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Based on a review of Governing Body bylaws, medical record, patient and staff interviews, policies and procedures, Medical Staff bylaws, complaint and grievance log, incident report log, facilities corrective disciplinary notice, it was determined that the facility's governing body failed to ensure that the facility staff administered medications and treated patient's deep tissue injury as ordered. The facility staff failed to treat three patients (P) (#1,2 and 4) of five sampled patients with deep tissue injuries and administer medication to one P (#1) of five sampled patients as ordered

Findings:
Cross refer to A-0063 as it relates to the Governing Body's failure to ensure safe and appropriate care for patients admitted.

Based on a review of medical record, patient and staff interviews, policies and procedures, Medical Staff bylaws, complaint and grievance log, incident report log, facilities corrective disciplinary notice, it was determined that the facility failed to treat three patients (P) (#1,2 and 4) of five sampled patients with deep tissue injuries as ordered.

Findings:
Cross refer to A-0396 as it relates to the facility's failure to ensure an appropriate care for patients admitted.

Based on a review of Governing Body bylaws, medical record, patient and staff interviews, policies and procedures, Medical Staff bylaws, complaint and grievance log, incident report log, facility's corrective disciplinary notice, it was determined that the facility's governing body failed to ensure that the facility staff administered medications and treated patient's deep tissue injury as ordered. The facility staff failed to treat three patients (P) (#1,2 and 4) of five sampled patients with deep tissue injuries and administer medication to one P (#1) of five sampled patients as ordered.

Findings:

A review of the facility's Governing Body bylaws revealed that individuals shall be elected to serve as the Board of Trustees in accordance with the nomination process. The Board of Trustees shall collaborate with and advise the members on local issues, including with respect to the following responsibilities:

1. Planning, implementing, and monitoring standards for patient care and safety, and overseeing quality and improvement goals consistent with the member's policies and protocols.
2. Recommending new clinical services and reviewing and providing input into any substantive changes in the clinical services provided by the corporation and its subsidiaries.
3. Ensuring compliance with all accreditation requirements, including but not limited to credentialing of physicians and other providers and other medical staff-related matters and ensuring medical staff privileges and reappointment applications are thoroughly reviewed and approved.


A review of P#1 medical record revealed that P#1 was 70 years old male who was presented to the facility on 11/16/21 at 1:44 pm with acute respiratory failure. P#1 had a past medical history of esophageal cancer, right internal carotid artery (ICA) (blood vessels to the brain) occlusion, LICA stenosis. P#1 was on NaCl (salt) tablets due to cerebral salt wasting and had recently had a hemicraniectomy (removal of a large part of the skull). P#1's other medical conditions included dysphagia (difficulty to swallow), deep venous thrombosis (DVT) (blood clot in deep veins), sacral ulcer (bedsore around tailbone), and hypertension (high blood pressure). P#1 was admitted to the facility for tracheostomy weaning (surgery to insert a tube in the trachea that provides an alternative airway for breathing, weaning means gradually returning airflow to the upper airway and restoring normal function) and rehabilitation.

P#1 treatment plan included the following:

i. Tracheostomy tube weaning protocol.
ii. Medication (Lovenox (Enoxaparin) (medication to prevent blood clot) for DVT, Candesartan (antihypertensive medication for high blood pressure)
iii. Sodium chloride (NaCl) tab q8hrs due to cerebral salt wasting.
iv. Physiatry, speech therapy, physical therapy consultation, and nutritional consultation.
v. Percutaneous endoscopic gastrostomy (PEG) (a tube passed to the stomach through the abdomen as a means of feeding) due to dysphagia (difficulty in swallowing).
vi. Follow up with neurosurgery for cranioplasty (surgical repair of the skull resulting from a previous removal of a portion of the skull) after discharge.

A review of P#1 initial nursing assessment on 11/16/21 at 1:57 pm revealed that P#1 had a small deep tissue injury on the coccyx and bilateral ear. P#1 Braden scale was 13 (A scale used to determine a patient risk for developing a pressure ulcer. A score of 15 to 18 is mild risk, 13 to 14 is moderate risk, 10 to 12 is high risk, and 9 or less is very high risk.)

On 11/16/2021 at 2:37 pm, an initial nutrition assessment done by the dietitian revealed that P#1 was tube feeding. P#1 had difficulty swallowing and relied on a PEG tube to meet nutrition needs. Dietitian noted she would follow up to ensure tube feeding tolerance and stable weight.

On 11/16/21 at 3:56 pm, P#1 medical record revealed that Wound Care Nurse (WCN) FF did an initial wound care evaluation. WCN FF documented that P#1 had a deep tissue injury on his coccyx (tail bone) as well as his left and right ears. The treatment plan included changing dressing one time per day, turning patient #1 every two hours, and cleaning wound with a wound cleanser.

On 11/16/21 at 4:07 pm, a review of the wound care orders requested by MD AA and entered by the Wound Care Nurse (WCN) FF revealed the following orders set:

Site: Coccyx
Change dressing 1 time per day and PRN (as needed).
Clean wound with wound cleanser, blot dry with gauze.
Apply no-sting Skin Prep to surrounding skin.
Dress with foam (Polyurethane).

A review of the clinical documentation wound care flow sheet from 11/16/21 to 1/24/22 included but not limited the following:

On 11/17/21 at 4:36 pm, RN documented that P#1's skin was intact and within the defined limit. Further review failed to reveal documentation of P#1's pressure injuries and dressing changes.

On 11/26/2021 at 3:42 pm, RN noted that P#1's skin was warm dry, intact, with no pressure ulcer, and within the defined limit. Further review failed to reveal documentation of P#1's bilateral ear and sacral injuries, and if any dressing changes were done.

On 11/26/2021 at 9:52 pm, RN DD documented that P#1's skin was within the defined limit and P#1 had no pressure ulcer. Further review failed to reveal documentation of dressing changes.

On 12/02/2021 at 11:27 am, P#1's skin was noted to be warm, dry, and integrity impaired. Further review failed to reveal dressing changes.

On 12/03/2021 at 10:59 am, P#1's skin was noted to be warm, dry, and integrity impaired. Further review failed to reveal dressing changes.

On 12/07/2021 at 8:52 am, P#1's skin was noted to be warm and dry. No documentation regarding dressing changes and skin integrity.

On 12/13/2021 at 1:17 pm, P#1's skin was noted to be warm, dry, and integrity impaired. Further review failed to reveal dressing changes.

A continuous review of P#1's wound care flow sheet failed to reveal documentation of wound care dressing changes for the following days: 12/15/21, 12/24/21, 12/25/21, 12/26/21.

On 1/10/22 at 4:18 pm, a review of P#1's medical record revealed an order entered by WCN FF for Darkin solution to be applied topically, 2 times per day to P#1's coccyx wound. Further review failed to reveal documentation that the order was performed on 1/21/22 and 1/23/22.

A review of the physician orders revealed but was not limited to the following medication orders:
1. On 11/16/21 at 12:58 pm. Famotidine (medication to decrease the amount of acid the stomach produces, to prevent ulcer) tablet 20 milligram(s) PEG tube 2 times per day.
2. On 11/16/21 at 3:57 pm. Enoxaparin (anticoagulant for clot prevention) 80 milligrams(s) subcutaneous every 12 hours.
3. On 11/16/21 at 7:17 pm. Sodium chloride (NaCl) 3-gram(s) PEG tube every 8 hours.

A review of the facility's document titled "eMAR Tasks" revealed the following:

1. Enoxaparin every 12 hours from 11/16/21 to 12/1/21.
On 11/25/21, RN noted administering Enoxaparin to P#1 left abdomen at 4:34 am, further review of the documentation failed to reveal any other administration of the medication on 11/25/21.

On 11/27/21, RN noted administering Enoxaparin to P#1's left abdomen at 6:28 pm, further review of the documentation failed to reveal administration of the medication at any other time on 11/27/21.

On 11/28/21 RN DD documented administering Enoxaparin to P#1's left abdomen at 3:46 am, 4:00 am, and at 6:07 pm. Further review revealed that the order was performed thrice on 11/28/21. Further review of the medical administration record (MAR) failed to reveal reasons why medications were not administered as ordered.

2. Famotidine, 2 times a day from 12/15/21 to 1/26/22.

On 12/25/21, Famotidine was administered once at 9:30 am.

On 1/10/22, Famotidine was administered once at 9:09 am. Further review failed to reveal any documented reasons medication was not administered as ordered.

3. Sodium chloride (NaCl) tab (salt due to cerebral salt wasting),3 times a day for 60 days from 11/16/21.

On 12/31/21, NaCl was administered twice at 9:00 am and at 2:00 pm. Further review failed to reveal reasons medication was not administered as ordered.

On 1/2/22, NaCl was administered twice at 9:14 am and at 2:00 pm. Further review failed to revealed reasons medication was not administered as ordered.


