HospitalInspections.org

Based on an observation, clinical record review, and interview with clinical and administrative staff, the hospital failed to ensure adequate nurses and ancillary staff to adequately care for 3 (Patient #2, #1, and #3) of 10 patients sampled.

The findings included:

1. Patient #2 was admitted to the hospital on 2/25/16. At the time of admission, the patient's skin was noted to be intact, but the patient was identified as being at risk for pressure ulcers.

A wound care specialist RN visited the patient on 2/26/16, and initiated Pressure Ulcer Prevention Protocol (PUPP). This protocol also included: appropriate wound care to prevent further breakdown, ongoing assessments, and review of the interventions were to be completed on each shift.

On 3/27/16 at 10:30 a.m., interview with RN Staff A indicated the wound care specialist nurse completes the initial wound description, assessment, measuring, and starts treatment. Thereafter, the floor nurses complete the treatments. The floor nurses also measure the wounds on a weekly basis.

In an interview on 4/26/16 at 4:45 p.m., the wound care specialist RN said she thought the treatment was hydrogel (a jelly-like material that can absorb fluid) to this area, and Aquacel foam (a specialized foam dressing). She felt the treatment should have been done at least every other day. She said her protocol to obtain orders for treatment was to call the physician once the assessment was completed.

No note was written by the physician until 4/5/16 regarding the pressure ulcer. At that time, it was noted the nurse told the doctor yesterday about the pressure ulcer. He gave orders to continue wound care and to change the patient's position every 2 hours.

Review of the nurses notes from 4/5/16 until the patient was discharged on 4/14/16, showed documentation of the dressing being intact, but very infrequent documentation (3 times over 9 days) documenting if the dressing had been changed by any of the nurses. There was documentation indicating the patient was turned and positioned, but nothing about the wound. There was no further documentation from the wound care specialist nurses. There was no documentation regarding the wound appearance after the 3/29/16 note from the wound care specialist nurse.

2. Patient #1 was admitted to the hospital on 4/25/16. The patient was diagnosed with aspiration pneumonia, dementia, and failure to thrive.
In an interview on 4/26/16 at 9:00 a.m., RN Staff A said Patient #1 was not very responsive.
Review of the record revealed there was no documentation of the patient being turned and positioned. The patient's perineal area was documented as red, but had no open areas.

On 4/26/16, at 9:42 a.m., Patient #1 was observed, and the wound care RN was present in the room changing the foam protectors to the heels. She said the patient was unable to move by herself. She stated the patient's heels were not offloaded from the bed when she came into the room.

3. In an interview on 4/25/16 at 10:45 a.m., Patient #3 said she thought the nurses were short-staffed. She said sometimes it takes 20 minutes for staff to get there with a bedpan. Patient #3 said she can't get out of bed and has to use the bedpan, and if they don't respond quick enough she would be incontinent.

4. On 4/25/16 at 1:38 p.m., Nurse Staff B said there is not enough staff. Usually there is a minimum of 5 to 6 patients per nurse and they are responsible for all care of the patient including medications, bathing, and any other care the patient requires. They do not have ancillary help to assist them.

On 4/25/16, at 3:30 p.m., the Staffing Coordinator said they were aware of the issues with staffing, and they have opened 3 positions for aides starting at the next orientation cycle. She also said 1 of the units is closed due to not enough staff.

Based on an observation, clinical record review, and interview with clinical and administrative staff, the hospital failed to ensure registered nurses (RN) assessed and evaluated the nursing care for 2 (Patient #2 and #1) of the 10 patients sampled. The hospital failed to ensure care was provided to Patient #2's pressure ulcer resulting in an increase in depth of the area. Patient #1's preventative treatment was not instituted.

The findings included:

1. Patient #2 was admitted to the hospital on 2/25/16. At the time of admission, the patient's skin was noted to be intact, but the patient was identified as being at risk for pressure ulcers.

A wound care specialist RN visited the patient on 2/26/16, and indicated there was a speciality surface in place. Part of the plan was to offload/pressure redistribution, and initiated Pressure Ulcer Prevention Protocol (PUPP). This protocol also included: Initiating target interventions to address each risk area; individualized plan of care; initiate appropriate wound care to prevent further breakdown; and include a dietary evaluation for nutritional status. Ongoing assessments and review of the interventions were to be completed on each shift.

On 2/26/16, the wound care specialist RN made another visit to the patient. This note indicated the patient had contractures of both hands from a previous stroke. The skin on the coccyx was pink and nonblanchable. The spouse reported the patient had a previous pressure ulcer in the same area in the past. The patient was identified as a high risk for a pressure ulcer. The patient's skin remained intact and offloading of heels was documented.

