HospitalInspections.org

Based on interview, record review, and policy review, the facility failed to ensure nursing staff consistently and accurately assessed, supervised, evaluated, administered, and documented nursing care/interventions for:
- Wound and/or pressure sore/ulcer (injury to the skin and/or underlying tissue usually over a bony prominence) care and prevention, for two current patients (#17 and #12) of two current patients reviewed for wound care;
- Blood glucose (sugar) testing, turn and reposition, elevation of heels off of bed, betadine (antiseptic solution) soaks, oral diet supplementation, and tube feedings for two current patients (#17 and #12) of two current patients and one discharged patient (#11) of one discharged patient reviewed.
- Urinary catheter (a small flexible tube inserted into the body through an opening of the urinary tract to drain urine) care for two current patients (#2 and #5) of two current patients reviewed with a urinary catheter.
These failures had the potential to place all patients at risk for a delay in treatment for the care of wounds, the increased risk for further wound development and worsening of current wounds, unknown blood sugar readings, decrease in nutritional status and risk for infection. The facility census was 64.

Findings included:

1. Review of the facility's policy titled, "Pressure Injury Assessment - Prevention and Treatment of Skin Breakdown," dated 03/07/17, showed the following treatment interventions for patients with deep tissue injuries:
- Keep off area at all times;
- Turn patient every 2 hours;
- Document on Skin Integrity Care Plan;
- Dressing;
a. Circulatory stimulant (a substance that improves blood flow through body tissues)

Review of the facility's policy titled, "Care of Patient with Alternative Feeding," dated 11/22/10, showed for care of patients with feeding tubes to refer to Lippincott's Nursing Procedures & Skills.

Review of "Lippincott's Procedures for Tube Feedings," dated 11/17/17, showed for staff to monitor the patient at least every four hours for appropriate tube positioning and then document the procedure.

Review of Patient #17's medical record showed:
- The patient was admitted on 03/31/18 with a recent left leg bypass (surgery to reroute the blood supply around a blocked blood vessel);
- On 04/03/18, the patient underwent below the knee amputation (BKA, removal of leg at the knee) and post-operatively was anemic (blood is deficient in red blood cells and/or hemoglobin which decrease the oxygen carrying capacity of the blood) and pain and was started on deep vein thrombosis (DVT, blood clot) prophylaxis medication and therapy and admitted for inpatient rehabilitation.
- A physician order for blood sugar testing four times daily before meals (AC) and at bedtime (HS) to start 04/07/18 at 9:00 PM;
- A physician order to elevate right heel off of bed ongoing to start 04/07/18 at 6:20 PM;
- A physician order for wound care to the right heel with betadine soaks two times daily, to start 04/09/18 at 9:00 PM;
- A physician order to turn patient and reposition every two hours to start 04/07/18 at 8:00 PM; and
- A physician order for an oral diet supplement with meals to start 04/13/18 at 3:35 PM.

Review of nursing flowsheet showed the following missing documentation:
- Four entries for blood sugar testing on 04/07/18 and 04/08/18, and one entry for 04/13/18 and one entry for 04/17/18;
- Daily entries for elevation of right heel off of bed for 04/08/18, 04/09/18, 04/10/18, 04/15/18, and 04/16/18;
- Two entries for wound care of the right heel for 04/15/18 and 04/16/18;
- 12 entries for turning and repositioning from 04/08/18 through 04/19/18; and
- Eight entries for oral dietary supplement from 04/13/18 through 04/17/18.

Review of Admission Nursing Assessment dated 04/07/18 at 10:49 PM showed skin breakdown to the right heel with black eschar (dead tissue) skin unstageable deep tissue injury, right great toe with black eschar, and a skin graft (surgical operation in which a piece of healthy skin is transplanted to a new site on the body) donor site to the left thigh. A wound care consult was initiated.

Review of Wound Care Consult dated 04/09/18 at 12:35 PM showed a three centimeter (unit of measurement, cm) round suspected deep tissue injury (stage 3, full thickness skin loss or stage 4, full thickness plus tissue loss, ulcer) that had not yet surfaced to the right heel and skin donor site to the left thigh that had almost healed.

