HospitalInspections.org

Based on observation, interview, record review and policy review, the facility failed to:
- Ensure that a Registered Nurse (RN) monitored, assessed and/or reassessed the skin of one patient (#7) of one patient observed with Hospital Acquired Pressure Ulcers.
- Ensure that an RN performed and documented dressing changes per physician orders for one current patient (#15) and one discharged patient (#19) of two patients who required dressing changes.
- Ensure that patients were monitored frequently enough to maintain safety for one patient (#29) of one patient observed.
- Monitor, supervise, instruct or intervene to ensure that every patient received personal hygiene care for five patients (#7, #8, #10, #20 and #25) of seven patients.

These failed practices had the potential to negatively affect all patient care being provided, when nursing processes were not effectively managed in the facility.
The facility census was 46.

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

Please see citation A0395 for details.

Based on observation, interview, record review and policy review the facility failed to:
- Ensure that a Registered Nurse (RN) monitored, assessed and/or reassessed the skin of one patient (#7) of one patient observed with Hospital Acquired (HA) Pressure Ulcers.
- Ensure that an RN performed and documented dressing changes per physician order for one patient (#15) of one patient observed and one discharged patient (#19).
- Ensure that patients were monitored frequently enough to maintain safety for one patient (#29) of one patient observed.
- Monitor, supervise, instruct or intervene to ensure that every patient received personal hygiene care for four current patients (#7, #8, #10 and #20) and one discharged patient (#25) of seven patients reviewed.
These failures had the potential to affect all patients in the facility. The facility census was 46.

Findings included:

1. Record review of the policy titled, "Assessment/Re-Assessment - Interdisciplinary Patient," dated 02/2014, showed: All patients at the facility will have an initial assessment and appropriate follow up assessments based upon patient specific identified needs including physical, psychological and social-cultural status.

Record review of the policy titled, "Prevention and Treatment of Pressure Ulcers and Non-Pressure Related wounds," dated 05/2015, showed the following: Pressure ulcer and other wound and skin related interventions are created in collaboration with the interdisciplinary team and implemented in order to identify, prevent or reduce the risk of acquiring pressure and/or non-pressure related wounds or skin issues. Treatment of existing or new wounds shall be initiated according to the principles of wound healing identified in evidence based practice. To provide guidelines to licensed staff and unlicensed facility personnel involved with patient care in the assessment, prevention and documentation of pressure and non-pressure related wounds, as well as general guidelines for skin care, pressure ulcer and wound management.

2. During an interview on 08/23/16 at 2:50 PM, on 3 North, Patient #7 stated, "I have two new pressure sores on both big (great) toes - one is black and one is open". He stated that his wife had seen them on Sunday evening [08/21/16] and that one of the toes was black and the other toe had a small opening. He stated that he had been in a different bed and that an apparatus hung over the footboard of the bed and it rubbed on both of his big toes. He stated that they told the nurse on Monday but no one had put anything on them yet.

Record review of Patient #7's History and Physical (H&P) dated 08/06/16, showed that he was a paraplegic (paralysis of both lower limbs due to spinal disease or injury). He had a Stage IV (full thickness tissue loss with exposed bone, tendon or muscle) with a right buttock pressure ulcer.

Record review of the patient's Plan of Care dated 08/06/16 showed that he had Impaired physical mobility; risk for infection; Impaired skin/tissue integrity and at risk for impaired skin/tissue integrity with a goal that "Patient will experience no further breakdown of skin due to moisture, friction, shear or pressure".

Record review of the patient's Nurses' Notes showed that the HA pressure ulcers had been assessed on 08/21/16 at 10:35 PM and showed staff assessed the pressure ulcer on the right great toe appropriately; however there was no evidence that staff assessed the patient's left toe.

Record review of the documentation of Staff X, Wound Care Nurse, showed that she assessed Patient #7's toes on 08/22/16 at 3:05 PM and documented the areas on both great toes were caused by "trauma".

During an interview on 08/23/16 at 3:20 PM, Staff X stated that the wounds on Patient
#7's toes were not pressure sores but were caused by trauma from rubbing on an apparatus that hung over the footboard of the patient's previous bed. She stated that trauma wounds are not staged (description of how severe the tissue damage is) and that the physician had not ordered a treatment for them.

The patient's record did not reflect a physician's order for treatment until 08/23/16 at 4:39 PM and was ordered to start on 08/24/16 at 9:00 AM or three days after the initial assessment.

During an interview on 08/25/16 at 10:34 AM, Staff B, Chief Clinical Officer (CCO), stated that Patient #7's toes should have been assessed by Staff X as pressure sores. She stated
that the RN's were to assess each patient assigned at least hourly and complete a head to toe skin assessment and document on each patient every shift.

3. Observation and concurrent interview on 08/24/16 at 10:00 AM, on 3 North, showed Patient #15 with gauze dressing to her left heel and a negative-pressure wound therapy (wound vacuum, a therapeutic technique using a vacuum dressing to promote healing) dressing to her right foot. Patient #15 stated that the dressing to her left heel was to be changed twice daily but that lately it had not been done consistently.

