HospitalInspections.org

Based on observation, interview, record review and policy review the hospital failed to ensure that:
- Nursing staff followed fall risk interventions for four current patients (#9, #21, #34 and #35) of 18 current patients observed, and one discharge patient (#12) of three discharged patients reviewed who were identified as high fall risks.
- Nursing staff performed appropriate daily skin assessments, frequent turning and repositioning to prevent a pressure injury (injury to the skin and/or underlying tissue, usually over a bony area) wound for one current patient (#17) of three current patients with wounds observed.
- Nursing staff documented wound vacuum assisted closure (Wound V.A.C., a device that decreases air pressure on a wound to help it heal more quickly, also known as Negative Pressure Wound Therapy) drainage output per the hospital's policy, for two current patients (#17 and #31) of two current patients observed on a wound V.A.C.
- Nursing staff followed wound care orders for dressing changes for three current patients, (#19, #31 and #34) of four current patients observed with dressing changes.

These failures had the potential to place all patients admitted to the hospital at risk for their health and safety. The hospital census was 357.

These practices resulted in a systemic failure and non-compliance with 42 CFR 482.23 Conditions of Participation: Nursing Services.


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Based on observation, interview, record review and policy review the hospital failed to ensure that:
- Nursing staff followed fall risk interventions for four current patients (#9, #21, #34 and #35) of 18 current patients observed, and one discharge patient (#12) of three discharged patients reviewed, who were identified as high fall risk.
- Nursing staff performed appropriate daily skin assessments, frequent turning and repositioning to prevent a pressure injury (injury to the skin and/or underlying tissue, usually over a bony area) wound for one current patient (#17) of three current patients with wounds observed.
- Nursing staff documented wound vacuum assisted closure (Wound V.A.C., a device that decreases air pressure on a wound to help it heal more quickly, also known as Negative Pressure Wound Therapy) drainage output per the hospital's policy, for two current patients (#17 and #31) of two current patients observed on a wound V.A.C.
- Nursing staff followed wound care orders for dressing changes for three current patients, (#19, #31 and #34) of four current patients observed with dressing changes.

These failures had the potential to affect the quality of care and endanger the safety of all patients that received care in the hospital. The hospital census was 357.

Findings included:

1. Review of the hospital's policy titled, "Patient Fall Prevention," revised 03/10/21, showed that staff were to assess a patient's fall risk at admission, every shift, change in level of care, after a fall, and day of discharge.

Review of the hospital's undated document titled, "Hester Davis Fall Precautions Levels of Risk and Interventions Tool," showed the hospital utilized the Hester Davis Fall Risk Prevention model and scoring system. For a score of 15 or greater, high fall risk precautions would be initiated and included the following:
- Place on bed/chair alarm; patient should have alarm when out of bed in chair or during transport. Fall alarms should be connected to call light when possible. Use medium or small zone for built in bed alarms.
- Place fall risk ID band on patient.
- Instruct patient/family to call staff for assistance when getting out of bed or accessing out of reach items.
- Place patient in room close to nursing station if available.
- Place fall mats on one or both sides of the bed or in front of chair when out of bed.

Review of the hospital's document titled, "Patient Safety Assistant: Safety Sitter," dated 05/12/21, showed that a patient safety assistant/sitter was a trained observer utilized to prevent safety events such as falls, and that a sitter could be implemented without a physician's order.