A review of P#2's medical record revealed P#2 was admitted to the facility on 1/6/22 with a diagnosis of respiratory failure. P#2 recieved a wound consult on 1/6/22. P#2's medical record revealed P#2's wound treatment plan including change of dressings for three abdominal wounds one time a day and PRN(as needed), change of dressings for P#2's buttocks three times a day, and PRN and cleaning of P#2's PEG (percutaneous endoscopic gastrostomy, a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach.) wash area one time per day and PRN.

Review of P#2's wound care flowsheets from 1/7/22 -1/23/22 revealed no documentation of wound care dressing changes of P#2's stomach and buttocks on the following days: 1/8/22, to 1/12/22, 1/18/22 1/19/22,1/20/22, 1/21/22, 1/23/22

A review of P#4 medical record revealed P#4 was presented to the facility on 1/7/22 due to respiratory failure. P#4 had a past medical history of diabetes, hypertension, sleep apnea and had recently had brain surgery due to a tumor of the brain. P#4 hospital course was complicated by respiratory failure and was transferred to the facility for continued ventilator weaning/support and medical management, with PT/OT/SPT therapy.

A review of the initial nursing assessment on 1/7/22 at 3:34 pm revealed that P#4 had a wound pressure ulcer on the sacrum on admission.

On 1/9/22 at 8:18 am, an initial wound evaluation by WCN FF revealed that P#4 had a pressure ulcer on his left and right coccyx, size 10*10*0.1. The treatment plan included changing dressing two times per day and PRN, turning P#4 every two hours, cleaning the wound with wound cleanser, and applying skin barrier cream.
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A review of P#4's wound care flow sheet from 1/7/22 to 1/26/22 revealed the following:
1/10/22 at 7:25 pm, RN noted that P#4's skin was within the defined limit. Further review failed to reveal documentation of dressing changes or pressure injuries.

1/15/22 P#4's wound care was treated, and dressing changes were documented once at 3:31 pm.
1/16/22 P#4's wound care was treated, and dressing changes were documented once at 11:41 am.
1/18/22 P#4's wound care was treated, and dressing changes were documented once at 9:48 pm.
1/20/22 P#4's wound care was treated, and dressing changes were documented once at 8:04 am.
1/21/22 P#4's wound care was treated, and dressing changes were documented once at 4:00 am.
1/22/22 P#4's wound care was treated, and dressing changes were documented once at 8:00 am.
1/23/22: P#4's wound care was treated, and dressing changes were documented once at 7:46 am.

A review of the clinical documentation flow sheet from 1/7/22 to 1/26/22 failed to reveal P#4 repositioning during the following days:

1/8/22 at 8 pm to 1/9/22 at 12 am.
1/9/22 at 4 am to 1/9/22 at 8 am.
1/10/22 at 8 am to 1/10/22 at 8 pm.
1/11/22 at 12 am to 1/11/22 at 8 am.
1/12/22 from 12 am to 6 am.
1/17/22 from 12:51 pm to 8 pm.
1/18/22 from 3:27 pm to 8 pm.
1/21/22 from 12 am to 4 am.
1/22/22 12 am to 8 am.
1/23/22 from 6 pm to 12 am.


During an interview with P#2 in his room on 1/24/22 at 12:30 p.m., P#2 was observed upright in bed watching a television program. During P#2's interview, a dumbbell (exercise equipment) and a Tupperware (container used to store food) was observed on the patient's food tray. In addition, P#2 was observed to have a stretched waistband across from his body. P#2 was observed to be clean of visible dirt and debris. In addition, P#2 had no noticable odors. P#2's linens were observed free of dirt, stains. P#2 explained that he was an emergency physician taking care of COVID patients for two years thereafter he contacted COVID-19. P#2 said he developed shortness of breath which got better then got worse and he went into a coma. P#2 said he had been to five hospitals since the incident and is currently at the facility for rehabilitation care that included physical therapy (PT), occupational therapy (OT), speech therapy (ST). P#2 stated he was active in his care, as he took steps in the hallway to assist with his care, P#2 stated he stepped 400 steps in the hallway on 1/23/21. In addition, P#2stated that when requests staff help from his patient call button or contact staff for assistance, it took a long time sometimes up to 3 hours and he thinks the staff was too busy. P#2 stated he nor his wife who also served as his patient advocate had any issues with the facility staff and were able to voice concerns.



During an interview with P#1's wife in P#1's room on 1/24/22 at 1:15 p.m., P#1's wife stated that her husband ended up at the facility due to a transfer from an Intensive Care Unit (ICU) from another facility, after P#1 experienced complications of an arterial surgery. P#1's wife also stated P#1 had his hip replaced around the same time frame. P#1 was observed to have protective boots, pillows on side of the patient. The patient was also observed as incontinent. P#1's wife stated her concerns for P#1 included being able to communicate with a neurologist, concerns with P#1's sodium and potassium levels. In addition, P#1's wife stated that P#1 had the wrong birth date listed on his armband and she has told several staff members about it and nothing was done to correct the issue. P#1's wife stated she is concerned with P#1's blood thinners, and that P#1 received two doses of a blood thinner instead of one dose of medication every 12 hours per the medication's directions. P#1's wife stated it is very difficult to speak to someone about P#1's care and messages are left on phones, but no one responds. P#1's wife stated that P#1's linens were not changed often, and she made marks on P#1's bedding to show that P#1's linens were not changed. P#1's wife further stated that P#1 developed bedsores while P#1 was at the facility but was told by MD AA P#1 had bedsores when P#1 was admitted into the facility. P#1's wife stated P#1 developed the bedsores at the facility because he was not being turned every 2 hours. In addition, P#1's wife stated that she also observed one day P#1's bedsheet was wet but the color was not yellow. P#1's wife stated she suspected it was P#1's antibiotic and that P#1 did not receive the antibiotic. P#1's wife also stated wound care was not done for P#1 and that the first time wound care was provided to P#1 was for wounds on his ear while P#1 was on the 5th floor. P#1's wife stated that P#1's alarms (IVs, monitors, etc) go/sound off all the time and staff does not respond for a long time. P#1's wife stated that she and her family spoke to the facility of her concerns and that there was a virtual call that was conducted to discuss P#1's care (date not defined, but P#1's wife stated the call happened January 2022).



An interview with P#4's wife took place on 1/24/22 at 2:10 pm during the tour. P#4's wife said that P#4 had been admitted at the facility for the past two weeks. P#4's wife explained that a few clinical staff were nice but some of them were very mean. She said that several times she would go to the nursing station to tell them what is going on and the staff would get upset. P#4's wife explained that on 1/23/22 when she arrived at her husband's bedside, water was underneath the bed. P#4's wife stated when she told the nurse about it, they got upset about cleaning it up and blamed her. She stated while the lady was cleaning it up they realized the urinary catheter had not been appropriately fixed. P#4's wife explained that whenever she uses the call bell the nurses would not respond for a long time and once she tries to reach out to them at the desk they get an attitude. P#4's wife explained that she was not aware of P#4's patient rights and was not given any patient right ' s form to sign upon admission. P#4's wife said when she asked the facility staff to assist with warming P#4's food they would not respond so she had to bring her food warmer from home. P#4's wife stated her husband had developed bedsore at the facility which had become worse over time. She said they only turned her husband twice a day. P#4's wife said the facility staff would tell her that P#4 was not their only patient which she understood but at the same time she needed to speak up for her husband. P#4' s wife recalled she had a meeting with the nurse and said she had to leave the facility in two weeks, and she had to either choose to take her husband to a nursing home or a hospice however her husband had been improving and wanted him to be at the hospital longer, P#4's wife further stated she was not aware of P#4's discharge rights and how to appeal a discharge. A follow-up interview with P#4's wife on 1/25/22 at 1:00 pm. P#4's wife said that the facility's security would not allow her into the facility until 11:00 am, she said that P#4's room was not cleaned for the past 3days, and she had not received a patient's right's booklet from the staff. P#4's wife said the facility staff reposition P#4 twice a day only whenever they are about to administer medication. P#4's wife said on 1/18/22 she found that P#4 had a big ball on his feet and heels, she further stated that it developed at the facility and the wound care nurse was notified. P#4's wife said the facility did not provide a heel protector for P#4 until after the incident.




During an interview with the Director of Nursing (DON) EE in the conference room on 1/25/22 at 11:13 a.m., Director EE stated medications come from the pharmacy and are placed in the Pyxis (drug storage dispensing equipment). DON EE stated nurses retrieve the medication by scanning a computer, and scanning patient's armband. In addition, DON EE stated nurses utilized the five medication administration rights (the right patient, the right drug, the right dose, the right route, and the right time) and utilized a computer to compare to the patient's armband of the patient's name and date of birth DON EE further stated if a patient could not speak or was alert, nurses could use the Medication Administration Record (MAR) to compare to the patient's armband with patient's date of birth account number or medical record number.

