HospitalInspections.org

Based on document review and interview, the medical staff failed to ensure the quality of medical care provided to 1 of 10 patients medical records (MRs) reviewed (patients 1's MR).


Findings include:

1. Review of patient 1's MR indicated the following. Patient was admitted on 10/15/2019 and discharged on 12/19/19.

2. Nurses note 10/16/19, 1139 (hours) indicated the following. Pressure injury sacrum, weekly wound care. Community acquired stage 3, length 6.3 cm (centimeters), width 1.2 cm, Depth 0.2 cm, full thickness skin loss involving damage or necrosis of subcutaneous tissue...

3. Physician orders on 10/16/2019, wound care. Sacrum, cleanse wound q (every) shift, stop after 30 days.

4. Physician order on 12/05/2019, wound care. Sacrum, cleanse wound Q6H (every 6 hours) stop after 30 days.

5. MR lacked documentation for sacrum wound orders other than apply barrier cream as needed with positioning q2h (every 2 hours) from 11/16/2019 through 12/04/ 2019.

6. Nurses note 12/16/19, 1356 (hours) indicated the following. Kennedy terminal ulcer sacrum, weekly wound care. Present on admission...length 23 cm (centimeters), width 16 cm, Depth 0.5 cm, full thickness skin loss involving damage or necrosis of subcutaneous tissue...

7. Interview on 2/6/2020, at approximately 1515, hours with N1 (Director of Quality Management) confirmed patient 1 had no sacrum wound orders (other than apply barrier cream as needed with positioning q2h) from 11/16/2019 through 12/04/2019.

Based on document review and interview, the facility failed to ensure evaluation of care provided for 10 of 10 patients medical records (MRs) reviewed (patients 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10's MR).

Findings include:


1. Review of facility policy, CORE: Routine Bathing, Release Date: 06/2019, indicated the following. Pre-moistened disposable cloths that contain a no-rinse surfactant are used for daily bathing.

2. Patient 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10's MR lacked daily bathing during admission.
Patient 1's, MR lacked daily bathing including but not limited to 10/17/2019 and 10/22/2019.
Patient 2's MR lacked daily bathing including but not limited to 01/04/2020 and 01/05/2020.
Patient 3's MR lacked daily bathing including but not limited to 10/17/2019 and 10/18/2019.
Patient 4's MR lacked daily bathing including but not limited to 01/01/2019 and 01/03/2019.
Patient 5's MR lacked daily bathing including but not limited to 12/06/2019.
Patient 6's MR lacked daily bathing including but not limited to 12/16/2019 and 12/17/2019.
Patient 7's MR lacked daily bathing including but not limited to 01/02/2020 and 01/03/2020.
Patient 8's MR lacked daily bathing including but not limited to 01/05/2020.
Patient 9's MR lacked daily bathing including but not limited to 01/02/2020 and 01/04/2020.
Patient 10's MR lacked daily bathing including but not limited to 11/23/2019 and 11/24/2019.


3. Patient 1's MR indicated the following. Admit date 10/15/2019, and discharged 12/19/19.
Physician orders reposition, apply barrier cream as needed with repositioning. Please document all refusals. Start 10/16/2019 q2h (every 2 hours), stop after 45 days.
Patient 1's MR lacked repositioning every 2 hours including but not limited to 10/16/19, patient was on right side at 1657 hours, 1835 hours and 2020 hours. On 10/17/19, patient was on left side at 1600 hours, 1823 hours and 2136 hours.

Patient 2's MR indicated the following. Admitted date 12/24/2019, and discharged on 01/09/20. Physician orders, reposition, apply barrier cream as needed with repositioning. Please document all refusals. Start 12/26/19, q2h, stop after 45 days.
Patient 2's MR lacked repositioning every 2 hours including but not limited to 12/26/2019, patient was supine at 1800 hours, 2000 hours and 12/27/2019 at 0000 hours and 0605 hours.


