HospitalInspections.org

Based on record review and interview, the facility staff failed to thoroughly evaluate and assess the skin of a patient identified as at risk for the development of pressure ulcer amd failed to appropriately asses the patient's skin care needs in accordance with accepted standards of nursing practice. Additionally, the facility failed to obtain a timely evaluation of a wound of a patient with an identified wound for 1 of 3 sampled patients (Patient #3)

The findings include:

Review of the clinical record for Patient # 3 revealed the patient was admitted to the facility on 12/9/2010. The initial nursing assessment documented that the patient's identified skin risk was a score of 13, medium risk. There are no identified skin issues documented on the initial nursing assessment of 12/9/2010 at 17:07. However on the 12/9/2010 21:50 Shift Assessment, the nurse identified that the patient had a wound (blister to left calf area) that was left open to air. The nurse documented that the physician was not notified , nor was a photo taken. There were no further details regarding the blister to the left calf. The following shift assessments were documented regarding the patient's wound to the left calf, however there is no evidence, the nursing staff contacted the physician or consulted wound care for evaluation of the identified wound. There were also documented changes in the wound, however there is no apparent measurement or pictures of the wound since the wound was identified on 12/9/2010 at 21:50 until the wound care nurse evaluated the wound on 12/16/2010.
12/10/2010 at 0900, wound remained open to air. Documented in the comment section was "open blister right shin"?.
12/10/2010 at 2000, wound to the left calf now dressed with Tegaderm. The physician was not notified nor were photos taken. The blister is open.
12/11/2010 at 0800, wound dressed with Tegaderm, wound color now dark black, closed blister noted. Physician not notified or photos taken.
12/11/2010 at 2040, 12/12/2010 at 0800, 12/12/2010 at 1935, 12/13/2010 at 0900, the nurse continued to document the wound remains closed, black and dressed with Tegaderm.
12/13/2010 at 2000. The nurse identified the wound as dressed with Tegaderm. No other information was documented concerning the left calf wound. The nurses continued to document the above, twice daily for the shift assessment regarding the patient's left calf wound until 12/16/10 at 2000. The wound is now dressed with Mediplex transfer. There continues to be no further documentation of the patient's wound to the left calf or indication the patient's physician was contacted.

Review of the clinical record did not provide evidence of the physician prescribing treatment for the patient's wound to the patient's left calf.

A referral for consult was made to the wound care nurse (WCN) on 12/12/2010 regarding the patient's newly identified wounds on her left and right buttocks.
The wound care nurse attempted to evaluate the patient on 12/13/2010 at 1323. The patient was medicated for pain at the time of the visit and "insist the wound care nurse come back later as she is in too much pain." The WCN agreed. However, there is no evidence the WCN returned to evaluate the patient until 12/16/2010 (3 days later). On 12/16/2010 at 1116, the WCN documented the patient had a 14 x 6 eschar (black) wound to the left lower leg, a 11 x 4 eschar wound to the abdomen and stage 2 to the buttocks. The WCN changed the wound care to the areas to Mediplex to the leg and abdomen and Allevyn gentle border to the buttock until evaluated by the wound care physician.

An interview was conducted on 2/8/2011 at 2:50 PM with the WCN, who evaluated the patient on 12/16/2010, and the Director of Wound Care. The WCN stated they are normally consulted for any skin issue and will be contacted for blisters and any change in the wound, i.e. closed blister to an open wound, change in staging in the wound. She did not know why wound care was not contacted for the leg wounds. Furthermore, she confirmed the nurses will usually contact wound care within 24 hours of identifying the wound. She further confirmed that wound care is "normally consulted for a blister". She stated, she remembers the wound being a large (black) eschar on the back of the patient's leg. She further confirmed, she wrote that the wound was trauma because the patient stated that she hit her leg. "Though it could have been pressure because of where the wound was located, the size of the patient and her inability to move." She further confirmed there were no measurements/photos of the wound and she could not compare the initial assessment, subsequent assessments and what she evaluated on 12/16/10. The WCN also was unable to explain, why there was a delay in the patient being evaluated by the wound care nurse after the consult was finally made. She confirmed another WCN attempted to evaluate the patient on 12/13/2010 but does not know why there was a delay from the initial attempt on 12/13/2010 and the actual evaluation on 12/16/2010. She was also uncertain of the wound's progression other than what the nurses documented, i.e. the wound was a blister that later opened and closed and was black in color. The Director of Wound Care also confirmed that she could not locate an order from the physician prescribing the wound care that was utilized on the wound. The Assistant Director of Nursing, who also reviews wound care joined the interview at 4:35 PM. She confirmed that the nurses' assessment does not identify a complete location of the wound. They assumed the wound on the calf was trauma. The surveyor then questioned, the staff regarding the explanation of the wound being identified as trauma but not documented until 12/16/2010 by the WCN, and prior to this, there is no indication of the wound type. They were unable to confirm this explanation because,the patient was very confused and was unable to inform the staff regarding this information for several days of her hospitalization. The WCN again stated the nurses can consult the WCN at any time. Though the facility's policy addresses pressure wounds, the nurses can consult wound care for areas of concern and ask them to come and look and evaluate the area. "It is up to the discretion of the nurse". If the wound is trauma, they do not necessarily have to contact wound care. The surveyor, then questioned regarding identifying, evaluation of the progression of wounds and treatment for wounds other than pressure. They again confirmed, the facility's policy addresses, pressure wound and had no further explanation regarding other wounds.