HospitalInspections.org

Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient's rights as evidenced by:
1) failure to ensure consulted providers assessed 3 (#1-#3) of 3 (#1-#3) patients in a timely manner to avoid delay in care (See findings under A-0145).

Based on record review and interview, the hospital failed to ensure the patient's right to be free from all forms of neglect. This deficient practice was evidenced by:
1) failure to ensure consulted providers assessed 3 (#1-#3) of 3 (#1-#3) patients in a timely manner to avoid delay in care.

Findings:

A review of hospital policy #115, titled "Abuse/Neglect Reporting", approved 08/16/2024, revealed in part: "Purpose: to ensure all patients are free from all forms of abuse and neglect. Definitions, In part: 1. Adult Patients, in part: B. "Neglect" means a negligent act or omission by an individual responsible for providing services in a facility rendering care or treatment which includes omissions such as failure to: establish or carry out an appropriated individual program or treatment plan."

1) Failure to ensure consulted providers have assessed 3 (#1-#3) of 3 (#1-#3) patients in a timely manner to avoid delay in care.
A review of hospital policy #46, titled "Referrals and Consultations", approved 08/16/2024, revealed in part: "Policy: It is the policy of Southeast Regional Medical Center to provide care. This care is facilitated by the availability of consultations and referrals between community service providers. Purpose: To provide for special evaluations and treatment(s) that are outside the professional domain and expertise of the staff. Procedure, in part: 4. Whenever possible, the consultation/referral will occur at the hospital or through telemedicine. 5. The consult/referral will be ordered by the attending physician or their designee and arrangements made by the nurse or their designee."

A review of hospital policy #94, titled "Wound Care", approved 09/23/2024, revealed in part: "Policy in part: Nursing, in collaboration with the health care team, will assess and manage skin integrity for all patients throughout the hospital stay. Purpose, in part: To promote prompt evaluation and intervention of any changes in skin integrity during the hospital stay. II. Skin Inspection, in part: A. On admission and daily: B, in part: The WOC nurse or therapist will be consulted as needed based on patient's skin condition and provider order. III. Interventions, in part: A. Plan of Care, in part: Recognition of early signs of skin breakdown with prompt interventions to minimize tissue damage. Identification of risk factors present or acquired, i.e. Surgical wounds, etc. Communication of skin care concerns so the entire healthcare team can implement interventions. B. Care and interventions, in part: The care and intervention for any identified skin breakdown or wound will be aimed at: Prevention of any further advancement of the wound, or additional skin breakdown. Implementation of appropriate evidence-based care indicated for the problem identified. Referral to additional resources when indicated-Wound Care Specialist (NP or WOC). D. Documentation, in part: Upon identification of a wound, a full wound assessment, including its location and description of the tissue involved will be completed."

Patient #1
A review of Patient #1's medical record revealed an admission date of 10/18/2024.

A review of Patient #1's "Admission Orders" revealed in part: Admission diagnoses: cutaneous abscess of right upper limb, osteomyelitis of vertebra thoracic region, chronic osteomyelitis other site, secondary esophageal varices without bleeding, and methicillin resistant staph infection. Provider orders: Wound care consult. Provider/Nursing Standing Orders, Wound Protocol: Cleanse the wound site with wound cleanser and dry with gauze. Cover with dry gauze and ABD padding. Secure with tape. If packing is needed, pack with gauze rolls, cover with dry gauze and ABD padding. Secure with tape. Notify wound care.

A review of Patient #1's "Nursing Admission Assessment" dated 10/18/2024 at 9:13 PM revealed the following wound assessment:
Wound culture obtained: Yes (the documentation failed to reveal from where the wound culture was obtained).
Wound #1:
Site: Chest. Assessment: Surgical incision. Length: Blank. Width: Blank. Depth: Blank. Undermining: Yes. Tunneling: Blank. Wound bed: Pink tissue. Necrosis: Blank. Exudate: Blank. Odor: Blank.
Wound #2:
Site: Chest. Assessment: Abscess. Length: Blank. Width: Blank. Depth: Blank. Undermining: Yes. Tunneling: Blank. Wound bed: Blank. Necrosis: Blank. Exudate: Blank. Odor: Blank.

Further review of "Nursing Admission Assessment" failed to reveal S7PT was notified as per policy.

