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Based on interviews and the review of medical record and other documents, it was determined the facility did not administer its quality assurance program to assure the implementation, through established mechanisms, of actions necessary to correct identified problems.

Findings include:

The review of the Pressure Ulcer Prevalence report submitted to the organization wide Performance Improvement Committee on April 12, 2011 noted the assessment, prevention and treatment of pressure ulcers have been identified as a quality issue.

In an Interview on 4/20/11 with the Director of Performance Improvement about Pressure ulcer prevalence, she stated that a pressure ulcer improvement team was established with collaboration by Nursing, Performance Improvement and Medical Staff to enhance the quality of care provided to patients. Pressure ulcer prevalence has however remained stable at a mean of 3.5% with annual aggregate of 3.25% in 2009 and 3.29 in 2010 according to the Annual Evaluation of Performance Improvement Plan for 2010-2011.

The review of 17 records of patients with pressure ulcers identified problems with early implementation of certain preventive measures for bed bound patients. Also noted was the lack of timely recognition and documentation of pressure ulcers as cited under Tag A-0396. There was evidence that staff members did not timely communicate the patients' needs to each other to ensure the care of patients follow a multidisciplinary approach as intended by the facility policy on Pressure Ulcers Prevention and Treatment.

MR #2
For example, this elderly patient presented to the Emergency Department on 12/22/10 at 14:53 with complaints of left facial droop and slurred speech. The patient's medical history was significant for diabetes, CVA- 2 years ago, acute renal failure and hypertension. The Nursing Admission Database on 12/23/10 noted discoloration in the sacral area. The Admission History on 12/23 noted the patient's skin was dry and intact. Blood albumin was 4.1 on 12/23/10. The patient was discharged on 4/7/11 with multiple pressure ulcers; a stage IV pressure ulcer on the sacrum; stage II on the right hip, unstageable pressure ulcer on the left hip and unstageable ulcer on both heels. The Wound Care Consultant on 1/18/11, 2/25/11 and 3/10/11 recommended a High Calorie-High Protein diet. The patient was nutritionally assessed on 12/24/10.The current diet order was Glucerna1.2 cal at 50ml/hr which provided 1200 calories- 60gms protein. The Dietitian calculated the patient's nutritional needs at 1875 calories; 60-75gms protein. The blood albumin on 12/23/10 was 4.1. The dietician noted the prescribed diet did not meet the patient's nutritional needs. The patient was reassessed Sixteen times during the course of hospitalization. On fifteen occasions, the dietitian determined that the prescribed diet did not meet patient's nutritional needs. She recommended that patient enteral feeding rate be increase to meet her calorie and protein needs. The patient's blood albumin gradually dropped to 1.8 on 4/6/11. She was discharged on 4/7/11. Hospital policy titled " Pressure Ulcers: Prevention and Treatment", under Dietitian's Responsibilities notes that the Dietitian will "confer and collaborate with members of the interdisciplinary team regarding coordination and documentation of assessments, plans and risk reduction strategies". There was no evidence the dietitian confer with members of the multidisciplinary team to ensure the patient's care needs were met. The medical staff did not follow up on the recommendation of the wound care nurse and the dietitian; the reason for not meeting the nutritional goal of the patient was not documented.







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Based on interviews, the review of medical records and other documents, it was determined that nursing staff failed to timely identify changes in patients' skin condition and confer with appropriate medical staff relative to the care of patients on an ongoing basis to ensure patients receive appropriate skin care. This finding is noted in 7 of 17 applicable medical records.

