HospitalInspections.org

Based on record review and interview, nursing services failed to adhere to facility policy and professional standards of nursing practice for 3 of 11 sampled patients [ Patient ID#'s: 5, 8, and 10] .

Nursing staff failed to:

a. ensure an accurate admission skin assessment was completed ( Patient ID # 8).

b. implement physician orders for indwelling urinary catheter changes (Patient # 5).

c. obtain physician orders prior to changing indwelling urinary catheter ( Patients 5, 10).


Findings included:

a. Accuracy of admission skin assessment:

Record review of Texas Administrative Code (TAC) Title 22; PART 11 Texas Board of Nursing ; CHAPTER 217 ; RULE §217.11 "Standards of Nursing Practice" showed:
(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall:
(B) Implement measures to promote a safe environment for clients and others;
(D) Accurately and completely report and document:
(ii) nursing care rendered;
(iii) physician, dentist or podiatrist orders;

Review of facility policy titled: " Assessment and Reassessment,"dated "10/21,"showed: Roles and responsibilities of RN: (1) performs a complete physical assessment of the patient and documents the admission assessment on the daily nursing assessment...analyzes data and physical assessment information to identify patient problems or needs.

Record review with Staff F, RN, of the electronic medical record (EMR) of Patient ID # 8 showed she was admitted on 10/14/2022. The nursing admission assessment was completed on 10/14/2022 at 8 PM. It showed : "integument /skin condition: warm, dry; skin alteration: none."

Record review of nursing progress note dated 10/15/2022 at 8 PM showed documentation of multiple skin alterations / wounds and bruises on Patient # 8 : bilateral heels; posterior & left shin; skin tear to right arm; bruises to both arms; scattered sores on sacrum and buttocks.

During an interview on 12/28/2022 at 1:30 PM with Staff F, RN , she verified the initial nursing assessment of Patient # 8 on 10/14/22 was not accurate as related to skin integrity /alteration.

b. Implementation of physician orders:

Record review on 12/29/222 of the EMR of Patient ID # 5 showed the following:

* Physician orders to "change Foley" dated : 5/31/22; 6/9/22; 6/24/22.

Staff G was unable to locate documentation the orders were implemented. During an interview on 12/29/2022 at 1:45 PM with Staff G, RN, she said orders not implemented should be clarified with the physician and discontinued .

c. Obtaining physician orders:

Review of facility policy titled: " Urinary Catheter Insertion, Maintenance, & Removal," dated "12/22" showed: "Urinary catheter insertion: 1. Verify physician order...."

Record review on 12/29/222 of the EMR of Patient ID # 5 and Patient 10 showed the following:

* Patient ID # 10: Foley catheter was changed on 8/30/22.

* Patient ID # 5: Foley catheter was changed on 5/12/2022 and 6/16/22

Staff G was unable to locate physician orders for the Foley catheter changes for Patient # 5 and 10. During an interview on 12/29/2022 at 2 PM with Staff G, RN, she said a physican order was required to insert Foley catheters.