Review of Patient #12's medical record dated 01/23/22 through 02/05/22, showed the following:
- He was an 86 year old male who presented to the ED on 01/23/22 at 8:55 AM, when he began coughing up blood.
- Past medical history included chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing), congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues), diabetes mellitus (DM, a disease that affects how the body produces or uses blood sugar, and can cause poor healing), high blood pressure, pneumonia, emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness) and shortness of breath.
- Physician documentation during the admission showed that Patient #12 knew who he was, where he was, his situation, he was alert, cooperative and in no distress. He had on oxygen at two liters via a nasal cannula (NC, a lightweight tube that splits into to two prongs for insertion into the nostrils and delivery of oxygen), and wore a continuous positive airway pressure (CPAP, used to treat sleep apnea by delivering a stream of oxygenated air into the airways through a mask or tube) at night. Prior to the hospital admission, Patient #12 lived at home with his wife, used a walker or cane when walking, and was mostly independent with his daily activities.
- Hester Davis Fall Risk Assessments on 01/23/22 and 01/24/22, indicated that Patient #12 scored a 10, which would place him at a low risk for falls. Staff indicated that Patient #12 had dizziness and generalized weakness and required assistance of one person for mobility, then indicated that Patient #12 did not need assistance with toileting. (This assessment was not accurately performed and the score should have been higher, indicating he was at least a moderate fall risk).
- Patient #12 was admitted to the hospital for intravenous (IV, in the vein) antibiotics for a suspected lung infection and was anticipated to be discharged to his home on 01/27/22.
- Nursing documentation on 01/24/22 at 9:14 PM, showed that a rapid response (a changing situation that requires more staff to address the current needs of the patient) was called after Patient #12 was found on the floor. His oxygen saturation (oxygen saturation in the blood) level was in the 80's and he did not have his oxygen on when he was found. The physician was notified of the fall and a computed tomography (CT, a combination of x-rays and a computer to create pictures of organs, bones and other tissues, which shows more detail that a regular x-ray) of the head was ordered at 9:33 PM, which resulted negative for findings.
- Nursing documentation on 01/24/22 at 11:46 PM, showed that Patient #12 was alert, and reported that he got up to use the restroom and he became confused and fell. "He knew he wasn't supposed to get up" and apologized for doing so. The nurse called Patient #12's wife to report the fall. Patient #12 was placed in his bed with a bed alarm.
- Hester Davis Fall Risk Assessment documented on 01/25/22 at 3:33 AM, scored Patient #12 at 15 (high fall risk). Interventions in place included a bed alarm, the bed locked in a low position, call light within reach and the patient using a bedpan.
- Physical therapy documentation on 01/26/22 at 3:04 PM, showed Patient #12 knew who he was and where he was, but did not know his situation or the time. After his physical therapy, he was placed back onto his bed with the bed alarm on. His anticipated discharge was to return home on 01/27/22.
- Hester Davis Fall Risk Assessment performed on 01/26/22 at 9:26 PM, scored Patient #12 at a 28. Interventions included a bed alarm, fall mats, bed locked in a low position, hourly rounding, frequent toileting, call light within reach and two side rails up.
- Nursing documentation on 01/26/22 at 10:00 PM, showed Patient #12 was found face up on the floor. He had a "knot" on the back of his head. The Nurse Practitioner was contacted and she ordered a head CT and a sitter. The patient's wife was contacted and she was very upset, she spoke with the charge nurse and the nurse manager upon her arrival to the hospital. The patient's wife also contacted the police to file a report.
- A CT of the head performed on 01/27/22 at 12:02 AM, showed a subarachnoid hemorrhage (a medical emergency where there is bleeding in the space between the brain and the tissue covering the brain) and swelling, which was not present on the prior exam. The critical value of the intracranial hemorrhage was discussed by telephone by the radiologist, physician, and Patient #12's nurse.
- Nursing documentation on 01/27/22 and 01/28/22, showed the patient had a sitter.
- Physician documentation on 01/29/22 at 9:05 AM, showed that Patient #12 had a poor prognosis and that placing him on comfort measures was a reasonable consideration.
- Physician documentation on 02/02/22 at 6:56 PM, showed that a rapid response was called because Patient #12 was found unresponsive by his nurse. Nursing staff reported that Patient #12 had been alert and awake during the day, but had sudden mental status changes. His history of subarachnoid hemorrhage caused concern for an intracerebral (within the skull) event that led to his mental status change. Patient #12 was transferred to the ICU for intubation (the insertion of a tube into a person's trachea for ventilation when a person is not breathing on their own) and a repeat CT scan of his head.
- Physician documentation on 02/03/22 at 8:58 PM, showed Patient #12 had a pulmonary embolism (a blood clot in the lungs). Due to his subarachnoid hemorrhage, Patient #12 could not be given an anticoagulant (drugs used to prevent blood clots) and the physician recommended an inferior vena cava (IVF, a medical device that is implanted by surgeons into the heart to prevent life threatening pulmonary emboli) filter be placed. Patient #12's wife was called for consent and she refused consent for placement stating, "He has been through too much and I don't think he can handle it."
- Physician documentation on 02/04/22 at 11:48 AM, showed that Patient #12 continued to be unresponsive and on a ventilator. His code status was changed to do not resuscitate (DNR, written instructions from a physician telling health care providers not to perform CPR).
- Physician documentation on 02/06/22 at 1:22 AM, showed Patient #12's time of death was 02/05/22 at 10:39 PM. The cause of death was respiratory failure in the setting of pulmonary embolism and subarachnoid hemorrhage.

