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Based on interview, record review and policy review, the facility failed to:
- Initiate a timely review of, and implement timely, effective measures and monitoring to prevent potential reoccurrence of a Sentinel Event (SE, a serious safety event affecting patients, staff or visitors) related to tracheostomy (trach, surgical procedure to create an opening in the windpipe, to insert a plastic tube to help a patient breath) care, which caused serious injury to one discharged patient. This had the potential to lead to serious injury or death of any patient in the hospital with a trach. (A0286)
- Monitor trach care for one current patient according to policy. This had the potential to lead to negative outcomes, serious injury or death of any patient in the hospital with a trach. (A0286)
- Collect and analyze quality data related to blood or blood product transfusions, a high volume, high risk area. This had the potential to affect all patients receiving blood transfusions in the hospital by failing to ensure that standards of care were met during blood administration. (A0273)
- Ensure that the Governing Body (Corporate Board of Directors) annually approved the hospital's Quality Assurance Performance Improvement program, known as the Performance Improvement and Patient Safety (PIPS) plan. This had to potential to affect the health outcomes and quality of care for all patients. (A0308)

The severity and cumulative effect of these systemic practices resulted in the facility being out of compliance with 42 CFR 482.21 Condition of Participation: Quality Assessment and Performance Improvement, and resulted in the facility's failure to ensure quality health care and safety.

Based on interview and record review, the facility failed to collect and analyze quality data related to blood or blood product transfusions, a high volume, high risk area. This had the potential to affect all patients receiving blood transfusions in the hospital by failing to ensure that standards of care were met during blood administration. The facility transfuses approximately 400 units of blood products per month. The facility census was 300.

Findings included:

1. Record review of the facility's "Performance Improvement and Patient Safety Plan 2016," showed the hospital's Quality Control (the ongoing monitoring of outcomes and processes to assure that expected levels of performance are maintained), monitored key patient care and organizational processes and functions, particularly those which impact patient safety and are high volume, high risk, high cost or problem-prone, and included "Blood and Blood Component Use (transfusion)".

2. Record review on 05/19/16, of the facility's "Transfusion" scorecard (documents monthly audit and analysis of 10 blood transfusions per month, including expected goals and whether those goals were reached) showed no audit or analysis of blood transfusions since 01/2016.

During an interview on 05/18/16 at 9:10 AM, Staff JJ, Regional Coordinator of Patient Safety and Quality, and Staff KK, Regional Director of Patient Safety and Quality, stated that the facility had not collected or analyzed quality data related to blood transfusions since 01/2016. Both stated that the facility was expected to monitor blood transfusions because blood transfusions were a high volume, high risk area. Staff KK stated that she was responsible for collecting and analyzing the data.

Based on interview, record review and policy review, the facility failed to initiate a timely review of, and implement timely, effective measures and monitoring to prevent potential reoccurrence of a Sentinel Event (SE, a serious safety event affecting patients, staff or visitors) related to tracheostomy (trach, surgical procedure to create an opening in the windpipe, to insert a plastic tube to help a patient breathe) care, which caused serious injury to one discharged patient (#68) of three discharged patient SE's reviewed. The facility also failed to monitor trach care, according to policy, for one of one current patient (#28) reviewed with a trach. This had the potential to lead to serious injury or death of any patient in the hospital with a trach. The facility census was 300. There were three current patients with trachs in the facility and 20 patients with trachs in the facility in the past six months.

Findings included:

1. Record review of the facility's policy titled, "Event Reporting," dated 10/01/14, showed that all staff and managers were responsible for ensuring "Events" of any type that they witness, become aware of or are involved in are reported through the online event reporting system in a timely manner.

Record review of the facility's policy titled, "Sentinel and Serious Event," dated 09/15/15, showed that:
- A SE was a patient safety event (not primarily related to the natural course of the patient's illness or underlying condition) that reaches a patient and results in death, permanent harm or severe temporary harm.
- A SE required a Root Cause Analysis (RCA, method of problem solving used to analyze sentinel and serious events) completed within 30 business days of the occurrence date and documents findings to include opportunities for improvement, actions and measures of success.
- A Serious Safety Event (SSE) was a breach or deviation from the standard of care (preventable) which resulted in moderate to severe harm or death.
- The SSE process included completing and documenting a preliminary patient safety investigation within seven business days.

