HospitalInspections.org

Based on findings from medical record (MR) review, document review and interview, in 1 of 3 MRs the nursing documentation in connection with pressure ulcer prevention and treatment
did not meet generally accepted standards of nursing practice. Also, the nursing service policy and procedure (P&P) addressing skin care was not complete.

Findings include:

-- Review of Patient #1's MR identified the patient was admitted on 10/21/15 for knee surgery.

-- Documentation by nursing staff on admission indicated Patient #1 was at moderate risk for pressure ulcer development (Braden Scale score 13) and did not have a pressure ulcer at that time.

-- Per review of hospital's P&P titled "Skin Care," last revised 12/5/14, it indicated that a moderate risk patient requires frequent turning, pressure reduction with support surface, moisture management, and nutrition management.

However, per MR review nursing staff did not ensure that the patients position was changed. For example on 10/22/15 at 2:00 am, Patient #1 was turned and repositioned and placed in supine position. Two hours later at 4:00 am, Patient #1's position was supine. At 6:00 am, the documented position was still supine. At 8:00 am, the documented position was supine. Patient #1 remained in the same position for 6 hours.

Also, on 10/26/15 at 10:29 pm, Patient #1 was transferred from the ICU to the medical unit. Nursing documentation from 10/26/15 at time of transfer and until 11/1/15 at 11:55 am, did not describe that the patient was turned and repositioned every 2 hours.

Additionally, per MR review there was no documentation in the intervention section indicating that Patient #1 was placed on an appropriate support surface after being identified as being at moderate risk for pressure ulcer development.

By 10/31/15, the patient developed a Stage 2 pressure ulcer and 2 skin tears to the right buttock.

-- The hospital's P&P titled "Skin Care," last revised 12/5/14, lacked the following:

1. A guide to the type of pressure ulcer prevention that should be used to address the Braden Scale subscale score.
2. An indication that a patient's Braden score of 18 or less places a patient at risk for pressure ulcer development.
3. Clear criteria for when nursing should request a wound care consult.
4. Instructions for staff to "float heels" while an at risk patient is positioned supine in bed.
5. Requirement that staff ensure all patients at risk for pressure ulcers are turned and repositioned at frequencies determined by the level of risk and tissue tolerance.

-- During interview with Staff A on 11/4/15 at 11:00 am, the above findings were acknowledged.

Based on findings from document review, observation and interview, in 1 of 1 observations nursing staff did not ensure basic safe handling of medications. Specifically, staff were leaving medication at the patients bedside. Additionally, in 1 of 8 MRs reviewed, medication orders were not complete.

Findings include:

-- The hospital's policy and procedure (P&P) titled "Medication Administration," last revised 9/29/15, indicated that medication shall never be left at the bedside.

-- Per observation on 11/2/15 at 2:40 pm, Patient #2 had a Dulera 200/5 inhaler at the bedside. Per observation the following day (11/3/15) at 8:30 am the inhaler was present at the bedside again.

-- During interview of Staff B on 11/3/15 at 9:00 am, he/she indicated there was no physician order for patient to self administer medication or to leave the inhaler at the bedside.

-- Review of Patient #3's MR identified that the patient was admitted on 11/3/15. On admission nursing staff documented multiple skin "wounds" (e.g., bilateral heels, bilateral ankles, bilateral shins) and pressure ulcer to the coccyx.
On 11/3/15 at 5:05 pm, Staff C ordered Mupricin 2% (antibiotic ointment) 1 application topically BID (twice daily) and Collagenase (enzymatic debriding ointment) 250 mg/gram ointment 1 application topically BID. There was no instruction as to where to apply the medication.

-- Per interview of Staff C on 11/3/15 at 9:30 am, he/she usually orders the site that topical medications should be applied to and acknowledged it was not done in this case.

Based on findings from document review, medical record (MR) review, and interview, in 1 of 1 MRs, nursing staff did not accurately document on the ABC alert record (code documentation) dated 4/25/15 found in Patient #4's medical record.

Findings include:

-- The hospital's policy and procedure (P&P) titled "ABC Alert Policy," last published date 1/29/15, states that: "ideally there should be one recorder for the duration of the code... and the record must be filled out completely because this is part of the medical record and is a legal document."

-- However, per review of Patient #4's MR the following was not documented:
1. the type of arrest the patient experienced,
2. whether the arrest was witnessed or unwitnessed,
3. the initial cardiac rhythm,
4. Cardio Pulmonary Resuscitation (CPR) time.
Additionally, in the narrative section of the form there was a nursing note without time, date, or initials.

-- During interview of Staff D on 11/4/15 at 9:10 am he/she indicated that pertinent medical information was missing.

-- During interview of Staff B on 11/4/15 at 9:30 am, he/she acknowledged that nursing staff did not accurately document on the ABC alert record.

Based on findings from observation, document review and interview, in 1 out of 1 observation a nursing staff member administered an injection without donning gloves as required by hospital's policy and procedure (P&P). This lapse in infection control may increase the risk of infection transmission.

Findings include:

-- During observation on 11/2/15 at 2:30 pm, Staff E gave a heparin subcutaneous injection without wearing gloves.

-- The hospital's P&P titled "Medication Administration Procedures," last reviewed 10/11/15, indicates always adhere to universal precautions with patient contact and use gloves when appropriate.

-- During interview of Staff F on 11/2/15 at 2:40 pm, he/she stated that gloves are to be worn when giving a subcutaneous injection.