HospitalInspections.org

Based upon review of the Performance Improvement (PI) Plan, Quality Indicators, and staff interviews, the hospital failed to measure, analyze, and track quality indicators relative to processes of care. This was evidenced by failing to identify and track the numbers of patients who were admitted with decubitus ulcers/skin breakdown versus patients who acquired decubitus ulcers/skin breakdown after admission to the hospital. Findings:

Review of the Performance Improvement Quality Indicators revealed there failed to be documented evidence the hospital tracked, for each month, the number of patients who were admitted to the hospital with decubitus ulcers or skin breakdowns versus patients who developed the ulcers or skin breakdown after being admitted.

Interview with Patient Care Coordinator for 2 West, Registered Nurse (RN) S8, on 10/21/10, 10:30 AM, revealed if a patient developed skin breakdown or a decubitus ulcer after hospital admission, an incident report would be completed and sent to the Director of Patient Safety (S7).

Review of the policy titled "Incident Reporting Procedure" revealed "...Reportable incidents involving injury or potential injury to patients or visitors include but are not limited to: Pressure sore development after admission."

Interview with the Director of Nursing (DON), RN S2, the Director of Infection Control, RN S6, and the Patient Safety Officer, RN S7, on 10/21/10, 3:00 PM, revealed the only data captured through the PI Program were the decubitus ulcers that were infected. When asked about the tracking of the incident reports submitted relative to patients who had developed decubitus ulcers or skin breakdown during the hospitalization, it was found this information was not tracked through the PI Program.

It was confirmed, through interview with the Performance Improvement Director, S3, on 10/22/10, 2:30 PM, the hospital did not track decubitus ulcers or skin breakdown that were health care acquired or track patients who were admitted with decubitus ulcers.

Based upon review of 2 of 8 medical records (#1, #8), policies and procedures, and staff interviews, the Registered Nurse failed to re-assess the patient's skin condition relative to patients who were at risk of developing skin breakdown/decubitus ulcers as evidenced by: 1) failing to identify patient #1's skin breakdown prior to discharge from the hospital, and 2) failing to identify and document specific data relative to the location, stage, size and appearance of patient #8's skin breakdown that was acquired during the hospital admission. Findings:

1) Review of patient #1's medical record revealed the patient was admitted into the Intensive Care Unit (ICU) on 07/18/10 with bilateral pneumonia, respiratory failure with ventilator assistance, and sepsis. The patient's medical history was significant for multi-infarct dementia, flexion contractures, and immobility due to previous cardio-vascular accidents (CVA's). Review of the admission nursing assessment, dated 07/18/10, revealed the patient was assessed as having no skin breakdown and according to the ICU RN's documentation on the Critical Care Record from 07/19/10 to 07/29/10, it was identified skin breakdown was absent. From 07/30/10 to 08/06/10 the ICU RN's documented on the Critical Care Record a Mepilex dressing was present on the patient's coccyx area to prevent skin breakdown. On 08/06/10, 8:00 PM, the patient was transferred to a Long Term Acute Care Hospital (Hospital A) for further ventilator care. Review of Hospital A's Registered Nurse's admission assessment of patient #1, dated 08/06/10, it was revealed the patient was assessed as having excoriated areas located in the left and right abdominal folds which measured 0.5 centimeters by 8 centimeters (cm). The patient also had excoriated areas located in the folds under the left and right breasts which measured 1 cm by 9 cm and 1 cm by 7 cm respectively.

2) Review of patient #8's medical record revealed the patient was admitted to the hospital on 06/28/10 and discharged on 07/21/10 with the diagnoses of End Stage Renal Disease, Diabetes Mellitus, and an infected right knee. Review of the Registered Nurse's (RN) admission assessment, dated 06/28/10, revealed the patient was free of skin breakdown. Review of the nursing notes revealed the Registered Nurse documented the following:
07/03/10 7:30 AM: "4 x 2 open area to right inner buttock.".
07/03/10 7:00 PM: "Red area noted to bilateral lateral buttocks, skin intact; moderate sized abrasion noted to left buttocks, no redness, swelling or drainage, advised to keep pressure off site and change position every 2 hours."
07/04/10, 1:00 AM: "Abrasion to left buttocks and red area to bilateral outer buttocks."
07/04/10, 7:30 AM: " Dressing in place. Sensi care to bottom at this time, open area with no drainage noted at this time. Turned to right side at this time."
07/05/10, 8:00 AM: "Deep tissue injury to buttocks".

On 07/05/10, 11:00 AM, an initial evaluation of patient #8 by the Wound Care Nurse, S4, revealed "...There is a deep purplish black wound noted on the soft tissue of the right buttocks 2cm x 8cm without depth. Extending beyond this is a deep pink colored line that goes to the lateral trochanter area. The line is 1 cm in width and has intact skin. The left buttocks has a similar pink line noted with intact tissue. ..." The plan of care suggested by the Wound Care Nurse included continuing with the sensi-care zinc barrier ointment twice a day to the buttocks and turning the patient every two hours to relieve pressure.