Record review of the facility's policy titled, "Administering Oxygen via a Continuous Aerosol," dated 01/2014, showed that:
- Continuous aerosol provided an increase in humidity (moisture) to the inspired air (air breathed in), to achieve mobilization of bronchial secretions (phlegm produced in the lungs) for easier removal and humidification of the respiratory tract.
- A heater was required with the use of continuous aerosol for patients with tracheosotmies.
- Aerosols are checked every four hours at which time excess water is drained from the tubing and bag, the water is changed if necessary, and equipment is checked to make sure it is functioning properly.

Record review of the facility's policy titled, "Tracheostomy Management Adult Patients," dated 03/2015, showed that tracheostomy care was performed every eight hours and as needed.

2. Record review of an event report (ER) dated 02/26/16 (entered as an event nine business days after the actual event occurred), showed:
- On 02/15/16 at approximately 10:00 PM (actual event occurred at 8:50 PM), Patient #68 coded (pulseless and not breathing), the code team (medical professionals administer life supporting measures to restore pulse and breathing) responded, the patient's pulse was restored (breathing was supported by a life support machine called a ventilator) and the patient was transferred to the Intensive Care Unit (ICU).
- The patient's family expressed concerns that the patient was not receiving proper respiratory care while on seven South (patient care unit), and felt it caused the patient to code.
- The manager's review of the event indicated that the patient coded due to the patient's trach being blocked with thick secretions.
- The event was caused by a deviation of the policy related to high humidity (administering oxygen via a continuous aerosol).
- The error was caused when Respiratory Therapy (RT) did not place the patient on heated humidity (aerosol) per policy and standards.
- Staff were unaware of the policy and reported that there were no heaters available, as three of them were broken and not usable.
- RT staff involved in the event were coached (educated on the errors made to prevent reoccurrence).
- There were no SE contributing factors (per the RT manager).

3. Record review of discharged Patient #68's medical record showed:
- Nurses notes for 02/14/16 until the patient coded on 02/15/16 at 8:50 PM, showed that the patient was not suctioned for greater than 24 hours prior to the event.
- There was no evidence that the patient received heat, with his continuous aerosol, through his trach.
- Nurses notes on 02/15/16 at 8:50 PM, documented that the patient was ventilated (forcing air into a patients lungs) by hand (indicates that hospital staff were administering life saving measures), and the patient was later placed on a ventilator (a machine that forces air into the lungs at a preset rate to simulate breathing when the patient cannot breathe on his/her own).
- The discharge summary indicated that the patient died on 04/27/16.

4. Record reviews of emails from Staff PP, Patient Safety and Quality, to and between other Patient Safety and Quality staff and management, showed an email dated 04/22/16 documented that the event was not yet determined to be a SE (67 days after the event occurred) and an email dated 05/06/16, documented that the RCA was not yet completed.

5. During an interview on 05/18/16 at 11:09 AM, Staff UU, RT Manager stated the following related to Patient #68's ER:
- She was not informed that the ER was not managed properly (not entered or investigated in a timely manner, not recognized to have SE contributing factors);
- She didn't realize that RT heaters were broken;
- The RCA action plan that was submitted wasn't approved until 05/06/16;
- Patients on trachs could be placed anywhere in the hospital, on any floor.

The facility failed to enter Patient #68's event into the event report system in a timely manner, failed to investigate the event in a timely manner, failed to determine the event was a SE in a timely manner, and the RCA was not completed in a timely manner, according to policy.

6. Record review of an undated "Sentinel Event RCA Form," indicated that the event which involved Patient #68 was a determined SE and showed:
- Root Cause/Contributing factors for the SE included that the patient was not placed on high humidity, RT missed assessment of the patient every four hours due to high demand of respiratory patients, respiratory therapy heaters were unusable because they were broken, Registered Nurses (RN) had not completed trach care per policy and there was a low volume of trach patients on seven South (prevented familiarity with trach care).
- Action Plans included review of the Continuous Aerosol policy with all RT staff and to highlight the need to add heater to aerosol system, required four hour monitoring of the patient to include proper functioning of aerosol and assessment of the patient's suctioning needs, complete order for additional aerosol heaters, review care of tracheostomy care policies with all RNs on seven South, and nurse collaboration with RT for real time education when patients with trachs were admitted to seven South.
- Success would be measured by audits of trach patients - five per month of RT documented trach care and 10 (per month) of nurse documented trach care (seven South only).
Record review of education rosters showed that trach care re-education was limited to only the nursing staff on seven South.

