Kindred Hospital Indianapolis North

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 49709 Based on document review and interview, nursing services failed to complete a per shift skin assessment and wound care as ordered for 1 of 10 medical records (MR) reviewed (P1); and failed to document repositioning every 2 hours for 9 of 10 patient medical records reviewed (P1, P2, P4, P5, P6, P7, P8, P9, and P10). The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 49709 Based on document review and interview, nursing services failed to complete a per shift skin assessment and wound care as ordered for 1 of 10 medical records (MR) reviewed (P1); and failed to document repositioning every 2 hours for 9 of 10 patient medical records reviewed (P1, P2, P4, P5, P6, P7, P8, P9, and P10). Findings include: 1. Review of policy/procedure titled, “CORE: Clinical Guidelines for Pressure Injury,” Policy number: H-PC 10-004, release date 06/2022; indicated under Policy: 1. The skin and wound assessment is conducted per the Registered Nurse (RN) b. Each shift (including the day of discharge). 5. Standard interventions for all patients can include but are not limited to: c. Repositioning orders (minimum every two-hour turns). Under Procedure: 8. Documentation: d. Within the electronic/paper medical record document: ii. Execution of the order. 2. Review of P1’s MR indicated: a. On 04/14/25 wound care nurse completed the admission skin assessment. P1 was noted to have a full thickness stage IV sacral wound that measured 8.7 centimeters (cm) x 8.5 cm x 1.3 cm with exposed fat layer, tan, soft, adherent slough, margin open attached to bare peeling epidermal layer mottled across dark non-blanching. b. The vital flow sheet & daily ADL’s sheet, lacked every two-hour entries for turns on: 05/21/25, 06/12/25, 06/13/25, 06/16/25, and 06/17/25. c. The MR lacked documentation of every shift skin assessment completed on 04/16/26, 04/27/25, 05/03/25, 05/09/25, 05/24/25, 05/27/25, 06/04/25, 06/05/25, 06/13/25, 06/14/25, and 06/23/25. d. The MR indicated P1 had wound care orders to be completed on Monday, Wednesday, and Friday starting on Monday, 04/14/25. The MR lacked documentation of wound care provided on 04/18/25, 04/28/25 through 05/26/2025, 05/28/25, 05/30/25, 06/02/25, 06/04/25, 06/11/25, 06/13/25, 06/16/25, 06/20/2025, 06/23/2025, 06/25/25, and 06/30/25. e. On 6/30/2025 the discharge skin assessment indicated P1’s pressure injury to their sacrum had increased in size; the wound had deteriorated to a KTU (Kennedy Terminal Ulcer) to the sacral region included bilateral ischial wounds as all are connected, with a measurement of 22 cm x 26.5 cm x 3.2 cm with eschar, slough, bone, granulation tissue, and muscle noted to wound bed. 3. Review of P2’s MR indicated the following: a. P2 admitted on 04/07/25 b. The vital flow sheet & daily ADL’s sheet, lacked every two-hour entries for turns on the following dates: 04/08/25. 4. Review of P4’s MR indicated the following: a. P4 admitted on 04/14/25 b. The vital flow sheet & daily ADL’s sheet, lacked every two-hour entries for turns on the following dates: 04/25/25 and 04/26/25. 5. Review of P5’s MR indicated the following: a. P5 admitted on 05/30/25 b. The vital flow sheet & daily ADL’s sheet, lacked every two-hour entries for turns on the following dates: 05/31/25 and 06/01/25. 6. Review of P6’s MR indicated the following: a. P6 admitted on 05/17/25 b. The vital flow sheet & daily ADL’s sheet, lacked every two-hour entries for turns on the following dates: 05/31/25 and 06/01/25. 7. Review of P7’s MR indicated the following: a. P7 admitted on 05/07/25 b. The vital flow sheet & daily ADL’s sheet, lacked every two-hour entries for turns on the following dates: 05/22/25 and 05/23/25. 8. Review of P8’s MR indicated the following: a. P8 admitted on 06/17/25 b. The vital flow sheet & daily ADL’s sheet, lacked every two-hour entries for turns on the following dates: 06/29/25. 9. Review of P9’s MR indicated the following: a. P9 admitted on 06/27/25 b. The vital flow sheet & daily ADL’s sheet, lacked every two-hour entries for turns on the following dates: 07/05/25. 10. Review of P10’s MR indicated the following: a. P10 admitted on 06/04/25 b. The vital flow sheet & daily ADL’s sheet, lacked every two-hour entries for turns on the following dates: 06/22/25 and 06/23/25. 