HospitalInspections.org

Based on the review of policies and procedures, medical records, and interview, it was determined the Hospital did not ensure the nursing staff assessed patient care to include:

1) notifying the physician of multiple skin breakdowns for Patient #3; and

2) documenting the assessment and description of the wounds to include location, and type for Patient #3.

Findings include:

1) The policy "Skin Integrity: Prevention and Early Intervention for Skin Breakdown" requires, "...Physicians are notified of skin breakdown...."

On 11/09/11, the Senior Manager of Intensive Care Unit (Sr Mgr of ICU) confirmed the Registered Nurse (RN) is to complete the "Wound Care Action" form as part of the wound care assessment. On the form it indicates the "Physician should be notified of all wounds."

She indicated Patient #3 on admission had 3 wounds, 1) an abrasion of the right elbow; 2) redness discoloration over the coccyx area; and 3) scabs on multiple locations of the body.

At the time of the investigation, the Sr Mgr of ICU confirmed the nursing staff did not document notifying the physician of Patient #3's skin breakdowns.

The nursing staff did not implement the policy of notifying the physician of Patient #3's skin breakdowns/wounds.

2) The policy "Skin Integrity: Prevention and Early Intervention for Skin Breakdown" requires, "...Patient's wounds are assessed...documented...and described in detail...."

On 11/09/11, the Sr Mgr of ICU, indicated there are 2 locations within the chart to document wounds, one is on the skin/wound assessment form, and the other is on the ICU assessments. She stated the wounds need to be assessed and a description documented every shift, to include location and type.

After the Sr Mgr of ICU reviewed Patient #3's medical record, she confirmed these dates/shifts, from 06/13/11 through 07/08/11, did not have documentation describing all of the 3 wounds:

06/16, nights
06/18, days
06/20, days
06/21, 06/22, and 06/23, days and nights
06/24, nights
06/26, nights
06/27, days

The nursing staff did not document every shift, the assessment, and the description of each of Patient #3's wounds, to include the location and the type of wound.

Based on a review of the medical record, and interview, it was determined the Hospital failed to require respiratory services follow orders to document the head of the bed (HOB) position, for a patient on mechanical ventilation (Patient #3).

Findings include:

On 06/28/11, at 0230, Patient #3 was intubated and placed on mechanical ventilation.

On 06/28/11, at 0259, the physician ordered Patient #3's HOB to be elevated to 30 degrees.

On 11/02/11, the Director of Respiratory Therapy (RT) confirmed the RT staff are to document the patient's HOB position, during airway assessments, while on a ventilator.

There is documented evidence that he was receiving tube feedings and no documented evidence that the HOB was elevated.

The Director of RT stated a respiratory therapist documented on 07/04/11, at 1200, that Patient #3's HOB was at 30 degrees.

She confirmed the RT staff did not document Patient #3's HOB position until 07/05/11, at 1923, (approximately 17 hours later).

Respiratory Services did not document for approximately 17 hours, Patient #3's HOB position, while on a ventilator.