HospitalInspections.org

Based on clinical record review, policy and procedure review and staff interview, it was determined of the 10 patients selected for two patients (#2 and #10 had skin impairment. In two of two patients (#2 and #10), the nursing staff did not accurately assess and care plan skin impairment. The failed practice prevented the nursing staff from determining if the skin impairment had improved, declined or remained the same. The failed practice affected Patient #2 and #10 and had the potential to affect all patients with skin impairment. The findings were:

A. Review of Patient #5's clinical record revealed there was no consistent documentation of an assessment of the patient's left heel, there was no specific order for treatment, there was no protocol in the clinical record for the type of impaired skin to identify treatment strategies, the care plan did not include treatment for the left heel and the policy and procedure did not address care and treatment for an unstageable pressure ulcer. The findings were:
1. Patient #5 was admitted on 04/06/11.
2. Review of the Adult Admission Assessment dated 04/06/11 revealed there was a bruise-pressure ulcer on the left heel. There was no description of the size, if there was tenderness to touch and whether the area was firm or boggy.
3. Review of the Patient Notes from 04/06/11 to 04/13/11 revealed:
a) On 04/06/11 at 1300, "Unstageable pressure area to left heel Measured, photographed. Safe clens, safe gel applied, telfa, 4x4's, kerlex applied."
b) There was no other documentation about the left heel until 04/13/11 at 1558. "Changed drsg (dressing) on L (left) heel PU (pressure ulcer). Measured at 4.5 cm (centimeters) by 3 cm. Closed. Applied Safe Cleanse and Safe gel and rewrapped."
C. Review of the Rehab (Rehabilitation) Nursing Weekly Progress Noted dated 04/13/11 revealed the patient had wound, non-surgical-pressure type, unstageable PU (pressure ulcer) to left heel, left heel appeared to be about to open up, daily dressing change with safe clens and safe gel, left heel with large read area with blackened area in center that appears blister like and seems likely to split open.
D Review of the plan of care revealed the problem of Altered Skin Integrity (unstageable ulcer to left heel) with interventions to initiate appropriate pressure ulcer algorithm and a daily dressing change. There was no evidence which algorithm was to be initiated or what the dressing change consisted of.
E. Review of the Physician's Orders from 04/06/11 to 04/13/11 revealed there was no order present for treatment of the left heel.
4. A request was made for the policy and procedure for skin impairment. The Assistant Director of the Rehabilitation Unit provided pressure ulcer algorithms for a Stage I, II, III and IV pressure ulcer. Review of the algorithms revealed there was no definition of an unstageable pressure ulcer; there was no outline for treatment of an unstageable pressure ulcer or impaired skin integrity. In an interview on 04/14/11 at 1400, the Assistant Director of the Rehabilitation Unit confirmed the findings for the algorithms. The National Pressure Advisory Panel defines an unstageable pressure ulcer as "Full Thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed." Based on the documentation of the left heel, it did not meet the definition of an unstageable pressure ulcer as the skin was intact and bruised on admission but on 04/13/11 the left heel had large read area with blackened area in center that appears blister like and seems likely to split open which still did not meet the definition of unstageable.
6. Since the assessments did not include all characteristics of skin impairment it could not be determined if the skin impairment had improved declined or remained the same with the current treatment intervention.
7. Interview on 04/14/11 at 1455, the Assistant Director of the Rehabilitation Unit confirmed there was no physician ' s order treatment, there was algorithm indicated to determine treatment, and the algorithms did not define an unstageable pressure ulcer.

B. Review of Patient #10 ' s clinical record revealed there was no ongoing assessment of the patient ' s right buttock, left heel and right heel, there was no specific order for treatment, and the care plan did not include treatment for the right and left heel. The findings were:
1. Patient #10 was admitted to the Unit on 02/22/11 and was discharged 03/09/11.
2. The admission assessment dated 02/22/11 reflected the patient had impaired skin integrity related to a skin tear on right buttock measuring 1.75 cm by 1.5 cm and a surgical incision on the left hip. There was no description of the left hip regarding the length of the incision, color, or drainage.
3. Review of the nursing notes from 02/23/11 to 03/09/11 revealed there was no ongoing assessment of the skin tear on the right buttock to include the size, depth, color, drainage/color, pain and firmness of area. The documentation was inconsistent in that some nurses referred to it as a skin tear while others referred to it as a shear.
4. Review of the nursing note dated 03/03/11 1540 revealed the patient had an open shear to right and left heel. There was no written description of the sheared areas to included size, depth, color, drainage/color, pain and firmness of area.
5. Review of the nursing note dated 03/04/11 at 1525 revealed the left heel was left open to air as it had a blister. There was no assessment to include the size, depth, color, drainage/color, pain and firmness of the area.
6. Review of the nursing notes from 03/05/11 to 03/09/11 revealed there was no evidence the right and left heel skin impairment was assessed as to size, depth, color, drainage/color, pain and firmness of the area.
7. Review of the Rehab Interdisciplinary Care Plan revealed Altered Skin Integrity was initiated on 02/22/11. The right and left heel was not addressed after identification on 03/03/11.
8. Since the assessments did not include all characteristics of skin impairment it could not be determined if the skin impairment had improved declined or remained the same with the current treatment intervention.
9. Interview on 04/14/11 at 1730, a request was made to have the clinical record information confirmed to the Director of the Rehabilitation Unit. It was decided she would review the closed clinical record the first part of next week and send me an e-mail of findings. On 04/18/11 at 1627, the Director of the Rehabilitation Unit confirmed they did not find any additional information.