7. Record review of facility audits on 05/19/16 (three months after Patient #68's event), showed that none of the RT audits had been completed, and only five nurse audits, which were limited to trach patients on seven South, had been completed.

Even after the facility recognized Patient #68's event was a SE, they failed to re-educate all nursing staff through out the facility who provided care to patients with trachs, and failed to ensure appropriate monitoring audits were initiated and completed in a timely manner to include all nursing areas caring for patients with trachs.

8. Record review of current Patient #28's medical record showed:
- A physician's order dated 04/18/16 for trach care once a day with warm water and soap (policy stated every eight hours).
- There was no documented trach care on the patient's flowsheets between 05/13/16 at 10:37 AM and 05/13/16 at 10:45 PM (approximately 12 hours), 05/14/16 at 7:56 AM and 0/14/16 at 11:43 PM (approximately 16 hours), 05/14/16 at 11:43 PM and 05/15/16 at 3:54 PM (approximately 16 hours), 05/15/16 at 10:39 PM and 05/16/16 at 11:26 PM (approximately 24 hours), 05/16/16 at 11:26 PM and 05/17/16 at 12:07 PM (approximately 11 hours), 05/17/16 at 8:46 PM and 05/18/16 at 5:42 PM (approximately 21 hours), 05/18/16 at 5:42 PM and 05/19/16 at 10:29 AM (approximately 16 hours).
- There was no documentation on the patient's flowsheet to show if staff suctioned the patient (option to choose yes or no was left blank) between 05/13/16 at 10:37 AM and 05/14/16 at 7:42 AM (approximately 21 hours), 05/14/16 at 7:56 AM and 05/16/16 at 4:44 AM (approximately 45 hours), 05/16/16 at 8:14 AM and 05/16/16 at 11:26 PM (approximately 15 hours); 05/17/16 at 9:22 AM and 05/17/16 at 8:46 PM (approximately 11 hours).
- Documentation of the oxygen therapy used on 05/15/16 at 4:37 AM did not indicate that the patient was receiving heat to his humidified oxygen through his trach.

9. Record review of facility audits on 05/19/16 showed that Patient #28's trach care was not audited by nursing or RT.

Because the facility failed to put timely measures in place to track and monitor all patients
with trachs, and because the facility failed to implement preventive actions that included feedback and learning throughout the facility, Patient #28's trach care was not completed according to policy, and the lack of trach care, trach suctioning and humidified oxygen went unrecognized by the facility.

Based on interview and record review, the facility failed to ensure that the Governing Body (Corporate Board of Directors) annually approved the hospital's Quality Assurance Performance Improvement (QAPI) program, known as the Performance Improvement and Patient Safety (PIPS) plan. This had to potential to affect the health outcomes and quality of care for all patients. The facility census was 300.

Findings included:

1. Record review of the PIPS plan for 2016 showed that annually, the hospital determined the number and scope of distinct quality and patient safety improvement priorities and projects proportional to the scope and complexity of the hospital's services and operations, and submitted it to the Board of Directors for approval. The Board of Directors was responsible and accountable for ensuring an ongoing program for quality improvement and patient safety, including the improvement in reliability of care delivery.

2. During an interview on 05/24/16 at 1:35 PM, Staff RR, Assistant Chief Nursing Officer, stated that the Board of Directors assumed full legal authority and responsibility for operations of the hospital.

During an interview on 05/18/16 at 3:40 PM, Staff KK, Regional Director of Patient Safety and Quality, stated that the Board of Directors had not approved the 2016 PIPS plan, and did not approve the 2015 PIPS plan, because it had been overlooked.