Record review of Patient #15's H&P dated 07/13/16 showed that she was admitted for wound care and antibiotics. The patient had bilateral pressure ulcers to the right and left heels. Left medial (toward the middle) heel was to have dressing changes every 12 hours by nursing staff.

Record review of the patient's nursing notes showed that between 08/17/16 and 08/24/16 dressing changes to the left heel were not done on the following dates:
- 08/18/16;
- 08/20/16;
- 08/21/16; and
- 08/22/16.

4. Record review of discharged Patient #19's medical record showed that the physician's order for dressing changes two times per day for Patient #19's sacrum pressure ulcer (bedsore caused from pressure on the triangular shaped bone at the bottom of the spine), was not performed or documented on the following dates:
- 06/29/16, AM shift;
- 06/30/16, AM shift;
- 07/01/16, AM shift;
- 07/09/16, PM shift;
- 07/10/16, AM shift;
- 07/19/16, AM shift;
- 08/03/16, AM shift;
- 08/09/16, PM shift; and
- 08/11/16, PM shift.

During an interview on 08/25/16 at 11:00 AM, Staff V, Charge Nurse, stated that she knew that some dressing changes were missed.

5. Even though requested, the facility failed to provide a "rounding" policy to indicate expectations on how often patients should be visualized and condition checked.

6. Observation on 08/23/16 at 2:55 PM on 2 North of Patient #29, showed urinary catheter (tube in penis that drains urine from bladder to an external bag) care in progress. Patient #29 did not respond when his penis was manipulated (typical response would be pain or grimace) or have interaction with staff in the room (unresponsive).

Record review of Patient #29's physician's H&P, dated 08/06/16, showed the patient was not able to speak, unable to open his eyes, unable to communicate and not able to move his right side.

During an interview on 08/23/16 at 3:10 PM Patient #29's sister confirmed that he was not responsive or able to communicate and that she spent several days (and nights) a week with him. The patient's sister stated that she was concerned that the patient could not push the call light, verbalize his needs or identify when his mouth needed to be suctioned. She stated that often she would go to the nurse's station to get someone to come into the room to check on her brother. She stated that several times no one came into the room for over four hours.

During an interview on 08/23/16 at 4:00 PM Staff Y, RN, stated that there was no specific policy about how often staff needed to visualize patients but between medication administrations and other care provided, staff were constantly in patient rooms.

During an interview on 08/25/16 at 10:45 PM Staff C, CCO, stated that although there was not a specific policy, staff was well aware of her expectation that every patient be visualized at least once an hour.

7. Record review of the policy titled, "Patient personal Hygiene, Care Delivery," dated 04/2014, showed the following:
- This policy is performed to ensure the mental, emotional and physical health and social well being of all patients.
- It is the responsibility of the staff to ensure that the patient is clean, comfortable and that the patient's appearance is maintained according to their personal preference.
- Planned personal hygiene is provided in a way that ensures the privacy and dignity of the patient.
- Planned personal hygiene is coordinated with the patient and caregivers based on individual patient assessment and needs.
- Patients will be offered personal hygiene daily.
- Personal hygiene will be accurately documented as completed/refused.
- The CCO or designee will monitor and validate personal hygiene through periodic audits of documentation and patient feedback.
- Procedures for personal hygiene may include:
Assisting with bath or shower
Bed bath
Bed making
Foot care;
Perineal care
Skin care
Toileting
Washing hair.

8. During an interview on 08/23/16 at 2:50 PM, Patient #7 stated, "I've never been offered a bath, I have to initiate it. We (he and his wife) change the sheets ourselves.

Record review of Patient #7's H&P showed that he was admitted to the facility on 08/03/16 and was a paraplegic. The Plan of Care showed that the patient had impaired wheelchair, transfer and bed mobility.

The first Nurses Notes for Hygiene was documented on 08/07/16 and showed that he required one person assistance for partial bath and perineal care ('peri care' refers to the region between the scrotum and the anus in males, and between the vaginal area and the anus in females). The following were the documentation entries for Hygiene assessment:
- On 08/09/16 and showed his bathing status as "peri care".
- On 08/15/16 and showed his bathing status as "peri care".
- On 08/23/16 and showed, "Patient refused to allow staff to give him his bath". The documentation was signed by Staff K, Patient Care Technician (PCT).

During an interview on 08/24/16 at 2:50 AM, Patient #7 stated, "I was never offered a bath".

During an interview on 08/25/16 at 6:30 AM, Staff K stated that he did offer Patient #7 a bath but he refused.

9. During an interview on 3 North, on 08/23/16 at 3:00 PM, Patient #8 stated that she had been at the facility for two and one half months. She stated that she had been given a bath last Thursday (08/18/16) but hadn't had one before that since 08/04/16. She stated that the 'caps' (disposable cap is pre-moistened with rinse-free shampoo, conditioner, and detangler) don't get her hair clean. Patient #8 stated that her mother and sister bring her own products and help her wash and put lotion on her skin.

