HospitalInspections.org

Based on medical record review and staff interview, nursing staff failed to provide to one of eight (#1) sampled patients with the activity of turning and repositioning every 2 hours to prevent skin breakdown and a development of pressure ulcers.

Findings:

1. During interview on 04/29/2013 at 11:30 AM, with the daughter of patient #1 stated that she was her mother every day and through the night between 01/28/2013 upon admission through 01/31/2013 on the surgical medical floor (3rd Floor), and that nursing staff did not turn and reposition her mother.

Medical record review revealed that patient #1 was admitted on 01/28/2013 with a right hip fracture, and a history of Congestive Heart Failure (CHF), Hypertension, Chronic Obstructive Pulmonary Disease (COPD), and Dementia, was bedfast during her stay and needed total care in bathing and hygiene.

Review of the facility's skin integrity/preventive skin care revealed that on 01/30/2013, the Braden Scale: for Predicting Pressure Ulcer Risk revealed that patient #1's Braden Scale Score was 14, which is noted as Moderate Risk: Total score 13-14.
Review of the Nursing flowsheet documentation for the month of 01/28 to 01/31 , 2013 revealed that patient #1's assessment for skin were noted as warm, dry, skin integrity intact, and documented as this patient was turned and repositioned every 2 hours, after interview with nursing staff and review of the development of pressure ulcers to her buttocks , it was determined this preventative care had not been done.

Review of documentation by the Charge Nurse on 01/31/2013 at 14:45 PM revealed that she was assisting with cleansing patient #1 with chlorhexadrine wipes prior to surgery. Upon turning patient #1 to change linens, redness and purple discoloration of the skin on her coccyx and buttocks noted. Also a small, bleeding area was noted on the left buttock. The wound care nurse, came to assess, and applied a dressing. Patient at this time was propped onto left side with pillows and patient #1's daughter expressed understanding. Patient #1's nurse, RN #1 (TH), was informed.

Review of the wound care nurse's documentation on her Wound progress note dated 01/31/2013 revealed assessment and documentation on the following 3 wounds:

WOUND #1- midline, sacral spine. Acute; pressure ulcer. Pressure ulcer staging- Pressure ulcer suspected Deep Tissue Injury (DTI). Wound appearance- purple with skin intact, Size 2 centimeter (cm) long (L), 2 cm. wide (W)Treatment Plan-Cleanse with Sterile Normal Saline (NS), Change Mepilex border dressing three times a week (protective dressing) while DTI evolves.

WOUND #2- Right, coccygeal cleft. Acute; pressure ulcer. Pressure ulcer Present on Admission- NO.- Pressure ulcer staging- Pressure ulcer suspected Deep Tissue Injury (DTI). Wound appearance- purple, draining, open areas, moist- Size (cm) Length X Width X Depth, 0.75 cm. circular epithelial layer open on one side, wound bed purple, Depth unknown related to (r/t) DTI, serosanquineous drainage; no odor, scant drainage amount. Treatment Plan-Cleanse with Sterile Normal Saline (NS), Change Mepilex border dressing three times a week (protective dressing) while DTI evolves.

WOUND #3- Left, gluteal, fold. Acute; pressure ulcer. Pressure ulcer Present on Admission- NO.- Pressure ulcer staging- Pressure ulcer suspected Deep Tissue Injury (DTI); intact skin with purple or maroon area, or blood blister. Wound appearance- purple,with skin intact, Size 4.5 centimeter (cm) long (L), 2 cm. wide (W). Treatment Plan-Cleanse with Sterile Normal Saline (NS), Change Mepilex border dressing three times a week (protective dressing) while DTI evolves.

Review of the Consult note written on 01/31/2013 at 9:00 PM by the Critical Care physician in the Intensive Care Unit (ICU), where patient #1 was transferred after her surgery was canceled revealed the following: The physician stated in his note, patient #1 developed worsening dyspnea with audible rales and evaluated in the pre-op area prior to her surgery prompting cancellation and transfer to the ICU for florid CHF. The patient developed a Sacral Decubitus Ulcer as a complication of her management on the medical ward.

Interview with the Charge Nurse of the Medical Unit on 04/29/2013 at 5:10 PM revealed that she is not aware why the care was not provided, that the activity did not occur, and that the patient was to be turned and repositioned to prevent skin breakdown every 2 hours as scheduled. The Charge nurse stated that she spoke with patient #1's day shift RN #1 (TH) and it was revealed that RN #1 stated that patient #1's daughter did not want her turned and repositioned because she was in to much pain from her fractured hip. Although there was not any assessments and to implement nursing care plans prevent the patient from not receiving necessary nursing care. Review of patient #1's medical record with the Charge Nurse revealed that there was not any documentation in the medical record of this conversation with the daughter, or that RN #1 had educated the daughter the risks and benefits of turning and repositioning to prevent development of skin breakdown and risks of a pressure ulcer. And she agreed and confirmed this had not been done.