Based on observation, interview, record review and policy review the facility failed to:
- Ensure one discharged patient (#68) and one current patient (#28), received tracheostomy (trach, surgical procedure to create an opening in the windpipe, to insert a plastic tube to help a patient breathe) care according to policy, of one current and one discharged patient reviewed who received trach care. (A395)
- Assess, measure and/or stage (a process by which pressure sores [any lesion caused by unrelieved pressure that results in damage to underlying tissue] are described by levels of severity and tissue involvement) pressure sores upon admission, and weekly per their policy direction, for three (#26, #27, and #28) of four patients with pressure sores reviewed. (A395)
- Obtain and document daily weights as ordered by the physician for two (#27 and #26) of two patients reviewed with orders for daily weights. (A395)
- Follow physician's orders for pressure sore treatments for two (#27 and #49) of four treatments observed. (A395)
- Follow care plan interventions and/or physician's orders for relief of pressure for two (#26 and #28) of four patients reviewed with pressure sores. (A395)
- Document the consumption of nutritional supplement (a liquid designed to increase calorie/protein intake) for two (#26 and #27) of two patients reviewed with orders for a nutritional supplement. (A395)
-Assess and document open mouth sores for one (#55) patient of one patient. (A395)
-Secure urinary catheters with Statlocks (device that adheres to the patient's thigh and clips to the urinary catheter tubing, reducing the risk of pulling it out of the bladder) and assess urinary catheters twice daily for four (#29, #38, #64 and #65) of seven patients. (A395)

The severity and cumulative effect of these systemic failures resulted in the facility being out of compliance with 42 CFR 482.23 Condition of Participation: Nursing Services.

These failures had the potential to lead to negative outcomes, serious injury or death of any patient in the hospital with a trach and the potential for harm to all patients in the facility who received unsupervised substandard nursing care.

On 06/27/16, it was determined that the cumulative effect of these systemic practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). The IJ was unabated.




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Based on observation, interview, record review and policy review the facility failed to:
-Ensure one discharged patient (#68) and one current patient (#28), received tracheostomy (trach, surgical procedure to create an opening in the windpipe, to insert a plastic tube to help a patient breathe) care according to policy, of one current and one discharged patient reviewed who received trach care. This had the potential to lead to negative outcomes, serious injury or death of any patient in the hospital with a trach. There were three current patients with trachs in the facility and 20 patients with trachs in the facility in the past six months.
- Assess, measure and/or stage (a process by which pressure sores [any lesion caused by unrelieved pressure that results in damage to underlying tissue] are described by levels of severity and tissue involvement) pressure sores upon admission, and weekly per their policy direction, for three (#26, #27, and #28) of four patients with pressure sores reviewed.
- Obtain and document daily weights as ordered by the physician for two (#27 and #26) of two patients reviewed with orders for daily weights.
- Follow physician's orders for pressure sore treatments for two (#27 and #49) of four treatments observed.
- Follow care plan interventions and/or physician's orders for relief of pressure for two (#26 and #28) of four patients reviewed with pressure sores.
- Document the consumption of nutritional supplement (a liquid designed to increase calorie/protein intake) for two (#26 and #27) of two patients reviewed with orders for a nutritional supplement.
-Assess and document open mouth sores for one patient (#55) of one patient reviewed with mouth sores.
These failures had the potential to affect all patients by allowing them to develop pressure sores, by not evaluating the deterioration and/or improvement of pressure sores, by not providing adequate treatment to hasten healing and by not monitoring weights and the nutritional status of patients with pressure sores/wounds. The facility identified a minimum of 24 facility-acquired pressure sores from 01/01/16 through 05/25/16.
-The facility also failed to secure urinary catheters to the upper thigh to prevent tension on the catheter for four (#29, #38, #64 and #65) of seven patients. This failure had the potential to affect all patients with catheters by allowing the tubing to be pulled causing pain and injury to the urinary tissues.
The facility census was 300.

Findings included:

1. Record review of the facility's policy titled, "Administering Oxygen via a Continuous Aerosol," dated 01/2014, showed that:
- Continuous aerosol provided an increase in humidity (moisture) to the inspired air (air breathed in), to achieve mobilization of bronchial secretions (phlegm produced in the lungs) for easier removal and humidification of the respiratory tract.
- A heater was required with the use of continuous aerosol for patients with tracheosotmies.
- Aerosols are checked every four hours at which time excess water is drained from the tubing and bag, the water is changed if necessary, and equipment is checked to make sure it is functioning properly.

Record review of the facility's policy titled, "Tracheostomy Management Adult Patients," dated 03/2015, showed that tracheostomy care was performed every eight hours and as needed.