During an interview on 04/17/18 at 9:15 AM, Staff A, Nursing Manager, stated it is the nurse's responsibility to ensure patients were turned and repositioned, per physician order. She verified that Patient #17 was not turned and repositioned as they should have been as evidenced by missing documentation.

Patient #17 had a suspected deep tissue injury and a skin donor site noted upon admission that was not consistently assessed or treated consistently per physician order. Missed assessments and treatments place the patient at a higher risk for delayed healing and potentially wound deterioration.

Review of Patient #12's medical record showed:
- The patient was admitted on 04/07/18 to begin an aggressive inpatient rehabilitation program after suffering a left sided intracranial hemorrhage (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain) and percutaneous endoscopic gastrostomy (PEG, endoscopic medical procedures where a tube is passed into a patient's stomach through the abdominal wall to provide a means of feeding) tube placement.
- A physician order for tube feeding four times daily to start 04/07/18 at 7:40 AM.
- A physician order to turn and reposition patient every two hours to start 04/06/18 at 6:00 PM.

Review of nursing flowsheet showed 24 total missing entries for tube feedings for 04/07/18, 04/10/18, 04/12/18, 04/15/18, 04/16/18, and 04/17/18 and 48 total missing entries for turning and repositioning for 04/04/18, 04/05/18, 04/12/18, and 04/13/18.

During an interview on 04/17/18 at 10:38 AM, Staff A, Nursing Manager, stated that the expectation was for nursing staff to document tube feedings at the time of administration, per physician order. She verified that Patient #12 did not receive tube feedings as they should have as evidenced by missing documentation.

Review of discharged Patient #11's record showed:
- The patient was admitted 02/12/18 and underwent BKA;
- A physician order to elevate the heels off of the bed to start 02/12/18; and
- A physician order to turn and reposition every four hours to start on 02/12/18.

Review of nursing flowsheet from 02/12/18 through 02/28/18, showed 13 missing entries for elevation of heels off of bed for 13 days and 36 missing entries for turning and repositioning.

Patients #12 and #11 had multiple missing entries of tube feedings, elevation of heels and turning and repositioning during their admission that indicated these tasks were not performed. These missed tasks placed both patients at risk for development of skin breakdown and a decrease in nutritional status.

2. Review of the document titled, "Lippincott Procedures - Indwelling urinary catheter (Foley [brand name]) care and management," dated 11/17/17 showed implementation of the procedure for staff to provide routine hygiene for meatal (opening) care using a washcloth and soap and water. The catheter should also be cleaned after each bowel movement.

Observation and concurrent interview on 04/16/18 at 1:55 PM, showed Patient #2 seated in a wheelchair in her room. She had a urinary catheter leg bag strapped to her left lower leg. She stated that the nursing staff didn't clean "around" her urinary catheter very often.

Review of the patient's medical record showed:
- She was admitted to the facility on 04/11/18 for rehabilitation therapy following a femoral artery occlusion (blockage in the large blood vessel in the thigh);
- She had a urinary catheter on admission; and
- A total of five missing entries for catheter care between her admission date of 04/11/18 and 04/16/18.

Observation on 04/16/18 at 2:50 PM, showed Patient #5 with a urinary catheter leg bag to his left leg.

Review of the patient's medical record showed:
- He was admitted to the facility on 04/06/18 for rehabilitation therapy following a spinal fracture;
- He had a urinary catheter on admission; and
- A total of nine missing entries for catheter care between his admisison date of 04/06/18 and 04/16/18.

During an interview on 04/16/18 at 3:20 PM, Staff H, Supervisor Clinical Nursing stated that patients with urinary catheters should be assessed every shift and that catheter care should be performed with bathing and if the catheter became soiled due to bowel movements. She verified that Patients #2 and #5 did not receive urinary catheter care as they should have as evidenced by the missing documentation.

Patient #2 only received catheter care one day out of six and Patient #5 only received catheter care one day out
of 10. The lack of consistent, daily catheter care placed both patients at risk for infection.










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