During an interview on 03/10/22 at 11:00 AM, Staff NNN, RN, stated that when when the patient fell the second time, he was found on the floor by Staff UUU, Clinical Partner, who reported that the bed alarm was not turned on.

During an interview on 03/10/22 at 9:00 AM, Staff MMM, Clinical Director of Telemetry, stated the following:
- Patient #12's wife had requested a sitter for him (after the patient's first fall, and prior to his second fall), but the Charge Nurse did not feel he qualified for a sitter.
- Patients who had a high risk for falls and who were at risk for trying to get out of bed, should have a sitter.
- Patient #12 should have had a sitter in place prior to his second fall.
- There was no policy or direction for nurses to follow in regards to using sitters if the patient wasn't having behavioral health issues.
- On 01/29/22 (after the patient's second fall), during a portion of the day, there was no sitter with Patient #12. The Charge Nurse, who had been pulled to work from another unit, was unaware that Patient #12 needed a sitter.

During an interview on 03/10/22 at 9:50 AM and 10:50 AM, Staff QQQ, Patient Safety Specialist, stated that they began an RCA on 01/28/22 related to Patient #12's falls, but its completion had been delayed. She felt that staff failed to follow their policy and procedure on fall prevention, per the Hester Davis Fall score.

Review of the hospital's RCA on 3/10/22 showed that it remained unfinished.

During an interview on 03/10/22 at 10:20 AM, Staff PPP, Chief Nursing Officer (CNO), stated that there had been discussions about Patient #12 and an RCA had been initiated, but there had been no changes made since this incident. The only education they had completed was in regards to the Hester Davis Fall Assessment.

The hospital was unable to provide documentation related to the RCA to support that education to prevent falls with high fall risk patients was provided, when it was provided, or to whom it was provided.

2. Review of Patient #9's medical record, showed that she was a 54 year old female from a nursing home, who was admitted to the hospital on 01/28/22 for severe anemia (low amounts of oxygen rich blood, causes paleness and weakness) and COVID-19 (highly contagious, and sometimes fatal, virus). Nursing documentation on 03/07/22 showed the patient was a high fall risk and the bed alarm was on.

Observation on 03/07/22 at 3:30 PM, on Unit Four North, showed a red high fall risk sign outside Room 427. Patient #9 was lying in bed, her bed alarm was not activated and she did not have a high fall risk sticker on her identification (ID) band.

During an interview on 03/10/22 at 11:10 AM, Staff RRR, RN, stated that she cared for Patient #9 on 03/07/22. High fall risk patients should have bed alarms and chair alarms on. She checked to make sure bed alarms were activated for high fall risk patients when she rounded on patients. Patient #9 was a high fall risk, but was immobile, and probably why her alarm was not on.

During an interview on 03/07/22 at 3:45 PM, Staff G, Four North Nurse Manager, stated that her expectation of nursing staff was to ensure high risk fall patients had bed alarms activated and fall risk indicated on the patient's ID band.

3. Review of Patient #21's medical record showed that she was a 90 year old female who was admitted to the hospital on 02/28/22, for a syncopal (temporary loss of consciousness) episode, collapsed left lung and mental status changes. Nursing documentation on 03/08/22 showed the patient was a high fall risk and the bed alarm was on.

Observation on 03/08/22 at 10:30 AM, on Unit Four South, showed a red high fall risk sign outside of Room 432. Patient #21 was lying in bed, her bed alarm was not activated and she did not have a high fall risk sticker on her ID band.

