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Based on interview and record review, the hospital failed to identify a pressure ulcer for 1 of 46 sampled patients (Patient 41), before it became unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (necrotic or dead tissue than can be yellow, tan, gray, green or brown) and/or eschar (scab formed in the colors of tan, brown or black in the wound bed). This failure resulted in Patient 41 developing an unstageable pressure ulcer to the mid lower back, 9 days after admission.

Findings:

A review of Patient 41's medical record was conducted on 8/7/12. It noted that the patient was admitted on 6/17/12 through the emergency department and was later transferred to the medical intensive care unit (MICU is a specialized section of a hospital that provides comprehensive and continuous care for persons who are critically ill). The diagnoses included altered mental status (decreased alertness) characterized by confusion, acute respiratory distress (difficulty breathing) and end stage renal disease (ESRD, the kidneys are no longer able to work at a level needed for day-to-day life) on dialysis (a process of filtering the blood, the way kidneys normally do, using a machine). Other diagnoses included diabetes mellitus (high glucose levels in the blood) and hypertension (high blood pressure).

A review of the entity reported incident noted that on 6/26/12, Patient 41 was identified with an unstageable pressure ulcer to the lower back. This was 9 days after admission.

A review of Patient 41's medical record was conducted on 8/7/12 at approximately 10:30 AM with the Quality Resource Nurse 1. The Nursing Adult Assessment completed on 6/17/12 at 1:20 PM, noted the following:
the patient received a Braden Score (an assessment tool to determine if the patient was high risk for skin breakdown) of 13. A score of 18 or below is often the prediction of pressure ulcer risk. Subsequent Braden Score results conducted between 6/17/12 and 6/26/12, noted a fluctuation in the scores between 8 and 13. For patient 41, the Braden Score represented: Sensory perception - ranged from no impairment on admission, to very limited to complete limited from 6/18/12 through 6/28/12. The patient was bedfast (stayed in bed) and completely immobile (required staff assistance for movement). Nutrition assessment ranged from probably inadequate, adequate to very poor. Friction/Shear to the skin fluctuated between a skin problem and potential skin problem.

A review of the skin assessment noted an Ulcer/Non-Blanchable/Erythema (redness to intact skin), Stage II (partial thickness dermis loss) to the left elbow. Ulcer/Non-Blanchable Erythema to the right heel, suspected deep tissue injury (an injury to a patients underlying tissue below the skin ' s surface that results from prolonged pressure in an area of the body). Vascular ulcer to the right lateral hip and erythema/redness to the posterior coccyx/sacrum (lower buttock). Erosion (ulceration) to the posterior coccyx/sacrum. There was no documented evidence of any new skin breakdown or pressure areas identified from admission until 6/26/12.

A review of the " Interdisciplinary Care Plan Current Interventions Adult Skin Assessment " completed on 6/17/12, included the following:
W1 (wound 1), Stage III (full thickness tissue loss) to left elbow. the intervention was to off load pressure (keep pressure off of the area).
W2, Non-Blanchable (erythema or redness to intact skin) to right heel. The intervention - "not visible" (could not determine the meaning).
W4, Stage II (partial thickness loss of dermis) deep tissue injury & erythema to coccyx (small bone at the base of the sacrum) and sacrum (the bottom of the spine). The intervention was to apply barrier cream (a special cream is rubbed on the skin to protect the skin from contact with harmful substances) and to off load pressure.
W5, erosion (ulceration) to scrotom (the external sac of skin that encloses the testicles). the intervention was to keep the area clean and apply barrier cream.
W6, Unsteagable to left lateral (outside area) hip. The intervention was to apply Telfa dressing (an absorbent and choice of dressing for partial thickness wounds).

A review of the "Wound Care Team", assessment completed on 6/19/12, included the following:

#1 Assessment: Ulcer/Non Blanchable Erythema to left elbow. length 2.5 cm x width 0.8 cm x depth 0.1 cm. Stage III pressure was present on admission. 95 % yellow/tan necrotic (dead or dying tissue) area with scant serosanguineous (consisting of both blood and serous fluid) drainage.

Recommendation:
a. Cleanse wound with wound cleanser.
b. Cover wound with Hydrocolloid (a therapeutic or protective material applied to a wound) every 3 days.
c. Strict turning schedule, low air loss bed (a mattress that provides a flow of air to assist in managing the heat and humidity of the skin), keep pressure off wound.
d. Float heels (keep pressure off the heels); heel lift boots.

