HospitalInspections.org

Based on document review and interview the registered nurses failed to ensure supervision of nursing care of repositioning patients every two hours and failed to ensure patient re-weighs were completed for 2 of 11 medical records (MR) reviewed (P3 and P7).

Findings include:

1. Review of policy/procedure "CORE: Clinical Guidelines for Pressure Injury," H-PC 10-004, indicates the following:
Policy:
5. Standard interventions for all patients can include but are not limited to:
c. Repositioning orders (minimum every (Q) 2 hour turns)
i. Consideration turning schedule of Q1 hours if patient is unable to turn and reposition self, has poor nutrition, multiple wounds, a recent change of condition (acute decline in hemodynamics), poor cognition, skin is moist or at risk for friction/shear injury.
Definition:
5. High risk:
A Braden Risk Score of 10 - 12
6. Severe risk:
A Braden Risk Score of 9 or less
This policy/procedure was last reviewed/revised 06/2022

2. Review of policy/procedure "CORE: Clinical Guidelines for Non-Pressure Related Wounds," H-PC 10-005, indicates the following:
Policy:
4. Standard interventions for all patients can include but are not limited to:
c. Wound care consult
e. Repositioning (minimum Q2 hour turns)
i. Turn and reposition the patients at a frequency based on the patient's individual needs.
ii. Consideration turning schedule of every 1 hours if patient is unable to turn and reposition self, has poor nutrition, multiple wounds, a recent change of condition (acute decline in hemodynamics), poor cognition, skin is moist or at risk for friction/shear injury.
This policy/procedure was last reviewed/revised 06/2022

3. Review of P3 MR indicated the following:
Patient was admitted on 04/20/24. On 04/22/24 wound care consult indicated the patient had a stage II pressure ulcer to right buttock with 2.3-centimeter (cm) x 3.0 cm x 0.1 cm and an unstageable to sacrum 6.9 cm x 2.7 cm unable to determine depth. P3 had Braden completed on 04/22/24 with score of 11 indicated high risk. On 06/25/24 P3's sacral wound measured 8.4 cm x 6 cm. P3 pressure ulcer care plan indicated turn and reposition Q2 hours.
Physician order on 04/20/24 at 1428 hours indicated the following: reposition using at least 2 staff persons, reposition using wedge/pillows. Assess skin and lines while repositioning. Change chux/linen if needed. Apply barrier to high-risk areas as needed. Document all refusals, bath, linen change, output. Start on 04/20/24 at 1600 hours, Q2h.
P3's MR indicated patient was in the following positions:
04/20/24 1716 hours to right side
04/20/24 2000 hours to left side
04/21/24 0400 hours to left side
04/21/24 0638 hours to right side
04/21/24 0925 hours to right side
04/21/24 1157 hours to left side
04/21/24 1430 hours to right side
04/22/24 0600 hours to supine
04/22/24 0830 hours to left side
04/22/24 1533 hours to left side
04/22/24 1847 hours to supine
04/22/24 2105 hours to left side
04/22/24 2200 hours to left side
04/23/24 0056 hours to right side
04/24/24 1558 hours to right side
04/24/24 1848 hours to supine
04/24/24 2150 hours to left side
04/25/24 2000 hours to right side
04/25/24 2317 hours to left side
04/29/24 0626 hours to supine
04/29/24 0926 hours to left side
04/30/24 0616 hours to supine
04/30/24 0917 hours to right side
05/02/24 0559 hours to right side
05/02/24 0848 hours to right side
05/02/24 1015 hours to left side
05/02/24 1301 hours to supine
05/02/24 1710 hours to right side
05/02/24 1959 hours to right side
05/02/24 2254 hours to left side
05/03/24 0146 hours to left side
05/03/24 0400 hours to right side
05/03/24 1543 hours to right side
05/03/24 1847 hours to left side
05/05/24 0200 hours to right side
05/05/24 0843 hours to right side
05/05/24 1939 hours to right side
05/05/24 2225 hours to left side
05/06/24 0109 hours to left side
05/06/24 0408 hours to right side
05/06/24 1425 hours to left side
05/06/24 1851 hours to right side
05/07/24 0931 hours to left side
05/07/24 1306 hours to right side
05/08/24 0000 hours to left side
05/08/24 0400 hours to left side
05/08/24 0845 hours no side listed
05/09/24 0540 hours to right side
05/09/24 0820 hours to left side
05/09/24 1449 hours to left side
05/09/24 2045 hours to right side
05/11/24 1959 hours to right side
05/11/24 2259 hours to left side
05/14/24 1340 hours to right side
05/14/24 1637 hours to left side
05/15/24 2208 hours to left side
05/16/24 0102 hours to supine
05/17/24 1348 hours to right side
05/17/24 1638 hours to left side
05/17/24 1743 hours to supine
05/17/24 2115 hours to right side
05/23/24 0600 hours to supine
05/23/24 0849 hours to right side
05/23/24 1600 hours to right side
05/23/24 2000 hours to right side
05/24/24 0148 hours to right side
05/24/24 0618 hours to supine
05/24/24 1600 hours to right side
05/24/24 1854 hours to supine
05/30/24 0216 hours to supine
05/30/24 0608 hours to right side
05/31/24 1338 hours to supine
05/31/24 1624 hours to left side
06/02/24 0119 hours to right side
06/02/24 0409 hours to left side
06/03/24 0521 hours to supine
06/03/24 0830 hours to right side
06/03/24 1527 hours to left side
06/03/24 1818 hours to right side
06/04/24 1800 hours to left side
06/04/24 2112 hours to right side
06/08/24 0958 hours to left side
06/08/24 1345 hours to right side
06/10/24 0344 hours to right side
06/10/24 0636 hours to left side
06/11/24 1708 hours to right side
06/11/24 2000 hours to right side
06/12/24 1801 hours to right side
06/12/24 2109 hours to right side
06/13/24 0506 hours to left side
06/13/24 0800 hours to left side
06/13/24 2031 hours no side listed
06/13/24 2328 hours to left side
06/14/24 1327 hours sitting up in chair
06/14/24 1752 hours to left side
06/18/24 0538 hours to left side
06/18/24 0836 hours to left side
06/19/24 0011 hours to right side
06/19/24 0316 hours to right side
06/19/24 2000 hours to right side
06/20/24 1549 hours to left side
06/20/24 1846 hours to right side
06/22/24 2130 hours to left side
06/23/24 0026 hours to right side
06/26/24 0541 hours to left side
06/26/24 0830 hours to right side