A review of Patient #1's "Wound Exam Initial" dated 10/24/2024 , not timed, revealed a diagnosis of MRSA and open wound site. Further assessment revealed the following:
Wound type: Non-pressure ulcer. Wound location: Chest. Wound status: Transfer of care. Skin temperature: Blank. Wound description Progress: Initial exam. Stage: Blank. Thickness: Full. Exudate Amount: Moderate. Exudate Type: Serosanguineous. Wound margin: Excoriated. Wound Measurements: Length 9 cm; Width 12 cm. Tunneling: --Sinus tract:--Undermining:--Hypergranulation:--Wound Bed: Slough (%) 26-50. Eschar (%) -Epithelialization (%) 26-50. Granulation (%) 26-50. Structure exposed: Muscle. Peripheral Skin. Appearance: Texture: Normal for patient. Moisture: Normal for patient. Color: Erythema
Signs and Symptoms of Infection Present:--
Treatment: every 48 hours. Dressing: gauze-dry, ABD padding. Wound Cleanser: Half strength Dakin's solution. End of assessment.

A review of Patient #1's Emergency Department 'A' medical records dated 11/28/2024 revealed patient diagnoses Open fracture of nasal bone. A CT Maxillofacial revealed comminuted nasal bone fracture including nasal septum. Further review revealed an ambulatory referral to ENT.

A review of Patient #1's medical records upon return to Southeast Regional Medical Center (SRMC) on 11/29/2024, failed to reveal an order for ENT consult.

A review of Patient #1's discharge orders dated 12/06/2024 at 7:51 AM, failed to reveal and ENT referral/consult.

During an interview on 12/17/2024 at 1:42 PM, S4RN confirmed Patient #1 had an ENT referral order from Emergency Department 'A' for nasal fracture dated 11/28/2024. S4RN verified Patient #1's medical records with SRMC failed to reveal an order for an ENT consult, no mention in the progress notes. S4RN confirmed Patient #1 did not see an ENT before discharge on 12/06/2024 and the discharge orders did not include an ENT consult.

During an interview on 12/18/2024 at 10:55 AM, S4RN confirmed a wound care consult was ordered by provider on 10/18/2024 and wound care specialist S7PT did not assess Patient #1 until 10/24/2024. S4RN verified Patient #1 had an open chest wound and the wound care assessment did not occur until 6 days after the consult. S4RN stated when an order for wound care consult is generated, the nurse should notify S7PT of the order but they do not always document the notification. S4RN indicated the nurses are not instructed to measure the wounds because S7PT completes this part of the assessment. S4RN reported patient wounds will receive a limited assessment until S7PT completes her wound care assessment.

During an interview on 12/18/2024 at 1:44 PM, S7PT confirmed she is notified, not consulted when a patient has a wound. There is no need for a wound consult order. There should be no wound consult orders. When a patient is admitted, the nurse waits for S7PT to do the assessment. S7PT stated nurses are not formally trained and validated to measure wounds. Wounds should only be noted and given a general assessment by nurses because this is considered general knowledge. S7PT indicated she is the only one to do measurements because she is the specialist-nurses doing the measurements are not considered best practice. S7PT reported a nurse will not see wound changes and so she does not need to measure the wound. There are no extreme changes in the wound, there should be no increase in wound size unless there is a trauma. We don't need to investigate unless the wound begins to increase in size. S7PT stated, "Prompt is relative". The nurses are already providing the treatment in the standing orders so a prompt consult is relative to changes that occur with the wound.

During an interview on 12/18/2024 at 3:44 PM, S8CNO confirmed when another provider is consulted, she expects the provider to assess the patient and provide the care needed within 2-3 days at most, unless an emergency, within 24 hours are sooner. S8CNO indicated, "consult" and "notify" are synonymous and require the consultant to see the patient. It is expected the consulted provider see the patient within 2-3 days with any consult such as a psychology consult or wound care consult.

Patient #2
A review of Patient #2's medical record revealed an admit date 12/15/2024.

A review of Patient #2's "Admission Orders" revealed, in part: Admission Diagnosis: Pressure Injuries, Paraplegia, and Osteomyelitis. Provider/Nursing Standing Orders, Wound Protocol: Cleanse the wound site with wound cleanser and dry with gauze. Cover with dry gauze and ABD padding. Secure with tape. If packing is needed, pack with gauze rolls, cover with dry gauze and ABD padding. Secure with tape. Notify wound care.

