HospitalInspections.org

Based on document review and interview the registered nurse failed to ensure patients were turned/repositioned and bathed per policy for one of ten patients. (Patient # 10)

Findings include:

1. The hospital policy titled, Guidelines and Protocols, Clinical, number S05-G, indicated on page one (1) - section Policy - To ensure quality patient care, certain standards of care must be upheld. The following table outlines basic tasks and designates the minimum frequency with which these tasks must be performed to maintain quality care. On page two (2) of the table - section Hygiene - Patient bathed/hair combed/shaved - Daily - On page two (2) of the table - section Activity/Mobility - Bedfast patients turned - Every two (2) hours. This policy was last revised on 01/01/2025.

2. Patient # 10's MR indicated the following:
a. The patient was a 70 y/o (year/old) who arrived at H # 2 (Long Term Acute Care-LTAC) hospital on 01/20/2025 with a diagnosis of acute hypoxic respiratory failure, on ventilator (trached), comatose state with severe encephalopathy, acute left ACA (acute cerebellar ataxia) and CVA (cerebrovascular accident).
b. Oral Care, Skin Care and Hygiene flowsheet dated 01/20/2025 through 02/19/2025 lacked documentation that the patient was bathed on four (4) instances - 01/21/2025, 01/23/2025, 02/12/2025 and 02/13/2025.
c. Turning/Repositioning flowsheet dated 01/20/2025 through 02/19/2025 lacked documentation the patient was turned and/or repositioned on twelve (12) instances - 01/26 at 1800 hours; 02/02 at 0200 hours and 0400 hours; 02/06 at 2200 hours and 0000 hours; 02/07 at 0200 hours, 0400 hours, 1200 hours and 1800 hours 02/14 at 0600 hours; and 02/16 at 0200 hours and 0600 hours - 2025 hours.

3. In interview on 04/29/2025 at approximately 4:30 pm with administrative staff member A # 2 (Chief Nursing Officer-CNO), confirmed patient # 10 should have been bathed daily and turned/repositioned every two hours.

Based on document review and interview the respiratory therapist failed to ensure a patient's tracheostomy (trach) ties were changed weekly in one instance. (Patient # 10)

Findings include:

1. The facility policy titled, Trach Care, Policy Number RC-T02, indicated on page two (2) - section Procedure - number twelve (12) - Change trach ties as needed when visibly soiled, no less than once per week. This policy was last revised on 10/01/2021.

2. The facility policy titled, Guidelines and Protocols, Clinical, number S05-G, indicated on page one (1) - section Policy - To ensure quality patient care, certain standards of care must be upheld. The following table outlines basic tasks and designates the minimum frequency with which these tasks must be performed to maintain quality care. On page four (4) - section Respiratory - Trach Ties/tube holder changed - Weekly and PRN (as needed). This policy was last revised on 01/01/2025.

3. Incident Report Log was reviewed for the months of January 2025 through April 2025. Patient # 10 - one (1) incident report dated 02/17/2025, indicating injury - (wound/laceration) to right lateral cervical spine trauma. DQM (Director Quality Management) reviewed patient # 10's medical record - appeared to be friction related-superficial area.

4. Patient # 10's MR indicated the following:
a. The patient was a 70 y/o (year/old) who arrived at H # 2 (Long Term Acute Care-LTAC) hospital on 01/20/2025 with a diagnosis of acute hypoxic respiratory failure, on ventilator (trached), comatose state with severe encephalopathy, acute left ACA (acute cerebellar ataxia) and CVA (cerebrovascular accident).
b. RT (Respiratory Therapy) Airway - LDA (Lines, Drains, Airways) flowsheet dated 01/20/2025 through 02/19/2025 indicated the patient's trach ties were changed - 01/20/2025 and again on 01/29/2025 which was greater than one (1) week. Changed - 02/05/2025 and again on 02/17/2025 which was greater than one (1) week.
c. RT Airway - LDA flowsheet dated 02/17/2025 at 8:14 pm, indicated wound on right side of neck where trach tie covers.
d. Wound Progress Note dated 02/18/2025 at 10:30 am by W # 1 (Registered Nurse-RN/Wound Nurse), indicated the wound was assessed - wound length - 1.0 cm (centimeter) - wound width 4.5 cm - wound depth 0.3 cm. Cleaned and dressing applied.

5. In interview on 04/30/2025 at approximately 2:07 pm with respiratory staff member R # 2 (Respiratory Therapist-RT/Manager), confirmed the RT department should have caught that and changed the ties according to the policy.