A follow-up interview with the Director of Nursing (DON) EE took place on 1/26/22 at 12:01 pm in the conference room. DON EE acknowledged she remembered P#1, she said P#1 was presented at the facility with acute respiratory failure and had wound care issues. DON EE said the facility organized an infectious disease team meeting where P#1 wound care was discussed but she cannot recall the details of the meeting. DON EE said her expectation is for her nursing team was to follow physician and wound care nursing orders. DON EE said she expected the nurses to administer medications based on physician orders, she further stated that if there was a reason why a medication was not administered her expectation was for the nurses to notify the physician and document why it was not given. DON EE stated her expectation was for Patient Care Technicians (PCT) to reposition patients per order. DON EE stated whenever there is a complaint about her department, she would try to reach out to the family to resolve the complaint and follow up with the complainant. She further explained that if the complaint cannot be resolved it becomes a grievance and she would refer them to the patient experience department.

During an interview with Pharmacist RR on 1/25/22 at 11:32 a.m. in the conference room, Pharmacist RR stated she had not recalled speaking with P#1 but that another pharmacist had spoken with P#1's wife regarding P#1s' medications. Pharmacist RR stated that depending on a medication, the medications are listed on an electronic Medication Administration Record (eMAR) and the pharmacy reviewed the appropriateness of the medication. In addition, Pharmacist RR stated once a medication has been signed off on an order, the medication is placed in a profile for nursing view and if the medication is in the PYXIS, it is an item nurses can give. Pharmacist RR further stated the medication would be taken from the Pyxis and barcode scanned and then medication scanned on the patient's wristband. Pharmacist RR stated that if a medication was not used after it has been taken out of the Pyxis, the medication can be placed back into the Pyxis. Pharmacist RR stated that the medication, Lovenox (Enoxaparin, medication is an anticoagulant that helps prevent the formation of blood clots) was able to fit and placed back into the Pyxis if it was taken out and needed to be placed back. In addition, Pharmacist RR stated that medications that could not be placed back into the PYXIS or were not placed back into the PYXIS could be returned to the facility's pharmacy. Pharmacist RR stated medications that were returned to the facility's pharmacy were documented that they were returned to the pharmacy. During a second interview with Pharmacist RR at 4:45 p.m. in the conference room, Pharmacist RR stated she ran a report for P#1 and did not see Lovenox returned to the facility's pharmacy.


During an interview with RN NN on the 4th-floor hallway on 1/25/22 at 3:00 p.m., RN NN stated she was responsible for five to six patients each shift. In addition, RN NN stated part of her duties included providing oral care every four hours, checking FiO2 levels, and ensuring vitals are stable. RN NN described that patient was required to be at least 30 degrees upright when intubated. RN NN stated for patients at risk for pressure ulcers were provided with wedges, heel boots, and the application of zinc cream and turning of the patient. RN NN stated she and staff documented repositioning was documented in a patient's medical record. RN NN stated for the administration of anticoagulant medication, the practice was to alternate sites of injection. In addition, RN NN stated once a doctor's order is received for medication, she and staff were to check for the right dose, check medication to match the same dose, and print a receipt after, and then the patient's ID is scanned before administration of medication. RN NN stated the receipt is then tossed in a bin for shredding.

An interview with the patient care technician (PCT) OO took place on 1/25/22 at 4:30 pm on the facility's fourth floor. PCT OO explained she had been working at the facility for three months, PCT OO said that patients are turned every 2 hours and are provided daily (CHG) baths to prevent skin break. PCT OO said incontinent patients are often bath more than once. PCT OO said for a patient with a heel ulcer, she would elevate their heel and ensure they wear heel protection. PCT OO explained that when the patient presses the call light it would be registered at the secretary's desk, and also appear in the hallway close to the patient's door. PCT OO said the staff respond promptly to call lights.

An interview with the Wound Care Nurse (WCN) (FF) took place on 1/25/22 at 5:06 pm. WCN FF said she had been working at the facility for 27 years and had been the director of wound care for 15 years. WCN FF explained that every patient that was admitted into the facility is initially assessed within 72 hours by the wound care team. WCN FF further stated that if the patient had a serious wound and require a disease-specific wound care program, the wound care team will see such patient weekly. WCN said she placed orders, treatment plans, and the frequency of treatment once the patient's wound is evaluated. When asked if WCN FF believed her orders should be followed as written, WCN FF stated that it depended on the patient condition, if a patient is unstable or have high blood pressure an order she has written may not be followed. In addition, WCN FF stated she would have a conversation with nursing staff to determine why her orders were not carried out if they were not carried out.

WCN FF stated the fact that P#1's pressure injury got bigger in diameter does not mean it got worse, P#1 was admitted at the facility with a deep tissue injury to his coccyx, left, and right ear. WCN FF said P#1 coccyx injury evolved over time and was treated appropriately. WCN FF said P#1 had a craniotomy (head surgery) and his wife refused to let P#1 use a cervical pillow.

WCN FF stated P#4 was also admitted to the facility with a coccyx wound which currently could be debrided. WCN FF said that she was aware of P#4 left foot concerns. P#4's left foot was a blister on his plantar (bottom) surface which could be due to third spacing. WCN FF said the blister was drained without any issues.


A telephone interview took place with MD BB on 1/26/22 at 10:11 am. MD BB said he recalled P#1 and had alternated with MD AA every week treating P#1. MD BB stated he had a meeting with P#1's family to update them about his condition and P#1's family indicated an interest in palliative care for P#1. MD BB stated P#1's family requested updates from the neurologist and the facility neurologist contacted the family. MD BB said the family also had concerns about P#1's wound care and this was discussed with the wound care nurse and the infectious disease team was requested. MD BB said a colostomy was also considered for P#1. MD BB said that the wound care nurse follows up with wound management and he spoke with the wound care team they said P#1 may need debridement.

During an interview with MD AA in the conference room on 1/26/22 at 11:29 a.m., MD AA stated that she and MD BB have treated P#1 for quite some time at the facility. MD AA stated she serves as a Pulmonary Specialist at the facility. MD AA further stated P#1's goals included but were not limited to getting P#1 off of the vent (a ventilator-medical device that assists with breathing). In addition, MD AA stated she has spoken with P#1's care team that included Infectious Disease and Wound Care. MD AA stated she spoke to P#1's wife numerous times and that P#1's wife has had a lot of complaints. MD AA further stated P#1's wife was having a hard time with feelings and emotion and was devasted by her husband's condition. MD AA further stated, she believed that there may be a cognitive issue with P#1's wife during the time of P#1's care. MD AA stated she spoke to other members of P#1's family including P#1's daughter, but MD AA stated she believes P#1 needs more family support because P#1's wife has not been relieved/rested since P#1 was admitted into the facility. MD AA said she called P#1's daughter who complained about repositioning P#1. MD AA explained that P#1's wife is very demanding of how P#1 was turned/re-positioned due to P#1's recent hemicraniectomy (part of P#1's cranium has been removed). In addition, MD AA said she was made aware of P#1's pressure injuries and she does not think it is getting better. MD AA said this could be related to several factors which included P#1 on PEG tube feeding, P#1's wife demands on how P#1 should be turned, and P#1's cerebral salt wasting (low blood sodium concentration and dehydration in response to injury). MD AA said she had a conversation with P#1's son in law and he had a concern about the neurologist not communicating with the family. MD AA said the neurologist team had spoken with the family two or three times and it was documented on P#1 medical record. MD AA said when there was a concern of a possible new bleed in his brain, P#1 had a CT scan, and the result was sent to P#1's neurosurgeon. MD AA said based on the finding it was not acute. MD AA stated P#1's family wants P#1 to leave but the facility can't find a place for P#1.

An interview took place with the Charge Nurse (CN) HH ON 1/27/22 at 11:14 am. CN HH said she interacted with P#1's wife and met with his son-in-law. CN HH said she couldn't recall the details of the interaction. CN HH said the standard practice at the facility is for nurses to follow the physician orders and it included wound care and medication orders. CN HH said if a nurse failed to administer a medication the reason should be documented.


Review of the facility's policy titled, "Medication Administration in Nursing" last effective 8/19/21 revealed, procedures for all facility nursing staff to ensure safe and accurate administration to all patients. In addition, the policy revealed medications would be administered to patients by or under the supervision of appropriately licensed personnel in accordance with state and federal laws governing such acts.

The policy further revealed Medication administration occurs pursuant to a valid provider's order and that prior to medication administration, all medications require pharmacist verification except in urgent clinical scenarios or in procedural areas under the direct supervision of a provider. The policy revealed the six (6) Rights will be used at the time of preparation and administration.
i. Right patient ii. Right Medication iii. Right Route iv. Right Dose v. Right Time vi. Right Documentation

The policy revealed in the event of a medication error:

a. Assess and monitor the care for the patient.
b. Notify physician and Unit Director/designee
c. Enter SAFE medication variance report.

The policy revealed the following documentation procedures in a patient's medical record:

1. Documentation of all medications is done at the time of administration.
2. On the electronic MAR, the time of administration for "scheduled medications" defaults to the scheduled time. For most medications, if the medication is given within one hour before or after the scheduled time, there is no need to change the defaulted administration time. If, however, the type of medication requires precise administration times or the medication is given outside these parameters, the time should be changed to reflect the actual medication administration time.
3. The process for medication double verification requires the signature of both nurses that verify the drug and dose. On the electronic eMAR the first nurse documents the
administration. The second verifying nurse accesses the system under his/her own ID and adds a comment to the documented administration information indicating that the patient, drug, and dose were verified. If a flowsheet is used [Emory Saint Joseph Hospital (ESJH) and Emory Johns Creek Hospital (EJCH) Heparin and Insulin flowsheets] the signature of both nurses are required.
4. For areas not transitioned to the electronic medical record, utilize the appropriate form for that department.