Findings include:

MR #1
1- This 54 year old male was admitted on 11/11/10 to the Surgical Intensive Care Unit for aggressive management of his blood pressure. The initial nursing assessment noted the patient's skin was intact with no physical impairments. The patient became debilitated during a protracted hospital course requiring long-term intubation for respiratory failure, multiple organ system failure and sepsis. The review of the Weekly Pressure Ulcer Progress Assessment Update revealed a pressure ulcer, stage II, 4x2 cm on the occipital was identified on 12/9/10. The size and the stage of the pressure ulcer indicated untimely recognition of the pressure point. The facility did not implement its guideline titled "Pressure Ulcer Prevention and Treatment" that indicates the maintenance of skin integrity and management of pressure ulcers will follow a multidisciplinary approach. While the nurse noted on 12/9/10 that a "Donut pillow" was initiated, there was no indication the physician was aware of the pressure ulcers and a multidisciplinary treatment plan implement in a timely manner. The earliest treatment order by the physician for the occipital pressure ulcer was bacitracin ointment application twice daily written on 1/7/11.

On 12/19/10, the "Weekly Pressure Ulcer Progress Assessment Update" revealed stage II pressure ulcers were identified on the sacrum (1cm x 3cm) and left buttocks (1?cm x 1? cm). Again, there was no evidence that these pressure points were timely identified. The nurse noted that Tegaderm was applied to the sites; however, there was no indication of physician involvement until 1/03/11, when an order for Tegasorb every 72 hours to sacral decubitus was written. The order did not include the treatment of the left buttock pressure ulcer.

The nurse identified an "unstagable" right heel ulcer (2.0 cm 2? cm) on 12/26/10 and noted heel booties were in place. By 1/2/11, the right heel ulcer was black and suspected of deep tissue injury. The review of nurses' progress notes showed there was no early intervention to prevent heel ulcers for this bed bound patient.

MR #3
2- This is a 79 year-old with multiple medical conditions including cerebrovascular accident x 2, seizure disorder, diabetes, hypertension, coronary artery disease and congestive heart failure. The patient was admitted on 4/5/11with changes in mental status. The initial nursing assessment and database on 4/5/11 noted the patient had no pressure ulcers but was identified as a high risk for developing pressure ulcers evidenced by a Braden score of 9. There was no documentation of changes in the patient's skin condition before a stage II, right buttock (4cm x 3cm) was documented on 4/12/11 in the "Weekly Pressure Ulcer Progress Assessment Update". The size and the stage of the pressure ulcer indicated a lack of timely recognition of the pressure point on the right buttocks that resulted in a partial thickness loss of the dermis.

MR #4
3- This 41 year-old male was a recent discharge who was readmitted on 4/13/11 to rule out sepsis. The patient medical history included AIDS, HIV encephalopathy, depression, anemia and seizure disorder. A physician examination on 4/13/11 revealed a stage II (2cm x 2cm), sacral decubitus. The patient remained in the Emergency Department while awaiting MICU bed that became available on 4/15/11. On arrival to the Medical Intensive Care Unit on 4/15/11, the patient was noted to have a sacral stage II, 8cm x 8cm and a right buttock stage II, 6cm x 5cm. By 4/17, additional pressure ulcers developed on the left ear lobe, right heel, left heel, right outer ankle and right hip. A physician order for application of Silverdene cream to sacral ulcer was written on 4/17. However, the treatment plan did not include the right buttocks and the left earlobe as at the time of medical record review on 4/19/11.

-MR #5
4- This 82-year-old male with past medical history of hypertension, diabetes and BPH was admitted for an elective TURP on 4/4/11. The patient developed urosepsis and was admitted to the SICU on 4/6/11. The initial nursing assessment identified the patient as a high risk for developing pressure ulcers evidenced by a Braden score of 9 on 4/6/11. A sacral ulcer, stage II (4cm x 4cm) and a right heel stage II were identified on 4/17 and 4/18 respectively. The sacral pressure ulcer was not timely identified and treated. There was no indication that the nurse confer with the responsible physician relative to changes in the patient ' s skin condition in a timely manner. A physician order for the treatment of the sacral ulcer was written two days after the identification of the pressure ulcer by the nursing staff. During observation tour on 4/19/11, the patient was found to have a Tegaderm dressing in place to the 2nd toe of the right foot which showed skin discoloration and a broken skin. The patient's nurse on interview at 11:15 AM indicated the broken skin on the right 2nd toe is not a pressure ulcer. The review of the patient's treatment plan noted the non pressure ulcer identified in this diabetic patient was not referred to the physician for assessment and treatment.


