HospitalInspections.org

Based on hospital staff interview, interview with staff at other health care providers, and clinical record review, the hospital failed to consistently re-assess identified wounds and failed to identify acquired hospital wounds for 3 of 10 sampled patients (#3, #5 and #6).

The findings include:

Patient #3

On 1/23/17 at about 11:15am, an interview was conducted with the Wound Care Manager (Nurse T) and the Wound Care Nurse (Nurse A). They were asked if there were any current wounds on the Orthopedics and Surgical unit (where patient #5 was discharged from). Both nurses stated that no, there were no current wounds on that unit.

On 1/23/17 at about 2:00pm, an interview was conducted with Nurse B, the Charge nurse of the Orthopedics and Surgical unit. Nurse B stated that the nurses do a full assessment twice every day. This includes a skin and wound assessment. If the nurse feels a wound needs further evaluation, they will put in a wound care consult. Nurse B stated that Patient #3 had a stage II pressure ulcer on admission, but currently has no wounds. Patient #3 is bed bound, confused and has been identified as having a high risk for skin breakdown. An arrangement was made for an observation of a skin assessment for the next morning.

On 1/24/17 at 8:40am, an observation was conducted of the twice daily skin /wound assessment as performed by Nurse K. Nurse K assessed the sacral fold area, and noted the whitish area on the right buttock. She stated that she found this wound yesterday during her assessment. She was not told of any wounds during shift report. She has been putting Venelex on it. She has not notified the wound care nurse of the new wound, as it is not open. No other wounds were identified by Nurse K.

A record review of skin and wound assessments was conducted for Patient #3. Nursing documented on the Wound Report, the Admission Assessment Report and the Daily Focus Assessment Report. Patient #3 had been admitted to the unit for a week. The notes were inconsistent regarding whether or not their was a wound and the wound appearance.

On 1/16/17 at 3:13am Nurse S wrote, "Patient (#3) appears to have multiple dime sized stage 1 pressure ulcers in between the skin fold of her sacrum. (the sacrum is at the bottom of the spine near the tailbone)"

On 1/16/17 at 7:45pm, Nurse S wrote that Patient #3 appears to have multiple dime sized stage 1 pressure ulcers to sacrum. Barrier ointment applied. Mepilex (a type of dressing) applied. Site CDI (clean, dry and intact).

On 1/17/17 at 7:00am Nurse R documented that there was no skin breakdown.

On 1/17/17 at 9:47am, Nurse A, the wound care nurse, wrote, "shearing wound to the gluteal cleft (buttocks fold) measuring approximately 2.5cm x 0.8cm x 0.1 cm (centimeters) with red, smooth, moist wound base. Open area is not over a bony prominence and does not appear to be pressure related. Area blanches upon palpation. Recommend Venelex ointment."

On 1/17/17 at 8:00pm, Nurse D wrote that there was no skin breakdown.

On 1/18/17 at 8:00am, Nurse C did not document anything about the wound, but wrote, "Refer to Wound Care"

On 1/18/17 at 8:00pm, Nurse E wrote that there was no skin breakdown.

On 1/19/17 at 8:00am, Nurse C did a skin assessment that did not state whether there was a wound or not.

On 1/19/17 at 8:00pm, Nurse F wrote that there was no skin breakdown, but then also wrote that there was skin breakdown and that the sacrum Mepilex dressing was CDI.

On 1/20/17 at 8:00am, Nurse C wrote, "coccyx (tail bone) reddened. Covered with Mepilex. Refer to Wound Care."

On 1/20/17 at 10:09pm, Nurse G wrote, "Multiple dime size open stage 1 wounds. Venelex."

On 1/21/17 at 8:00am, Nurse H documented that there was no skin breakdown.

On 1/21/17 at 7:36pm, nurse J wrote, "Venelex applied to small open areas on sacrum / buttocks. OTA (open to air)"

On 1/22/17 at 8:00am, Nurse I documented that there was no skin breakdown.

On 1/22/17 at 7:49pm, Nurse J wrote, "Venelex applied to small open areas on sacrum, OTA"

On 1/23/17 at 8:00am, Nurse K wrote that there was skin breakdown, with no further information.

On 1/24/17 at 4:00pm, an observation of the sacral wound was conducted with Nurse A, the wound care nurse. The wound was in the sacral fold about 3cm long with 2 skin bridges. Additionally, on the right buttock at the sacral fold was a 1cm whitish area that appeared to be a healed wound and the medial left buttock had a small .3 cm round open area. Venelex was applied. Nurse A stated that the overall length of the area was about the same size as previously assessed on 1/17/17, but overall, the wound was improved. Previously there were no skin bridges, and now there were.