During an interview on 03/10/22 at 11:40 AM, Staff SSS, RN, stated that she cared for Patient #21 on 03/08/22. High fall risk patients should have a bed alarm and chair alarm on, fall mats in place, bed in low position, a room close to the nurse's station if possible, call light within reach, a sign outside the door and yellow socks on. Before she left a patient room, she made sure the bed alarm was on if the patient was a high fall risk. Patient #21 was a high fall risk, was immobile and did not move a lot, and that staff may have forgot to put the bed alarm back on after caring for her.

During an interview on 03/10/22 at 11:50 AM, Staff A, Medical/Surgical Director, stated that her expectation of nursing staff on Four South was to have bed alarms on when patients were a high fall risk. High fall risk patients that were immobile, even though their chances of falling out of bed were low, required a bed alarm to be activated and fall risk precautions in place.

4. Review of Patient #34's medical record dated 03/03/22 through 03/08/22, showed the following:
- He was a 76 year old male who presented to the ED on 03/03/22 at 5:07 AM, after falling in his home and hitting his head. He had a large laceration to the back of his scalp, complained of back pain and had increased confusion.
- A fall from the previous week resulted in a compression fracture to his spine and the patient was ordered to wear a brace for his fracture.
- On 03/08/22 his nursing assessment included a Hester Davis Fall Risk assessment that placed him at a high risk for falls.
- Interventions included a bed alarm, call light/belongings in reach, his bed was to be locked and in a low position, two side rails up, adequate lighting and a clutter free environment.

Observation on 03/08/22 at 2:00 PM, on Unit Two North, showed a red high fall risk sign outside of Patient #34's room. Patient #34 was standing alone in his room, struggling with medium sized luggage, his walker was located across the room and not within his reach. The surveyor asked Patient #34 to please sit in his chair for a few minutes, which he did, and when he stood up, his chair alarm sounded. Staff F, Critical Care Manager and Staff WW, RN, came in, turned the chair alarm off, and exited the room with Patient #34 standing, unassisted, and his walker still located across the room.

During an interview on 03/08/22 at 2:23 PM, Staff WW, RN, stated that Patient #34 was a high risk for falls and still on fall precautions. Patient #34 should not have been in his room without assistance, and should be in his chair with the alarm on and not up by himself.

5. Review of Patient #35's medical record dated 03/01/22 through 03/08/22, showed the following:
- She was a 60 year old female who presented to the ED on 03/01/22 at 11:48 PM, after she became unresponsive at her long term care facility.
- Past medical history included altered mental status (mental functioning ranging from slight confusion to coma), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors) and psychosis (a serious mental illness characterized by defective or lost contact with reality).
- Nursing documentation on 03/08/22 at 7:34 AM, showed that Patient #35 was a high risk for falls, and interventions included a bed alarm, her call light within reach and hourly rounding.
- Rounding was not documented hourly.
- On 03/08/22 at 1:03 PM, documentation showed that Patient #35 was in her bed with the bed alarm on.

Observation on 03/08/22 at 2:25 PM on Unit Two North, showed a red high fall risk sign outside of Patient #35's room. The patient was in her bed, the bed alarm was not turned on, and her call light was not within her reach.

During an interview on 03/08/22 at 2:40 PM, Staff F, Critical Care Manager, stated that Patient #35's bed alarm should have been on and her call light should have been within reach.

6. Review of the hospital's policy titled, "Skin Care for Adults," dated 08/15/19, showed:
- A head-to-toe skin assessment would be conducted upon admission and at least every shift, if the patient is at risk for skin breakdown, or has an alteration in skin integrity.
- A skin risk score, Braden Score (an assessment tool for predicting the risk of pressure sores), would be completed upon admission and at least daily.
- Assessment of all wounds would be completed every shift, including status/integrity of dressing if present, observation for changes in drainage, foul odor, and tissue necrosis. Document all dressing changes.