MR #6
5-This 69 year male was evaluated in the Emergency Department (ED) on 1/24/11 and was admitted to 13EOB unit on 1/25/2011 at 17:08. The nurse noted in the ED on 1/24/11 that the patient was treated for frost bite, hypothermia and edema to both foot. However, the initial nursing assessment documented in the Nursing Patient Admission Database form under the section " Musculoskeletal & Skin " did not include the description of the patient's skin. The complete description and treatment plan for the patient's feet was not documented.

The vascular surgery consultant on 1/26/11 noted that the patient had drainage from the sole the left foot; purulent drainage from both lower extremities and drainage to left foot abscess. A wound care order dated 1/28/11 at 10:10 instructed nursing staff to change the patient ' s foot dressing twice daily. The order did not specify the type of dressing to be applied to the wound. The nurse noted dressing to foot in the Medication Administration Record (MAR) but did not indicate the type of dressing applied. There was no evidence that nursing staff clarified the order with the medical staff. The physician noted on 1/29/11 " no more dressing change necessary " ; however, the MAR revealed wound dressing was initiated on 1/28/11 and continued to 2/7/11.

MR #7
5 - The patient was admitted to the facility on 3/30/11 with intact skin. On 4/14/11 at 0735, the nurse noted "stage I (? cm by ? cm) in the coccyx; the area cleaned with normal saline and MD paged pending return call". By 2300 on the same day, the nurse noted a stage II sacral ulcer (1cm x 1cm) in the sacrum. On 4/15/11 at 0500, the nurse noted skin break on the sacrum and MD was informed. There was no documentation of a follow-up with the physician until 05/15/11 at 5:00 AM, a day later. There was no written order for the treatment of the pressure ulcers until on 5/15/11 at 5:20 AM. The treatment was implemented on 4/15/11 at 0700.

Simillar findings related to inadequate documentation of interventions aimed at prevention and mangement of pressure ulcers were noted in MR #8.



Based on interviews, the review of medical records and other documents, it was determined that the facility did not ensure that patients placed on restraints are monitored appropriately and for each patient on restraint a new order is obtained daily to reinstate the restraint.

Findings:

Review of MR# 9
1- This elderly patient with a history of Alzheimer's disease and hypertension was placed on bilateral wrist restraints on 4/13/11 at 6:39AM to prevent interference with treatment. The patient's restraints were discontinued on 4/19/11. The review of the restraint flow sheets revealed the patient was not monitored in accordance with the facility ' s protocol on Restraint and Seclusion. There was no evidence the patient was monitored and the wrist restraints released on 4/18/11 from 2000 to 2400.


Review of MR# 10
2- This adult patient was orally intubated in the Emergency Department on 4/14/11. The patient was status post motor vehicle accident with facial edema and left orbit medial wall fracture. The patient was placed on bilateral wrist restraints on 4/15 at 7:30 AM due to agitation, restlessness and to prevent self extubation. The wrist restraints were discontinued on 4/19/11. The review of the restraint flow sheet revealed no evidence of restraint monitoring on 4/17 for two hours from 1030 to 1230.

MR #3
3- A physician order for bilateral wrist restraint was obtained on 4/10/11 to prevent this patient from pulling out her endotracheal tube. The facility ' s policy titled Restraint and Seclusion requires a new order to be obtained to reinstate restraints even if the time on the original order has not expired. The review of the restraint flow sheet noted the application of bilateral wrist restraint from 4/10 until 4/18. A physician orders was not obtained to reinstate bilateral wrist restraint on 4/12 and 4/13; however, on both days the patient had bilateral wrist restraints applied.




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