HospitalInspections.org

Based on document review and interview the facility failed to:

1. document the assessment, notify the admitting physician of assessment findings, and receive orders for care and treatment of multiple skin/tissues wounds on the bilateral lower extremities of 1 of 7 patients (patient #1)

Refer to Tag 1048

2. establish a specific nursing plan of care to treat multiple skin/tissue wounds on the lower extremities of 1 of 7 patients (patient #1).

Refer to tag 1050

Based on document review and interview, the facility failed to document the assessment, notify the admitting physician of assessment findings, and receive orders for care and treatment of multiple skin/tissues wounds on the bilateral lower extremities of 1 of 7 patients (patient #1)

This deficient practice had the likelihood to affect all patients of the facility.


Findings:

Assessment:

On 2/18/2020, in the office of the quality director the medical record for patient #1 (Pt/pt) was reviewed. Pt #1 was admitted on a Saturday. The admitting nurse documented "pictures had been taken". During the review process six (6) color photographs were identified. Although each picture had a white wound identification sticker captured within the photograph , none of the identification sticker had a wound number, pt identification number, date, or initial of the nurse. The wound stickers were not aligned with the length or width of the wound to accurately gain a true measurement of the wounded skin.

After further review and with the assistance of the Quality Coordinator (QC) and Chief Nursing Officer (CNO), it was confirmed that one (1) photo likely was taken on the date of admission as the date of 11/9/2019 was repeated in three different location. The remaining five (5) photographs had dates that ranged from 11/11/2019 to 11/21/2019.

A review of the initial nursing skin assessment identified no data describing the wounded tissue photographed on 11/9/2019.


Notification to physician:

On 11/9/2019, the date of admission, a single photo was placed in the medical record (MR) for pt #1. This photograph captured two areas of skin discoloration on the right lateral foot. The first was a circular red area and the second was an elongated area than extended from the mid portion of the lateral right foot and into the 5th digit of the foot. The photograph captured this area of the lateral foot, outlined in red. There was no documentation from the admitting nurse of any description for this photograph. The admitting nurse failed to record if she notified the admitting physician of her findings of tissue injury after she photographed pt #1's right foot.

A review of the admission orders did not include prevention or treatment orders for skin/pressure wound care and treatment, indicating the admitting physician was not aware of pt #1's tissue injury to his foot.

A review of the medical record for pt #1 dated 11/11/2019, Monday morning after admission, the following wounds were pictured and entered into the MR.

Wound #1: (Scanned into the electronic MR 11/11/2019) "Left Heel of left foot" (sic). The photograph reflected a large dark red area demarcated at the planter surface of the right heel and extending up the dorsal surface of the heel. By color, the photograph indicated deep tissue injury.

Wound #2: (Scanned into the electronic system 11/11/2019) "Side of right foot" (sic). The photograph reflected a dark purple elongated area surrounded by red inflammation beginning mid lateral right foot and continuing to the Metatarsal (MT) joint. At the MT joint the center of the purple discoloration was white, with reddened inflammation extending to the tip of the 5th digit. This photograph was a close up and pt #1's skin was indented with very small ringed mark. This likely was the results of TED, Anti-embolism stocking being placed over right lower extremity in an effort to reduce swelling. This observation was confirmed by both the Quality Coordinator(QC) and the Chief Nursing Officer(CNO).

An interview with the QC and CNO confirmed the facility used Registered Nurse Practitioners (RNP) Monday through Friday and weekends 8-12 noon. The Floor nurses would communicate patient needs to the RNP who then would make rounds with the physician and communicate those needs to the physician. Pt #1 was admitted to the facility late Saturday Morning.

As other photographs of additional wounds were entered into pt #1's MR, there was no nursing documentation the medical staff, (admitting physician or Registered Nurse Practitioner) had been made aware of pt #1's bilateral lower extremely wounds.


The hospital employs Registered Nurse Practitioners (RNP) as mid level services providers. The RNP had ordered, "Sequential Compression Device" (SCD). A review of pt #1's MR revealed the SCD was used every other shift. However, TED stockings were applied at least once. There was no physician or RNP order to apply the stockings and no explanation documented by a nurse explaining why the stocking were applied. The added pressure, of anti-embolism stocking, created deeper tissue damage in the areas of the already existing pressure wounds.

A review of medical surgical floor nurses, RNP, or physician documentation failed reflect awareness of pt #1 multiple pressure related wounds to his bilateral feet/ankle at the time of discharge.

On the date of discharge, 11/21/2019, the following wounds were photographed and placed in pt #1's MR with no further written nursing documentation.

Wound #1 "Right heel". This concluded the nursing assessment documented for a photographed area of reddish purple skin on the right heel, with a large loose patch of skin attached to the heel.

Wound #2 "Right little toe". This concluded the nursing assessment documented for the photograph which captured a round red area to the lateral aspect of the right foot and a separate elongated area of the lateral aspect of the right foot beginning behind the MT joint extending to the last joint of the 5th digit. The area was reddish purple with a gray white area just behind the MT joint.

Wound #3 "Right ankle". This concluded the nursing assessment documentation. The photograph is in such close proximity it was difficult to determine the true size or location. The photograph captured a dark red area with an irregular order.

Wound #4 "Left foot great toe joint". This concluded the nursing assessment documentation. This photograph was also a very close proximity and included the planter and lateral surface of the joint with a pink interior discoloration and a dark red border visible on the lateral surface of the foot surrounding the top of the joint.