Patient #5

A record review of hospital skin and wound assessments was conducted for Patient #5. Nursing documented on the Wound Report, the Admission Assessment Report and the Daily Focus Assessment Report. There were numerous entries regarding a surgical incision to the left knee. The first nursing entry regarding issues with skin breakdown was documented on 10/16/16 at 7:31am by nurse L. Nurse L wrote, "erythema (redness) noted to sacrum. Mepilex applied,"

The next sacrum assessment was documented 3 days later on 10/19/16 by the Wound Care Nurse (Nurse A). On 10/19/16 at 11:48am, Nurse A wrote, "SDTI (suspected deep tissue injury) to sacral area measures approximately 6cm x 8cm and is deep red/purple in color. Surrounding tissue is red and unblanchable. Recommend Venelex ointment twice a day and offload area as much as possible. Air mattress ordered.

On 10/20/16 at midnight, Nurse L wrote, "Venelex applied to sacrum. Covered with Mepilex. No active drainage from wound".

The last entry was on 10/20/16 at 8:30am by nurse U. Nurse U wrote, "Venelex cream applied to sacral wound. Mepilex covered over. No active drainage noted."

There were no further skin assessments and the clinical record indicates that Patient #5 was discharged to Facility Z on 10/20/16 at 4:00pm.

The hospital Discharge Summary dated 10/20/16 (dictated 11/15/16) does not mention pressure ulcers.

A record review of nursing notes was conducted at Facility Z. The record indicates that Patient #5 was admitted to Facility Z at 8:00pm. The initial nursing assessment was completed by the DON (nurse P) on 10/21/16 at 7:30am. Nurse P documented: Skin assessment is performed at this time and reveals multiple pressure ulcers. Coccyx has a stage III pressure ulcer which is draining red drainage. Wound bed is moist and contains pencil eraser sized eschar (dead necrotic tissue) with 50% granulation tissue. Right foot has multiple ulcers including right outer heel unstageable, right outer malleolus stage 1, right outer mid foot stage 1, right outer pinky toe stage II, right inner heel has a large blister which is intact. Right index finger is warm and swollen. Left foot has a stage II pressure ulcer on the inner heel. Left outer heel has an unstageable ulcer / suspected DTI. His left knee has an incision which is approximated and stapled. Dressing is CDI. The most significant pressure ulcer is a stage III on the coccyx. Facility physician notified. Appointment made for 10:00am today. Facility Z took photographs of the wounds at that time (photographic evidence obtained).

On 1/24/17 at about 3:30pm, an interview was conducted regarding the discrepancy between the the hospital wound assessment and Facility Z's assessment with the hospital Manager of Risk Management, the Director of Performance Improvement and Regulatory Compliance, the Chief Quality Officer and the Risk Manager. The hospital staff were very concerned about the wounds of Patient #5. They showed where the floor nurse (nurse U) had documented an assessment of pedal (feet) pulses on 10/20/16 at 8:00am stating that they can't imagine the nurse would not have noticed the wounds on patient #5's feet if they were present at the time. Per the hospital notes, patient #5 discharged shortly after 4:00pm. The hospital staff expressed the possibility that the wounds developed while waiting for transport, or during transport, or during the night at Facility Z.

On 1/25/17 at 11:05am, an interview was conducted with the DON (Nurse P) from Facility Z. Nurse P stated that she visited Patient #5 in the hospital on 12/19 or 12/20, after he was placed on the air mattress. The air mattress gave her cause for concern over possible skin issues, so she did a skin assessment on him at that time and noted the pressure ulcer to his buttocks, feet, ankles and knees. This is how she knew to come assess him promptly upon return to the facility and bring a camera the morning of 10/21/16. He got back late on 10/20/16, around 8:00pm.

Patient #6

Bay Medical Center Skin Assessments for Patient #6 were reviewed. The skin assessments from 12/13/16 through discharge on 12/19/16 all showed no skin breakdown. The clinical record was reviewed by the Manager of Risk Management on 1/23/17 at about 4:00pm. The Manager concurred that the nursing assessments indicated no wounds.

On 12/19/16, patient #6 was discharged from the hospital and admitted to a local nursing facility (Facility Y). On 1/24/17 beginning at about 12:50pm, Facility Y wound assessments were reviewed and an interview conducted with the Director of Nurses (nurse M) and the Wound Care nurse (nurse N). Upon admission to Facility Y on 12/19/16, the wound care nurse noted 2 wounds. One was was a deep tissue injury (DTI) on the left lateral ankle. The wound measured 2.5cm x2.5 cm in size, was dark maroon in color and non-blanching (did not turn whitish with light pressure). The periwound area (skin surrounding the wound) had redness and was mushy/boggy. The other wound was on the left foot, on top of the 5th digit, measuring 1 cm x 0.5cm x 0.25cm and assessed as a Stage II pressure ulcer. A small amount of sero-sanguineous drainage was noted. Redness was noted to the periwound area. Wound treatment was ordered. An interview was conducted with Facility Y's wound care nurse (nurse N). The nurse stated the DTI was not on the malleolus (bony prominence), rather under it and behind it. Patient #6's left leg/foot is naturally rotated outward. The wounds of the left ankle and the toe followed the natural rest potion of Patient #6's foot. It would have been easy to over-look the wounds the way he kept his foot, and it was difficult to move the leg to assess.