4. Review of P7 MR indicated the following:
Patient was admitted on 07/26/24. On 07/29/24 wound care consult indicated the patient admitted with deep tissue pressure injury to right sacrum 1.8 cm x 2.0 cm. On 08/21/24 P7 acquired an open blister to their right lateral thigh measuring 5 cm x 5 cm x 0.1 cm. P7 had Braden completed on 09/07/24 with score of 9 indicated high risk. On 09/17/24 P7's open blister wound measured 8.4 cm x 6 cm. P7 pressure ulcer care plan indicated turn and reposition Q2 hours.
Physician order on 07/26/24 at 1626 hours indicated the following: reposition using at least 2 staff persons, reposition using wedge/pillows. Assess skin and lines while repositioning. Change chux/linen if needed. Apply barrier to high-risk areas as needed. Document all refusals, bath, linen change, output. Start on 07/26/24 at 1800 hours, Q2h.
P7's MR indicated patient was in the following positions:
07/29/24 0200 hours to left side
07/29/24 0448 hours to right side
07/29/24 1118 hours to supine
07/29/24 1423 hours to right side
07/29/24 1935 hours to left side
07/29/24 2337 hours to left side
07/30/24 0957 hours to right side
07/30/24 1244 hours to supine
07/30/24 1947 hours to right side
07/30/24 2326 hours to left side
07/31/24 0130 hours to right side
07/31/24 0422 hours to left side
07/31/24 0505 hours to right side
07/31/24 0805 hours to left side
07/31/24 1730 hours to supine
07/31/24 2019 hours to right side
08/02/24 0356 hours to left side
08/02/24 0652 hours to supine
08/02/24 0800 hours to right side
08/02/24 1101 hours to left side
08/03/24 0148 hours to right side
08/03/24 0446 hours to left side
08/03/24 2008 hours to right side
08/03/24 2257 hours to left side
08/04/24 1805 hours to supine
08/04/24 2122 hours to left side
08/09/24 1801 hours to right side
08/09/24 2054 to right side
08/10/24 1753 hours to left side
08/10/24 2104 hours to right side
08/12/24 0524 hours to supine
08/12/24 0900 hours to right side
08/14/24 1834 hours to supine
08/14/24 2318 hours to left side
08/16/24 1124 hours to supine
08/16/24 1400 hours to right side
08/18/24 1811 hours to supine
08/18/24 2117 hours to right side
08/19/24 0021 hours to supine
08/19/24 0713 hours to supine
08/19/24 2311 hours to supine
08/20/24 0205 hours to right side
08/20/24 1114 hours to right side
08/20/24 1400 hours to left side
08/22/24 0042 hours to right side
08/22/24 0507 hours to left side
08/22/24 1102 hours to right side
08/22/24 1426 hours to left side
08/24/24 0000 hours to right side
08/24/24 0258 hours to left side
08/24/24 1200 hours to left side
08/24/24 1941 hours to right side
08/25/24 0119 hours to left side
08/25/24 0421 hours to left side
08/25/24 0630 hours to left side
09/08/24 0005 hours to supine
09/08/24 0557 hours to left side
09/08/24 1200 hours to supine
09/08/24 1459 hours to left side
09/08/24 2331 hours to right side
09/09/24 0250 hours to left side
09/09/24 0331 hours to right side
09/09/24 0655 hours to left side
09/09/24 1421 hours to left side
09/09/24 1721 hours to supine
09/09/24 1959 hours to right side
09/09/24 2253 hours to left side
09/10/24 0331 hours to right side
09/10/24 0657 hours to left side
09/11/24 1134 hours to left side
09/11/24 1443 hours shifted
09/11/24 1547 hours to right side
09/11/24 1847 hours to left side
09/12/24 1600 hours to supine
09/12/24 1855 hours to supine
09/13/24 0001 hours to right side
09/13/24 0306 hours to left side
09/14/24 1243 hours to left side
09/14/24 1541 hours to left side
09/14/24 1957 hours to right side
09/14/24 2245 hours to left side
09/15/24 0543 hours to left side
09/15/24 0931 hours to right side
09/15/24 1151 hours to left side
09/15/24 1510 hours to right side
09/15/24 2200 hours to right side
09/16/24 0200 hours to right side
09/16/24 0334 hours to supine
09/16/24 0636 hours to left side
09/16/24 1131 hours to supine
09/16/24 1404 hours to right side