Record review of Patient #8's H&P showed that she was admitted to the facility on 06/17/16. She had a history of advanced multiple sclerosis and "can basically move only the right arm, otherwise she has no movement".

Record review of the Nurses Notes for Hygiene was documented on 08/07/16 and showed that she required one person assistance for peri care. The following were the documentation entries for Hygiene assessment for August:
- On 08/07/16 and showed her bathing status as "peri care".
- 08/11/16 stated "1 person assist".
- 08/12/16 showed her bathing status as "peri care".
- 08/23/16 showed, "suprapubic catheter care (a hollow flexible tube that is used to drain urine from the bladder. It is inserted into the bladder through a cut in the stomach, a few inches below the navel).
- 08/24/16 showed, "Patient refused her bath".

During an interview on 3 North, on 08/24/16 at 3:10 PM, Patient #8 stated, "Yeah, they woke me up at 5 o'clock and wanted to give me a bath. I told them I wanted my baths in the evening before bed. One time they woke me up at 2:30 in the morning to give me a bath. Who wants to be woken up for a bath at 2:30 in the morning?"

10. During an interview on 08/23/16 at 3:10 PM, Patient #10 stated that he had never been offered a bath. He stated that he took care of that himself. He stated that he rinses his hair in the sink with water and gives himself 'spit' baths. He stated that they (staff) will change the bed linens if they are soiled or if he asks them to.

Record review of Patient #10's H&P showed that he was admitted to the facility on 07/26/16.

Record review of the Nurses Notes for Patient #10 showed that he had "Impaired physical mobility". There was no documentation for the patient under Hygiene.

11. Record review of the daily Report Sheet showed a column for 'Bath' for each patient and the following codes:
- D1;
- D2;
- N1;
- N2; and
- HA.

During an interview on 08/24/16 at 9:20 AM and 9:45 AM, Staff M, Nurse Supervisor, stated, "They just changed the hygiene bath process yesterday (08/23/16) and I don't know what those codes mean". She stated that the patients didn't think they were being bathed when the aides used the "bath in a bag" wipes (an alternative to the traditional bed bath, and performed with a series of washcloths and a no-rinse liquid cleanser) and that the staff members were confused as to what day the patient was to be bathed. She stated that there were two bath aides during the day that "take the heavier patients" but she could not verbalize what criterion was used to determine the 'heavier patients'. She stated that there was no policy or procedure for the new bath schedule. Staff M stated that the education regarding the new bathing schedule had not been completed for all staff members and that it had only been discussed in morning staff huddles.

During an interview on 08/24/16 at 9:40 AM, Staff N, PCT, Bath Aide, stated that she worked eight hours a day Monday through Friday and there was another Bath Aide that worked with her four days per week. She stated that her job was to give baths, document I&O (patient intake and output) and feed patients. She stated the criteria for the 'heavy patients' was based on the patients neurological status, patients with tracheostomies (breathing is done through the tracheostomy tube rather than through the nose and mouth. The term "tracheotomy" refers to the incision into the trachea (windpipe) that forms a temporary or permanent opening, which is called a "tracheostomy") and bariatric (bariatric surgery: surgery on the stomach and/or intestines to help a person with extreme obesity lose weight) patients. She stated that the code HA stands for Hygiene Aide and that told her on the schedule which patients she must bathe. Staff N stated that D1 and N1 meant staff were scheduled to give patients baths on Monday and Thursday and D2 and N2 meant staff were scheduled to give patients baths on Tuesdays and Fridays.

During an interview on 08/24/16 at 10:00 AM, Staff L, Nurse Supervisor, stated that he prepared the Report Sheet schedule but that "They just changed the hygiene bath process yesterday and I wasn't here so I don't know what those codes mean".

During an interview on 08/25/16 at 10:34 AM, Staff B, Chief Clinical Officer (CCO), stated that she wasn't aware that the new codes were already placed on the Report Sheet. She stated that staff had not been educated on the new process and that there was no Policy or Procedure written. Staff B stated that she knew that patients weren't receiving their baths and they have worked on improving their system.

12. Record review of Patient #20's medical record from 06/04/16 and 08/24/16 showed that baths were not done between the following dates:
- 06/11/16 and 06/21/16;
- 06/21/16 and 06/29/16;
- 07/07/16 and 07/15/16;
- 07/17/16 and 07/22/16;
- 07/23/16 and 08/05/16;
- 08/05/16 and 08/14/16;

During an interview on 2 South, on 08/24/16 at 10:20 AM, Patient #20 stated that she only received a bath one time per week and they never asked her if she needed a bath.

13. Record review of discharged Patient #25's medical record from 03/02/16 and 03/20/16 showed that baths were not done between the following dates:
- 03/02/16 and 03/06/16;
- 03/07/16 and 03/15/16;
- 03/16/16 and 03/20/16.

During an interview on 08/25/16 at 11:00 AM, Staff V, Charge Nurse, stated that the CNA's gave the baths and usually let her know when the baths were done.







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