Review of the facility's policy titled, "Clinical Practice Guidelines for Prevention and Treatment of Wounds and Pressure Injuries, no date listed revealed, the facility's procedures for prevention and treatment of wounds and pressure injuries. The policy revealed the facility's wound care team included the wound care nurse, physical therapist, occupational therapist, or any licensed wound care clinician.

The facility revealed that an assessment included admission to the Long-Term Acute Care (LTAC) unit and that all patients would have a complete skin assessment completed by the admitting nurse, with the results documented. In addition, the Braden Scale (measure elements of risk that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure) would be used to screen and assess risk for development of pressure ulcers. Further review of the policy revealed a Braden Scale score of 18 or below indicates the patient is at risk (maximum score 23). The policy revealed a wound team member would assess all patients within 72 hours of admission. Ongoing risk assessments were to be completed daily using a Braden Scale so that nurses can implement the protocol per the facility's Skin and Prevention and Breakdown Protocol and consult wound care as needed

The policy further revealed a member of the Wound Care Team would reassess pressure ulcers/wounds at least every week, with the treatment plan updated as appropriate. Documentation would be completed in the patient record. In addition, nutritional issues would be discussed with the Dietitian and Speech Therapist, and wound pain would be assessed and documented with each wound care intervention.

The policy revealed prevention protocols including but not limited to:
Management of Tissue Loads
While in bed

· Avoid positioning patients on a pressure ulcer
· Use positioning devices to raise the pressure ulcer off the bed, esp. the heels.
·

Based on a review of Governing Body bylaws, medical record, patient and staff interviews, policies and procedures, Medical Staff bylaws, complaint and grievance log, incident report log, facility's corrective disciplinary notice, it was determined that the facility's governing body failed to ensure that the facility staff administered medications and treated patient's deep tissue injury as ordered. The facility staff failed to treat three patients (P) (#1,2 and 4) of five sampled patients with deep tissue injuries and administer medication to one P (#1) of five sampled patients as ordered.

Findings:

A review of the facility's Governing Body bylaws revealed that individuals shall be elected to serve as the Board of Trustees in accordance with the nomination process. The Board of Trustees shall collaborate with and advise the members on local issues, including with respect to the following responsibilities:

1. Planning, implementing, and monitoring standards for patient care and safety, and overseeing quality and improvement goals consistent with the member's policies and protocols.
2. Recommending new clinical services and reviewing and providing input into any substantive changes in the clinical services provided by the corporation and its subsidiaries.
3. Ensuring compliance with all accreditation requirements, including but not limited to credentialing of physicians and other providers and other medical staff-related matters and ensuring medical staff privileges and reappointment applications are thoroughly reviewed and approved.


A review of P#1 medical record revealed that P#1 was 70 years old male who was presented to the facility on 11/16/21 at 1:44 pm with acute respiratory failure. P#1 had a past medical history of esophageal cancer, right internal carotid artery (ICA) (blood vessels to the brain) occlusion, LICA stenosis. P#1 was on NaCl (salt) tablets due to cerebral salt wasting and had recently had a hemicraniectomy (removal of a large part of the skull). P#1's other medical conditions included dysphagia (difficulty to swallow), deep venous thrombosis (DVT) (blood clot in deep veins), sacral ulcer (bedsore around tailbone), and hypertension (high blood pressure). P#1 was admitted to the facility for tracheostomy weaning (surgery to insert a tube in the trachea that provides an alternative airway for breathing, weaning means gradually returning airflow to the upper airway and restoring normal function) and rehabilitation.

P#1 treatment plan included the following:

i. Tracheostomy tube weaning protocol.
ii. Medication (Lovenox (Enoxaparin) (medication to prevent blood clot) for DVT, Candesartan (antihypertensive medication for high blood pressure)
iii. Sodium chloride (NaCl) tab q8hrs due to cerebral salt wasting.
iv. Physiatry, speech therapy, physical therapy consultation, and nutritional consultation.
v. Percutaneous endoscopic gastrostomy (PEG) (a tube passed to the stomach through the abdomen as a means of feeding) due to dysphagia (difficulty in swallowing).
vi. Follow up with neurosurgery for cranioplasty (surgical repair of the skull resulting from a previous removal of a portion of the skull) after discharge.

A review of P#1 initial nursing assessment on 11/16/21 at 1:57 pm revealed that P#1 had a small deep tissue injury on the coccyx and bilateral ear. P#1 Braden scale was 13 (A scale used to determine a patient risk for developing a pressure ulcer. A score of 15 to 18 is mild risk, 13 to 14 is moderate risk, 10 to 12 is high risk, and 9 or less is very high risk.)

On 11/16/2021 at 2:37 pm, an initial nutrition assessment done by the dietitian revealed that P#1 was tube feeding. P#1 had difficulty swallowing and relied on a PEG tube to meet nutrition needs. Dietitian noted she would follow up to ensure tube feeding tolerance and stable weight.

On 11/16/21 at 3:56 pm, P#1 medical record revealed that Wound Care Nurse (WCN) FF did an initial wound care evaluation. WCN FF documented that P#1 had a deep tissue injury on his coccyx (tail bone) as well as his left and right ears. The treatment plan included changing dressing one time per day, turning patient #1 every two hours, and cleaning wound with a wound cleanser.

On 11/16/21 at 4:07 pm, a review of the wound care orders requested by MD AA and entered by the Wound Care Nurse (WCN) FF revealed the following orders set:

Site: Coccyx
Change dressing 1 time per day and PRN (as needed).
Clean wound with wound cleanser, blot dry with gauze.
Apply no-sting Skin Prep to surrounding skin.
Dress with foam (Polyurethane).

A review of the clinical documentation wound care flow sheet from 11/16/21 to 1/24/22 included but not limited the following:

On 11/17/21 at 4:36 pm, RN documented that P#1's skin was intact and within the defined limit. Further review failed to reveal documentation of P#1's pressure injuries and dressing changes.

On 11/26/2021 at 3:42 pm, RN noted that P#1's skin was warm dry, intact, with no pressure ulcer, and within the defined limit. Further review failed to reveal documentation of P#1's bilateral ear and sacral injuries, and if any dressing changes were done.

On 11/26/2021 at 9:52 pm, RN DD documented that P#1's skin was within the defined limit and P#1 had no pressure ulcer. Further review failed to reveal documentation of dressing changes.

On 12/02/2021 at 11:27 am, P#1's skin was noted to be warm, dry, and integrity impaired. Further review failed to reveal dressing changes.

On 12/03/2021 at 10:59 am, P#1's skin was noted to be warm, dry, and integrity impaired. Further review failed to reveal dressing changes.

On 12/07/2021 at 8:52 am, P#1's skin was noted to be warm and dry. No documentation regarding dressing changes and skin integrity.

On 12/13/2021 at 1:17 pm, P#1's skin was noted to be warm, dry, and integrity impaired. Further review failed to reveal dressing changes.

A continuous review of P#1's wound care flow sheet failed to reveal documentation of wound care dressing changes for the following days: 12/15/21, 12/24/21, 12/25/21, 12/26/21.

On 1/10/22 at 4:18 pm, a review of P#1's medical record revealed an order entered by WCN FF for Darkin solution to be applied topically, 2 times per day to P#1's coccyx wound. Further review failed to reveal documentation that the order was performed on 1/21/22 and 1/23/22.

A review of the physician orders revealed but was not limited to the following medication orders:
1. On 11/16/21 at 12:58 pm, Famotidine (medication to decrease the amount of acid the stomach produces, to prevent ulcer) tablet 20 milligram(s) PEG tube 2 times per day.
2. On 11/16/21 at 3:57 pm, Enoxaparin (anticoagulant for clot prevention) 80 milligrams(s) subcutaneous every 12 hours.
3. On 11/16/21 at 7:17 pm, Sodium chloride (NaCl) 3-gram(s) PEG tube every 8 hours.

A review of the facility's document titled "eMAR Tasks" revealed the following:

1. Enoxaparin every 12 hours from 11/16/21 to 12/1/21.
On 11/25/21, RN noted administering Enoxaparin to P#1 left abdomen at 4:34 am, further review of the documentation failed to reveal any other administration of the medication on 11/25/21.

On 11/27/21, RN noted administering Enoxaparin to P#1's left abdomen at 6:28 pm, further review of the documentation failed to reveal administration of the medication at any other time on 11/27/21.

On 11/28/21 RN DD documented administering Enoxaparin to P#1's left abdomen at 3:46 am, 4:00 am, and at 6:07 pm. Further review revealed that the order was performed thrice on 11/28/21. Further review of the medical administration record (MAR) failed to reveal reasons why medications were not administered as ordered.

