HospitalInspections.org

1) Based on clinical record review, document review and staff interview the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for 2 of 10 patient's identified with pressure ulcers (patient #'s1 and 2).
The failure to supervise and evaluate nursing care placed 2 patients at risk to develop pressure ulcers. Patient #1 developed a pressure ulcer.

Findings include:

- The "Hospital Wound Care Policy and Procedure" reviewed on 12/16/10 titled "Evaluation" directed staff to perform an evaluation of wounds on admission, weekly, and on discovery. Under Procedure: 3. the policy states, "Evaluation results are communicated to the members of the care team through documentation, case conference and care planning." The Follow Up Assessment/Documentation Section II-Reference-12, stated and directed staff, "The patient care plan should be updated to reflect any changes in interventions".

- Patient #1's closed medical record reviewed on 12/14/10 to 12/16/10 revealed an admission date of 8/31/10 with diagnoses of a spinal cord injury fracture of C1 and C2,(cervical vertebra). Patient #1's care plan reviewed on 12/14/10 to 12/16/10 lacked evidence nursing staff identified or implemented a plan for the risk for impaired skin integrity or the actual skin impairment. The wound nursing assessment on 9/16/10 revealed nursing staff documented patient #1 developed a Stage II, (Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as a abrasion blister or shallow crater) coccyx pressure ulcer, 16 days after admission.

Staff A interviewed on 12/15/10 at 1:00pm acknowledged nursing supervision failed to ensure staff developed and initiated a care plan for patient #1's Quadriplegia (immobility) which put the patient at high risk for skin impairment and the development of a Stage II coccyx ulcer.

- Patient #2's medical record reviewed on 12/15/10 and 12/16/10 revealed an admission date of 12/3/10 with a diagnosis of a Respiratory Failure secondary to Guillian Barre. The "Nursing Admission History" revealed patient #2 had a coccyx wound at admission. The nursing assessment dated 12/3/10 described the patient's coccyx ulcer as a Stage III (Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue).

Patient #2's initial care plan dated 12/3/10 and reviewed on 12/14/10 lacked evidence nursing identified impaired skin integrity as a priority nursing problem or implemented a care plan for the patient's Stage III pressure ulcer.

Staff B interviewed on 12/15/10 at 9:00am acknowledged patient #2's initial care plan failed to identify the pressure sore as a nursing priority problem, develop and implement a plan of care.

2) Based on clinical record review, document review and staff interview the hospital failed to ensure a supervisor nurse developed a system to ensure staff completed daily flow sheets and turn records for each shifts. Supervisory staff failed to ensure direct care staff documented care provided on daily flow sheet for 2 of 2 patients in the sample (#'s 1 and 2) with a physician order to turn every two hours.

Findings include:

- "The "Position Description" reviewed on 12/15/10 titled, "Registered Nurse/Nursing Supervisor/Charge Nurse (LTACH)," states under, "Essential Duties and Responsibilities, "...4. Implements the patient plan of care and evaluates the patient's response. 5. Directs and supervises care given by other personnel to patient...16. Evaluation of Care A. The effectiveness of nursing interventions, medications, etc., is evaluated and documented in the progress notes...20. Documentation A...reflects knowledge...that include;...e. Nursing flow sheets."

- Patient #1's closed medical record reviewed on 12/14/10 to 12/16/10 revealed an admission date of 8/31/10 with diagnoses of a spinal cord injury fracture of C1 and C2,(cervical vertebra). Physician orders on 9/1/10 at 10:00am ordered patient #1 turned every two hours to take off the weight load off the coccyx.

Patient #1's "Daily Nursing Documentation Sheet" reviewed on 12/15/10 recorded the 9/1/10 "Nursing Interventions, Turns", schedule in the turn column. Staff documented they turned the patient at 7:00pm and again 13 hours later at 8:00am on 9/2/10. On 9/2/10 staff documented they turned the patient at 11:00am and eight hours later at 8:00pm. On 9/3/10 the turn column lacked hourly checks except at 9:00pm when nursing documented an "R" (refuses) at 9:00pm stating " Pt. often refuses-Hurts to much. " On 9/5/10 the turn column lacked documentation from 7:00am to 8:00pm, 13 hours later. On 9/6/10 the turn column lacked documentation from 8:00am to 8:00pm, 12 hours without turning. On 9/7/10 the turn column lacked documentation from 7:00am to 8:00pm, 13 hours without turning. The nursing note on 9/8/10 at 11:00am documented staff turned the patient every two hours. From 11:00am until 6:00pm, a total of 7 hours, staff failed to document they turned the patient. On 9/9/10 the nursing note at 10:05am documented they turned the patient every 2-3 hours. From 6:00pm to 6:00am, a total of 12 hours, staff failed to document they turned the patient. On 9/10/10 the turn column lacked documentation from 7:00am until 5:00pm, a total of 10 hours without turning.

