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Based on medical record review, facility policy/protocol review, and staff interview, the facility failed to ensure staff clarified dressing orders upon admission, and failed to follow physician orders for turning every two hours, to apply and external catheter, and frequent repositioning per the faciltiy protocol for hourly rounding one (#3) of ten medical records reviewed and failed to ensure staff nurses followed a physician order to turn one patient every two hours and place an external catheter. This affected Patient #3.

Findings include:

Review of the medical record of Patient #3 revealed the patient was admitted to the facility on 02/23/24 at 2:00 PM. According to the attending physician's History & Physical (H&P), the patient had a past medical history of multiple sclerosis. The patient had been experiencing worsening spasticity, impaired ambulation, and functional decline for the past several years. The patient underwent elective placement of an intrathecal blacofen pump on 02/22/24 at an outside hospital. The pump was placed in the right lower quadrant with the catheter tip at the thoracic vertebrae 12 (T12) level. There were no procedural or postoperative complications.

Two staff registered nurses (RN) conducted an assessment of the patient's skin at 6:20 PM as required by facility policy. Surgical incisions were noted on the patient's right lower back, right inguinal area, and right abdomen. The three surgical incisions were open to air.

Review of the Continuity of Care form provided by the outside hospital at admission included an order for dressings to the surgical site until postoperative day four. Once the dressings were removed, the patient could shower, pat the incisions dry, and leave the incisions open to air. This order, however, was not continued once the patient was admitted to the facility. The medical record contained no evidence any dressings were ever present on the surgical incisions.

A physician order on 02/23/24 at 2:07 PM advised staff nurses to turn the patient every two hours. Another physician order on 02/23/24 at 2:07 PM advised that the patient should receive frequent repositioning. The order to turn the patient every two hours was discontinued on 02/26/24 at 3:26 PM. The medical record also lacked documentation nursing staff turned the patient every two hours as ordered. The order to reposition the patient frequently remained active until the patient was discharged from the facility on 03/06/24. A physician order on 02/25/24 advised nursing staff it was okay to use a PureWick external catheter. The medical record lacked documentation staff nurses placed the PureWick. The patient remained incontinent of urine during this hospitalization.

Review of purposeful rounding times revealed staff completed hourly rounding beginning 02/23/24 at 3:22 PM. A staff member performed hourly rounding next at 10:00 PM, more than six hours later. Hourly rounding continued until 6:02 PM on 02/24/24. The medical record lacked documentation staff rounded on the patient again until 7:00 AM on 02/25/24, more than 12 hours later. Staff members resumed hourly rounding until 03/01/24 at 3:00 PM. The medical record lacked documentation nursing staff rounded on the patient again until 8:08 PM, five hours later. Documentation of hourly rounding continued until 03/06/24 when the patient was transported to a follow-up appointment. During the follow-up appointment, a physician discovered a dehiscence of the surgical incision on the patient's right lower back. There was also a concern for for an infection of this wound. The patient did not return to the facility after the follow-up appointment. She was admitted to the outside hospital where initial wound cultures resulted in Proteus mirabilis. According to the discharge summary, the patient was treated with intravenous antibiotics and on 03/10/24 underwent a revision of the lumbar wound.

The patient was re-admitted to the facility after treatment of the infected and dehisced surgical incision on 03/12/24 at 7:39 PM. A Foley catheter was in place on re-admission.

Review of purposeful rounding times revealed staff completed hourly rounding beginning 03/12/24 at 8:00 PM. Nursing staff continued hourly rounding until 03/14/24 at 2:05 AM. The medical record lacked documentation nursing staff provided hourly rounding for approximately five hours until 7:00 AM. Nursing staff continued hourly rounding until 03/21/24 at 11:21 AM. The medical record lacked documentation nursing staff provided hourly rounding until 8:00 PM, more than eight hours later. Hourly rounding was provided by nursing staff on 03/22/24 from 12:00 AM to 2:00 AM. The medical record lacked documentation rounding occurred again until 03/22/24 at 2:00 PM, 12 hours later.

On 03/22/24 at 2:00 PM Patient #3 was transferred to an outside hospital to be assessed following a fall. The patient returned to the facility on 03/23/24 at 10:30 AM. The medical record lacked documentation nursing staff resumed purposeful rounding until 8:45 PM. The patient was discharged from the facility on 03/26/24.

The facility protocol titled "Hourly Rounding" revealed the protocol for hourly rounding, nurses round during even hours and technicians round during odd hours. Elements of hourly rounding include addressing the five P's. The five P's are potty, pain, position, plan of care, and personal items such as hair brush/comb, and tooth brush. According to the protocol for hourly rounding, staff members are instructed that hourly rounding prevents falls and risk for pressure ulcers.

Interview on 04/29/24 at 2:50 PM Staff A and Staff B stated the Continuity of Care form should have been reviewed by the RN at admission and the RN should have clarified the orders for the dressings on the incision sites. It was confirmed the medical record lacked documentation the admitting nurse clarified the order as required and the dressings were not completed.

Interview on 04/29/24 at 12:00 PM Staff A confirmed that nursing staff did not perform hourly rounding as required. She further stated it was the expectation that staff members perform purposeful rounding on every patient hourly. Nursing staff should be asking if patients need assistance with toileting during purposeful rounding. It was also confirmed that the medical record lacked documentation nursing staff followed physician orders to turn the patient every two hours.

Interview on 04/30/24 at 3:45 PM Staff A confirmed the medical record lacked documentation nursing staff performed purposeful rounding as required during the second admission.

Interview on 04/30/24 at 4:00 PM Staff A and Staff B confirmed nursing staff did not place the PureWick as ordered for Patient #3.