Patient 3's MR indicated the following. Admitted date 10/11/2019, and discharged on 10/28/2019. Physician orders, reposition, start 10/11/19, q2h, stop after 45 days.
Patient 3's MR lacked repositioning every 2 hours including but not limited to 10/12/2019, patient supine at 0600 hours and 0849 hours and placed on right side at 1007 hours. 10/12/2019 patient on right side at 1952 hours, 2200 hours and 10/13/2019 at 0026 hours, patient was placed on left side at 0200 hours.


Patient 4's MR indicated the following. Admitted date 12/24/2019, and discharged on 02/04/20. Physician orders, reposition, apply barrier cream as needed with repositioning. Please document all refusals. Start 12/24/19, q2h, stop after 45 days.
Patient 4's MR lacked repositioning every 2 hours including but not limited to 12/25/2019, patient on left side at 1000 hours, 1200 hours, 1415 hours and 1636 hours.


Patient 5's MR indicated the following. Admitted date 11/14/2019, and discharged on 12/09/19. Physician orders, reposition, apply barrier cream as needed with repositioning. Please document all refusals. Start 11/14/19, q2h, stop after 45 days.
Patient 5's MR lacked repositioning every 2 hours including but not limited to 11/15/2019, patient sitting up in chair at 1022 hours and 1133 hours, patient on left side at 1342 hours. Patient was on right side at 1824 hours, 2031 hours, patient on left side at 2250 hours.


Patient 6's MR indicated the following. Admitted date 12/13/2019, and discharged on 01/14/2020. Physician orders, reposition, start 12/13/19, q2h, stop after 45 days.
Patient 6's MR lacked repositioning every 2 hours including but not limited to 12/24/2019, patient on left side at 0615 hours, 0813 hours, patient on right side at 1000 hours. On 12/26/2019, patient was on left side at 1000 hours, 1200 hours, patient supine at 1400 hours.


Patient 7's MR indicated the following. Admitted date 12/28/2019, and discharged on 02/04/20. Physician orders, reposition, apply barrier cream as needed with repositioning. Please document all refusals. Start 12/28/19, q2h, stop after 45 days.
Patient 7's MR lacked repositioning every 2 hours including but not limited to 12/31/2019, patient sitting up in chair at 1400 hours and 1600 hours. Patient was in high fowlers position (upper half of body is between 60 degrees and 90 degrees in relation to lower half of body) at 1800 hours and to supine position at 2000 hours. On 12/29/2019, patient supine at 1800 hours and 2000 hours. Patient was on right side at 2223 hours.


Patient 8's MR indicated the following. Admitted date 12/23/2019, and current patient. Physician orders, reposition, apply barrier cream as needed with repositioning. Please document all refusals. Start 12/24/19, q2h, stop after 45 days.
Patient 8's MR lacked repositioning every 2 hours including but not limited to patient supine on 12/25/2019 at 1757 hours, 2000 hours and 2200 hours, patient to right side on 12/26/2019 at 0000 hours. On 12/27/2019, patient in supine position at 1600 hours and 1829 hours, patient on right side at 2000 hours.


Patient 9's MR indicated the following. Admitted date 12/20/2019, and current patient. Physician orders, reposition, apply barrier cream as needed with repositioning. Please document all refusals. Start 12/20/19, q2h, stop after 45 days.
Patient 9's MR lacked repositioning every 2 hours including but not limited to on 12/21/219, patient on right side at 0524 hours, 0830 hours, positioned on left side at 1030 hours and 1222 hours, repositioned to right side at 1443 hours.

Patient 10's MR indicated the following. Admitted date 11/19/2019, and current patient. Physician orders, reposition, apply barrier cream as needed with repositioning. Please document all refusals. Start 11/20/19, q2h, stop after 45 days.
Patient 10's MR lacked repositioning every 2 hours including but not limited on 11/29/2019, patient supine, at 0200 hours, 0400 hours and 0617 hours, positon to right at 0800 hours.

6. Interview on 2/6/2020, at approximately 1300, hours with N1 (Director of Quality Management) confirmed patients 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 lacked documentation of daily baths. Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 lacked documentation of reposition every 2 hours.