Interview with the RN #2 (WD) regarding patient #1 on 04/29/2013 at 6:45 PM confirmed that resident #1's was to turned and repositioned every 2 hours every day by nursing staff. He stated that that on 01/31/2013 at the beginning of his night shift, the daughter did not want her moved because she felt patient #1 was in so much pain from her hip fracture, but he stated that he explained to the daughter that the risks and benefits of turning and repositioning to prevent development of skin breakdown and risks of a pressure ulcer. Although there was not any documentation in the medical record of this, or that RN #2 (WD)had educated the daughter the risks and benefits of turning and repositioning to prevent development of skin breakdown and risks of a pressure ulcer. And he agreed and confirmed this had not been done.

Further interview with the Manager of the Medical Unit on 04/29/2013 at 1:30 PM revealed that he has spoken to the family member of patient #1 and has confirmed that she has not been turned and repositioned to prevent skin breakdown every 2 hours as scheduled. Although the care and documentation still remained that care of turning and repositioning have not been provided. The Manager of the Medical Unit stated that he had spoke with the daughter of patient #1 on 02/07/2013 and expressed to her that there was an misunderstanding of what kind of bed her mother was lying on, that it was a special bed for orthopaedic patients with fractures, not a specialty bed to prevent skin breakdown. He further stated that when he spoke with RN #1 (TH) regarding not turning and repositioning patient #1 for the day shifts of 01/29, 01/30, 01/31/2013, she stated that the daughter did not want her moved because she felt patient #1 was in so much pain from her hip fracture. Although there was not any documentation in the medical record of this, or that RN #1 (TH)had educated the daughter the risks and benefits of turning and repositioning to prevent development of skin breakdown and risks of a pressure ulcer. And he agreed and confirmed this had not been done.

Interview on 04/29/2013 at 6:50 PM with the Chief Nursing Officer (CNO) confirmed that documentation of a Care Plan for Skin Breakdown, accurate nursing assessments, and nursing notes regarding education to family members regarding the risk of not turning and repositioning patient #1, and failure to do assessments and to implement nursing care plans prevent the patient from not receiving necessary nursing care. Review of patient #1's medical record with the CNO revealed that there was not any documentation in the medical record of this conversation with the daughter, or that RN #1 had educated the daughter the risks and benefits of turning and repositioning to prevent development of skin breakdown and risks of a pressure ulcer. And she agreed and confirmed this had not been done.

Based on medical record review, facility policy review, and interview the facility failed to insure that nursing assessments were done and nursing care plan was implemented for skin breakdown, for 1 (Patient #1) of 6 sampled patients.

Findings:

1. During interview on 04/29/2013 at 11:30 AM, with the daughter of patient #1 stated that she was her mother every day and through the night between 01/28/2013 upon admission through 01/31/2013 on the surgical medical floor (3rd Floor), and that nursing staff did not turn and reposition her mother.

Medical record review revealed that patient #1 was admitted on 01/28/2013 with a right hip fracture, and a history of Congestive Heart Failure (CHF), Hypertension, Chronic Obstructive Pulmonary Disease (COPD), and Dementia, was bedfast during her stay and needed total care in bathing and hygiene.
Review of the facility's skin integrity/preventive skin care revealed that on 01/30/2013, the Braden Scale: for Predicting Pressure Ulcer Risk revealed that patient #1's Braden Scale Score was 14, which is noted as Moderate Risk: Total score 13-14.

Review of the Nursing flowsheet documentation for the month of 01/28 to 01/31 , 2013 revealed that patient #1's assessment for skin were noted as warm, dry, skin integrity intact, and documented as this patient was turned and repositioned every 2 hours, after interview with nursing staff and review of the development of pressure ulcers to her buttocks , it was determined this preventative care had not been done.

Review of documentation by the Charge Nurse on 01/31/2013 at 14:45 PM revealed that she was assisting with cleansing patient #1 with chlorhexadrine wipes prior to surgery. Upon turning patient #1 to change linens, redness and purple discoloration of the skin on her coccyx and buttocks noted. Also a small, bleeding area was noted on the left buttock. The wound care nurse, came to assess, and applied a dressing. Patient at this time was propped onto left side with pillows and patient #1's daughter expressed understanding. Patient #1's nurse, RN #1 (TH), was informed.

