HospitalInspections.org

Based on interview and record review the hospital failed to inform/communicate with 1 of 1 patient [Patient #1's] legal guardian regarding altered skin integrity sustained during the inpatient stay. [Patient #1] sustained altered skin integrity to the left hand, face, neck, thigh, left heel and left arm skin graft. The legal guardian did not find out about the altered skin integrity until after [Patient #1] was discharged and admitted to the inpatient hospice facility.

Findings Included:

The physician discharge summary dated 04/05/11 reflected, "61 year old female with a history of traumatic brain injury, subdural hematoma with craniotomy in the past who was brought in from a nursing home for altered mental status and unresponsiveness...the patient was intubated in the emergency room...she was found to have Pneumonia, UTI [Urinary Tract Infection], and Sepsis, and was treated with antibiotics...the patient continued to be unresponsive during her stay...unable to be weaned from the vent due to her poor prognosis and mental status...guardian contacted and options of tracheostomy...versus hospice were discussed...it was decided care would be withdrawn...comfort care measures initiated and patient discharged to....hospice care center..."

The physician's orders dated 03/26/11 timed at 10:15 AM reflected, "CT abdomen, pelvis with contrast stat..."

The nursing note dated 03/26/11 timed at 5:29 PM reflected, "IV [Intravenous] L [Left] hand, 18 single lumen...reddened, swollen, ecchymotic, removed...IV dye extravasated...pressure dressing applied wrapped in warm blanket and elevated..."No documentation indicating [Patient #1's] guardian was informed.

The nursing note dated 03/27/11 timed at 4:15 AM reflected, "Wound #1, blister...L [Left] hand...oozing serous drainage...cracked/blisters/broken; length 7 cm [Centimeters], Width 10 cm, dressing dry and intact..."

The nursing note dated 03/28/11 timed at 7:37 AM reflected, "Wound #1, blister...left hand....drainage serous..."

The physician progress note dated 03/30/11 timed at 04:44 reflected, "Spoke with patient's guardian regarding patient's decompensation...informed that she is starting to have multi-organ failure despite efforts...guardian expressed her desire to continue every thinkable measure in efforts to treat the patient...we will commence with RotoProne bed...we will discuss with guardian regarding any major changes in patient's status..." No documentation was found indicating the guardian was notified of altered skin integrity for [Patient #1] throughout her inpatient stay.

The nursing note dated 03/30/11 timed at 05:27 AM reflected, "Doctor...at bedside to evaluate patient...orders received to RotoProne patient at this time due/to declining respiratory status..."

The physician's orders dated 03/30/11 timed at 05:30 AM reflected, "RotoProne Bed."

The nursing notes dated 03/30/11 timed at 05:00 AM to 04/01/11 timed at 08:00 AM reflected, [Patient #1] was on the RotoProne bed.

The nursing note dated 04/01/11 timed at 10:00 AM reflected, [Patient #1] was removed from the RotoProne bed and placed on "total care/waffle overlay..."

The nurse's note dated 04/03/11 timed at 5:30 PM reflected, "Wound #1...blister left hand...drainage serous...Wound #2....blister to face..."

The nurse's note dated 04/03/11 timed at 8:25 PM reflected, "Wound #1...blister left hand...Wound #2...blister face..."

The nurse's note dated 04/04/11 timed at 3:29 PM reflected, "Wound #1...blister left hand...at 3:48 PM Wound #2...abrasion face..."

The nursing note dated 04/05/11 timed at 12:08 PM reflected, "Wound #1...blister left hand...Wound #2 type face, location abdomen...Wound #3...blister left thigh...." No documentation was found indicating [Patient #1's] skin changes were reported to the legal guardian.

The inpatient hospice notes dated 04/05/11 reflected, "Abrasions to face and right neck...left heel pressure ulcer stage I, three centimeters in length, 2.5 centimeters wide, depth none...left thigh blister, 9 centimeters in length, five centimeters wide...filled with yellow fluid...dressing placed over blister to collect fluid and drainage if it ruptures...left hand 8.5 centimeters in length, 7.5 centimeters wide...beefy red, slough 90% [percent]...drainage serosanguineous yellow and red, moderate amount...left arm on graft site...blister filled with yellow fluid, 2.5 centimeters in length, 2.0 centimeters wide....right wrist serous drainage, yellow...appears to be site of multiple blood collections...skin around sites also draining yellow liquid..."