2. Famotidine, 2 times a day from 12/15/21 to 1/26/22.

On 12/25/21, Famotidine was administered once at 9:30 am.

On 1/10/22, Famotidine was administered once at 9:09 am. Further review failed to reveal any documented reasons medication was not administered as ordered.

3. Sodium chloride (NaCl) tab (salt due to cerebral salt wasting),3 times a day for 60 days from 11/16/21.

On 12/31/21, NaCl was administered twice at 9:00 am and at 2:00 pm. Further review failed to revealed reasons medication was not administered as ordered.
On 1/2/22, NaCl was administered twice at 9:14 am and at 2:00 pm. Further review failed to revealed reasons medication was not administered as ordered.


A review of P#2's medical record revealed P#2 had a wound consult on 1/6/22. In addition, P#2's medical record revealed P#2's wound treatment plan including change of dressings for three abdominal wounds one time a day and PRN(as needed), change of dressings for P#2's buttocks three times a day, and PRN and cleaning of P#2's PEG (percutaneous endoscopic gastrostomy, a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach.) wash area one time per day and PRN.

Review of P#2's wound care flowsheets from 1/7/22 -1/23/22 revealed no documentation of wound care dressing changes of P#2's stomach and buttocks on the following days: 1/8/22, to 1/12/22, 1/18/22 1/19/22,1/20/22, 1/21/22, 1/23/22

A review of P#4 medical record revealed P#4 was presented to the facility on 1/7/22 due to respiratory failure. P#4 had a past medical history of diabetes, hypertension, sleep apnea and had recently had brain surgery due to a tumor of the brain. P#4 hospital course was complicated by respiratory failure and was transferred to the facility for continued ventilator weaning/support and medical management, with PT/OT/SPT therapy.

A review of the initial nursing assessment on 1/7/22 at 3:34 pm revealed that P#4 had a wound pressure ulcer on the sacrum on admission.

On 1/9/22 at 8:18 am, an initial wound evaluation by WCN FF revealed that P#4 had a pressure ulcer on his left and right coccyx, size 10*10*0.1. The treatment plan included changing dressing two times per day and PRN, turning P#4 every two hours, cleaning the wound with wound cleanser, and applying skin barrier cream.
.
A review of P#4's wound care flow sheet from 1/7/22 to 1/26/22 revealed the following:
1/10/22 at 7:25 pm, RN noted that P#4's skin was within the defined limit. Further review failed to reveal documentation of dressing changes or pressure injuries.

1/15/22 P#4's wound care was treated, and dressing changes were documented once at 3:31 pm.
1/16/22 P#4's wound care was treated, and dressing changes were documented once at 11:41 am.
1/18/22 P#4's wound care was treated, and dressing changes were documented once at 9:48 pm.
1/20/22 P#4's wound care was treated, and dressing changes were documented once at 8:04 am.
1/21/22 P#4's wound care was treated, and dressing changes were documented once at 4:00 am.
1/22/22 P#4's wound care was treated, and dressing changes were documented once at 8:00 am.
1/23/22: P#4's wound care was treated, and dressing changes were documented once at 7:46 am.

A review of the clinical documentation flow sheet from 1/7/22 to 1/26/22 failed to reveal P#4 repositioning during the following days:

1/8/22 at 8 pm to 1/9/22 at 12 am.
1/9/22 at 4 am to 1/9/22 at 8 am.
1/10/22 at 8 am to 1/10/22 at 8 pm.
1/11/22 at 12 am to 1/11/22 at 8 am.
1/12/22 from 12 am to 6 am.
1/17/22 from 12:51 pm to 8 pm.
1/18/22 from 3:27 pm to 8 pm.
1/21/22 from 12 am to 4 am.
1/22/22 12 am to 8 am.
1/23/22 from 6 pm to 12 am.


During an interview with P#2 in his room on 1/24/22 at 12:30 p.m., P#2 was observed upright in bed watching a television program. During P#2's interview, a dumbbell (exercise equipment) and a Tupperware (container used to store food) was observed on the patient's food tray. In addition, P#2 was observed to have a stretched waistband across from his body. P#2 was observed to be clean of visible dirt and debris. In addition, P#2 had no visible odors. P#2's linens were observed free of dirt, stains. P#2 explained that he was an emergency physician taking care of COVID patients for two years thereafter he contacted COVID-19. P#2 said he developed shortness of breath which got better then got worse and he went into a coma. P#2 said he had been to five hospitals since the incident and is currently at the facility for rehabilitation care that included physical therapy (PT), occupational therapy (OT), speech therapy (ST). P#2 stated he was active in his care, as he took steps in the hallway to assist with his care, P#2 stated he stepped 400 steps in the hallway on 1/23/21. In addition, P#2stated that when requests staff help from his patient call button or contact staff for assistance, it took a long time sometimes up to 3 hours and he thinks the staff was too busy. P#2 stated he nor his wife who also served as his patient advocate had any issues with the facility staff and were able to voice concerns.



During an interview with P#1's wife in P#1's room on 1/24/22 at 1:15 p.m., P#1's wife stated that her husband ended up at the facility due to a transfer from an Intensive Care Unit (ICU) from another facility, after P#1 experienced complications of an arterial surgery. P#1's wife also stated P#1 had his hip replaced around the same time frame. P#1 was observed to have protective boots, pillows on side of the patient. The patient was also observed as incontinent. P#1's wife stated her concerns for P#1 included being able to communicate with a neurologist, concerns with P#1's sodium and potassium levels. In addition, P#1's wife stated that P#1 had the wrong birth date listed on his armband and she has told several staff members about it and nothing was done to correct the issue. P#1's wife stated she is concerned with P#1's blood thinners, and that P#1 received two doses of a blood thinner instead of one dose of medication every 12 hours per the medication's directions. P#1's wife stated it is very difficult to speak to someone about P#1's care and messages are left on phones, but no one responds. P#1's wife stated that P#1's linens were not changed often, and she made marks on P#1's bedding to show that P#1's linens were not changed. P#1's wife further stated that P#1 developed bedsores while P#1 was at the facility but was told by MD AA P#1 had bedsores when P#1 was admitted into the facility. P#1's wife stated P#1 developed the bedsores at the facility because he was not being turned every 2 hours. In addition, P#1's wife stated that she also observed one day P#1's bedsheet was wet but the color was not yellow. P#1's wife stated she suspected it was P#1's antibiotic and that P#1 did not receive the antibiotic. P#1's wife also stated wound care was not done for P#1 and that the first time wound care was provided to P#1 was for wounds on his ear while P#1 was on the 5th floor. P#1's wife stated that P#1's alarms (IVs, monitors, etc) go/sound off all the time and staff does not respond for a long time. P#1's wife stated that she and her family spoke to the facility of her concerns and that there was a virtual call that was conducted to discuss P#1's care (date not defined, but P#1's wife stated the call happened January 2022).



An interview with P#4's wife took place on 1/24/22 at 2:10 pm during the tour. P#4's wife said that P#4 had been admitted at the facility for the past two weeks. P#4's wife explained that a few clinical staff were nice but some of them were very mean. She said that several times she would go to the nursing station to tell them what is going on and the staff would get upset. P#4 ' s wife explained that on 1/23/22 when she arrived at her husband's bedside, water was underneath the bed. P#4's wife stated when she told the nurse about it, they got upset about cleaning it up and blamed her. She stated while the lady was cleaning it up they realized the urinary catheter had not been appropriately fixed. P#4 ' s wife explained that whenever she uses the call bell the nurses would not respond for a long time and once she tries to reach out to them at the desk they get an attitude. P#4 ' s wife explained that she was not aware of P#4 's patient rights and was not given any patient right ' s form to sign upon admission. P#4's wife said when she asked the facility staff to assist with warming P#4's food they would not respond so she had to bring her food warmer from home. P#4 ' s wife stated her husband had developed bedsore at the facility which had become worse over time. She said they only turned her husband twice a day. P#4's wife said the facility staff would tell her that P#4 was not their only patient which she understood but at the same time she needed to speak up for her husband. P#4 ' s wife recalled she had a meeting with the nurse and said she had to leave the facility in two weeks, and she had to either choose to take her husband to a nursing home or a hospice however her husband had been improving and wanted him to be at the hospital longer, P#4 ' s wife further stated she was not aware of P#4's discharge rights and how to appeal a discharge. A follow-up interview with P#4's wife on 1/25/22 at 1:00 pm. P#4's wife said that the facility's security would not allow her into the facility until 11:00 am, she said that P#4's room was not cleaned for the past 3days, and she had not received a patient's right's booklet from the staff. P#4's wife said the facility staff reposition P#4 twice a day only whenever they are about to administer medication. P#4 ' s wife said on 1/18/22 she found that P#4 had a big ball on his feet and heels, she further stated that it developed at the facility and the wound care nurse was notified. P#4 ' s wife said the facility did not provide a heel protector for P#4 until after the incident.