Review of the wound care nurse's documentation on her Wound progress note dated 01/31/2013 revealed assessment and documentation on the following 3 wounds:

WOUND #1- midline, sacral spine. Acute; pressure ulcer. Pressure ulcer staging- Pressure ulcer suspected Deep Tissue Injury (DTI). Wound appearance- purple with skin intact, Size 2 centimeter (cm) long (L), 2 cm. wide (W)Treatment Plan-Cleanse with Sterile Normal Saline (NS), Change Mepilex border dressing three times a week (protective dressing) while DTI evolves.

WOUND #2- Right, coccygeal cleft. Acute; pressure ulcer. Pressure ulcer Present on Admission- NO.- Pressure ulcer staging- Pressure ulcer suspected Deep Tissue Injury (DTI). Wound appearance- purple, draining, open areas, moist- Size (cm) Length X Width X Depth, 0.75 cm. circular epithelial layer open on one side, wound bed purple, Depth unknown related to (r/t) DTI, serosanquineous drainage; no odor, scant drainage amount. Treatment Plan-Cleanse with Sterile Normal Saline (NS), Change Mepilex border dressing three times a week (protective dressing) while DTI evolves.

WOUND #3- Left, gluteal, fold. Acute; pressure ulcer. Pressure ulcer Present on Admission- NO.- Pressure ulcer staging- Pressure ulcer suspected Deep Tissue Injury (DTI); intact skin with purple or maroon area, or blood blister. Wound appearance- purple,with skin intact, Size 4.5 centimeter (cm) long (L), 2 cm. wide (W). Treatment Plan-Cleanse with Sterile Normal Saline (NS), Change Mepilex border dressing three times a week (protective dressing) while DTI evolves.

Review of the Consult note written on 01/31/2013 at 9:00 PM by the physician in the Intensive Care Unit (ICU), where patient #1 was transferred after her surgery was canceled revealed the following: The physician stated in his note, patient #1 developed worsening dyspnea with audible rales and evaluated in the pre-op area prior to her surgery prompting cancellation and transfer to the ICU for florid CHF. The patient developed a Sacral Decubitus Ulcer as a complication of her management on the medical ward.

Interview with the Charge Nurse of the Medical Unit on 04/29/2013 at 5:10 PM revealed that she is not aware why the care was not provided, that the activity did not occur, and that the patient was to be turned and repositioned to prevent skin breakdown every 2 hours as scheduled. The Charge nurse stated that she spoke with patient #1's day shift RN #1 (TH) and it was revealed that RN #1 stated that patient #1's daughter did not want her turned and repositioned because she was in to much pain from her fractured hip. Although there was not any assessments and to implement nursing care plans prevent the patient from not receiving necessary nursing care. Review of patient #1's medical record with the Charge Nurse revealed that there was not any documentation in the medical record of this conversation with the daughter, or that RN #1 had educated the daughter the risks and benefits of turning and repositioning to prevent development of skin breakdown and risks of a pressure ulcer. And she agreed and confirmed this had not been done.

Interview with the RN #2 (WD) regarding patient #1 on 04/29/2013 at 6:45 PM confirmed that resident #1's was to turned and repositioned every 2 hours every day by nursing staff. He stated that that on 01/31/2013 at the beginning of his night shift, the daughter did not want her moved because she felt patient #1 was in so much pain from her hip fracture, but he stated that he explained to the daughter that the risks and benefits of turning and repositioning to prevent development of skin breakdown and risks of a pressure ulcer. Although there was not any documentation in the medical record of this, or that RN #2 (WD)had educated the daughter the risks and benefits of turning and repositioning to prevent development of skin breakdown and risks of a pressure ulcer. And he agreed and confirmed this had not been done.


Further interview with the Manager of the Medical Unit on 04/29/2013 at 1:30 PM revealed that he has spoken to the family member of patient #1 and has confirmed that she has not been turned and repositioned to prevent skin breakdown every 2 hours as scheduled. Although the care and documentation still remained that care of turning and repositioning have not been provided. The Manager of the Medical Unit stated that he had spoken with the daughter of patient #1 on 02/07/2013 and expressed to her that there was an misunderstanding of what kind of bed her mother was lying on, that it was a special bed for orthopaedic patients with fractures, not a specialty bed to prevent skin breakdown. He further stated that when he spoke with RN #1 (TH) regarding not turning and repositioning patient #1 for the day shifts of 01/29, 01/30, 01/31/2013, she stated that the daughter did not want her moved because she felt patient #1 was in so much pain from her hip fracture. Although there was not any documentation in the medical record of this, or that RN #1 (TH)had educated the daughter the risks and benefits of turning and repositioning to prevent development of skin breakdown and risks of a pressure ulcer. And he agreed and confirmed this had not been done.


