6:15 p.m. until 10/26/2020 at 1:10 p.m., in addition to bath not given on days 10/30/2020; 11/3/2020 and 11/6/2020.

The facility's Patient Care Assistant (PCA) Job Description revealed the PCA staff did not follow the PCA Job responsibilities: " ...Performs direct patient care duties as assigned under the direction of licensed nursing personnel ...and completing assigned goals...".

Review of the facility's Patient Care Policy revealed nursing staff did not follow the Bathing Guidelines in the Patient Care Policy: " ... To provide a daily bath for patients unable to self bathe, unless medically contraindicated, to improve hygiene and promote comfort ...".

During the Exit Conference on 10/18/2020 at 3:45 p.m., survey findings were discussed with no further documentation submitted for review.