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Based on interviews and documentation review, it was determined the Hospital had not (yet) fully developed and implemented a Corrective Action Plan related to its Internal Investigation of Patient #1's hospital-acquired Stage III pressure ulcer.

Findings included:

Medical record documentation indicated Patient #1 suffered an anoxic brain injury (brain injury/dysfunction secondary to a lack of oxygen) secondary to a cardiac arrest following a myocardial infarction (heart attack) and has been in a persistent vegetative state with severe spasticity (partial paralysis due increased muscle tone or contractions), a tracheostomy (a surgically created opening into the windpipe with insertion of a [tracheostomy] tube [to maintain the airway]), PEG (feeding tube) and foley (urinary) catheter for 9+ years. Medical record documentation also indicated Patient #1 developed a Stage III pressure ulcer under a skin fold at the back the neck related to the use of tracheostomy ties, and treatment interventions were immediately initiated.

A review of Hospital Incident/Variance Reports completed during the time period of 1/1 - 3/31/10 revealed a Report related to Patient #1's hospital-acquired Stage III pressure ulcer.

A review of the Hospital Internal Investigation related to Patient #1's Stage III pressure ulcer revealed it determined: Patient #1 had multiple risk factors for the development of pressure ulcers, was appropriately assessed to be at risk for the development of pressure ulcers, received skin assessments and tracheostomy care every shift, and had skin folds at the back of the neck that changed with body positioning and; tracheostomy ties were changed when soiled/as needed.

The Director of Medical/Surgical Nursing, Clinical Coordinator #1 and the Director of Risk Management were interviewed together, in person, at 12:40 PM on 4/14/10. They said the Hospital (a small community hospital) doesn't see/care for many patients with tracheostomy tubes and although Patient #1's hospital-acquired pressure ulcer clearly indicated re-education of the Nursing Staff regarding the assessment of skin surfaces under and near tracheostomy ties (as well as skin surfaces in, under and/or near other medical equipment and/or devices) was in order, the revision or development of policies, procedures or protocols related to the changing of tracheostomy ties and/or the placement of protective padding or a protective dressing under ties was still being discussed/evaluated.

A review of the Corrective Action Plan related to the Hospital Internal Investigation regarding Patient #1's Stage III pressure ulcer (to-date) revealed it called for Nursing education regarding the assessment of skin surfaces in, under and/or near medical equipment and/or devices (including tracheostomy ties), revision of the Tracheostomy Care policy/procedure to include a tracheostomy site and back of the neck skin checks at the time of daily tracheostomy tube holder changes, and revision of the Interdisciplinary Patient History and Assessment and the Patient Assessment Flow Sheet Forms to include the following instructions in the Pressure Ulcer Stage Assessment section: Implement measures for the prevention and treatment of pressure ulcers (Prime Air/AccuMax mattress, KCI overlay, bed turning schedule, lift sheet, elevate heels, protect elbows, check medical equipment i.e. CPM, oxygen tubing, trach ties etc.).

A review of the Corrective Action Plan implementation revealed the Tracheostomy Care policy/procedure was revised, but was not (yet) approved, the Interdisciplinary Patient History and Assessment and the Patient Assessment Flow Sheet Forms were revised, but not (yet) printed, and Nursing education regarding the assessment of skin surfaces in, under and/or near medical equipment and/or devices, the revised Tracheostomy Care policy/procedure and the revised Interdisciplinary Patient History and Assessment and the Patient Assessment Flow Sheet Forms was not (yet) completed.