#4. Assessment: Ulcer/Non -Blanchable Erythema to coccyx/sacrum. 1 cm x 0.2 cm x 0 cm. Stage II pressure ulcer present on admission with scant serosanguineous.

Recommendation:
a. Cleanse with wound cleanser.
b. Cover with Mepilex (is a soft and highly conformable foam dressing that absorbs exudate and maintains a moist wound environment) sacral border, change every 3 days.
c. Strict turning schedule, low air loss bed, keep pressure off wound.
d. Float heels, heel lift boots.

#6 Assessments: Ulcer/Non-Blanchable Erythema unstageable pressure ulcer to left hip, present on admission; 4 cm x 3 cm x 0 cm; no drainage.

Recommendation:
a. Cleanse with wound cleanser.
b. Cover with Hydrocolloid, change every 3 days.
c. Strict turning schedule, low air loss bed, keeps pressure off wound.
d. Float heels, heel lift boots.
e. Nutritional and physical mobility evaluation.

Further review of the medical record noted that on 6/23/12 at 7:00 PM, Patient 41 was on the Low Air Loss Bed. The Wound Care Consultant had recommended a Low Air Loss Bed on 6/19/12. A review of the physician order dated 6/23/12 at 9:25 AM, confirmed an order for a specialty bed for wound.

A review of the "Interdisciplinary Care Plan Current Interventions Adult Skin Assessment" noted, Unstageable deep tissue injury to lower back. There was no measurement or description of the wound. Intervention was to cleanse the wound with soap and water; apply Mepilex; (6/26/12) Low Air Loss Bed.

A review of the "Wound Care Team" assessment completed on 6/27/12, noted the following:

Wound # 7, Ulcer/Non-Blanchable Erythema to lower back. Proximal end of wound is open and unstageable. Medial part of the wound is blood filled blister and distal part of the wound is deep tissue injury. There is Unblanchable Erythema that connects the three areas of the wound. The wound was unstageable and measured 12 cm (4 ? inches) x 3 cm x 0 cm with scant serosanguineous drainage. The wound was not present on admission. The treatment was for wet to moist dressing changes.

An interview was conducted on 8/7/12, at approximately 10:35 AM, with the Quality Resource Nurse 1, during the review of Patient 41's medical record. There was no documented evidence in the medical record of any new skin break down or pressure area to Patient 41's lower back/spine from admission until 6/26/12; when the area was identified as unstageable. The Resource Nurse 1 stated that it was possible that the patient was admitted with the pressure area to the lower back and that the nurses were documenting the wrong location in the medical record. A later comparison of the wound photographs taken on 6/17/12 noted a stage 11 pressure area to the patient's coccyx/sacrum and the photograph taken 6/26/12 noted the new wound to the middle lower back/spine area.

An interview was conducted on 8/7/12, at approximately 11:00 AM, with Registered Nurse (RN) Educator 1. RN Educator 1 stated that she was familiar with Patient 41's medical condition and the care that was provided. RN Educator 1 confirmed that wound #7 was not present on admission. She stated that the patient was very sick and that there were times when the patient coded (heart stopped and had to resuscitated) and that the patient was not able to be turned due to his medical condition. She also stated that the patient had diarrhea since admission and during his entire hospital stay which increased his risk for skin breakdown. RN Educator 1 stated that a head to toe skin assessment was completed on Patient 41 whenever he received baths, chux and linen changes. RN Educator 1 responded that she was not sure why the area to the lower back was not identified prior to it becoming unstageable on 6/26/12.

A review of patient 41's "Flow-sheet: Pressure Ulcer Review", from 6/17/12 to 6/26/12 noted the following:

On 6/17/12, there were multiple entries noting normal skin color, skin warm with moist mucus membrane and no problem with skin turgor (a reflection of the skin elasticity).

On 6/17/12, 9:05 AM, it was noted that the patient diaper and linen were changed. There was no documentation of any new skin break down or pressure areas.

On 6/18/12 at 7:30 AM, it was noted that the patient skin temperature was cold with fragile skin turgor.

On 6/18/12, at 8:45 AM the patient chux (an absorbant pad) and linen was changed. Barrier cream was applied.