During an interview with the Director of Nursing (DON) EE in the conference room on 1/25/22 at 11:13 a.m., Director EE stated medications come from the pharmacy and are placed in the Pyxis (drug storage dispensing equipment). DON EE stated nurses retrieve the medication by scanning a computer, and scanning patient's armband. In addition, DON EE stated nurses utilized the five medication administration rights (the right patient, the right drug, the right dose, the right route, and the right time) and utilized a computer to compare to the patient's armband of the patient's name and date of birth DON EE further stated if a patient could not speak or was alert, nurses could use the Medication Administration Record (MAR) to compare to the patient's armband with patient's date of birth account number or medical record number.

A follow-up interview with the Director of Nursing (DON) EE took place on 1/26/22 at 12:01 pm in the conference room. DON EE acknowledged she remembered P#1, she said P#1 was presented at the facility with acute respiratory failure and had wound care issues. DON EE said the facility organized an infectious disease team meeting where P#1 wound care was discussed but she cannot recall the details of the meeting. DON EE said her expectation is for her nursing team was to follow physician and wound care nursing orders. DON EE said she expected the nurses to administer medications based on physician orders, she further stated that if there was a reason why a medication was not administered her expectation was for the nurses to notify the physician and document why it was not given. DON EE stated her expectation was for Patient Care Technicians (PCT) to reposition patients per order. DON EE stated whenever there is a complaint about her department, she would try to reach out to the family to resolve the complaint and follow up with the complainant. She further explained that if the complaint cannot be resolved it becomes a grievance and she would refer them to the patient experience department.

During an interview with Pharmacist RR on 1/25/22 at 11:32 a.m. in the conference room, Pharmacist RR stated she had not recalled speaking with P#1 but that another pharmacist had spoken with P#1's wife regarding P#1s' medications. Pharmacist RR stated that depending on a medication, the medications are listed on an electronic Medication Administration Record (eMAR) and the pharmacy reviewed the appropriateness of the medication. In addition, Pharmacist RR stated once a medication has been signed off on an order, the medication is placed in a profile for nursing view and if the medication is in the PYXIS, it is an item nurses can give. Pharmacist RR further stated the medication would be taken from the Pyxis and barcode scanned and then medication scanned on the patient's wristband. Pharmacist RR stated that if a medication was not used after it has been taken out of the Pyxis, the medication can be placed back into the Pyxis. Pharmacist RR stated that the medication, Lovenox (Enoxaparin, medication is an anticoagulant that helps prevent the formation of blood clots) was able to fit and placed back into the Pyxis if it was taken out and needed to be placed back. In addition, Pharmacist RR stated that medications that could not be placed back into the PYXIS or were not placed back into the PYXIS could be returned to the facility's pharmacy. Pharmacist RR stated medications that were returned to the facility's pharmacy were documented that they were returned to the pharmacy. During a second interview with Pharmacist RR at 4:45 p.m. in the conference room, Pharmacist RR stated she ran a report for P#1 and did not see Lovenox returned to the facility's pharmacy.


During an interview with RN NN on the 4th-floor hallway on 1/25/22 at 3:00 p.m., RN NN stated she was responsible for five to six patients each shift. In addition, RN NN stated part of her duties included providing oral care every four hours, checking FiO2 levels, and ensuring vitals are stable. RN NN described that patient was required to be at least 30 degrees upright when intubated. RN NN stated for patients at risk for pressure ulcers were provided with wedges, heel boots, and the application of zinc cream and turning of the patient. RN NN stated she and staff documented repositioning was documented in a patient's medical record. RN NN stated for the administration of anticoagulant medication, the practice was to alternate sites of injection. In addition, RN NN stated once a doctor's order is received for medication, she and staff were to check for the right dose, check medication to match the same dose, and print a receipt after, and then the patient's ID is scanned before administration of medication. RN NN stated the receipt is then tossed in a bin for shredding.

An interview with the patient care technician (PCT) OO took place on 1/25/22 at 4:30 pm on the facility's fourth floor. PCT OO explained she had been working at the facility for three months, PCT OO said that patients are turned every 2hours and are provided daily (CHG) baths to prevent skin break. PCT OO said incontinent patients are often bath more than once. PCT OO said for a patient with a heel ulcer, she would elevate their heel and ensure they wear heel protection. PCT OO explained that when the patient presses the call light it would be registered at the secretary's desk, and also appear in the hallway close to the patient's door. PCT OO said the staff respond promptly to call lights.

An interview with the Wound Care Nurse (WCN) (FF) took place on 1/25/22 at 5:06 pm. WCN FF said she had been working at the facility for 27 years and had been the director of wound care for 15 years. WCN FF explained that every patient that was admitted into the facility is initially assessed within 72 hours by the wound care team. WCN FF further stated that if the patient had a serious wound and require a disease-specific wound care program, the wound care team will see such patient weekly. WCN said she placed orders, treatment plans, and the frequency of treatment once the patient's wound is evaluated. When asked if WCN FF believed her orders should be followed as written, WCN FF stated that it depended on the patient condition, if a patient is unstable or have high blood pressure an order she has written may not be followed. In addition, WCN FF stated she would have a conversation with nursing staff to determine why her orders were not carried out if they were not carried out.

WCN FF stated the fact that P#1's pressure injury got bigger in diameter does not mean it is got worse, P#1 was admitted at the facility with a deep tissue injury to his coccyx, left, and right ear. WCN FF said P#1 coccyx injury evolved over time and was treated appropriately. WCN FF said P#1 had a craniotomy (head surgery) and his wife refused to let P#1 use a cervical pillow.

WCN FF stated P#4 was also admitted to the facility with a coccyx wound which currently could be debrided. WCN FF said that she was aware of P#4 left foot concerns. P#4's left foot was a blister on his plantar (bottom) surface which could be due to third spacing. WCN FF said the blister was drained without any issues.


A telephone interview took place with MD BB on 1/26/22 at 10:11 am. MD BB said he recalled P#1 and had alternated with MD AA every week treating P#1. MD BB stated he had a meeting with P#1's family to update them about his condition and P#1's family indicated an interest in palliative care for P#1. MD BB stated P#1's family requested updates from the neurologist and the facility neurologist contacted the family. MD BB said the family also had concerns about P#1's wound care and this was discussed with the wound care nurse and the infectious disease team was requested. MD BB said a colostomy was also considered for P#1. MD BB said that the wound care nurse follows up with wound management and he spoke with the wound care team they said P#1 may need debridement.

During an interview with MD AA in the conference room on 1/26/22 at 11:29 a.m., MD AA stated that she and MD BB have treated P#1 for quite some time at the facility. MD AA stated she serves as a Pulmonary Specialist at the facility. MD AA further stated P#1's goals included but were not limited to getting P#1 off of the vent (a ventilator-medical device that assists with breathing). In addition, MD AA stated she has spoken with P#1's care team that included Infectious Disease and Wound Care. MD AA stated she spoke to P#1's wife numerous times and that P#1's wife has had a lot of complaints. MD AA further stated P#1's wife was having a hard time with feelings and emotion and was devasted by her husband's condition. MD AA further stated, she believed that there may be a cognitive issue with P#1's wife during the time of P#1's care. MD AA stated she spoke to other members of P#1's family including P#1's daughter, but MD AA stated she believes P#1 needs more family support because P#1's wife has not been relieved/rested since P#1 was admitted into the facility. MD AA said she called P#1's daughter who complained about repositioning P#1. MD AA explained that P#1's wife is very demanding of how P#1 was turned/re-positioned due to P#1's recent hemicraniectomy (part of P#1's cranium has been removed). In addition, MD AA said she was made aware of P#1's pressure injuries and she does not think it is getting better. MD AA said this could be related to several factors which included P#1 on PEG tube feeding, P#1's wife demands on how P#1 should be turned, and P#1's cerebral salt wasting (low blood sodium concentration and dehydration in response to injury). MD AA said she had a conversation with P#1's son in law and he had a concern about the neurologist not communicating with the family. MD AA said the neurologist team had spoken with the family two or three times and it was documented on P#1 medical record. MD AA said when there was a concern of a possible new bleed in his brain, P#1 had a CT scan, and the result was sent to P#1's neurosurgeon. MD AA said based on the finding it was not acute. MD AA stated P#1's family wants P#1 to leave but the facility can't find a place for P#1.

An interview took place with the Charge Nurse (CN) HH ON 1/27/22 at 11:14 am. CN HH said she interacted with P#1's wife and met with his son-in-law. CN HH said she couldn't recall the details of the interaction. CN HH said the standard practice at the facility is for nurses to follow the physician orders and it included wound care and medication orders. CN HH said if a nurse failed to administer a medication the reason should be documented.


Review of the facility's policy titled, "Medication Administration in Nursing" last effective 8/19/21 revealed, procedures for all facility nursing staff to ensure safe and accurate administration to all patients. In addition, the policy revealed medications would be administered to patients by or under the supervision of appropriately licensed personnel in accordance with state and federal laws governing such acts.