Review of the facility policy - Type of Policy: NURSING DEPARTMENT. Title: SKIN INTEGRITY/PREVENTATIVE SKIN CARE (ADULT INPATIENT) dated revision of 04/2013 revealed the following regarding the policy:
I. PURPOSE; This policy outlines the process for the maintenance of skin integrity and preventive skin care.
II. DEFINITIONS: When used in this policy, the term Braden Scale refers to the instrument designed to predict the risk of pressure ulcer development. Potential scores range from 4-23. Patients scoring 18 or below are considered at-risk for pressure ulcer formation.
III. POLICY: It is the policy of South Lake Hospital that skin care be:
A. Provided to all patients at South Lake Hospital
B. Tailored to the individual needs of each patient.
C. assessed using the Braden Scale assessment tool on admission, each shift and with any negative change in the patient's condition.
D. To prevent, recognize and treat pressure ulcers at the earliest possible stage.
IV. PROCEDURE:
A. Risk Assessment Goal: Identify at-risk patients needing prevention and their specific risk factors.
1. Assess and document the at-risk pressure ulcer screening criteria (Braden Scale) on all patients on admission, each shift or if there is a negative change in the patient's condition.
a. For an at-risk score of 18 or below, if the patient's condition warrants, initiate preventative skin care guidelines.
b. For an at-risk score of 12 or below, consult Wound Management Support Team via Clinical information System (CIS).
c. For existing skin alterations notify physician and Wound management.
2. Reassess all patients each shift, with any negative change in condition, and when received on transfer from another unit.
3. Initiate preventative interventions for identified specific low scoring factor (physical condition, mobility, mental status, incontinence, or poor nutrition). Modify care according to individual factors.
C. Support Surfaces Goal: Protect against the adverse effects of external mechanical forces, pressure, shear and friction.
1. Any patient in bed who is assessed to be at-risk for developing pressure ulcers ( AT-RISK SCORE OF 18 OR BELOW) will be repositioned at least every 2 hours and more frequently depending on other risk factors and if a pressure redistribution device is not in place.

Review of the facility policy - Type of Policy: PATIENT CARE. Title: ASSESSMENT AND REASSESSMENT OF PATIENTS dated revision of 09/2011 revealed the following regarding the policy:
I. PURPOSE: This policy outlines the process for all patient admission assessments and subsequent assessments to determine the appropriate care, treatment, and services to meet the initial needs as well as his or her changing needs while in the setting.
II. DEFINITIONS: When used in this policy these terms have the following meanings:
A. Physical Review of Systems: Examination of the body by inspection, auscultation, palpation, percussion, and/or olfaction.
B. Nursing Assessment: The process of obtaining pertinent and necessary information about a patient and using the information to provide the patient with the appropriate setting, level of care, and intervention. this process is performed by a Registered Nurse (RN) or Graduate Nurse (GN) only.
VI. PROCEDURE:
A. Nursing responsibilities:
1. The Patient Data and Screening Record (PDSR) (patient admission history)
a. Will be initiated upon admission and completed within 24 hours on all patients.
B. Ancillary responsibilities:
1. Complete an individual assessment or functional screen as initiated by the Patient Data and Screening Record, information and/or physicians orders.
2. Provide interventions based on the Plan of Care, Treatment, or services ordered.
3. Document interventions in the medical record.
4. Coordinate care with nursing as appropriate
5. reassess the patient per department- specific standards
V. DOCUMENTATION: As appropriate in the medical record.

Interview on 04/29/2013 at 6:50 PM with the Chief Nursing Officer (CNO) confirmed that documentation of a Care Plan for Skin Breakdown, accurate nursing assessments, and nursing notes regarding education to family members regarding the risk of not turning and repositioning patient #1, and failure to do assessments and to implement nursing care plans prevent the patient from not receiving necessary nursing care. Review of patient #1's medical record with the CNO revealed that there was not any documentation in the medical record of this conversation with the daughter, or that RN #1 had educated the daughter the risks and benefits of turning and repositioning to prevent development of skin breakdown and risks of a pressure ulcer. And she agreed and confirmed this had not been done.