HospitalInspections.org

Based on observations, interviews, and record review, the facility failed to involve the Patient's Representative (PR) in the plan of care and advocate for Patient 1's necessary care when the facility failed to facilitate necessary outpatient ophthalmology (medical doctor specializing in eye care) consultations for 1 of 28 sampled patients (Patient 1) when:

a. The facility failed to inform Patient 1's PR of an injury to Patient 1's eye;
b. The facility delayed seeking medical care for Patient's 1's eye injury from 5/13/24 until 5/15/24;
c. The facility failed to follow the instructions from an emergency department physician to seek
follow up ophthalmology care within two days;
d. The facility failed to ensure case management staff adhered to facility policies and procedures for timely care coordination.

These failures resulted in a corneal abrasion (injury to the eye surface) which further deteriorated into a descemetocele (a rare condition when the descemet membrane protrudes through the cornea, a condition usually caused by an untreated corneal injury and ulcer) which had the potential to lead to severe vision loss or blindness.

Findings:

A review of Patient 1's "History & Physical (H&P)" indicated Patient 1 was admitted to the facility on in January of 2024 for diagnoses including "Locked in Syndrome" (a disorder caused by damage to the Pons area of the brain resulting in complete paralysis while mental function and awareness are not affected.) Further review of Patient 1's H&P indicated Patient 1 had a history of bleeding in the brain causing severe brain damage, a tracheotomy (a surgical opening in the neck to place a tube into the windpipe to help air reach the lungs), kidney failure requiring dialysis (artificial means to remove waste from the kidneys), and a PEG tube (a feeding tube that is surgically placed into the stomach through the abdomen for food and nutrition). The H&P included an assessment of both eyes open with conjunctival hemorrhages in both eyes (a bright red patch in the white part of the eye caused by a broken blood vessel in the eye) and no corneal reflexes (involuntary blinking of the eye when stimulated). The H&P indicated Patient 1, "is not following commands" and "intermittent posturing and non-purposeful movement of his toes."

During a review of Patient 1's medications at admission on 1/24/24 included physicians' orders for a (trade name) eye antibiotic to be applied to both eyes twice daily and (trade name) artificial tears into both eyes every four hours while awake.

In an interview and concurrent observation on 1/21/25 at 8:42 a.m. with Registered Nurse (RN)1, RN 1 stated Patient 1 has never been responsive and has never closed his eyes. RN 1 further indicated she is a dialysis nurse employed by the facility and provides dialysis services to Patient 1 every Monday, Wednesday and Friday for approximately 3.5 hours. Patient 1 was observed in bed receiving dialysis, both eyes were open and the eyelids were flickering, both eyes had clear shields covering the eye. The left eye was observed appearing white and cloudy with scant amount of white drainage and the right eye appeared clear with no drainage.

In an interview with Infection Preventionist Registered Nurse (IPRN) on 1/21/25 at 11:07 a.m., IPRN, indicated Patient 1 had a left eye injury on 5/13/24 and was sent to the emergency department on 5/15/24 for evaluation of the eye injury at the request of Patient 1's PR. The IPRN further indicated there were no documentation in the medical record seeking eye care on 5/13/24 or 5/14/24.

In an interview on 1/21/25 at 2:25 p.m., with the Director of Nursing (DON), the DON indicated "(Patient 1's) eye had been getting progressively worse since admission." DON further indicated family (PR) had reported concerns about left eye and questioned what the facility was doing to seek ophthalmology care for Patient 1. The DON stated Patient 1 had a "cataract on admission", however, the DON was not able to provide requested documentation of Patient 1 having a cataract upon admission. The DON indicated case management was responsible for obtaining appointments outside of the facility.

In an interview on 1/22/25 at 3:29 p.m. with Registered Nurse (RN) 2, RN 2 indicated he had provided care for Patient 1 "many times" and had never seen Patient 1 close his eyes or have any purposeful movement. RN 2 further indicated he had never seen Patient 1 move his head or give a thumbs up.

In an interview on 1/22/25 at 4:11 p.m., with Patient 1's PR, the PR stated he was not notified in May when the eye injury occurred but discovered what he believes to be an injury when he arrived at the facility on 5/13/24 and observed the left eye which appeared completely white. The PR stated he asked Registered Nurse (RN) 4 what happened to Patient 1's eye to which he was told she did not know but had noticed what appeared to be a 'bubble on the left eye." PR indicated he requested a physician be notified which he believes was done by RN 4. During further interview with Patient 1's PR, he stated he had requested an ophthalmology physician exam for Patient 1's left eye "for months" after the May injury and the PR stated he was not aware of any attempts to contact an ophthalmology physician to see Patient 1 until December 2024.