2. Record review of discharged Patient #68's medical record showed:
- The patient (located on Seven South, patient care unit) had a trach and staff did not suction the patient for greater than 24 hours prior to the patient's arrest (pulseless and not breathing) on 02/15/16 at 8:50 PM.
- Nurses notes on 02/15/16 at 8:50 PM, documented that staff ventilated (forcing air into a patients lungs) the patient by hand (indicates that hospital staff were administering life saving measures), and the patient was later placed on a ventilator (a machine that forces air into the lungs at a preset rate to simulate breathing when the patient cannot breathe on his/her own).
- The discharge summary indicated that the patient died on 04/27/16.

Record review of an event report (ER) dated 02/26/16, showed that the patient's family expressed concerns that the patient was not receiving proper respiratory care and felt it caused the patient to arrest. The manager's review of the event indicated that the patient coded due to the patient's trach being blocked with thick secretions.

3. Record review of an undated "Sentinel Event Root Cause Analysis Form (focused investigation of an event that lead to, or had the potential to lead to, a serious or life threatening event)," showed:
- RNs had not completed trach care per policy.
- Action Plans included the review of Tracheostomy Care policies with RNs on Seven South, and nurse collaboration with Respiratory Therapists for real time education when patients with trachs were admitted to Seven South.
- Success would be measured by 10 monthly audits of nurse documentation of trach care.

4. Record review of education rosters showed that trach care re-education was limited to RNs on Seven South, and not provided to all nursing staff who cared for trach patients.

5. Record review of facility audits on 05/19/16 (three months after Patient #68's event), showed that only five nurse documentation audits, which were limited to trach patients on Seven South, had been completed.

The facility failed to re-educate all nursing staff who provided care to patients with trachs, and failed to ensure appropriate monitoring was initiated in a timely manner to include all patient care areas with trach patients.

6. Record review of current Patient #28's medical record showed:
- A physician's order dated 04/18/16 for trach care once a day with warm water and soap (policy stated every eight hours).
- There was no documented trach care on the patient's flowsheets between 05/13/16 at 10:37 AM and 05/13/16 at 10:45 PM (approximately 12 hours), 05/14/16 at 7:56 AM and 0/14/16 at 11:43 PM (approximately 16 hours), 05/14/16 at 11:43 PM and 05/15/16 at 3:54 PM (approximately 16 hours), 05/15/16 at 10:39 PM and 05/16/16 at 11:26 PM (approximately 24 hours), 05/16/16 at 11:26 PM and 05/17/16 at 12:07 PM (approximately 11 hours), 05/17/16 at 8:46 PM and 05/18/16 at 5:42 PM (approximately 21 hours), 05/18/16 at 5:42 PM and 05/19/16 at 10:29 AM (approximately 16 hours).
- There was no documentation on the patient's flowsheet to show if staff suctioned the patient (option to choose yes or no was left blank) between 05/13/16 at 10:37 AM and 05/14/16 at 7:42 AM (approximately 21 hours), 05/14/16 at 7:56 AM and 05/16/16 at 4:44 AM (approximately 45 hours), 05/16/16 at 8:14 AM and 05/16/16 at 11:26 PM (approximately 15 hours); 05/17/16 at 9:22 AM and 05/17/16 at 8:46 PM (approximately 11 hours).
- Documentation of the oxygen therapy used on 05/15/16 at 4:37 AM did not indicate that the patient was receiving heat to his humidified oxygen (aerosol) through his trach.

7. Record review of a facility policy titled, "Skin Care," revised 10/2014, showed the following:
- Skin integrity is to be maintained or improved.
- Maintain preventative measures for patients at risk for skin breakdown.
- Provide appropriate interventions for the patient with altered skin integrity and with pressure sores.
- A head-to-toe assessment will be completed upon admission to assess incontinence, nutritional status, activity level, mobility, friction and shear.
- Wound/dressing assessment will be conducted every shift.
- A Braden score (a tool utilized to determine risk for skin breakdown) of 18 or less requires preventive measures including measurement of pressure sores in centimeters (cm) length by width and documentation.
- Initiate treatments (per protocol that do not require physician's order). Contain incontinence by utilizing skin protectant, and use pillows or positioning wedges.
- Contact physician to obtain orders for further treatment and to notify of skin alteration.
- Apply skin protectant with zinc oxide as soon as possible (with physician's order) for open areas related to incontinence.

8. Record review of Patient 28's History and Physical (H&P) dated 02/11/16, showed the patient was admitted on that date with diagnoses of diabetes (can contribute to development of pressure sores related to poor circulation), and severe sepsis (a systemic infection).

