HospitalInspections.org

Based on record review, staff interview and policy review, the hospital failed to ensure a registered nurse supervised and evaluated nursing care (A395).

Based on record review, staff interview and policy review, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of three of ten patients reviewed (Patient #7, #1 and #2). The facility census was 29.

Findings include:

Review of the policy and procedure titled, Inpatient Nursing Documentation for the Permanent Medical Record, last revision date: 09/20/21, next review date: 09/20/22, revealed the purpose of this document is to provide guidelines for documenting the nursing process within the medical record. Review of page 10 of 13 revealed the clinical guidelines for long term acute care hospitals (LTACH) included documenting turning and repositioning patients every two hours unless they turned themselves.

1. Review of the medical record for Patient #7 revealed the patient was admitted on 10/18/21 from another hospital for ventilator weaning, wound care related to multiple gunshot wounds, nutritional support and physical and occupational therapy. The principal diagnosis was Traumatic Brain Injury from a gunshot wound. The patient was stable post craniectomy and paraplegia at T 11-12. The patient was discharged to the skilled nursing facility located within this hospital on 11/12/21.

Review of the patient's skin assessment on admission did not identify any pressure ulcers. Documentation on the wound care consult assessment dated 10/19/21 revealed the patient's heels, coccyx, sacrum, and occipital were intact. Foley care performed, patient bathed due to multiple bowel movements during assessment. The Braden score was a 13 (high risk for skin breakdown). Interventions in place included an air loss pressure reduction mattress, heel protectors, turn and reposition every two hours. Use Sween 24 cream (moisturizing cream) to hydrate and moisturize skin. Use moisture barrier cream to protect groin, perianal skin and buttocks from incontinence and a barrier cream to his coccyx as needed for protection and prevention of skin breakdown. The patient's initial mobility assessment on admission revealed the patient needed total assistance to roll in bed, two person assist to move from a supine position to a sitting position, and two person assist to move from a sitting position to a supine position. The patient also needed maximum assistance for sitting static balance (the ability to maintain an upright posture and to keep the line of gravity within the limits of the base of support) and maximum assistance and dependent for sitting dynamic balance (the ability to maintain stability during weight shifting, often while changing the base of support).

On 04/11/22, the patient's turning and repositioning schedule was reviewed. On 10/18/21 at 3:22 PM the patient had pillow support. There was no documentation until 7:00 PM when the patient was in the semi-fowler's position. On 10/19/21 at 9:38 AM, the patient was in the semi-fowler's position with pillow support and no documentation until 2:00 PM when the patient was in the semi-fowler's position. There was no documentation between 4:05 PM when the patient was in the semi-fowler's position on the left side and 8:00 PM when the patient was in the semi-fowler's position with pillow support. At 9:00 PM, it was documented the patient was in the semi fowler's position with pillow support. There was no documentation until 8:00 PM on 10/20/21 when it was documented the patient was in the semi fowler's position. On 10/20/21 at 5:00 AM the patient was on his left side and there was no documentation until 8:00 PM when the patient was on his right side. On 10/22/21 at 1:00 AM the patient was on his right side and the next entry was at 5:00 AM when the patient was on his left side. The next entry was at 8:00 AM when the patient was on his left side. At 8:00 PM on 10/22/21 the patient was in the semi-fowler's position and there was no documentation until 9:50 AM on 10/23/21 when the patient had pillow support lying right side. At 5:00 PM the patient had pillow support lying right side and at 8:00 PM the patient was in semi-fowler's with pillow support. There was no documentation until 10/24/21 at 8:40 AM when the patient was on his right side. On 10/24/21 at 8:00 PM, the patient was in semi-fowler's and there was no documentation until 10/25/21 at 8:00 PM when the patient was in semi-fowler's with pillow support. On 10/26/21 at 5:00 AM it was documented the patient was left side pillow support. There was no documentation until 8:00 PM when the patient had pillow support. On 10/26/21 at 9:00 PM the patient was on his left side and there was no documentation until 10/27/21 at 5:26 AM when the patient was on his right side with pillow support. There was no documentation until 8:00 PM on 10/27/21 when the patient had pillow support. On 10/27/21 at 9:30 PM the patient had pillow support left side and there was no documentation until 10/28/21 at 5:15 AM when the patient was right side with pillow support. The next entry was at 8:00 PM when the patient was in semi-fowler's right side. At 11:00 PM the patient was on his right side and the next entry was at 5:50 AM on 10/29/21 when the patient had pillow support. The next entry was at 9:25 AM when the patient was sitting in bed. On 10/30/21 at 12:00 PM the patient was in semi-fowler's with pillow support and the next entry was at 6:00 PM when the patient was in semi-fowler's with pillow support. On 11/01/21 at 6:00 AM the patient was in the semi-fowler's position and the next entry was at 9:00 PM when the patient was on his left side with pillow support. On 11/02/21 at 5:00 AM the patient had pillow support on left side and the next entry was on 11/03/21 at 9:00 PM when the patient was on his left side. At 11:00 PM the patient was on his left side and the next entry was at 5:00 AM on 11/04/21 when the patient was on his left side. The next entry was at 8:00 AM when the patient was in semi-fowler's. At 8:56 AM the patient was on his left side, the next entry at 2:00 PM the patient was in semi-fowler's with pillow support, and the next entry at 7:00 PM the patient was lying on his right side. On 11/05/21 at 7:00 AM the patient was on his right side and there was no documentation until 8:10 PM when the patient was on his left side. On 11/06/21 at 12:56 PM the patient was on his left side and there was no documentation until 8:00 PM when the patient was in semi-fowler's. At 9:00 PM the patient was in semi-fowler's with pillow support. The next entry was at 1:00 AM on 11/07/21 when the patient was on his left side. There was no documentation until 11/07/21 at 8:00 PM when the patient was on his left side. There was no documentation until 11/08/21 at 7:00 PM when the patient was in semi-fowler's. On 11/09/21 at 5:00 AM the patient was in semi-fowler's and the next entry was at 8:00 AM when the patient was in semi-fowler's. On 11/10/21 at 6:00 AM the patient was in semi-fowler's with pillow support. There was no documentation until 7:00 PM when the patient was in semi-fowler's. On 11/11/21 at 11:00 AM the patient was in semi-fowler's with pillow support. There was no documentation until 11/12/21 at 8:00 AM when the patient had pillow support. The documentation did not reflect that the patient was turned and repositioned every two hours.

