HospitalInspections.org

Based on interviews and documentation review, it was determined the Hospital had not developed/implemented a Corrective Action Plan related to its investigation of the Patient's SRE .

Findings included:

At the time of the onsite investigation the Hospital's corrective action plan regarding the development of the Patient's stage I right ankle pressure to a stage III pressure ulcer on 6/25/10 had not been developed or implemented.

Review of documentation provided from the Hospital's internal review of the Patient's SRE indicated that the despite ongoing nursing interventions the Patient developed Stage III pressure ulcers on the right ankle and buttocks (actually the stage III pressure ulcers were on the Patient's coccyx area and a stage II pressure ulcer was noted on the Patient's buttocks). However, the investigation did not identify that ongoing assessments were consistently documented despite Nurse #1 stating she did not identify a stage I on the Patient's right ankle when she performed a skin consult on 6/21/10.

Nurse #1 said she was a wound nurse specialist. She said she assessed the Patient on 6/21/10 she did not see a stage I pressure ulcer on the Patient's right ankle. She said her assessment indicated an assessment of that area was no longer required because she did not see a pressure ulcer. However, there was no documentation in the Patient's medical record indicating the right ankle pressure ulcer until 6/25/10.

Review of Hospital policies and procedures regarding skin pressure ulcers indicated at least daily inspection of skin for pressure ulcers.

Based on review of one of three applicable records review (the Patient) it was determined the nursing staff failed to consistently document at least daily an assessment of the Patient's right ankle after a stage I pressure was identified upon admission.

Findings include:

Admission assessment dated 6/18/10 and 6/19/10 indicated the Patient had left heel ulcer that was unstageable and a right ankle stage I pressure ulcer.

Review of Hospital policies and procedures regarding skin pressure ulcers indicated at least daily inspection of skin for pressure ulcers.

Despite nursing documentation indicating that all skin surfaces, particularly sacrum, back, buttocks, heels and elbows were inspected every shift, review of daily nursing documentation indicated no assessment of the Patient's right ankle after 6/21/10 at 2:47 PM until 6/25/10 at 1:35 PM, at which time a stage III right ankle pressure ulcer was identified. There was no assessment documented of the right ankle pressure area on 6/22/10, 6/23/10 and on 6/24/10.

The wound consult performed on 6/25/10 indicated three stage III pressure ulcers measuring 0.5 centimeters (cm) x 0.3cm, 0.8cm x 0.5cm, 1.5cm x 0.5cm were identified in the coccyx area and a stage III ulcer measuring 2.1cm x 0.5 x 0.2 cm was assessed on the Patient's right lateral ankle.