Record review of nursing documentation related to skin condition from admission on 02/11/16 to 05/14/16 showed the patient developed a pressure sore on his coccyx/sacrum (tailbone) on 02/17/16. This pressure sore was not staged until 05/24/16, and then it was described as a Stage III (full thickness skin loss involving damage or necrosis of subcutaneous tissue. It may present as a deep crater with or without undermining). The facility failed to measure this pressure sore. The patient developed a pressure sore on his right ear on 03/26/16. This pressure sore was not staged until 05/24/16, and then it was described as unstageable (usually means there is slough or dying tissue). The facility failed to measure this pressure sore from development through 05/14/16, or for 50 days.

Record review of physician's orders dated 04/21/16, directed staff to relieve pressure to the right ear with positioning.

Observation on 05/16/16 at 3:26 PM, showed Patient #28 lying directly on his right ear (causing pressure to the existing pressure sore).

Observation in Patient #28's room and concurrent interview on 05/17/16 at 11:15 AM, showed the following:
- Patient #28 was lying directly on his right ear (causing pressure to the existing pressure sore). The pillow utilized to keep the patient off of his right side was very flat and ineffective.
- Staff A, Registered Nurse (RN) and Team Leader for Five North, stated that it was difficult to keep Patient #28 off of his right ear.
- Staff A was not aware of any other method, or available device to keep the pressure off of the patient's right ear.
- Staff failed to follow the physician's order to relieve the pressure on the patient's right ear.

During an interview on 05/16/16 at 3:40 PM, Staff A stated that the nurses did not stage wounds, only the wound care nurses (WCNs) and physicians did. Staff A also stated that wounds were measured on identification, and weekly.

During an interview on 05/18/16 at 10:04 AM, Staff P, WCN, stated that staff should relieve pressure on the ear with frequent repositioning and use of medical devices. Staff P stated that the facility currently had no known devices that elevated the patient's ear off of the pillow.
Staff P stated that all nurses should measure and describe any skin issue found on admission and/or when identification, and follow physician's orders.

9. Record review of Patient #27's H&P dated 05/14/16 showed the patient was admitted on 05/13/16 with diagnoses of a decreased mental status, infected pressure sores, and a urinary tract infection. The H&P did not include staging and/or measurement of the pressure sores.

Record review of the patient's Braden scores from admission through 05/17/16 showed a score of "11" or "12," indicating the patient was a high risk for development of pressure sores. The patient was very moist (from urinary incontinence), and bedfast (risk factors for development of pressure sores).

Record review of the patient's physician's orders dated 05/16/16, showed staff were to treat the right ischium (lower buttock- where the upper thigh meets the buttock) by cleansing with wound cleanser, applying Silvasorb gel (a dressing that provides continuous bacterial and fluid management) and cover with dry gauze twice daily and as necessary. The right heel required cleansing, and a normal saline (a sterile mixture of salt and water which is similar to other body fluids) wet-to-dry dressing daily and as necessary.

Record review of the facility's skills content for male perineal (area of the body between the pubic bone and tailbone) care dated 05/24/16, showed staff were to cleanse the penis and scrotum, and apply skin protectant.

Observation and concurrent interview in the patient's room on 05/17/15 at 10:40 AM, showed the following:
- The patient had been incontinent of bowel and bladder. His knees were drawn up into a fetal position. His scrotum was very swollen, red and had many small open areas on it.
- Staff A stated that it was the facility's protocol to use incontinence care to the scrotum, which included cleansing and use of a barrier cream. Staff A cleansed the patient's rectal/bottom area, but failed to clean the patient's groin, penis, and scrotum. Staff A failed to put a barrier cream on the patient's scrotum.
- Staff I, RN, treated the patient's right ischium (a Stage III-full thickness skin loss presenting as a deep crater) pressure sore with the treatment orders for the right heel (a Stage IV-full thickness skin loss with extensive destruction, tissue death or damage to bone or muscle) pressure sore and treated the right heel with the orders for the right ischium.
- Staff A stated that Staff I got the orders mixed up.

Record review of the patient's skin assessment documentation, throughout his stay, showed no evidence staff assessed, measured, or contacted the physician regarding the patient's scrotal skin issues.