On 06/09/11 at approximately 2:15 PM, Staff #5 was interviewed. Staff #5 was asked to review the medical record. Staff #5 stated she could find no documentation indicating [Patient #1's] guardian was notified of the altered skin integrity.

On 06/10/11 at 10:30 AM Staff #11 was interviewed. Staff #11 was asked if [Patient #1's] altered skin integrity was documented. Staff #11 stated she did not document, nor did she tell the guardian. She stated she spoke with the guardian towards the end of [Patient #1's] stay about her declining condition.

On 06/10/11 at 7:30 PM [Patient #1's] responsible party was interviewed. The responsible party stated she was unaware [Patient #1] had multiple skin problems while in the hospital. The responsible party stated when she went to the hospice she was surprised by the abrasions, blisters and condition of [Patient #1's] skin. The responsible party stated she was not notified by hospital personnel regarding the condition of [Patient #1's] skin.

The policy entitled, "Patient Notification of Unexpected Outcomes or Errors" with an effective date of 03/21/08 reflected, "Disclosure of outcomes of care including unanticipated outcomes...is made to the patient. If the patient is deemed incapable of understanding...the surrogate decision maker substitutes for the patient...the individual designated as the primary communicator with the patient and/or family documents in the patient's medical record what was communicated and any response by the patient and/or family or other discussion..."

The policy entitled, "Nursing Clinical Documentation" with an effective date of 09/14/10 reflected, "Document the name and title of staff notified about specific events or patient's change of condition. Include physicians and family members...entries in the nursing record are concise, pertinent, and related to the plan of care. All entries support or elaborate on nursing care provided, findings, and/or result...the patient's significant other(s) are involved in the assessment process as necessary or appropriate...nursing observations and care provided..."

Based on interview and record review the hospital failed to ensure 1 of 1 patient [Patient #1's] altered skin integrity to the left hand, face, neck, thigh, left heel and left arm skin graft sites was identifed, evaluated and/or provided treatment by the RN [Registered Nurse] unit nurse and/or RN wound nurse during [Patient #1's] inpatient stay.

Findings Included:

The physician discharge summary dated 04/05/11 reflected, "61 year old female with a history of traumatic brain injury, subdural hematoma with craniotomy in the past who was brought in from a nursing home for altered mental status and unresponsiveness...the patient was intubated in the emergency room...she was found to have pneumonia, UTI [Urinary Tract Infection], and sepsis, and was treated with antibiotics...the patient continued to be unresponsive during her stay...unable to be weaned from the vent due to her poor prognosis and mental status...guardian contacted and options of tracheostomy...versus hospice were discussed...it was decided care would be withdrawn...comfort care measures initiated and patient discharged to....hospice care center..."

The physician's orders dated 03/26/11 timed at 10:15 AM reflected, "CT abdomen, pelvis with contrast stat..."

The physician's orders dated 03/27/11 to 04/05/11 reflected no documentation indicating treatment was ordered for [Patient #1's] altered skin integrity.

The nursing note dated 03/26/11 timed at 5:29 PM reflected, "IV [Intravenous] L [Left] hand, 18 single lumen...reddened, swollen, ecchymotic, removed...IV dye extravasated...pressure dressing applied wrapped in warm blanket and elevated..." No documentation was found indicating physician orders for treatment was obtained.

The nursing note dated 03/27/11 timed at 4:15 AM reflected, "Wound #1, blister...L [Left] hand...oozing serous drainage...cracked/blisters/broken; length 7 cm [Centimeters], Width 10 cm, dressing dry and intact..."

The nursing note dated 03/28/11 timed at 7:37 AM reflected, "Wound #1, blister...left hand....drainage serous..."

The wound nurse progress note dated 03/28/11 timed at 10:20 AM reflected, "Consulted for low Braden score. No skin breakdown per RN [Registered Nurse]...will follow weekly...on low Braden interventions for now reconsult if any further skin/wound needs..." No assessment was found addressing the left hand IV site which was red, swollen and ecchymotic.