Further review of the nursing notes from 07/06/10 until patient #8 was re-evaluated by the Wound Care Nurse on 07/14/10 revealed inconsistent documentation of the location, stage, size and appearance of the skin breakdown located on the patient's buttocks. These descriptions varied from "deep tissue wound to sacrum (documented by the RN on 07/06/10)" to "Wound to right butt cheek approximately 3 inches long and 1/2 inch thick in shape of smile on face. Blister size of quarter to bottom of left butt cheek. (documented by the RN on 07/07/10, 8:00 PM)"

On 07/14/10, 9:00 AM, a consultation was triggered, due to a low Braden Scale Score of 13, for the Wound Care Nurse S4 to re-evaluate the patient's skin breakdown. Documentation by the Wound Care Nurse revealed the following "...Patient is currently being seen by wound care due to pressure ulcer to buttocks, unstageable. Patient turns with minimal assist when prompted. Currently on regular hospital bed. Heels are intact..." On 07/15/10, at 8:15 AM and 11:36 AM, the Wound Care Nurse documented she was unable to evaluate the patient due to a procedure and transfer of the patient into the Intensive Care Unit. On 07/19/10, 2:48 PM, the Wound Care Nurse documented "...The wound on the right gluteal area continues to be dry black stable eschar. There is minimal drainage. The wound edges are pink and the eschar is pulling away from the wound edges. There is no odor...The right lateral heel has a deep purple intact wound noted measuring 2cm x 2.5cm. The deep tissue injury was covered with a Mepilex foam dressing. Pillows were placed between legs and under lower legs to float heels off bed at all times."

There RN failed to document an accurate description of patient #8's skin breakdown from 07/05/10 to 07/19/10. According to the RN's documented skin assessment, dated 07/19/10, 7:30 AM, it was documented "Skin integrity maintained, no signs of injury noted. At 9:16 AM, on 07/19/10, this same RN documented "Eschar noted to patient right butt cheek, wound care nurse (S4) states that it was from where his underwear was pulled up so tight and caused soft tissue damage. Mepilex dressing applied to buttock. Soft tissue damaged area noted to patients right outer heel, Mepilex dressing also applied."

Interview with the Wound Care Nurse (S4) on 10/20/10, 8:50 AM, revealed when asked how she would be consulted for wound assessments, S4 stated if upon admission to the hospital a patient scored 13 or less on the Braden Scale, an automatic consult would be initiated. S4 further stated the patient's physician could also write an order for a wound consult. When asked about the evaluation process and wound treatments, S4 stated after evaluating a wound, she provides recommendations to the physician for wound treatment orders. If the consult was the result of a low Braden Score, the recommendations were for preventative measures the RN could initiate, such as the application of a skin barrier for protection of the skin or floating the patient's heels off the bed to prevent pressure from being applied to the area.

Review of the hospital's policies and procedures revealed a policy titled "Nursing - Skin/Wound Care Guidelines", Nursing Management of Pressure Sore: Documentation: Identification and recording of specific data: location, stage, size, appearance, drainage, odor (mild, foul, none), inflammation, undermining on tunneling.

There failed to be documented evidence the Registered Nurse followed the Skin/Wound Care Guidelines policy and procedure, relative to patient #1, and identify and record specific data relative the skin breakdown located under the patient's breasts and abdominal folds. For patient #8, the RN failed to accurately identify and record the location, stage, size and appearance of the skin breakdown that developed on the patient's buttock areas.

Based upon review of 1 of 8 medical records (#1), policies and procedures and staff interview, the hospital failed to ensure the Registered Nurse revised the plan of care for patient's #1 and #8 as evidenced by: 1) failing to revise the nursing care plan when patient #1 had the potential for impairment of skin integrity, and 2) failing to revise patient #8's nursing care plan when the patient developed skin breakdown. Findings:

1) Review of the nursing care plan implemented for patient #1 revealed on 07/18/10, the Registered Nurse identified "Manage Moisture: Keep local areas of skin clean, dry and free of body waste or wound drainage." The interventions included "Provide: Pressure Relief/Reduction, Positions body with pillows, Keep linen dry and wrinkle free, Elevate heels off of bed."

On 08/06/10, 8:00 PM, patient #1 was discharged and transferred to Hospital A, a Long Term Acute Care Hospital, for further ventilator support. Review of the admission assessment of patient #1, conducted by an RN at Hospital A, revealed the patient had excoriated areas located in the bilateral abdominal folds which measured 0.5 cm (centimeter) by 8 cm. The patient also had excoriated areas located in the folds under the left and right breasts which measured 1cm by 9 cm and 1 cm by 7 cm respectively.

Review of the nursing notes from 07/18/10 to 08/06/10 revealed the Registered Nurse failed to identify patient #1 had any skin breakdown or excoriated areas located in the abdominal folds or under the bilateral breasts.

Review of the hospital policies and procedures revealed a policy titled "Nursing Process Implementation - Assessment, Planning, Implementation and Evaluation" Planning: #1. A Plan of Care is developed by the RN during the initial admission process. #6. The Plan of Care is reviewed daily by an RN. Evaluation and revisions to the Plan of Care are done as indicated by the patient condition and needs on a daily basis. Evaluation: #1. Evaluation of the patient is done on a continual basis through assessment. #3. Response to care is assessed and documented.

During an interview with the Director of Nursing on 10/20/10, it was found the hospital utilized a computerized form titled "Plan of Care: Decubitus Care" for the patient who had an actual or the potential for development of decubitus ulcers. The form identified the nursing diagnosis "Potential impairment of skin integrity" with nursing interventions listed. Charting Evaluation Frequency was to be every shift. The goals were for the patient to be free of decubims and pressure areas and the RN was to designate a target date. If the patient had skin integrity impairment related to pressure ulcers, the nursing interventions included "2. Note in nursing notes, 3. Continue preventive measures, 4. Observe for favorable response to treatment, and 7. Keep skin clean and dry." The Charting/Evaluation Frequency was to be every shift and the goal was to prevent further tissue damage, provide healing measures and note progress of healing.

The Registered Nurse failed to follow hospital policy and procedure relative to implementation of the plan of care for patient #1. During the initial admission assessment, the RN identified on the plan of care the patient had the potential for alteration in skin integrity; however, there failed to be documented evidence the RN assessed the patient's skin folds to ensure they were clean and dry and implement nursing interventions to ensure the patient was free of skin breakdown.