Record review of the facility's skin protocol shows staff are to use a barrier cream with zinc on open areas. Staff failed to use this barrier.

During an interview on 05/24/16 at 1:00 PM, Staff RR, Assistant Chief Nursing Officer, confirmed that staff should have cleansed the groin, penis and scrotal areas of the patient after incontinence, with a zinc-based barrier applied.

10. Record review of the facility's policy titled, "Nutrition Care of Patients," revised 06/09/15, showed staff were to screen patients for nutrition needs, prescribe, distribute oral supplements and monitor the patient's response.

Record review of Patient #27's laboratory values for Albumin (a protein in the blood whereby a low level can be indicative of a poor ability to heal) showed a low value of 2.2 gm/dL. (grams per deciliter, normal = 3.4-5.0).

Record review of dietary orders and assessment dated 05/14/16, showed staff were to provide high protein Ensure twice daily (provided 160 calories and 16 grams of protein per serving) with lunch and dinner. The patient had increased nutrient needs related to increased demand for nutrients because of altered skin integrity.

During an interview on 05/16/16 at 3:30 PM, Staff A, RN, stated that staff were to document the percentage of oral supplement consumed in the patient's record. Staff A confirmed there was no evidence of the percentage of Ensure consumed by Patient #27 from 05/14/16 through the current time.

During an interview on 05/18/16 at 10:50 AM, Staff N, Clinical Nutritionist, stated that increased protein was typically instituted/ordered to improve healing for those patients with pressure sores. Staff N stated that it was difficult to assess the efficacy of a nutritional supplement if the percentage consumed was not documented.

11. Record review of the facility's policy titled, "Procedure for Obtaining and Documenting Inpatient Heights and Weights," effective 01/2015, showed patients will be weighed upon admission, every seven days, and as ordered.

During an interview on 05/16/16 at 3:55 PM, Staff A stated that the technician or nurse should weigh the patient, via the bed scale, and document that weight as ordered. Staff A confirmed there was no evidence of weights for Patient #27 since ordered through the current time.

12. Record review of Patient #26's H&P dated 05/14/16, showed the patient was admitted on 05/13/16 with diagnoses of pressure sores on the heels and sacrum (tailbone), and a bacterial infection in the stool called Clostridium difficile. The patient was confused, was moderately malnourished with a low Albumin of 2.3 and a low Total Protein (a measure of the different types of protein in the body-a low level can mean insufficient protein intake and can also contribute to poor wound healing) of 6.0 gm/dL (normal = 6.4-8.2). The H&P did not include staging and/or measurement of the pressure sores.

Record review of physician's orders (on 05/16/16 at 3:50 PM), dated 05/14/16, and concurrent interview showed Ensure (high protein nutritional supplement) ordered on 05/14/16 (at 5:15 PM) to be delivered twice daily. Also ordered, were daily weights as of 05/14/15 at 3:57 AM. Staff A confirmed there was no evidence of the percentage of Ensure consumed by Patient #26, or for the daily weights from 05/14/16 through the current time.

During an interview on 05/24/16 at 9:14 AM, Staff QQ, Educator, stated that she did not get involved in pressure sore training unless asked as the WCNs did it annually. Staff QQ confirmed that documentation regarding supplement consumption did not always happen.

Record review of the patient's care plan dated 05/16/16 directed staff to relieve pressure from bony prominences, and to measure and describe any skin breakdown.

Observation in the patient's room on 05/17/16 at 8:30 AM, showed the following:
- The patient had blue booties on both feet; however, staff failed to elevate the patient's heels off of the bed.
- The right heel was soft and mushy (usually means the tissue below the surface is damaged and this will eventually open).
- The left heel had a Stage II pressure sore on it.
- The sacrum (tailbone) had a Stage II pressure sore on it.
(Other areas were not observed by the surveyor)

During an interview on 05/24/16 at 1:00 PM, Staff Q, WCN, stated that Blue Booties relieved some pressure on the heels, but staff still needed to elevate the heels for complete off-loading (relief of pressure).

Record review of the patient's Braden score dated 05/13/16 showed a score of "14," or a high risk for skin breakdown.