In an interview on 1/23/25 at 8:30 a.m., with RN 4, RN 4 indicated she had not noticed anything wrong with Patient 1's eye until late in her shift on 5/13/2024 when Patient 1's father (PR) brought concerns about Patient 1's eye to her attention. RN 4 indicated when she observed Patient 1's left eye it appeared to have a "white blister on the surface". RN 4 stated she did not know what happened to Patient 1's eye. RN 4 indicated she had notified the Medical Director. RN 4 was not aware of any further care for the eye but stated she believed Patient 1 had been seen by an ophthalmologist.

Review of an untitled document dated 5/13/24 at 4:42pm and signed by RN 4 reflected, "In afternoon went in to assess patient and notice a bubble had formed in left eye...Notified [Medical Doctor 1]...had this RN consult [MD 2 for an ophthalmologic assessment referral", and, "Family suggested head flopped onto medical equipment in bed."

Review of a document titled "After Visit Summary" from [Hospital], dated 5/15/24, directed, "Follow up with ophthalmology MD in 2 days". The document further indicated, "Specialty: Ophthalmology, Pediatric Ophthalmology" ... "Diagnosis Corneal Ulcer (eye injury) of left eye".

Review of a document dated 6/7/24 at 12:00 p.m., titled "Discharge Summary- Attending Only" indicated multiple diagnoses including, "Left Eye Keratopathy (inflammation of the cornea caused by injury and causes blindness)... secondary to exposure or some trauma in the past".

Review of a document dated 7/30/24, titled "Case Management Weekly Progress Note" indicated, "[PR] is requesting ophthalmology appointment for previous trauma to left eye."

Review of a document dated 9/4/24, titled "Case Management Weekly Progress Summary" indicated, "[PR] at bedside requesting follow up regarding eye trauma" ...

Review of a document dated 10/14/24 titled "Case Management Weekly Progress Note" indicated "Ophthalmology consult ordered. Awaiting date and time." ...

Review of a document dated 10/14/24, titled "Case Management Note" indicated "Attempted to schedule ophthalmology follow up "Contacted Ophthalmologist MD" ... " Left voicemail. Awaiting callback. Plan to follow up."

Review of a document dated 11/11/24 titled "Case Management Note" indicated "spoke with [Patient 1's PR] and updated him on ophthalmologist referrals have been sent to [Hospital] for further evaluation ..."

Patient 1 was seen in December 2024 for the eye injury that occurred in May of 2024. Review of a document dated 12/4/24 at 10:00 a.m., titled "OPHTH General", reflected the corneal ulcer in the [left eye] is "bulging" and "large scar in the center of the cornea which appears to be an old descemetocele that previous perforated (penetration of the clear part of the eye which controls and focuses the entry of light into the eye). Further documentation indicated, "anterior chamber is shallow (the distance between the cornea and lens of the eye is smaller than normal)." The document revealed, "Left iris and left lens: no view (light is no longer passing through the iris or lens needed for vision)".

Review of a facility Policy and Procedure (P &P) titled "Case Management Responsibilities", dated April 2024, directed, "Policy: The Case Management model assures all case management responsibilities are completed effectively and efficiently and minimize duplication of case management services ...", "Performs admission and concurrent reviews, including managed care patient coordination/communication ...", "Coordinates/ facilitates plans of care", "Performs ongoing discharge planning, arranges for discharge needs, including alternate level of care transfers" and," Collaborates with community agencies for patient post-acute needs ...".

Based on interview and record review, the facility failed to provide nursing care to one of twenty eight sampled patients (Patient 27) when scheduled daily sponge baths were not done.

This failure resulted in Patient 27 to feel neglected and unclean, which had the potential to negatively impact his physical and psychological well-being.

Findings:

During the review of Patient 27's History and Physical (H&P), the H&P indicated Patient 27 was admitted to the facility on 4/18/22 for diagnosis of Left hemiplegia (paralysis affecting only side of the body) post gunshot wound, multiple fractures, respiratory failure (difficult to breathe on your own and lungs can't get enough oxygen into the blood) and right temporal (head) wound infection. A review of Patient 1's discharge note indicated patient 1 was discharged from the facility on 6/29/22.