Review of the hospital's undated document titled, "Inpatient Skin Care Guidelines," showed:
- Patients with a Braden score of 18 or less would be on an individual turn schedule, and would be turned or repositioned frequently, with the goal of at least every two hours.
- Pillows or positioning devices would be used for repositioning and bony prominences would be protected with these devices.
- Skin would be inspected every shift.
- Wound/dressing assessments and documentation would be completed every shift.
- Documentation of dressing changes would include drainage, foul odor and tissue necrosis.
- The physician would be contacted for treatment orders.

Review of the hospital's policy titled, "Skin: Negative Pressure Wound Therapy (NPWT)," dated 10/16/19 showed the following:
- Shift is defined as the period of time the staff nurse is scheduled to work, but is not to exceed 12 hours.
- Document shift output from canister in appropriate NPWT flowsheet at least once per shift.
- Assess and document wound per skin care for adults and include the type of wound, type and amount of drainage, signs and symptoms of infection, wound dimensions and characteristics upon arrival and per the policy, label the dressing with date, time, number and type of dressings used.

Review of Patient #17's medical record showed the following:
- He was a 64 year old male who presented to the ED on 11/16/21, after becoming unresponsive on his way to an outpatient appointment.
- Medical history included a stroke (occurs if the flow of oxygen-rich blood cannot reach a portion of the brain) in 2018 and ongoing seizures (excessive activity in the brain which causes uncontrolled jerking movements) since his stroke. He was admitted for a neurology consult and further treatment.
- Nursing documentation on 11/16/21 showed a Braden score of 15 (high risk for skin breakdown). His skin was within normal limits and there were no open wounds. There was no documentation that the patient's position was changed between 10:15 PM and 11/17/21 at 10:55 AM (over 12 hours).
- Nursing documentation on 11/17/21 showed a Braden score of 14. His skin was within normal limits and intact. There was no documentation that the patient's position was changed between 10:55 AM and 9:41 PM (almost 11 hours), and between 9:41 PM and 11/18/22 at 10:41 AM (over 12 hours).
- Nursing documentation on 11/18/21, showed a Braden score of 15. His skin was within normal limits and intact. At 2:49 PM he was placed in a chair, where he remained until 8:04 PM (five hours). He was then returned to bed, and there was no documentation that the patient's position was changed between 8:04 PM and 11/19/21 at 3:15 AM (seven hours).
- Nursing documentation on 11/19/21, showed a Braden score of 14. His skin was within normal limits and intact. There was no documentation that the patient's position was changed between 3:15 AM and 10:14 PM (19 hours), and between 10:14 PM and 11/20/21 at 8:57 AM, he was repositioned every four hours.
- Nursing documentation on 11/20/21, showed a Braden score of 13. His skin was within normal limits and intact. There was no documentation that the patient's position was changed between 8:57 AM and 11/22/21 at 12:23 AM (over 39 hours).
- Nursing documentation from 11/22/21 at 12:23 AM, to 11/23/21 at 4:21 AM, showed that he was repositioned every four to six hours. His Braden score remained a 13. His skin was within normal limits and intact.
- Nursing documentation on 11/23/21 showed a Braden score of 14, then later in the day a 13. His skin was within normal limits and intact. At 1:04 PM, he was positioned on his back with the head of his bed raised to high position (creates significant pressure to the skin covering the tailbone), where he remained until 9:20 PM (eight hours). At 9:20 PM, his head of bed was lowered, where he remained on his back until 11/24/21 at 2:55 PM (over 17 hours).
- Nursing documentation on 11/24/21 showed a Braden score of 14. His skin was within normal limits and intact. At 2:55 PM, the head of his bed was again raised to high position, where he remained on his back until 11:56 PM (nine hours). At 11:56 PM, his head of bed was lowered, with no documented position changes until 11/26/21 at 11:51 PM (48 hours).
-Nursing documentation on 11/26/21, showed a Braden score of 16. His skin was within normal limits and intact. There was no documentation that the patient's position was changed between 11:51 PM and 11/27/21 at 10:48 AM (11 hours).
- Nursing documentation on 11/27/21, showed a Braden score of 16. His skin was within normal limits and intact. There was no documentation that the patient's position was changed between 10:48 AM and 11:00 PM (almost 12 hours).
- Nursing documentation showed Braden scores daily from 11/16/21 through 11/28/21 of less than 18.
- Nursing documentation on 11/28/21, at 11:26 AM, showed a sacrum (triangular shaped bone which lies above the tailbone) wound measuring six centimeters (cm, unit of measurement) in length, by six cm in width, with no depth documented. A wound consultation was ordered.
- Nursing documentation on 11/29/21 showed a wound nurse consultation. The wound nurse placed a photo of the wound in the electronic health record. She noted that the wound was an unstageable pressure injury (a deep opening in the skin in which the extent of the tissue damage cannot be confirmed due to the presence of dead tissue in the wound) but that after dead tissue was removed it would likely be either, a Stage 3 pressure injury (a deep opening in the skin that varies in depth based on location, fatty tissue may be visible, but no bone or muscle are exposed), or a Stage 4 pressure injury (injury to the skin that extends to the bone and muscle).
- On 12/06/21 (eight days after the initial wound nurse assessment), a physician's operative report showed that dead tissue, including skin, subcutaneous (under the skin) tissue and muscle, down the level of the fascia (thin casing that surrounds and holds organs, blood vessel, muscle and bone in place) of the coccyx and sacrum were removed. The pressure ulcer measured a width of 10 cm, length of 5 cm and a depth of 4 cm.
- A physician's operative report, on 12/20/21, showed a colostomy (a surgically created opening in the abdominal wall for digested food to pass through) was placed due to contamination of the pressure injury with stool.
- Nursing documentation on 12/28/21, showed that a wound V.A.C. was ordered for treatment of the pressure injury.
- Wound care documentation from 12/28/21 to 03/07/21, showed that drainage output from the wound V.A.C. was only documented eight times. The patient's dressing was scheduled to be changed every Monday, Wednesday and Friday, or as needed (more frequently).

