HospitalInspections.org

Based on review of facility policy, review of a skills competency checklist, medical record review, and interview, the facility failed to follow and update a Plan of Care for 1 patient (#1) of 5 patients reviewed.

The findings included:

Review of facility policy, Interdisciplinary Plan of Care, dated 1/20/15, revealed "...in order to ensure that the plan continues to be individualized and meeting the needs of the patient...the plan of care shall be reviewed by the clinician at regular daily intervals (not less than once per shift)...during handoffs, changes in the level of care and end of treatments or procedures...documenting progress toward the goal in the plan is the expected documentation when reviewing the IPOC [interdisclinary plan of care]..."

Review of facility policy, Skin Care, last revised 9/2014, revealed "...initiate and review appropriate IPOC for skin integrity..."

Review of a facility, Skills Competency Checklist for Urinary Cauterization, not dated, revealed "...secure the urinary catheter to the patient using [named urinary catheter] stabilization device..."

Medical record review revealed Patient #1 was admitted to the facility on 6/8/16 with diagnoses including Acute Urinary Tract Infection (UTI), Clinical Sepsis, and acute Hyponatremia (low sodium in the blood). Further review revealed the patient was discharged on 6/14/16.

Medical record review of an Admission History and Physical dated 6/8/16 at 12:44 PM revealed "...past medical history of recurrent UTI [urinary tract infections]...chronic catheter..."

Medical record review of a Nursing Admission Assessment dated 6/8/16 at 1:00 PM revealed the patient's Braden Scale (tool used to predict pressure ulcers) was 12 (16 or below indicates high risk of pressure ulcers).

Medical record review of a Wound Care Report dated 6/8/16 at 10:08 PM revealed "...on the left [buttock] there is considerable scarring from a previous skin disruption. There are no open ulcers noted, no redness or blanching redness. On the right buttock similarity, there is evidence of previous healed ulcerations but no active discoloration, induration or other problems..." Further review revealed "...assessment: no current sign of skin ulceration. The patient certainly is at risk given her inability to change positions..."

Medical record review of a Plan of Care dated 6/8/16 at 4:36 PM revealed "...skin integrity, risk of impaired [pressure ulcer prevention]..." Further review of the Plan of Care revealed "...urinary catheter...urinary securement device..."

Medical record review of the Urinary Catheter Plan of Care dated 6/8/16 at 9:34 AM revealed interventions included a urinary securement device (used for stabilization of catheter tubing).

Medical record review of nurses' assessment revealed no documentation of the use of a securement device from 6/8/16 until 6/11/16.

Medical record review of a Wound Care Report dated 6/13/16 at 10:48 PM revealed "...I was called back to see this patient as there had been a change in... buttocks...dark discoloration has been noted today..." Further review revealed "...the patient was turned on left buttock, there was a nonblanching dark discoloration measuring approximately 2.2 x 2.9 cm [centimeters] irregular without signs of redness. The skin was loose and appears to have epidermal shear. There is a wrinkled blister like appearance without underlying fluid. On the right, there is an area of discoloration, again nonblanching, measuring approximately 1.4 x 2 cm, though it is irregular as well...no signs of infection or redness..." Further review revealed "...assessment: pressure injury, recurrent to right and left ischial areas, unstageable, with suspected deep tissue injury. It is also possible the catheter could have slipped under her and created a pressure ulcer..."

Medical record review of the Plan of Care dated 6/14/16 (the day the patient was discharged) revealed no documentation of the wound.

Interview with the Wound Care Physician on 8/3/16 at 8:10 AM, in the conference room, revealed "...she had scars from previous wounds to her buttocks and that is what she was admitted with... when I saw her on 6/8/16 she had a blue discoloration but there were no open wounds at all..." Further interview revealed "...was asked to see the patient again on 6/13/16...when I looked at the wound it was unstageable but had worsened...it was not open but had a blister with some fluid...this was not a big surpise to me given the patient's status, immobility, and nutritional status...this wound was almost unavoidable..." Continued interview revealed "...I think the urinary catheter may have become lodged in the perineal area and could have been the cause for the wound change...I am not sure if she had a securement device in place but would have certainly helped to keep the urinary catheter from the wound site..."

Interview with the Chief Nursing Officer on 8/3/16 at 10:45 AM, in the conference room, confirmed there was no documentation on the Plan of Care regarding the patient's wounds and the Plan of Care was not updated to reflect the patient's wounds. Further interview revealed "...it looks like the securement device was not initiated for the patient until 6/11/16 which would ensure the urinary catheter was not displaced and had no contact with the patient's wound...." Further interview confirmed the Plan of Care was not followed for the patient.