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Based on observation, interview, and record review, the hospital failed to ensure RN 2's qualification and competency were verified prior to providing direct patient care. This failure created the potential risk of unsafe care to the patient.

Findings:

Review of the hospital's P&P titled Core: Evaluation & Verification of Competency dated June 2023 showed the purpose of this P&P is to assure that all individuals who work in the hospital demonstrate knowledge and skill to fulfill their assigned responsibilities; to assure qualifications, health status, and facility orientation of individuals providing direct patient care are verified by the appropriate process for the individual's affiliation or employment. Each member of the hospital staff is assigned clinical and managerial responsibilities based on educational preparation, applicable law and regulation, and an assessment of current competence. Components of the competency system include an initial Competency Assessment /Skill Validation. In collaboration with Education, the department supervisors, managers and/or directors are responsible for ensuring staff competency.

On 12/4/24 at 1018 hours, during an observation in the medical/surgical telemetry unit, Patient 2 was observed positioned to the right side with wedge supporting on the back. The patient had a pair of waffle boots on the heels.

On 12/4/24 at 1018 hours, during the concurrent interview with RN 3 regarding to the patient's wound treatment, RN 3 stated Patient 2 had the following wound treatment order for the left heel and left 5th toe: apply betadine (antiseptic) soaked gauze to the wound bed. The treatment scheduled three times a week. The last treatment was completed on 12/3/24.

Patient 2's medical record was reviewed with the DQM on 12/4/24 at 1525 hours.

Review of the Nurses Notes dated 12/3/24 at 2205 hours, showed RN 2 documented the assessment for Patient 2.

Review of the Night Shift Assignment dated 12/3/24, showed RN 2 and LVN 1 were assigned for nine patients.

On 12/4/24 at 1525 hours, the DQM was interviewed for RN 2's competency. The DQM stated RN 2 was from a registry agency. RN 2 worked as the contracted staff. RN 2 was not the hospital employee and would not have the same hiring process as the hospital's employee. The DQM stated to verify RN 2's qualification and competency, the hospital would be getting personnel information from the cooperate and previous RN 2's worked the hospital.

On 12/5/24 at 1117 hours, a telephone interview was conducted with the Education Manager. When asked for the registry agency RN's requirement regarding the direct patient care. The Education Manager stated the registry nurses had to be trained by the hospital staff. This was the corporate office's policy. They were not able to work on the floor without completing their competency. The registry RN should be trained by the hospital staff who was the first group using the registry RN.

On 12/5/24 at 1125 hours, during a follow-up interview with the DMQ, the DQM stated they did not have any documents to show RN 2's qualification or competency provided by corporate office or other hospital. The DQM confirmed on 12/3/24, RN 2 was assigned and providing direct patient care in the medical/surgical telemetry unit without verification of the competency as per the P&P. The House Supervisor for that shift would be responsible to verify the RN's competency.

Based on interview and record review, the hospital failed to adhere to the hospital's P&Ps as evidenced by:

1. The nursing staff did not turn and reposition one of two sampled patients (Patient 1) every two hours as per the hospital's P&P.

2. The hospital's P&P related to Wound Care Team Assessment was not reviewed at least every three years as per the corporate's P&P.

3. The hospital's P&P related to Skin and Wound Care Program Overview was not reflected the hospital's current practice.

These failures posed the potential to result in poor health outcomes to the patients.

Findings:

1. Review of the hospital's P&P titled Core: Clinical Guidelines for Pressure Injury dated June 2022 showed the standard interventions for all patients can include but are not limited to repositioning orders (minimum every two hours turn). Unstageable pressure injury is defined as an obscured full-thickness skin and tissue loss which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by shough or eschar.

On 12/4/24 at 0851 hours, Patient 1's closed medical record was reviewed with the DQM.

Patient 1's medical record showed Patient 1 was admitted to the hospital on 11/29/23.

Review of the Nurse Notes dated 11/29/23 at 1656 hours, showed Patient 1 was evaluated for a community acquired pressure injury to the coccyx. The patient had an unstageable pressure injury to the coccyx area measuring 7 cm (length) x 5.5 cm (width) x unable to determine the wound depth.

Review of the reposition document showed the following:

* On 12/07/23 at 1616 hours to 2040 hours, Patient 2 was on the right side.
* On 12/23/23 at 2021 hours to 12/24/23 at 0018 hours, Patient 2 was turned to the right.

The DQM confirmed the findings.

On 12/4/24 at 1233 hours, during an interview with RN 1, RN 1 stated the patients who could not perform their own self-care or had a pressure injury, the CNA and nursing staff would turn the patients every two hours and the CNA would document the turning in the patients' medical records.

2. On 12/5/24 at 1105 hours, the DQM provided the Corporate Policy titled Policy on Policies.

Review of the Corporate Policy titled Policy on Policies dated 12/18/23, showed the policy owners must review policies at least every three years or more frequently as needed.

Review of the hospital's P&P titled Core: Wound Care Team Assessment showed the P&P was released on June 2021. The DQM confirmed this P&P was overdue for review and there was no updated P&P for Wound Care Team Assessment.

3. Review of the hospital's P&P titled Core: Skin & Wound Care Program Overview dated June 2023 showed reassessment of wound characteristics is completed with each dressing change.

On 12/5/24 at 1356 hours, an interview was conducted with RN 3, a wound care RN. RN 3 reviewed the hospital's P&P and Patient 1's medical record. RN 3 stated the patient's wound care dressing change was done every day by the wound care vocational nurse or a LVN. The LVN was not able to reassess for the patient's wound but collected the data related to the wound appearance. RN 3 stated this P&P was not reflected their current practice.