During an interview with the Registered Nurse (RN) 3 on 1/22/25 at 8:54 a.m., RN 3 stated bathing/sponge baths are provided daily to patients. RN 3 stated Certified Nursing Assistant's are assigned daily and it is documented in the computer (medical record).

During a concurrent interview and record review with the HIM Technician (HIM Tech) on 1/22/25 at 11:40 a.m., Patient 27's "ADL Flowsheets" dated 4/18/22 to 4/29/22 were reviewed. The ADL Flowsheets indicated Patient 27 received 2 sponge baths on 4/20/22 and 4/26/22. The HIM Tech stated there was no documentation that Patient 27 received bath/sponge baths daily.

During an interview with the Certified Nurse Assistant (CNA) 2 on 1/23/25 at 10:21 a.m., the CNA 2 stated patient gets sponge bath or shower daily. We are assigned for the schedule daily by the management. We document baths in the computer under ADL's (Activities of Daily Living).

During an interview with the Director of Nursing (DON) on 1/23/25 at 10:35 a.m., the DON indicated they do not have the policy on "Activities of Daily Living Assistance" from 2022. The DON acknowledged if bathing/sponge baths are not documented in the medical record, they were not done.

Based on observation, interview and record review, the facility failed to implement their policies and procedures on pressure ulcer prevention and management when four of 28 sampled patients (Patients 12, 13, 15 and 27) were not repositioned per protocol and established care plans.

These failures resulted in Patient 13 and Patient 27 to be distressed and upset, and negatively impact the healing of Patients 12 and 15's existing pressure injuries.

Findings:

Patient 15
A review of "Intake Information", dated "02/07/2023", indicated a complaint related to Patient 15's pressure injury (a skin injury caused by prolonged pressure on a bony area of the body) and questioned whether he was repositioned every two hours.

During an interview on 1/21/25 at 10:50 a.m., CNA (Certified Nursing Assistant) #1 stated patients with pressure injuries and those at-risk were repositioned every two hours to help decrease putting more pressure on their wound sites and other bony areas where pressure injuries might develop.

A review of Patient 15's "History and Physical" indicated he was admitted to the facility on the evening of 9/23/22 with diagnoses including paraplegia (loss of muscle function in the lower half of the body, including both legs) after a motorcycle accident. Patient 15's "Admission Assessment" indicated he had a pressure wound on his sacrum (lower back) and had a Braden Score of 11 (a number that predicts the risk of a patient developing pressure ulcers. A score of 18 or less is generally considered at-risk.). A review of Patient 15's "Care Plan", dated "09/24/22", indicated, "Pressure Ulcer - Impaired Skin Integrity ... Intervention: TURN AND REPOSITION PATIENT EVERY 2 HOURS USING 30 DEGREE SIDE-LYING POSITION ..."

During a concurrent interview and record review on 1/23/25 at 8:33 a.m. with HIM Technician (HIM Tech), Patient 15's "ADL Flowsheets" dated "9/24/22-9/27/22" were reviewed. The ADL Flowsheet indicated he was on his back on 9/24/22 for approximately nine hours, from 12:08 a.m. to 8:45 a.m. Further review of the flowsheet indicated Patient 15 was lying on his left side on 9/24/22 at 2:30 p.m. and was repositioned to his back at 9:57 p.m., about seven hours later. The flowsheet further indicated Patient 15 was positioned on his left side at 1:57 p.m. on 9/25/22. HIM Tech confirmed there was no documentation of Patient 15 being repositioned from then, until he was turned to his right side almost 10 hours later, at 12:02 a.m. on 9/26/22. The ADL Flowsheet for 9/26/22 indicated Patient 15 was lying on his right side at 2:50 p.m. HIM Tech stated there was no documentation he was repositioned until another 10 hours later, when he was moved to his back at 12:21 a.m. HIM Tech stated there should have been documentation of patient repositioning every two hours.

Patient 13
During a concurrent observation and interview on 1/21/25 at 11:02 a.m., Patient 13 stated it was important for her to be repositioned every two hours. Patient 13 stated it was very upsetting to not be repositioned regularly, adding there were shifts when no one would come and move her. Patient 13 stated she had to remind staff to help reposition her regularly, pointing to handwritten signs posted by her bed which read, "OK to wake me up at night when you have to reposition me every 2 hours."