On 3/14/16, the wound care specialist RN was consulted. Between 2/26/16 and 3/14/16, the patient's condition declined. The patient developed a large amount of fluid in the abdomen, which necessitated the removal of this fluid on 3/13/16. At the same time, fluid was removed from the patient's lungs, which resulted in a collapsed lung. The patient was transferred to the Intensive Care Unit (ICU) after this.

On 3/14/16, the wound care specialist RN visited this patient and indicated the patient had a pressure ulcer on the sacrum/right buttock area, measuring 4 centimeters (cm) X 3 cm X 0.1 cm deep. The wound care specialist nurse identified the area as a "possible Kennedy Ulcer, and the patient has multiple organ failures." (A Kennedy Terminal Ulcer is a type of pressure ulcer wound which develops rapidly in size and depth and is associated with multi system organ failure seen at end of life.) The wound care specialist RN asked the patient's nurse to get the physician to evaluate this area for type of ulcer verses deep tissue injury related to multiple organ failure. There was no documentation the physician made this evaluation and no indication the nurse communicated this question to the physician. There was no evidence by either the physician order, or nursing documentation of any treatment initiated at the time for the open area.

On 3/27/16 at 10:30 a.m., interview with RN Staff A indicated the wound care specialist nurse completes the initial wound description, assessment, measuring, and starts treatment. Thereafter, the floor nurses complete the treatments. The floor nurses also measure the wounds on a weekly basis.

On 3/29/16, a different wound specialist RN Staff C evaluated the patient. The documentation reflected the patient had just returned from having a procedure to insert a pigtailed catheter into the pleural space (the area between the lungs and the chest cavity) to allow the removal of fluids. It was also noted the patient was incontinent of stool and had thin skin overlying the sacrum. The sacral wound was noted to be 3 cm x 2.2 cm x 0.5 cm deep and meant the area was slightly smaller, but was now deeper. The patient had also developed a pressure ulcer on the toe. The wound nurse noted the straps holding the foam boot in place were repositioned to reduce the pressure to the area.

In an interview on 4/26/16 at 4:45 p.m., the wound care specialist RN said she thought the treatment was hydrogel (a jelly-like material that can absorb fluid) to this area, and Aquacel foam (a specialized foam dressing). She felt the treatment should have been done at least every other day. She said her protocol to obtain orders for treatment was to call the physician once the assessment was completed.

No note was written by the physician until 4/5/16 regarding the pressure ulcer. At that time, it was noted the nurse told the doctor yesterday about the pressure ulcer. He gave orders to continue wound care and to change the patient's position every 2 hours.

Review of the nurses notes from 4/5/16 until the patient was discharged on 4/14/16, showed documentation of the dressing being intact, but very infrequent documentation (3 times over 9 days) documenting if the dressing had been changed by any of the nurses. There was documentation indicating the patient was turned and positioned, but nothing about the wound. There was no further documentation from the wound care specialist nurses. There was no documentation regarding the wound appearance after the 3/29/16 note from the wound care specialist nurse.

2. Patient #1 was admitted to the hospital on 4/25/16. The patient was diagnosed with aspiration pneumonia, dementia, and failure to thrive. In an interview on 4/26/16 at 9:00 a.m., RN Staff A said Patient #1 was not very responsive and it was essential to have nothing by mouth. Review of the record revealed there was no documentation of the patient being turned and positioned. The patient's perineal area was documented as red, but had no open areas.

On 4/26/16, at 9:42 a.m., Patient #1 was observed, and the wound care RN was present in the room changing the foam protectors to the heels. She stated the patient's heels were not offloaded from the bed when she came into the room. She also said the patient was unable to move by herself and was on a speciality mattress.

3. In an interview on 4/25/16 at 10:45 a.m., Patient #3 said she thought the nurses were short-staffed. She said sometimes it takes 20 minutes for staff to get there with a bedpan. Patient #3 said she can't get out of bed and has to use the bedpan, and if they don't respond quick enough she would be incontinent.

On 4/25/16 at 1:38 p.m., Nurse Staff B said there is not enough staff. Usually there is a minimum of 5 to 6 patients per nurse and they are responsible for all care of the patient including medications, bathing, and any other care the patient requires. They do not have ancillary help to assist them.

On 4/25/16, at 3:30 p.m., the Staffing Coordinator said they were aware of the issues with staffing, and they have opened 3 positions for aides starting at the next orientation cycle. She also said 1 of the units is closed due to not enough staff.