Staff A interviewed on 12/15/10 at 2:00pm verified patient #1's clinical record lacked evidence staff followed the physician order to turn the patient every two hours.

- Patient #2's medical record reviewed on 12/15/10 and 12/16/10 revealed an admission date of 12/3/10 with a diagnosis of a Respiratory Failure secondary to Guillian Barre. The physician orders on 12/6/10 at 1:15pm ordered staff to turn the patient every 2 hours.

Patient #2's "Daily Nursing Documentation Sheet" reviewed on 12/16/10 recorded the 12/6/10 "Nursing Interventions, Turns", schedule in the turn column. Staff documented they turned the patient at 10:00am and 8:00 hours later at 6:00pm. Staff documented on 12/7/10 they turned the patient at 7:00am and 11 hours later at 6:00pm. Staff documented on 12/8/10 they turned the patient at 4:00pm and 16 hours later at 8:00am. The nursing interventions on 12/10/10 lacked documentation of turns for 11 hours from 6:00am to 5:00pm.

Staff B interviewed on 12/15/10 at 9:00am acknowledged the documentation on the turn schedule was incomplete. Staff B verified nursing staff should complete the daily flow sheet for turning.

Based on observation, staff interview, and document review the hospital failed to follow their policy and procedure to develop and keep current a nursing care plan for 1 of 9 inpatient's and 1 closed patient record identified with skin wounds and pressure sores (patients #'s 1 and 2).

Findings include:

The Hospital 's nursing policy and procedure reviewed on 12/16/10, titled "Care Planning, Implementation, and Evaluation" directed RN (Registered Nurse) staff to develop a treatment plan based "on after" an initial assessment of the patient the RN and LPN (Licensed Practical Nurse) staff are to evaluate each problem identified and initiate a Nursing Problem for each priority problem. Care plans are customized and individualized to address the specific needs, outcomes, and interventions planned for the patient.

- Patient #1's closed medical record reviewed on 12/14/10 to 12/16/10 revealed an admission date of 8/31/10 with diagnoses of a spinal cord injury (fracture of C1 and C2(cervical vertebra). Review of the "Weekly Wound Tracking Worksheet" dated for the "week of 9/6/10" and the nursing assessment dated 9/8/10, revealed nursing staff identified a "Red" Rectal wound that was treated with "Butt Paste". Review of the "Weekly Wound Tracking Worksheet" dated "week of 9/13/10", nursing assessment dated 9/16/10, revealed nursing staff documented the patient developed a Stage II pressure ulcer on the coccyx(Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion blister or shallow crater).

Review of the initial problem list and care plan dated 8/31/10 lacked evidence nursing identified or implemented a care plan for the patient's "Skin Integrity: Impaired skin integrity and/or risk for impaired skin integrity/actual pressure ulcer/disruption of skin surface (not r/t pressure)." Nursing failed to document the patient's red rectal wound or document and develop of a Stage II coccyx ulcer on the problem list. RN staff failed to develop and implement a plan of care for the open area on the buttocks between the dates of 9/8/10 to the patients discharge on 10/2/10.

Staff A interviewed on 12/15/10 at 1:00pm acknowledged patient #1's care plan lacked evidence staff developed and initiated a care plan for Skin Integrity related to the development of a red rectal wound on 9/8/10 and patient #1's open pressure sore identified on 9/16/10.

- Patient #2's medical record reviewed on 12/15/10 and 12/16/10 revealed an admission date of 12/3/10 with a diagnosis of a Respiratory Failure secondary to Guillian Barre. The "Nursing Admission History" revealed patient #2 was admitted with a coccyx wound with Methicillin Resistant Staph Aureus (MRSA - an infection-causing bacteria resistant to almost all antibiotics). Review of the hospital's "Weekly Wound Tracking Worksheet" dated 11/29/10 to 12/3/10" and nursing assessment dated 12/3/10 described the patient's coccyx ulcer as a Stage III (Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue).

Patient #2's initial problem list and care plan dated 12/3/10 reviewed on 12/14/10 lacked evidence nursing staff identified impaired skin integrity as a priority nursing problem or implemented a care plan. Hospital policy defined "Skin Integrity: Impaired skin integrity and/or risk for impaired skin integrity/actual pressure ulcer/disruption of skin surface (not r/t related to pressure)." Nursing failed to identify the Stage III coccyx ulcer on the nursing problem list and implement a plan of care for the patient's Stage III pressure sore identified on 12/3/10.

- Staff C observed on 12/14/10 at 2:25pm revealed they performed wound care on patient #2's Stage III pressure ulcer. Staff C confirmed patient #2 pressure ulcer was present on admission to the hospital.

Staff B interviewed on 12/15/10 at 9:00am acknowledged nursing staff failed to care plan for patient #2's Stage III pressure ulcer. Staff B verified hospital policy requires nursing staff to initiate a care plan about skin integrity for all new admissions because of the high acuity of patient's admitted.