On 6/18/12, at 3:00 PM, a bath was provided and barrier cream applied. The chux and linen were changed. There was no documentation of any new skin break down or pressure areas. Also, there was no documentation of skin protective/comfort devices being used.

On 6/19/12, at 1:00 PM, a bath was provided, barrier cream applied and the linen was changed.

On 6/19/12, at 7:00, partial linen change took place.

On 6/19/12, at 9:00 PM, bath, chux and linen changes were provided. There was no documentation of any new pressure areas or skin breakdown. Also, there was no documentation of skin protective/comfort devices being used.

On 6/20/12, at 3:00 PM, the chux was changed and barrier cream was applied. There was no documentation of any new pressure areas or skin breakdown. Also, there was no documentation of skin protective/comfort devices being used.

On 6/21/12, at 1:00 AM and 11:00 PM, baths were provided. The chux and linen were changed. There was no documentation of any new skin breakdown or pressure areas.

On 6/21/12, at 5:00 PM and 9:00 PM, the chux and linen were changed. There was no documentation of any new skin breakdown or new pressure areas.

On 6/22/12, there was no notation of bath, chux or linen change. There was no documentation of any new skin breakdown or new pressure areas.

On 6/23/12 at 7:00 PM the linen was changed. There was no documentation of any new skin breakdown or pressure areas.

On 6/24/12 at 1:00 PM the linen was changed. There was no documentation of any new skin breakdown or pressure area.

On 6/25/12, there was no documentation of bath, chux or linen change. There was no documentation of any new skin breakdown or pressure area.

On 6/26/12 at 2:00 AM and 9:00 PM, baths were provided and barrier cream applied. The chux and linen were changed. There was no documentation of any new pressure areas or skin breakdown.

A review of the hospital policy titled, "Assessment and Reassessment", effective 7/12, included the following: "Reassessment - The patient is reassessed (a) a minimum of each shift for all inpatients .... "

An interview was conducted on 8/8/12, at approximately 12:35 PM, with the Wound Care Consultant who verified that Patient 41's unstageable pressure ulcer was not present to the lower back on 6/19/12, when she completed the first wound assessment of the patient. The Wound Care Consultant stated that the patient was in poor health and that she had speculated that the patient developed the deep tissue injury to the spine when he went to CT (computed tomography) Scan (a machine that takes detailed pictures inside the body from different angles) couple of days before. (Patient 41 completed the CT Scan on 6/20/12; the unstageable area was not identified until 6/26/12). The Wound Care Consultant stated, "The patient was in renal failure, poor health with the bones were protruding from his spine; the same areas that developed the unstageable pressure ulcer. The patient was very thin and debilitated and was prone to skin breakdown". The Wound Care Consultant responded when asked why the pressure area was not identified earlier before it became unstageable, "It is usually not evident at the time the injury occurred, it shows up later".

A review of the document titled, " Mosby ' s Skills- pressure Ulcer: Risk Assessment (Adult and Pediatric) " received on 8/8/12, (guidelines for nurses to follow when assessing and treating patients with pressure ulcers or at risk for pressure ulcers) included the following for Pressure Ulcer Risk Assessment and prevention:

" 1. Perform a risk assessment using the Braden Scale for the adult population .... at least once a shift. Adult patients with a Braden scale score of 18 or less are noted at increased risk for skin breakdown. "

" 2. Assess patient ' s skin general condition, temperature, color and turgor, including general condition of mucous membranes at least once a shift.

" 4 ...Assess and treat incontinence: clean and dry skin after each incontinence episode using a PH-balance cleanser. Use incontinence skin barriers as needed to protect and maintain skin integrity .... "

" 5. Initiate and modify as appropriate the patient care plan for those patients identified at increased risk for skin breakdown. "

The following was noted under Assessment and preparation:

" ...6. Assess condition of patient ' s skin over region of pressure:
a. Inspect skin for discoloration (redness in light-tone skin; purplish or bluish in darkly pigmented skin), inspect tissue consistency (firm or boggy feel) and/or palpate for abnormal sensations ... .... "
b. Palpate discolored area for blanching. "
d. Inspect for absence of superficial skin layers " .
Procedure: " When repositioning a patient, observe for skin discoloration in the area that was under pressure .... "