The policy further revealed Medication administration occurs pursuant to a valid provider's order and that prior to medication administration, all medications require pharmacist verification except in urgent clinical scenarios or in procedural areas under the direct supervision of a provider. The policy revealed the six (6) Rights will be used at the time of preparation and administration.
i. Right patient ii. Right Medication iii. Right Route iv. Right Dose v. Right Time vi. Right Documentation

The policy revealed in the event of a medication error:

a. Assess and monitor the care for the patient.
b. Notify physician and Unit Director/designee
c. Enter SAFE medication variance report.

The policy revealed the following documentation procedures in a patient's medical record:

1. Documentation of all medications is done at the time of administration.
2. On the electronic MAR, the time of administration for "scheduled medications" defaults to the scheduled time. For most medications, if the medication is given within one hour before or after the scheduled time, there is no need to change the defaulted administration time. If, however, the type of medication requires precise administration times or the medication is given outside these parameters, the time should be changed to reflect the actual medication administration time.
3. The process for medication double verification requires the signature of both nurses that verify the drug and dose. On the electronic eMAR the first nurse documents the
administration. The second verifying nurse accesses the system under his/her own ID and adds a comment to the documented administration information indicating that the patient, drug, and dose were verified. If a flowsheet is used [Emory Saint Joseph Hospital (ESJH) and Emory Johns Creek Hospital (EJCH)] (Heparin and Insulin flowsheets) the signature of both nurses are required.
4. For areas not transitioned to the electronic medical record, utilize the appropriate form for that department.


Review of the facility's policy titled, "Clinical Practice Guidelines for Prevention and Treatment of Wounds and Pressure Injuries, no date listed revealed, the facility's procedures for prevention and treatment of wounds and pressure injuries. The policy revealed the facility's wound care team included the wound care nurse, physical therapist, occupational therapist, or any licensed wound care clinician.

The facility revealed that an assessment included admission to the Long-Term Acute Care (LTAC) unit and that all patients would have a complete skin assessment completed by the admitting nurse, with the results documented. In addition, the Braden Scale (measure elements of risk that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure) would be used to screen and assess risk for development of pressure ulcers. Further review of the policy revealed a Braden Scale score of 18 or below indicates the patient is at risk (maximum score 23). The policy revealed a wound team member would assess all patients within 72 hours of admission. Ongoing risk assessments were to be completed daily using a Braden Scale so that nurses can implement the protocol per the facility's Skin and Prevention and Breakdown Protocol and consult wound care as needed

The policy further revealed a member of the Wound Care Team would reassess pressure ulcers/wounds at least every week, with the treatment plan updated as appropriate. Documentation would be completed in the patient record. In addition, nutritional issues would be discussed with the Dietitian and Speech Therapist, and wound pain would be assessed and documented with each wound care intervention.

The policy revealed prevention protocols including but not limited to:
Management of Tissue Loads
While in bed

· Avoid positioning patients on a pressure ulcer
· Use positioning devices to raise the pressure ulcer off the bed, esp. the heels.
· Patients should be turned at least every 2 hours, even wh

Based on observation, medical record review, interviews, and the facility's "Patient Armband" policy, the facility failed to administer drugs in accordance to accepted standards of practice for one patient (P#1) out of five sampled patients.

During a tour of the facility's clinical units on 1/24/22 at 1:31 p.m., it was observed that P#1's arm band/identification bracelet listed P#1's date of birth (DOB) as 11/13/51.

Review of P#1's medical record revealed P#1's DOB was listed as 10/13/51.

During an interview in P#1's patient room on 1/24/22 at 1:15 p.m., family member of P#1 stated P#1's birth date on P#1's arm identification bracelet was incorrect, and that P#1's birth date was 10/13/51. In addition, family member of P#1 stated she informed the facility several times of P#1's birth date error on P#1's arm identification bracelet but the error was not corrected.

During an interview in the conference room on 1/24/22 at 5:00 p.m., MGR SS stated she would look into P#1's identification arm band/bracelet details regarding P#1's date of birth. On 1/25/22 at 9:15 a.m., in the conference room, MGR SS stated after obtaining information from the facility's patient registration department, incorrect information for P#1's birth date was entered and thus the incorrect date was printed on P#1's identification bracelet.

During an interview with Director of Nursing (DON) EE in the conference room on 1/25/22 at 2:00 p.m., DON EE stated medications come from the pharmacy and placed in a drug storage dispensing cabinet. DON EE stated nurses retrieved medication by scanning a computer work unit with utilization of the five medication administration rights (the right patient, the right drug, the right dose, the right route, and the right time), and subsequently scanned the patient's armband with the patient's name and date of birth before medication administration to the patient. DON EE further stated, if a patient could not speak or was not alert, nurses utilized the Medication Administration Record (MAR) to compare the patient's armband with the patient's date of birth, account number or medical record number.

During an interview at the nurse's station on 1/25/22 at 3:00 p.m., registered nurse (RN) NN stated once a doctor's medication order was received, she and staff were to check for the right dose, right medication to match the same dose and print a receipt from the drug storage dispensing cabinet. RN NN stated after medication was retrieved from the drug storage dispensing cabinet, the patient's identification band is scanned before administration of medication.

Review of the facility's policy titled, "Patient Armband" last effective date 1/28/19 revealed, guidelines for correct placement and replacement procedures for patient identification bands. The policy further revealed, it was the responsibility of employees to ensure all inpatients wear a hospital armband/patient identification band (patient ID
band). The policy revealed the patient care staff would identify the patient using two identifiers on the patient identification armband prior to administering care, treatment, or services.

Based on a review of medical record, patient and staff interviews, policies and procedures, Medical Staff bylaws, complaint and grievance log, incident report log, it was determined that the facility failed to administer medications per physician orders for one patient (P#1) of five sampled patients.

Findings:

A review of P#1 medical record revealed that P#1 was 70 years old male who was presented to the facility on 11/16/21 at 1:44 pm with acute respiratory failure. P#1 had a past medical history of esophageal cancer, right internal carotid artery (ICA) (blood vessels to the brain) occlusion, LICA stenosis. P#1 was on NaCl (salt) tablets due to cerebral salt wasting and had recently had a hemicraniectomy (removal of a large part of the skull). P#1's other medical conditions included dysphagia (difficulty to swallow), deep venous thrombosis (DVT) (blood clot in deep veins), sacral ulcer (bedsore around tailbone), and hypertension (high blood pressure). P#1 was admitted to the facility for tracheostomy weaning (surgery to insert a tube in the trachea that provides an alternative airway for breathing, weaning means gradually returning airflow to the upper airway and restoring normal function) and rehabilitation.

P#1 treatment plan included the following:

i. Tracheostomy tube weaning protocol.
ii. Medication (Lovenox (Enoxaparin) (medication to prevent blood clot) for DVT, Candesartan (antihypertensive medication for high blood pressure)
iii. Sodium chloride (NaCl) tab q8hrs due to cerebral salt wasting.
iv. Physiatry, speech therapy, physical therapy consultation, and nutritional consultation.
v. Percutaneous endoscopic gastrostomy (PEG) (a tube passed to the stomach through the abdomen as a means of feeding) due to dysphagia (difficulty in swallowing).
vi. Follow up with neurosurgery for cranioplasty (surgical repair of the skull resulting from a previous removal of a portion of the skull) after discharge.

A review of the physician orders revealed but was not limited to the following medication orders:

1. On 11/16/21 at 12:58 pm, Famotidine (medication to decrease the amount of acid the stomach produces, to prevent ulcer) tablet 20 milligram(s) PEG tube 2 times per day.
2. On 11/16/21 at 3:57 pm, Enoxaparin (anticoagulant for clot prevention) 80 milligrams(s) subcutaneous every 12 hours.
3. On 11/16/21 at 7:17 pm, Sodium chloride (NaCl) 3-gram(s) PEG tube every 8 hours.

A review of the facility's document titled "eMAR Tasks" revealed but not limited to the following:

1. Enoxaparin Q12 (every 12 hours) from 11/16/21 to 12/1/21.

On 11/25/21, RN noted administering Enoxaparin to P#1 left abdomen at 4:34 am, further review of the documentation failed to reveal any other administration of the medication on 11/25/21.

On 11/27/21, RN noted administering Enoxaparin to P#1's left abdomen at 6:28 pm, further review of the documentation failed to reveal administration of the medication at any other time on 11/27/21.

On 11/28/21, RN DD documented administering Enoxaparin to P#1's left abdomen at 3:46 am, 4:00 am, and at 6:07 pm. Further review revealed that the order was performed thrice on 11/28/21. Further review of the medical administration record (MAR) failed to reveal reasons why medications were not administered as ordered (Q12).

2. Famotidine, 2 times a day from 12/15/21 to 1/26/22.

On 12/25/21, Famotidine was administered once at 9:30 am.

On 1/10/22, Famotidine was administered once at 9:09 am. Further review failed to reveal any documented reasons medication was not administered as ordered (2 times a day).

3. Sodium chloride (NaCl) tab (salt due to cerebral salt wasting),3 times a day for 60 days from 11/16/21.

On 12/31/21, NaCl was administered twice at 9:00 am and at 2:00 pm. Further review failed to revealed reasons medication was not administered as ordered.