A review of Patient #2's "Nursing Admission Assessment" dated 12/15/2024 at 9:05 PM revealed the following wound assessment:
Wound #1.
Site: Rite Ischial. Assessment: Small area pink with yellowish tissue. Length: Blank. Width: Blank. Depth: Blank. Undermining: Yes. Tunneling: Blank. Wound bed: pink with yellowish tissue. Necrosis: Blank. Exudate: Blank. Odor: Blank.
Wound #2:
Site: Left Ischial. Assessment: tissue pink and yellowish tissue. Length: Blank. Width: Blank. Depth: Blank. Undermining: Yes. Tunneling: Blank. Wound bed: red tissue granulation. Necrosis: Blank. Exudate: Blank. Odor: Blank.
Wound #3:
Site: Coccyx. Assessment: pink with yellowish tissue. Length: Blank. Width: Blank. Depth: Blank. Undermining: Blank. Tunneling: Blank. Wound bed: Blank. Necrosis: Blank. Exudate: Blank. Odor: Blank.

During an interview on 12/18/2024 at 10:49 AM, S4RN indicated at time of interview that Patient #2 had not had a full wound assessment completed and wounds had not been measured. S4RN indicated the nurses are not instructed to measure the wounds because S7PT completes this part of the assessment. S4RN reported patient wounds will receive a limited assessment until S7PT completes her wound care assessment.

Patient #3
A review of Patient #3's medical record revealed an admit date 12/16/2024.

A review of Patient #3's "Admission Orders" revealed, in part: Admission Diagnosis: Pressure Injury of hip Stage IV and Subacute Osteomyelitis of right femur. Wound care orders: Follow standing orders. Provider/Nursing Standing Orders, Wound Protocol: Cleanse the wound site with wound cleanser and dry with gauze. Cover with dry gauze and ABD padding. Secure with tape. If packing is needed, pack with gauze rolls, cover with dry gauze and ABD padding. Secure with tape. Notify wound care.

A review of Patient #3's "Nursing Admission Assessment" dated 12/16/2024 at 4:35 PM revealed, in part, Patient #1 was bedbound, immobile, and incontinent of bowel and bladder. Review of Skin section revealed, in part: Pressure areas-stage(s) I, II, III, IV. Location: Sacral, Coccyx, Hip L/R, Ankle, Other: feet, knees. Further review revealed on 12/16/2024 at 7:00 PM, wound care notified of patient admit.

A review of Patient #3's medical record revealed no evidence a full wound assessment done for each wound identified in the nursing admission assessment dated 12/16/2024.

During an interview on 12/18/2024 at 10:49 AM, S4RN indicated Patient #3 admitted for wound care with multiple pressure wounds at different sites and stages. S4RN indicated at time of interview that Patient #3 had not had a full wound assessment completed and wounds had not been measured. S4RN indicated the nurses are not instructed to measure the wounds because S7PT completes this part of the assessment. S4RN reported patient wounds will receive a limited assessment until S7PT completes her wound care assessment.

During an interview on 12/18/2024 at 3:59 PM, S9RN confirmed medical records for Patient #2 and Patient #3 contained no evidence S7PT had completed wound assessments.

Based on record review and interview, the registered nurse failed to ensure each patient received care according to physician's orders. The deficient practice is evidenced by failure to follow provider orders in 1 (#1) of 3 (#1-#3) patients sampled.
Findings:

A review of Patient #1's "Admission Orders" dated 10/18/2024 at 9:13 PM revealed Provider/Nursing Standing Orders that indicated, in part: Wound Protocol, in part: Beneprotein 1 scoop PO daily for mild to moderate wound severity, Beneprotein 1 scoop BID for severe wounds. Cleanse wound site with wound cleanser and dry with gauze. Cover with dry guaze and ABD padding Secure with tape. If packing is needed , pack with guaze rolls, cover with dry gauze and ABD padding. Secure with tape. Notify wound care.

A review of Patient #1's "Patient Assessment" dated 10/20/2024 at 8:00 AM and 10/21/2024 at 7:30 a.m. failed to reveal Beneprotein on the Medication Administration Record.

During an interview on 12/18/2024 at 11:44 AM., S4RN verified Patient #1 did not receive the Beneprotein per physician orders. S4RN confirmed Patient #1's Standing order dated 10/18/2024 for Beneprotein once or twice a day was not implemented until 10/25/2024.

A review of Patient #1's Patient Assessments dated 10/20/2024 and 10/21/2024 failed to reveal wound care treatment was completed.

During an interview on 12/18/2024 at 11:44 AM, S4RN confirmed Patient #1's Standing orders dated 10/18/2024 for wound care were not implemented on 10/20/2024 and 10/21/2024.