Review of a progress note dated 11/10/21 at 3:00 PM revealed the wound care nurse documented hospital acquired pressure injury (HAPI) Stage two (partial-thickness skin loss into but no deeper than the dermis). The documentation on page revealed writer made aware by the nursing staff that Patient #7 had an open area to his coccyx. Upon assessment, the writer noted superficial Stage two to coccyx area. The measurements were 1.5 centimeters (cm) x 0.5 cm x 0.1 cm and the wound was described as being partial thickness Stage two, clean, moist, red, non granulation tissue, peri wound area clean, dry, intact. Cleansed with saline, open to air and Triad hydro (cream used for the local management of partial- and full-thickness pressure and venous stasis ulcers, dermal lesions/injuries, and first and second-degree burns) applied.

Preventative measures at this time included offload pressure points and provide pressure relief, low air loss mattress, turning wedge, heel boots, and pillows to offload pressure points, use Sween 24 to hydrate and moisturize skin, use moisture barrier cream to protect groin, perianal skin and buttocks from incontinence. The risk factors for skin breakdown were documented as decreased movement, incontinence, nutrition and diagnosis.

Review of a medication order dated 11/10/21 revealed Triad paste (zinc oxide) was ordered two times a day for the coccyx area. The order was discontinued on 11/12/21 at 3:20 PM when the patient was admitted to the skilled unit.

The findings were confirmed in an interview with Staff D on 04/11/21 at 1:00 PM.

2. Review of the medical record for Patient #1 revealed the patient was admitted on 01/12/22. The primary diagnosis was acute on chronic respiratory failure due to COVID-19 and the patient was admitted for vent weaning. Active diagnoses included hypothyroidism, Type 2 diabetes, chronic obstructive pulmonary disease (COPD), heart failure, and chronic pain syndrome.

Patient #1's mobility assessment for turning and repositioning on admission was maximum assist and patient completed 25-49 percent of the turning themselves and staff helped with more than 50 percent of the patient's turning.

The Braden scale skin assessment on admission showed a score of 13 (high risk for skin breakdown). Interventions on admission included turning and repositioning, increased heels off bed, multi podus boots (designed to suspend heels to prevent skin breakdown from occurring on the bottom of the heel), and low air loss mattress.

Review of the wound care consult note dated 01/14/22 revealed the wound care team (WCT) documented Patient #1 was without pressure ulcers or wounds. The WCT will not be following patient or doing weekly skin assessments. Floor nursing to notify WCT if any skin issues. Continue pressure ulcer prevention measures. Preventative measures included offloading pressure points and providing pressure relief, use low air loss mattress, turning wedge, heel boots, and pillows to off load pressure points. Use Sween 24 cream (moisturizing cream) to hydrate and moisturize skin. Use moisture barrier cream to protect groin, perianal skin and buttocks from incontinence.