Record review of the admission nursing documentation dated 05/13/16, showed the patient with the following:
- A Stage II (partial thickness skin loss, usually presenting as an abrasion, blister or shallow crater) pressure sore on the left heel that measured 4.0 cm by 2.5 cm.
- A Stage II pressure sore on the left anterior foot, that staff failed to measure until 05/17/16 (after surveyor inquiry), whereby it measured 1.5 cm by 1.0 cm.
- An unstageable pressure sore on the right anterior foot.
- A Stage II pressure sore on the right heel that staff failed to measure until 05/17/16 (after surveyor inquiry), whereby it measured 4.0 cm by 3.5 cm.
- A partial thickness pressure sore on the buttock, that staff failed to stage or measure until 05/17/16 (after surveyor inquiry), whereby it measured 6.5 cm by 6.0 cm. Staff still did not stage this pressure sore.

13. Record review of current Patient #49 medical record showed:
- A Wound Care Note dated 05/13/16, documented that the wound care nurse recommended the use of a silver alginate (soft gauze like material which contains silver, aids in reducing wound bacteria) covered by a foam dressing, to be changed daily and as needed for the patient's coccyx (skin covering the end of the tailbone) wound.
- A Physician's order dated 05/13/16 at 3:03 PM, documented that the patient's coccyx wound care should include a silver alginate dressing to the wound bed (open part of the wound) and covered with a foam dressing, to be changed daily or if heavily soiled.
- A Wound Care Note dated 05/16/16, documented that she recommended current treatment to the wound to continue.

Record review of Patient #49's flowsheet showed that on:
- 05/13/16 at 4:25 PM, the patient's dressing was changed, but silver alginate was not used on the wound.
- 05/15/16, the patient's dressing was not changed.
- 05/16/16 at 5:18 AM and 4:31 PM, the patient's dressing was changed, but silver alginate was not used on the wound.

Observation and concurrent interview on 05/17/16 at 1:15 PM, showed that when Staff K, RN removed Patient #49's dressing, there was no silver alginate found in the patient's dressing. Staff K and Staff J, Interim Team Lead, verified that according to the physician's order, there should have been a silver alginate in the dressing that was removed from the patient, but none was found.

14. Observation on 05/18/16 at 10:30 AM on Three North in Patient #55's room, showed open sores on patient's lips. Patient was admitted on 05/07/16 and these sores were never assessed. The wound care nurse was consulted for other wounds on patient's legs, but never addressed the lip sores. No documentation found in patient's chart under skin assessment or mouth care.
During an interview on 05/18/16 at 11:16 AM, Staff U, RN stated that these sores have been documented in the chart under daily mouth care. She stated that when physicians do their rounds, she would bring this to their attention.

During an interview on 05/18/16 at 11:21 AM, Staff W, Charge Nurse, stated that she expected nurses to document everything and bring it to the physician or wound care nurse's attention.
During an interview on 05/23/16 at 3:00 PM, Staff Q, WCN, stated that nursing staff were not monitored to see if wound treatments, or assessments were completed accurately or as ordered.

15. Record review of the facility's policy titled, "Indwelling Urinary Catheter: Assessment of Need, Insertion, Maintenance and Removal," dated 12/16/2015 showed that all urinary catheters should be secured to the upper thigh to prevent tension on the catheter.

16. Observation on 05/17/16 at 9:55 AM, on Three North in Patient #38's room, showed the patient had a urinary catheter with no Statlock (device that adheres to the patient's thigh and clips to the urinary catheter tubing, reducing the risk of pulling it out of the bladder) in place.

17. Observation on 05/17/16 at 1:00 PM, on Three North in Patient #29's room, showed the patient had a urinary catheter and a Statlock was not attached to the patient's thigh.

18. Observation on 05/18/16 at 10:10 AM, on Three North in Patient #64's room, showed the patient had a urinary catheter and the tubing was wrapped around the patient's leg causing tension.

19. Observation and concurrent interview on 05/18/16 at 10:15 AM, on Three North in Patient #65's room, showed a Statlock in place, but there was tension on the catheter due to incorrect placement of the Statlock. Staff S, RN, stated that she makes sure that Statlocks are secure and should check to see if they are pulling too tight.

During an interview on 05/18/16 at 1:27 PM, Staff T, Team Leader of Three North, stated that all patients with urinary catheters should be checked for slack in the tubing and catheter care should be assessed per shift or if soiled.

During an interview on 05/18/16 at 2:00 PM, Staff R, Director of Three North and Three South, stated that she expected staff to place Statlocks properly and address and document all wounds.




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