On 1/2/22, NaCl was administered twice at 9:14 am and at 2:00 pm. Further review failed to revealed reasons medication was not administered as ordered.


On 1/10/22 at 4:18 pm, a review of P#1's medical record revealed an order entered by WCN FF for Darkin solution to be applied topically, 2 times per day to P#1's coccyx wound. Further review failed to reveal documentation that the order was performed on 1/21/22 and 1/23/22.

During an interview with P#1's wife in P#1's room on 1/24/22 at 1:15 p.m., P#1's wife stated that her husband ended up at the facility due to a transfer from an Intensive Care Unit (ICU) from another facility, after P#1 experienced complications of an arterial surgery. P#1's wife also stated P#1 had his hip replaced around the same time frame. P#1 was observed to have protective boots, pillows on side of the patient. The patient was also observed as incontinent. P#1's wife stated her concerns for P#1 included being able to communicate with a neurologist, concerns with P#1's sodium and potassium levels. In addition, P#1's wife stated that P#1 had the wrong birth date listed on his armband and she has told several staff members about it and nothing was done to correct the issue. P#1's wife stated she is concerned with P#1's blood thinners, and that P#1 received two doses of a blood thinner instead of one dose of medication every 12 hours per the medication's directions. P#1's wife stated it is very difficult to speak to someone about P#1's care and messages are left on phones, but no one responds. P#1's wife stated that P#1's linens were not changed often, and she made marks on P#1's bedding to show that P#1's linens were not changed. P#1's wife further stated that P#1 developed bedsores while P#1 was at the facility but was told by MD AA P#1 had bedsores when P#1 was admitted into the facility. P#1's wife stated P#1 developed the bedsores at the facility because he was not being turned every 2 hours. In addition, P#1's wife stated that she also observed one day P#1's bedsheet was wet but the color was not yellow. P#1's wife stated she suspected it was P#1's antibiotic and that P#1 did not receive the antibiotic. P#1's wife also stated wound care was not done for P#1 and that the first time wound care was provided to P#1 was for wounds on his ear while P#1 was on the 5th floor. P#1's wife stated that P#1's alarms (IVs, monitors, etc) go/sound off all the time and staff does not respond for a long time. P#1's wife stated that she and her family spoke to the facility of her concerns and that there was a virtual call that was conducted to discuss P#1's care (date not defined, but P#1's wife stated the call happened January 2022).


During an interview with the Director of Nursing (DON) EE in the conference room on 1/25/22 at 11:13 a.m., Director EE stated medications come from the pharmacy and are placed in the Pyxis (drug storage dispensing equipment). DON EE stated nurses retrieve the medication by scanning a computer, and scanning patient's armband. In addition, DON EE stated nurses utilized the five medication administration rights (the right patient, the right drug, the right dose, the right route, and the right time) and utilized a computer to compare to the patient's armband of the patient's name and date of birth DON EE further stated if a patient could not speak or was alert, nurses could use the Medication Administration Record (MAR) to compare to the patient's armband with patient's date of birth account number or medical record number.

A follow-up interview with the Director of Nursing (DON) EE took place on 1/26/22 at 12:01 pm in the conference room. DON EE acknowledged she remembered P#1, she said P#1 was presented at the facility with acute respiratory failure and had wound care issues. DON EE said the facility organized an infectious disease team meeting where P#1 wound care was discussed but she cannot recall the details of the meeting. DON EE said her expectation is for her nursing team was to follow physician and wound care nursing orders. DON EE said she expected the nurses to administer medications based on physician orders, she further stated that if there was a reason why a medication was not administered her expectation was for the nurses to notify the physician and document why it was not given. DON EE stated her expectation was for Patient Care Technicians (PCT) to reposition patients per order. DON EE stated whenever there is a complaint about her department, she would try to reach out to the family to resolve the complaint and follow up with the complainant. She further explained that if the complaint cannot be resolved it becomes a grievance and she would refer them to the patient experience department.

During an interview with Pharmacist RR on 1/25/22 at 11:32 a.m. in the conference room, Pharmacist RR stated she had not recalled speaking with P#1 but that another pharmacist had spoken with P#1's wife regarding P#1s' medications. Pharmacist RR stated that depending on a medication, the medications are listed on an electronic Medication Administration Record (eMAR) and the pharmacy reviewed the appropriateness of the medication. In addition, Pharmacist RR stated once a medication has been signed off on an order, the medication is placed in a profile for nursing view and if the medication is in the PYXIS, it is an item nurses can give. Pharmacist RR further stated the medication would be taken from the Pyxis and barcode scanned and then medication scanned on the patient's wristband. Pharmacist RR stated that if a medication was not used after it has been taken out of the Pyxis, the medication can be placed back into the Pyxis. Pharmacist RR stated that the medication, Lovenox (Enoxaparin, medication is an anticoagulant that helps prevent the formation of blood clots) was able to fit and placed back into the Pyxis if it was taken out and needed to be placed back. In addition, Pharmacist RR stated that medications that could not be placed back into the PYXIS or were not placed back into the PYXIS could be returned to the facility's pharmacy. Pharmacist RR stated medications that were returned to the facility's pharmacy were documented that they were returned to the pharmacy. During a second interview with Pharmacist RR at 4:45 p.m. in the conference room, Pharmacist RR stated she ran a report for P#1 and did not see Lovenox returned to the facility's pharmacy.

During an interview with RN NN on the 4th-floor hallway on 1/25/22 at 3:00 p.m., RN NN stated she was responsible for five to six patients each shift. In addition, RN NN stated part of her duties included providing oral care every four hours, checking FiO2 levels, and ensuring vitals are stable. RN NN described that patient was required to be at least 30 degrees upright when intubated. RN NN stated for patients at risk for pressure ulcers were provided with wedges, heel boots, and the application of zinc cream and turning of the patient. RN NN stated she and staff documented repositioning was documented in a patient's medical record. RN NN stated for the administration of anticoagulant medication, the practice was to alternate sites of injection. In addition, RN NN stated once a doctor's order is received for medication, she and staff were to check for the right dose, check medication to match the same dose, and print a receipt after, and then the patient's ID is scanned before administration of medication. RN NN stated the receipt is then tossed in a bin for shredding.

An interview took place with the Charge Nurse (CN) HH ON 1/27/22 at 11:14 am. CN HH said she interacted with P#1's wife and met with his son-in-law. CN HH said she couldn't recall the details of the interaction. CN HH said the standard practice at the facility is for nurses to follow the physician orders and it included wound care and medication orders. CN HH said if a nurse failed to administer a medication the reason should be documented.


Review of the facility's policy titled, "Medication Administration in Nursing" last effective 8/19/21 revealed, procedures for all facility nursing staff to ensure safe and accurate administration to all patients. In addition, the policy revealed medications would be administered to patients by or under the supervision of appropriately licensed personnel in accordance with state and federal laws governing such acts.

The policy further revealed Medication administration occurs pursuant to a valid provider's order and that prior to medication administration, all medications require pharmacist verification except in urgent clinical scenarios or in procedural areas under the direct supervision of a provider. The policy revealed the six (6) Rights will be used at the time of preparation and administration.
i. Right patient ii. Right Medication iii. Right Route iv. Right Dose v. Right Time vi. Right Documentation

The policy revealed in the event of a medication error:

a. Assess and monitor the care for the patient.
b. Notify physician and Unit Director/designee
c. Enter SAFE medication variance report.

The policy revealed the following documentation procedures in a patient's medical record:

1. Documentation of all medications is done at the time of administration.
2. On the electronic MAR, the time of administration for "scheduled medications" defaults to the scheduled time. For most medications, if the medication is given within one hour before or after the scheduled time, there is no need to change the defaulted administration time. If, however, the type of medication requires precise administration times or the medication is given outside these parameters, the time should be changed to reflect the actual medication administration time.
3. The process for medication double verification requires the signature of both nurses that verify the drug and dose. On the electronic eMAR the first nurse documents the
administration. The second verifying nurse accesses the system under his/her own ID and adds a comment to the documented administration information indicating that the patient, drug, and dose were verified. If a flowsheet is used [Emory Saint Joseph Hospital (ESJH) and Emory Johns Creek Hospital (EJCH) Heparin and Insulin flowsheets] the signature of both nurses are required.
4. For areas not transitioned to the electronic medical record, utilize the appropriate form for that department.

A review of the facility's Medical Staff Bylaws, policies, rules and regulations approved on 9/4/18 revealed that all medication orders clearly state the name of the medication, the dose, the route of administration, the administration times or the time intervals between doses.

Medication errors.

Any medication error or apparent drug reaction shall be reported immediately to the ordering physician and to the attending physician if different from the ordering physician. An entry of the medication dose given in error or the apparent drug reaction shall be recorded in the patient's medical record. All suspected medication errors and drug reactions shall be reported to the pharmacy


A review of the facility's incident reports from 7/1/21 through 1/24/22 revealed seven incident reports related to medication reportable events which included medication timing issues, administration of incorrect doses and missed doses.