Review of Patient #1's turning and repositioning schedule revealed on 01/14/22 at 6:00 AM the patient was on her right side, but no documentation of the patient being turned until 01/14/22 at 9:00 PM. On 01/15/22 at 5:00 AM the patient was on her left side and there was no documentation the patient was turned again until 01/15/22 at 9:00 AM. On 01/17/22 from 5:00 AM until 10:00 AM documentation showed the patient lying in bed supine head of bed (HOB) elevated 30 degrees and then at 10:00 AM the patient was turned to her right side. On 01/17/22 there was documentation the patient was turned again at 4:00 PM to semi-fowlers position and at 8:00 PM pillow support. There was no documentation the patient was turned until 01/18/22 at 8:00 AM. On 01/18/22 at 9:00 AM the patient was sitting in bed, at 10:00 AM they were in the semi-fowler's position. There was no documentation until 01/18/22 at 9:00 PM when it was documented the patient was turned to the left side. There was no documentation until 01/19/22 at 3:00 AM when the patient was turned to the left side. On 01/19/22 at 5:00 AM it was documented the patient was lying in bed and at 01/19/22 at 8:00 AM it was documented the patient was lying in bed. On 01/19/22 at 9:16 AM it was documented the patient was lying in bed with pillow support and then on 01/19/22 at 9:00 PM it was documented the patient was lying in bed. On 01/20/22 at 5:00 AM documentation showed pillow support and at 01/20/22 at 8:55 AM it was documented the patient was on her right side and that she was able to to turn self. On 01/20/22 at 8:00 PM it was documented the patient turns self. There was no documentation again until 01/21/22 at 9:00 AM when the patient had pillow support. On 01/21/22 at 8:00 PM documentation showed moderate assist semi-fowler's. On 01/22/22 at 1:00 AM documentation showed semi-fowler's, head of bed elevated 30 degrees, maximum assistance does 25 to 49 percent with help.

The medical record revealed Patient #1 was incontinent of bowel times two on 01/19/22, cleansed with soap and water and barrier cream applied. On 01/20/22 redness to the patient's coccyx was noted at 11:00 AM and barrier cream applied.

On 01/21/22 the WCT documented unable to inspect buttocks/sacral area due to additional staff unavailable for turning and repositioning. The patient's Braden score was assessed at 15.

On 01/26/22 the WCT consult revealed excoriation, but there was no documentation where the excoriation was located. There was no evidence the barrier cream was applied.

On 01/27/22 and 01/28/22 there was documentation by a staff nurse that there was excoriation to the peri area/coccyx, but there was no documentation the barrier cream was applied.

Patient #1 was seen by the WCT on 02/01/22. The WCT progress note dated 02/01/22 revealed Patient #1 had a Stage 2 pressure ulcer (the topmost layer of skin (epidermis) is broken, creating a shallow open sore. The second layer of skin (dermis) may also be broken) to her left buttocks that measured 2.5 centimeters (cm) x 2.5 cm by 0.1 cm and a barrier film; protective barrier was to be applied. Area is fragile, moist, pink, pale, and yellow. The right buttocks were observed to be intact, excoriated, fragile, no bleeding, no hematoma and red. Cleanse with soap and water, apply barrier film and protective barrier.

These findings were confirmed with the administrative staff on 04/01/22 at 2:00 PM.

3. Review of the medical record for Patient #2 revealed the patient was admitted to 3 North on 12/16/21 from another hospital and discharged on 02/10/22 to a skilled nursing facility on the second floor at this hospital. The admitting diagnosis was sternal wound infection coronary artery bypass graft (CABG) in July 2021 and was complicated by a sternal wound infection which dehisced. The patient also had a history of Methicillin-resistant Staphylococcus aureus (MRSA) infection.

The skin assessment on admission was a deep tissue injury to the left lower back related to chest tube tubing on admission. The patient did not have any other pressure ulcers on admission.

The patient's Braden scale skin assessment on admission was 16 (high risk for skin breakdown). Interventions on admission included pressure reduction mattress, offload pressure points and provide pressure relief, use pressure reducing mattress, and pillows to off load pressure points, use Sween 24 cream to hydrate and moisturize skin, use moisture barrier cream to protect groin, perianal skin and buttocks from incontinence.

Review of Patient #2's mobility status for turning on admission was the patient was assessed as supervision or touching assistance with turning and repositioning. Patient turned self in bed.

Interview with Staff B on 04/01/22 at 11:56 AM revealed supervision or touching assistance only pertained to completing activities and not for turns. Patient #2 could turn himself without staff present and without reminders.

Further review of the patient's record revealed documentation on 01/31/22 of an unstageable pressure ulcer to the right heel and documentation on 02/02/22 of an unstageable pressure ulcer to the right buttocks.

Treatments ordered on 01/31/22 for the right heel was betadine daily and leave open to air. Treatments ordered on 02/02/22 for the right buttocks included plain mist to buttocks, continue low air loss mattress, medihoney and foam border and to change the dressing three times a week.

There was no documentation betadine was applied to the patient's right heel on 02/03/22, 02/04/22, and 02/09/22 as ordered.

Review of the patient's record revealed the dressing change to the patient's right buttocks was done on 02/02/22 and 02/07/22 and then the patient was transferred to the skilled nursing facility on 02/10/22 at 11:10 AM. The dressing change was only done two times in the week before the patient was transferred.

This finding was confirmed in an interview with the administrative staff on 04/01/22 at 2:00 PM.