During an interview on 03/10/22 at 9:00 AM, Staff S, RN, stated the following:
- Skin assessments were to be done every 12 hours and were expected to include the full body.
- Any patient with a Braden score of less than 18 would be placed on a two hour turning and repositioning schedule.
- Patient #17's skin assessment on 11/27/21 at 11:00 PM, that showed his skin was within normal limits and intact, was likely incorrect as "that wound would have taken more than one shift to be that extensive."
- She "felt that based on the first discovery of the wound, he was likely not receiving appropriate skin assessments or repositioning."

During an interview on 03/10/22 at 9:15 AM, Staff J, Nurse Manager, stated the following:
- Skin assessment were to be documented a minimum of once a shift, and that the assessment should include the full body, including rolling the patient over and also assessing buttocks, skin folds, heel and in between the toes.
- Any changes in skin integrity would be documented at that time.
- She would expect that if a patient had a Braden score of less than 18 that they would be repositioned every two hours, and the position change be documented at that time.
- When a wound was identified, there were standing orders and a wound algorithm to determine initial treatment.
- Patient #17 was incontinent of stool frequently and that could have contributed to his skin breakdown.
- Identifying tissue injuries like Patient #17's was difficult in patients with dark skin, unless the nurse was opening the skin folds to assess the area.
- Based on the initial photo of the wound, taken on 11/28/21, the wound could not have developed in a day or two.

During an interview on 03/10/22 at 8:30 AM, Staff OOO, Advanced Practice Registered Nurse (APRN), stated that:
- In conjunction with the physician, she ordered all wound treatments for Patient #17.
- She initially saw the patient on 12/03/21 and that surgical removal of the dead tissue had to be delayed, as the patient had to be off his blood thinner medication for three days prior to surgery.
- She was unsure how long it would take for an unstageable pressure injury to develop, however the patient's wound would not have developed to that extent in one day.
- The wound continued to increase in size, partially due to the patient's immobility.
- Patient #17's wound V.A.C. was to be changed three times a week, on Monday, Wednesday and Friday, and more frequently if needed.