11. Interview with A4 (Nursing Supervisor) on 08/12/25 at approximately 4:17 p.m., confirmed if a wound treatment is completed it is to be signed off on the treatment administration record. 12. Interview with A1(Chief Operating Officer) and A2 (Chief Executive Officer) confirmed P1, P2, P4, P5, P6, P7, P8, P9, and P10 lacked every two-hour turns.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 49709 Based on document review and interview, nursing services failed to document repositioning every 2 hours for 1 of 10 patient medical records reviewed (P3). Findings include: 1. Review of policy/procedure titled, “CORE: Clinical Guidelines for Pressure Injury,” Policy number: H-PC 10-004, release date 06/2022; indicated under Policy: 5. Standard interventions for all patients can include but are not limited to: c. Repositioning orders (minimum every two-hour turns). 2. Review of P3’s MR, vital flow sheet & daily ADL’s, indicated lack of documented every two-hour entries of repositioning on the following dates: 01/16/25, 01/23/25, 01/24/25, 01/25/25, 01/28/25, 01/31/25, 02/09/25, and 02/12/25. 3. Interview with A2 on 03/03/25 at approximately 6:05 p.m., confirmed P3’s MR lacked every two-hour entries for turns on the following dates: 01/16/25, 01/23/25, 01/24/25, 01/25/25, 01/28/25, 01/31/25, 02/09/25, and 02/12/25.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 49709 Based on document review and interview, nursing services failed to ensure call lights were answered in a timely manner in 3 of 3 patient rooms (Room 214, 215, and 216) reviewed; failed to ensure prevention and treatment of pressure ulcers in 1 of 10 (P4) patients reviewed; and failed to document completion of peri-care, turns, transfers, bath, and linen change completed daily in 2 of 9 inpatient days reviewed (12/24/24 and 12/25/24). Findings include: 1. Review of policy/procedure titled, “CORE: Clinical Guidelines for Pressure Injury,” H-PC 10-004, release date 06/2022; indicated under Purpose: This policy and procedures establish guidelines for the Registered Nurses (RN) role in preventing and treating pressure injuries based on Braden Risk score and subscales. Under Policy: 2. All patients are considered at risk for pressure injuries. Therefore, patients are routinely screened to determine their Braden risk level: b. Daily. 5. Standard interventions for all patients can include but are not limited to: c. Repositioning orders (minimum every two-hour turns). 2. Review of policy/procedure titled, “Activities of Daily Living,” SAU-QL-10, release date 10/2022; indicated under Procedure: 7. Assistance is provided to patients who need extensive or total assistance with maintenance of nutrition, grooming, and personal and oral hygiene. 3. Review of Unit Activity Report for dates from 12/17/2024 through 12/25/2024 indicated patient call lights were not answered in a timely manner 177 times the call light was activated out of 327 call light activations. The report indicated the following: a. Room 214 call light report indicated the call light was not answered timely 118 out 210 times the call light was activated. These include but are not limited to 12/17/2024-21 minutes, 6 minutes, and 5 minutes. 12/18/2024-34 minutes, 33 minutes, and 15 minutes. 12/19/2024-16 minutes, 15 minutes, and 9 minutes. 12/20/2024-37 minutes, 35 minutes, and 28 minutes. 12/21/2024-1 hour 27 minutes, 1 hour 23 minutes, and 41 minutes. 12/22/2024-34 minutes, 25 minutes, and 13 minutes. 12/23/2024-31 minutes, 24 minutes, and 20 minutes. 12/24/2024-1 hour 18 minutes, 41 minutes, and 19 minutes. 12/25/2024-1 hour 8 minutes, 46 minutes, and 27 minutes. b. Room 215 call light report indicated the call light was not answered timely 20 out 37 times the call light was activated. These include but are not limited to 12/17/2024-17 minutes and 5 minutes. 12/18/2024-20 minutes, 17 minutes, and 14 minutes. 12/19/2024-25 minutes, 10 minutes, and 6 minutes. 12/21/2024-8 minutes and 6 minutes. 12/24/2024-18 minutes, 13 minutes, and 6 minutes. 12/01/2024-16 minutes, 15 minutes, and 9 minutes. c. Room 216, P4’s room, call light report indicated the call light was not answered timely 39 out 80 times the call light was activated. These include but are not limited to 12/17/2024-26 minutes, 10 minutes, and 6 minutes. 