The physician progress note dated 03/30/11 timed at 04:44 reflected, "Spoke with patient's guardian regarding patient's decompensation...informed that she is starting to have multi-organ failure despite efforts...guardian expressed her desire to continue every thinkable measure in efforts to treat the patient....we will discuss with guardian regarding any major changes in patient's status..."

The physician's orders dated 03/30/11 timed at 05:30 AM reflected, "RotoProne Bed."

The nursing notes dated 03/30/11 timed at 05:00 AM to 04/01/11 timed at 08:00 AM reflected, [Patient #1] was on the RotoProne bed.

The nursing note dated 04/01/11 timed at 10:00 AM reflected, [Patient #1] was removed from the RhotoProne bed and placed on "total care/waffle overlay..."

The nursing note dated 04/03/11 timed at 5:30 PM reflected, "Wound #1...blister left hand...drainage serous...Wound #2....blister to face..."

The nursing note dated 04/04/11 timed at 3:29 PM reflected, "Wound #1...blister left hand...at 3:48 PM Wound #2...abrasion face..."

The wound care nursing note dated 04/04/11 timed at 14:00 PM reflected, "Follow-up for low Braden consult...low Braden interventions in place...per RN no skin breakdown....continue current skin management..." No evaluation of [Patient #1's] skin was completed.

The nursing note dated 04/05/11 timed at 12:08 PM reflected, "Wound #1...blister left hand...Wound #2 type face, location abdomen...Wound #3...blister left thigh...." No treatment orders were found which addressed the wounds documented.

The inpatient hospice notes dated 04/05/11 reflected, "Abrasions to face and right neck...left heel pressure ulcer stage I, three centimeters in length, 2.5 centimeters wide, depth none...left thigh blister, 9 centimeters in length, five centimeters wide...filled with yellow fluid...dressing placed over blister to collect fluid and drainage if it ruptures...left hand 8.5 centimeters in length, 7.5 centimeters wide...beefy red, slough 90% [percent]...drainage serosanguineous yellow and red, moderate amount...left arm on graft site...blister filled with yellow fluid, 2.5 centimeters in length, 2.0 centimeters wide..."

On 06/08/11 at 3:40 PM Staff #4 was interviewed. Staff #4 was asked to review [Patient #1's] medical record. Staff #4 stated only trauma patients are seen head to toe by the wound care. Staff #4 stated [Patient #1] had a low Braden score. She stated she spoke to the primary nurse and reported [Patient #1] had no skin alterations as documented in both of her note entries. Staff #4 stated she did not perform a skin assessment on [Patient #1]. Staff #4 stated the nurses should have called and requested a skin consult when new issues occurred.

On 06/09/11 at approximately 2:15 PM, Staff #5 was interviewed. Staff #5 was asked to review the medical record. Staff #5 stated she could find no treatment orders for [Patient #1's altered skin integrity. Staff #5 stated no head to toe skin assessment was documented.

On 06/10/11 at 7:30 PM [Patient #1's] responsible party was interviewed. The responsible party stated she was unaware [Patient #1] had multiple skin problems while in the hospital. The responsible party stated when she went to the hospice she was surprised by the abrasions, blisters and condition of [Patient #1's] skin.

The policy entitled, "Skin Management Program" with an effective date of 02/20/07 reflected, "Identification of opportunities to promote and improve client care...promotion of educational opportunities for clients, families, and health care providers regarding cost effective skin care management...documentation of wound, treatment and recommendations in the physician's progress notes...all wounds are staged, regardless of cause this includes but is not limited to surgical wounds, stasis ulcers, burns, and pressure areas...the ET Nurse receives referrals from nursing services and physicians...the ET nurse monitors care and e-evaluates the clients skin management program as appropriate...the client's family is involved in skin care issues and speciality bed decisions..."