During a concurrent interview and record review on 1/21/25 at 3:21 p.m. with Case Manager (CM), Patient 13's medical records were reviewed. Patient 13's "History and Physical", dated "1/2/25", indicated she was admitted to the facility with diagnoses including cervical (neck) fracture and paraplegia after a car accident. Patient 13's nursing care plan, dated 1/2/25, indicated she had a potential for skin breakdown, and among the listed interventions was repositioning every two hours. Further review of Patient 13's ADLs from a sample period of 1/7/25 to 1/21/25 indicated she stayed in the same supine (on her back) position in bed for six hours (4 p.m. to 10 p.m.) on 1/8/25 and 1/11/25, another six-and-a-half hours (4 p.m. to 10:30 p.m.) on 1/13/25, and another six hours (12 a.m. to 6 a.m.) on 1/15/25. CM confirmed there was no documentation that Patient 13 was repositioned, or why she was not repositioned, during the afternoon shifts on 1/8/25, 1/11/25, 1/13/25 and the night shift on 1/15/25.

Patient 12
During a concurrent interview and record review on 1/21/25 at 2:15 p.m. with CM, Patient 12's medical records were reviewed. Patient 12's "History and Physical", dated "12/13/24", indicated she was admitted to the facility with the a stage 4 pressure ulcer (the most severe stage of a pressure sore, where the damage extends through all layers of the skin, exposing underlying muscle, tendon, or bone, often with significant tissue loss and a high risk of infection) on her sacrum. Patient 12's care plan, with an initiation date "12/13/24", indicated repositioning every two hours as part of interventions for her altered skin integrity. A review of Patient 12's "ADL Flowsheets", for a sample period of "1/7/25 to 1/21/25", indicated she was supine for approximately 11 hours, from 4 a.m. until 3 p.m. on 1/20/25. CM confirmed there was no documentation Patient 12 was repositioned during the 11-hour period. CM stated there should have been "something documented", as Patient 12's care plan indicated her need to be repositioned every two hours.

During an interview on 1/22/25 at 8:40 a.m., Licensed Vocational Nurse #1 stated repositioning every two hours helped prevent current pressure ulcers from worsening.

Patient 27
A review of the History and Physical dated 4/18/22 at 5:36 p.m., indicated that Patient 27 was admitted on 4/18/22 status post Gunshot wound with chief complaint of wound care, Neuro (brain injury) recovery Program and Tracheostomy (surgical procedure where a hole is made in front of neck and into windpipe to help with breathing) weaning. There was no documented pressure wounds present on admission.

A review of the nursing care flowsheets, dated from 4/19/22 to 4/29/22, indicated that approximately 72 opportunities for turning and repositioning documentation for Patient 27 were missed, with periods ranging from three to sixteen hours without staff documenting turning or repositioning.

A review of Patient Anatomical Assessment Report by Wound Team Visit notes, dated 4/23/22 at 12:59 p.m., indicated Patient 27 had sacrum pressure injury Stage 2 measuring 0.5cm x 1.1cm x 0.1cm.

A review of the Care Plan dated 4/19/22, indicated the following interventions: Turn and reposition every 2 hours, prn and position at 30 degrees laterally.

During an interview with the HIM Tech on 1/21/25 at 11:40 a.m., the HIM Tech confirmed Patient 27 had frequent missed opportunities for the required documentation of turning and repositioning per patient's care plan.

During an interview with the Certified Nurse Assistant (CNA) 2 on 1/23/25 at 10:21 a.m., CNA 2 stated the patient should be reposition every 2 hours and documented in the computer under ADL's per policy.

A review of the facility policy titled, "Wound Care: Skin Integrity and Pressure Injury Prevention", dated "04/2024", indicated, "Care plan interventions will be individualized based on the level of risk determined by the total Braden and sub-scale scores as well as additional risk factors (physical assessment findings, clinical complexity/stability and co-morbidities). See Attachment B - example of recommended Care Plan interventions... Licensed nurse responsibilities: 2. Supervises nursing assistants to ensure and assess, the quality of direct patient care on an ongoing basis... obtains notes and implements qualifies health care provider orders... Nursing assistant carries out direct patient care with special emphasis on prevention and skin integrity management. a) Turns and repositions patients..."