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Based on record review, review of approved hospital policy and procedures, and staff interview, the hospital failed to ensure that each patient received care based on periodic individualized assessment of needs, in accordance with approved hospital policy and procedure for 2 of 8 patient records reviewed (Patient #'s 2 and 7).

Failure to implement care based on individualized patient assessment risked patient health and safety, and may have contributed to skin breakdown for Patient #2.

Findings:

Patient #2 was admitted on 7/17/2010 with diagnoses including fever and a decline in mental status. Review of the emergency record evidenced the 79 year old patient had a non-operable hip fracture, and had a history of diabetes and congestive heart failure. The emergency nursing admission note documented the patient, "has redness noted to coccyx. No tissue breakdown." The History and Physical noted morbid obesity, chronic venous stasis, and diarrhea. The Nursing Admission Adult Assessment dated 7/17/10 documented that the patient "continues to have loose stools," had "very poor" intake with unintentional weight loss, and documented skin as "fragile, diaphoretic/clammy." Upper arms and ankles were documented as reddened, with abrasions or scabbing. Coccyx and buttocks were documented as a reddened area 6 X 6 cm. in size. The bed surface was described as "Hospital Bed." Staff interview on 3/16/2011 revealed that standard medical floor mattresses did not have a pressure relieving surface.

The hospital's Policy and Procedure, "Pressure Ulcer Prevention" (#8720-P-17) was reviewed. It directed, "Patients at risk for pressure sores will be re-evaluated every shift, and with changes in condition such as surgery, mobility, or change in nutritional status." It identified patient populations at increased risk for pressure ulcer development including those with peripheral vascular disease, fractures, neurological disorders, diabetes, congestive heart failure, dementia, etc. Item #4 directed minimizing pressure for patients in bed and included, "Use pressure redistribution mattresses/surfaces."

Staff interview on 3/16/2011 identified that nursing staff could request an order for an air mattress for patient skin care based on individualized assessment of the patient's care needs.

Nursing Progress Notes for Patient #2 dated 7/20/2010 at 1425 (2:25 p.m.-over 2 days after admission) documented, "Requires frequent turns and repositioning for preservation of skin integrity;" and at 2020 (8:20 p.m.) documented, "Wife asks about air mattress." The shift assessment at that time described Patient #2's skin as "fragile, dry, and " friction/shear " as a problem. The coccyx area was described as reddened with the addition of "Ecchymotic/Bruising" identified. The Braden Score was 7. (A score of 12 or less is an indicator of skin at "high risk.")

On 7/21/2010 at 7:08 a.m. Nursing Progress notes documented, "Aware that patient's bottom is breaking down and aware that patient continues to resist all cares. Note for MD on chart about skin break down and wife's interest in an air mattress." At 0750 nursing documented, "Patient frequently incontinent of loose tan stool. Stage II decub to right buttock with serous drainage..."

Nursing notes documented placement of the air mattress overlay at 1330 (1:30 p.m.) on 7/21/2010. Physician Progress Notes dated 7/21/2010 at 1455 (2:55 p.m.) documented, "...with skin breakdown, sacral decub stage 2-3."

Staff failed to provide appropriate skin care measures per approved hospital policy and procedure based on Patient #2's initial and on-going signs and symptoms. Skin breakdown may have been prevented if skin care interventions had been implemented on admission when the reddened coccyx, obesity, diabetes, loose stools, hip fracture, and friable skin were first identified.

Similar care needs existed for a current 93 year old medical floor patient (#7) reviewed during the course of this investigation. Chart review evidenced he was admitted on 3/13/2011 with a diagnosis of pneumonia. Review of admission nursing notes documented the patient as "dependent and non-weight bearing, incontinent of bowels and bladder...pitting edema bilaterally...skin is fragile with several skin tears and bruises...reddened area to coccyx." Notes on 3/15/2011 further documented, "unable to make needs known, does not use the call light appropriately...patient is incontinent of bowel and bladder. Patient has fragile skin." Review of the care plan did not identify an air mattress as a skin care intervention. Staff interview confirmed that no air mattress had been placed to protect the patient's skin.

Failure to implement needed care interventions based on patient assessment and care needs risked patient health and safety to prevent skin breakdown.