RotoProne Therapy System [Prone Positioning]manufactuers documents reflected, " The RotoProne Therapy System allows an immobile patient to be positioned from a supine position [lying on one ' s back] to a prone position [lying face down]. This therapy allows the patient ' s caregivers options in helping to treat lung complications, such as ARDS [Acute Respiratory Distress System], in a critically ill patient ...the patient will be lying face down, supported by special foam positioning packs which can be customized to the patient ' s size. A mask designed to decrease pressure will support the patient ' s face ...the patient may have swelling of the face, lips, eyes, hands, feet and/or chest ...patients who are proned may develop pressure sores on the body and face ... "

Based on interview and record review the hospital failed to ensure 1 of 3 patients [Patient #1's] nursing care plan was current and addressed altered skin integrity to the left hand, face, neck, thigh, left heel and left arm skin graft.

Findings Included:

The physician discharge summary dated 04/05/11 reflected, "61 year old female with a history of traumatic brain injury, subdural hematoma with craniotomy in the past who was brought in from a nursing home for altered mental status and unresponsiveness...the patient was intubated in the emergency room...she was found to have pneumonia, UTI [Urinary Tract Infection], and sepsis, and was treated with antibiotics...the patient continued to be unresponsive during her stay...unable to be weaned from the vent due to her poor prognosis and mental status...guardian contacted and options of tracheostomy...versus hospice were discussed...it was decided care would be withdrawn...comfort care measures initiated and patient discharged to....hospice care center..."

The nursing note dated 03/26/11 timed at 5:29 PM reflected, "IV [Intravenous] L [Left] hand, 18 single lumen...reddened, swollen, ecchymotic, removed...IV dye extravasated...pressure dressing applied wrapped in warm blanket and elevated..."

The nursing note dated 03/27/11 timed at 4:15 AM reflected, "Wound #1, blister...L [Left] hand...oozing serous drainage...cracked/blisters/broken; length 7 cm [Centimeters], Width 10 cm, dressing dry and intact..."

The nursing note dated 03/28/11 timed at 7:37 AM reflected, "Wound #1, blister...left hand....drainage serous..."

The wound nurse progress note dated 03/28/11 timed at 10:20 AM reflected, "Consulted for low Braden score. No skin breakdown per RN [Registered Nurse]...will follow weekly...on low Braden interventions for now reconsult if any further skin/wound needs..." .

The nursing note dated 03/30/11 timed at 05:27 AM reflected, "Doctor...at bedside to evaluate patient...orders received to RotoProne patient at this time due/to declining respiratory status..."

The nursing note dated 04/03/11 timed at 5:30 PM reflected, "Wound #1...blister left hand...drainage serous...Wound #2....blister to face..."

The nursing note dated 04/04/11 timed at 3:29 PM reflected, "Wound #1...blister left hand...at 3:48 PM Wound #2...abrasion face..."

The wound care nursing note dated 04/04/11 timed at 14:00 PM reflected, "Follow-up for low Braden consult...low Braden interventions in place...per RN no skin breakdown....continue current skin management..."

The nursing care plan with a review date of 04/04/11 reflected no care plan which addressed [Patient #1's] altered skin integrity.

The nursing note dated 04/05/11 timed at 12:08 PM reflected, "Wound #1...blister left hand...Wound #2 type face, location abdomen...Wound #3...blister left thigh...." documented.

The inpatient hospice notes dated 04/05/11 reflected, "Abrasions to face and right neck...left heel pressure ulcer stage I, three centimeters in length, 2.5 centimeters wide, depth none...left thigh blister, 9 centimeters in length, five centimeters wide...filled with yellow fluid...dressing placed over blister to collect fluid and drainage if it ruptures...left hand 8.5 centimeters in length, 7.5 centimeters wide...beefy red, slough 90% [percent]...drainage serosanguineous yellow and red, moderate amount...left arm on graft site...blister filled with yellow fluid, 2.5 centimeters in length, 2.0 centimeters wide..."

On 06/09/11 at 1:10 PM Staff #1 was asked to review [Patient #1's] care plan for documentation which addressed skin integrity. Staff #1 stated the careplan did not address [Patient #1's] altered skin integrity.

The policy entitled, "Continuum of Care Plan" with a revision date of 06/17/08 reflected, "Enhance the patient's/family's ability to participate in and follow through with the plan of care....the patient's physical and psycho-social status...summary of care provided and progress towards goal..."