5. Facility policy titled, "CORE: Weight Measurement," H-PC 04-011, indicated the following:
Procedure:
9. Weigh patient on the appropriate scale NOTE: If a patient has a 5 pound or more weight difference from the most recent weight, the scale shall be re-balanced, the rough calibration was completed, and the weight was taken again to confirm accuracy. Request a licensed nurse to verify re-weigh for accuracy and documentation purposes.
This policy/procedure was last reviewed/revised 06/2021.

6. Review of P3 MR indicated the following:
Patient was admitted on 04/20/24 with an admission weight of 212.3 pounds (lb). Physician order on 04/20/24 at 1648 hours indicated P3 was to have a daily weight. Start on 04/21/24 at 0500 hours.
MR indicated P3's weight had a documented difference greater or less than 5 pounds or more from the prior weight on:
04/21/24 204.6 lb
04/23/24 208.56 lb
04/24/24 203.5 lb
04/25/24 198 lb
04/28/24 192.5 lb
04/29/24 200.2 lb
04/30/24 178.2 lb
05/01/24 200.4 lb
05/02/24 180.4 lb
05/03/24 169.62 lb
05/05/24 175 lb
05/06/24 163.9 lb
05/07/24 169.4 lb
05/11/24 158.4 lb
05/12/24 166.1 lb
05/1424 165 lb
05/15/24 159.5 lb
05/18/24 155.1 lb
05/19/24 160.6 lb
05/20/24 158.4 lb
05/21/24 163.9 lb
05/25/24 161.7 lb
05/26/24 154 lb
05/27/24 160.6 lb
05/31/24 162.8 lb
06/01/24 157.3 lb
06/10/24 152.9 lb
06/11/24 185.9 lb
06/14/24 185.9 lb
06/15/24 195.8 lb
06/17/24 195.8 lb
06/18/24 182.6 lb
MR lacked documentation of re-weigh and request of a licensed nurse to verify re-weigh for accuracy and documentation purposes per policy for above dates.

7. Review of P7 MR indicated the following:
Patient was admitted on 07/26/24 with an admission weight of 140.8 lb. Physician order on 07/26/24 at 1702 hours indicated P7 was to have a daily weight. Start on 07/27/24 at 0500 hours.
MR indicated P7's weight had a documented difference greater or less than 5 pounds or more from the prior weight on:
07/29/24 138.38 lb
07/30/24 144.1 lb
07/31/24 137.5 lb
08/07/24 139.7 lb
08/08/24 187 lb
08/09/24 139.7 lb
08/10/24 146.3 lb
08/20/24 138.6 lb
08/21/24 145.2 lb
08/23/24 145.86 lb
08/24/24 140.8 lb
08/25/24 145.2 lb
08/26/24 136.4 lb
09/07/24 134.2 lb
09/08/24 127.6 lb
09/15/24 127.6 lb
09/16/24 133.1 lb
MR lacked documentation of re-weigh and request of a licensed nurse to verify re-weigh for accuracy and documentation purposes per policy for above dates.

Based on document review and interview the facility failed to ensure that nursing staff were competent in the use of intra-anal management system for 7 of 7 (A5-Registered Nurse [RN], A10-RN, A11-RN, A12-RN, A13-RN, A14-RN, A15-Licensed Practical Nurse [LPN]) nursing personnel files reviewed.

Findings include:

1. Facility policy titled, "CORE: Incontinence Diarrhea Management," H-PC 03-002, indicated under Policy: The policy of Kindred Hospital is to ensure the following: 4. Intra-anal management system: c. Clinicians should have competencies on file for the maintenance and insertion of the system. This policy/procedure was last reviewed/revised 06/2022.

2. Review of 7 out of 7 (A5-RN, A10-RN, A11-RN, A12-RN, A13-RN, A14-RN, A15-LPN) nursing personnel education files lacked documentation of competency for intra-anal management system.

3. Interview with A7 (Registered Nurse, Educator), on 09/19/24 at approximately 1:45 p.m., confirmed intra-anal management system is not included in new hire training and/or annual training.