During an interview on 03/10/22 at 9:35 AM, Staff PPP, Doctor of Osteopathy (DO) stated the following:
- The wound likely developed due to inadequate pressure reduction.
- Even when the wound was small, it's proximity to the anus caused it to be contaminated with stool constantly, which created the need for the colostomy.
- Multiple debridements of the wound had been performed. The last one on 03/04/22, was to remove undermining (caused by erosion under the wound edges, where surface of wound does not represent the true underlying damage) and dead fascia and bone.
- The wound was likely not improving, due to continued inadequate pressure reduction.

7. Review of Patient #19's medical record showed the following:
- He was a 35 year old male admitted to the hospital on 02/25/22 at 10:46 PM, for gunshot wounds resulting in multiple injuries, including vascular injury and a bone fracture of the right arm.
- On 02/26/22, he underwent surgery to the right arm, and the surgical incisions were kept open and covered with a dressing.
- On 03/01/22 at 2:30 PM, an order was placed for daily dressing changes to the right arm.
- No dressing change to the patient's right arm was documented on 03/04/22, 03/05/22 or 03/06/22.

Observation on 03/08/22 at 9:25 AM, showed Staff X, RN and Staff Y, RN, changed Patient #19's right arm dressing.

During an interview on 03/08/22 at 9:30 AM, Patient #19 stated that his right arm dressing hadn't been changed for two or three days, and when the dressing was changed on 03/07/22, it was very painful when the old dressing was removed. Staff X apologized to the patient and stated that the dressing should have been changed daily.

During an interview on 03/10/22 at 12:05 PM, Staff TTT, RN, stated that she took care of Patient #19 in the ICU on 03/06/22. She did not change Patient #19's arm dressing because she was told by staff that the surgeons were coming in each morning and changing the dressings. She did not know if the surgeons had changed the right arm dressing on 03/06/22.

During an interview on 03/09/22 at 9:00 AM, Staff FFF, ICU Manager, stated that her expectation of nursing staff was to change dressings as ordered.

8. Review of Patient #31's medical record showed the following:
- He was a 70 year old male who presented to the hospital on 01/25/22 at 5:34 AM, with abdominal pain.
- He had abdominal exploratory surgery and had a wound V.A.C placed to the abdominal surgical incision on 01/25/22.
- There was no wound V.A.C. output documented in the medical record from the placement on 01/25/22 through 03/11/22.

Observation on 03/08/22 at 12:55 PM, showed the following:
- The existing wound V.A.C. dressing on Patient #31's abdomen was not labeled with a date, time, number or type of dressings used.
- Staff RR, RN, removed the dressing and cleaned the wound. She then placed a contact layer (non-adherent dressing for fragile skin used to prevent tissue trauma with dressing removal) to the wound bed, placed black foam to the wound bed and secured it and started the wound V.A.C.
- Staff RR did not label the new wound V.A.C dressing with the date, time, number or type of dressing.

During an interview on 03/08/22 at 1:30 PM, Staff RR, RN, stated the following:
- Normally she would add the date and time to a dressing but due to pain she did not label Patient #31's new dressing.
- The wound V.A.C. output should be documented once per shift.
- There was no physician's order for the contact layer she placed in the wound bed.

9. Review of Patient #34's medical record showed the following:
- He was a 76 year old male who presented to the ED on 03/03/22 at 5:07 AM, after falling in his home and hitting his head. He had a large laceration to the back of his scalp, complained of back pain and had increased confusion.
- He had wounds to his right lower leg, left calf and right heel.
- Physician's orders dated 03/03/22 at 2:04 PM, for dressing changes to the right heel, right lower leg wounds, and left calf.
- There were no dressing changes documented in the medical record from 03/04/22 until 03/08/22.

Observation on 03/08/22 at 2:00 PM, showed Patient #34 with a dressing to his right lower leg that did not have a date, time, number or type of dressing. There was no dressing present on the left calf and there was a large scabbed area open to air.

During an interview on 03/08/22 at 2:00 PM, Patient #34 stated that his dressings had not been changed since the day he went to the hospital.

During an interview on 03/10/22 at 10:20 AM, Staff PPP, CNO, stated that his expectation was for nursing staff to follow physician orders for wound care, complete shift skin assessments, perform patient turning and document the output from wound V.A.C. per policy.


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