12/18/2024-19 minutes, 13 minutes, and 12 minutes. 12/19/2024-18 minutes, 13 minutes, and 12 minutes. 12/20/2024-30 minutes, 29 minutes, and 19 minutes. 12/21/2024-11 minutes, 6 minutes, and 5 minutes. 12/22/2024-21 minutes, 10 minutes, and 9 minutes. 12/23/2024-50 minutes, 28 minutes, and 19 minutes. 12/24/2024-25 minutes and 5 minutes. 4. Review of P4’s MR indicated MR lacked documentation of daily skin assessments completed on 12/19/24 - 12/23/24. MR lacked documentation of daily Braden assessment completed on 12/18/24, 12/22/24 and 12/23/24. 5. Interview with P12 (current patient) on 01/16/25 at approximately 4:00 p.m., indicated the call lights are not answered timely unless their family is there. 6. Interview with P11 (current patient) on 01/16/25 at approximately 3:45 p.m., indicated sometimes it takes a long time to get their call light answered. 7. Interview with A7 (Nursing Supervisor) on 01/16/25 at approximately 4:30 p.m., indicated patients are rounded on every hour and turned/repositioned every two hours and toileted at that time or as needed. A7 indicated the facility does not have a policy indicating the time to answer a call light, but the goal is to answer a patient call light timely.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 49709 Based on document review and observation the facility failed to maintain a clean and sanitary environment by not ensuring patient rooms were cleaned daily in 9 of 9 days reviewed (12/17/24 - 12/25/24); and failed to ensure 2 out of 2 patient rooms were clean (P11 & P12). 1. Review of policy/procedure titled, “Cleaning of Shared Patient Medical Equipment,” H-IC 02-015, release date 06/2022; indicated under Purpose: This policy establishes guidelines to assure that shared patient medical equipment has been cleaned and disinfected prior to use on other patients so that transmission of infections is minimized. Under Policy: 3. Ensure that all equipment is cleaned, disinfected using the appropriate contact time. 2. Review of policy/procedure titled, “Patient Room Cleaning - Daily Cleaning Service,” policy number 16, review date 04/2024; indicated under Zone ONE (Bed): Use the first cloth to clean all parts of the bed. Wipe down all bed rails, headboards, and footboards. 3. Review of F1 Environmental Services (EVS) housekeeper job description indicated patient areas are to be cleaned daily, included but not limited to contact items such as phone, bedside table, over-bed table, empty trash, and mop floors. 4. Review of the housekeeping daily cleaning sheets lacked documentation the following patient rooms were cleaned daily as follows: a. Rooms 211, 216, 218, 220, 222, 223, 224, 225, 226, and 227 lacked documentation that the rooms were cleaned on 12/17/24. b. Rooms 207, 219, 220, 222, 223, 225, 226, and 227 lacked documentation that the rooms were cleaned on 12/18/24. c. Rooms 205, 222, 223, 225, 226, and 227 lacked documentation that the rooms were cleaned on 12/19/24. d. Rooms 222, 223, 225, 226, and 227 lacked documentation that the rooms were cleaned on 12/20/24. e. Rooms 205, 218, 222, 223, 224, 225, 226, and 227 lacked documentation that the rooms were cleaned on 12/21/24. f. Rooms 205, 217, 218, 220, 222, 223, 224, 225, 226, and 227 lacked documentation that the rooms were cleaned on 12/22/24. g. Rooms 202, 220, 223, 224, 225, 226, and 227 lacked documentation that the rooms were cleaned on 12/23/24. h. Rooms 202, 205, 218, 223, 224, 225, 226, and 227 lacked documentation that the rooms were cleaned on 12/24/24. i. Rooms 202, 212, 213, 223, 224, 225, 226, and 227 lacked documentation that the rooms were cleaned on 12/25/24.. 5. On 01/16/25 at approximately 3:40 p.m. this surveyor, accompanied by A1 (Director of Quality Management) and A10, was given a tour of the 200 unit. The patient rooms observed had trash on the floor, cluttered over-bed tables, an over-bed table that was peeling, a full bag of trash tied up to be removed sitting in the trash can, wet floor under the water container for the patients O2 and no wet floor sign, and a used urinal left on the over-bed table. In the nourishment room, the counter was wet under the ice machine. In the unoccupied patient rooms indicated ready for patient admissions, this surveyor observed a water leak in the bathroom, and a mattress cover that had a rip.”