Wound #5 "Left foot top". This concluded the nursing assessment. The photograph captured a deep tissue injury to the dorsal mid left foot. This photograph also captured a wound measurement sticker that aided in establishing the wound was 3.5 Centimeter in length. The border was irregular. The colors of the wound were dark pink, gray, tan and purple.


A review of the facility's policy for admission assessment indicated the following:

Reference Number 136030-0002

Policy:
1. As part of the admission assessment, a health history will be completed on all adult patients admitted to a nursing unit. The nurse completes the health history with input from the patient and/or family members/significant others, as warranted.

2. The Adult Health History, integrated into the Adult Assessment Form is considered part of the assessment data and is a permanent part of the medical record.

Procedure:
1. Health History information is collected within 24 hours of admission with the assessment data.

2:12 Physical Systems of :

2.12.11 Skin

2.13 Mobility


An interview with the CNO confirmed there was no other policy that could assist the nursing department with assessing wounds and be applied to her facility. The facility is a Critical Access Hospital and the system wide policies (which were mandated to be followed) were written for a larger hospital system that had resources available to provide specialty services. Referral to in house wound care being one.

Pt #1 was admitted for swing bed services to received Intravenous anti-biotic's for pylonephritis. At the completion of 12 days he was transferred back to the original hospital for wound care services for 5 wounds on his bilateral extremities.

Based on document review and interview, the facility failed to establish a specific nursing plan of care to treat multiple skin/tissue wounds on the lower extremities of 1 of 7 patients (pt #1).


This deficient practice had the likelihood to effect all patients of the facility.


Findings:


On 11/9/2019, the date of admission, a single photo was placed in the medical record (MR) for pt #1. This photograph captured two areas of skin discoloration on the right lateral foot. The first was a circular red area and the second was an elongated area than extended from the mid portion of the lateral right foot and into the 5th digit of the foot. The photograph captured this area of the lateral foot, outlined in red. There was no documentation from the admitting nurse of any description for this photograph. The admitting nurse failed to record if she notified the admitting physician of her findings of tissue injury after she photographed pt #1's right foot, and failed to initiate a patient specific nursing care plan with written nursing interventions that nursing staff would follow to improve this patients skin condition.

A review of the medical record for pt #1 dated 11/11/2019, Monday morning after admission, the following wounds were pictured and entered into the MR.

Wound #1: (Scanned into the electronic MR 11/11/2019) "Left Heel of left foot" (sic). The photograph reflected a large dark red area demarcated at the planter surface of the right heel and extending up the dorsal surface of the heel. By color, the photograph indicated deep tissue injury.

Wound #2: (Scanned into the electronic system 11/11/2019) "Side of right foot" (sic). The photograph reflected a dark purple elongated area surrounded by red inflammation beginning mid lateral right foot and continuing to the Metatarsal (MT) joint. At the MT joint the center of the purple discoloration was white, with reddened inflammation extending to the tip of the 5th digit. This photograph was a close up and pt #1's skin was indented with very small ringed mark. This likely was the results of TED, Anti-embolism stocking being placed over right lower extremity in an effort to reduce swelling. This observation was confirmed by both the Quality Coordinator(QC) and the Chief Nursing Officer(CNO).

The RN, who took the Monday photographs, failed to document notification the physician or Advanced Practice RN (APRN) related to treatment orders. The RN who took the photographs failed to document pt specific nursing interventions and failed to acquire physician issued treatment orders to improve the quality of pt #1's skin/tissue on his feet.

Additional photographs of additional wounds were entered into pt #1's MR during his stay. At no time during his stay did any nurse document pt #1 had developed new skin/tissue damage. Measurements were not recorded and care planning was not documented to implement nursing interventions to measure skin/tissue improvement or guide nursing staff with care of pt #1.


A review of medical surgical floor nurses, APRN, or physician documentation failed to reflect awareness of pt #1 had multiple pressure related wounds to his bilateral feet/ankle at the time of discharge.

On the date of discharge, 11/21/2019 the following wounds were photographed and placed in pt #1's MR.

Wound #1 "Right heel". This concluded the nursing assessment documented for a photographed area of reddish purple skin on the right heel, with a large loose patch of skin attached to the heel.

Wound #2 "Right little toe". This concluded the nursing assessment documented for the photograph which captured a round red area to the lateral aspect of the right foot and a separate elongated area of the lateral aspect of the right foot beginning behind the MT joint extending to the last joint of the 5th digit. The area was reddish purple with a gray white area just behind the MT joint.

Wound #3 "Right ankle". This concluded the nursing assessment documentation. The photograph is in such close proximity it was difficult to determine the true size or location. The photograph captured a dark red area with an irregular order.

Wound #4 "Left foot great toe joint". This concluded the nursing assessment documentation. This photograph was also a very close proximity and included the planter and lateral surface of the joint with a pink interior discoloration and a dark red border visible on the lateral surface of the foot surrounding the top of the joint.

Wound #5 "Left foot top". This concluded the nursing assessment. The photograph captured a deep tissue injury to the dorsal mid left foot. This photograph also captured a wound measurement sticker that aided in establishing the wound was 3.5 Centimeter in length. The border was irregular. The colors of the wound were dark pink, gray, tan and purple.


The care plan being followed by the nursing staff was the pre-programmed electronic care plan to provide off loading (pressure relief) for a patient with no existing skin/tissue damage. This care plan was designed for the prevention of skin/tissue injury. The computer generated care plan did not provide nursing interventions for patient's admitted with skin/tissue damage.

Pt #1 was admitted for swing bed services to received Intravenous anti-biotic's for pylonephritis. At the completion of 12 days he was transferred back to the original hospital for wound care services for 5 wounds on his bilateral extremities.