HospitalInspections.org

Based on staff interview and record review the Critical Access Hospital (CAH) failed to ensure that care was provided in accordance with written policies and procedures for skin problems, pressure ulcers, and wounds for 5 of 10 patients reviewed (Patient #1, Patient #2, Patient #3, Patient #4, and Patient #6). Findings include:

1. Per record review, Patient #1 was admitted to the hospital on 5/26/20. On 6/3/20, Patient #1 was discharged to a Swing Bed (The patient swings from receiving acute-care services and reimbursement to receiving skilled nursing (SNF) services and reimbursement.) and was waiting for placement in a nursing facility. On 6/17/20, Patient #1 was discharged from the hospital to a residential care facility. On 6/18/20, Patient #1 was readmitted to the hospital for evaluation and treatment of several wounds.

Per review of a physician's progress note from 5/26/20, Patient #1 had a history of alcohol abuse, peripheral vascular disease,(A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs.), heart failure, hypertension (high blood pressure), hyperlipidemia (A high concentration of fats in the blood.), gastro-esophageal reflux disease (A digestive disease in which stomach acid or bile irritates the food pipe lining.), anxiety, and depression. Patient #1 presented to the Emergency Department (ED) after being found on the floor at home by a neighbor. S/He was lying on his/her right side next to a dresser that had been knocked over. Patient #1 was alert but unable to recall any events leading to his/her fall. S/He had a history of frequent falls; and had been discharged from a nursing facility on 5/20/20 after recovering from sacral fractures. Patient #1's ED course showed acute kidney injury (A condition in which the kidneys suddenly can't filter waste from the blood.), elevated troponin level(shows damage to the heart muscle possibly indicating a heart attack.), altered mental status (confusion), leukocytosis (elevated white blood cell count), new onset atrial fibrillation (irregular heart beat), and intractable back pain. The physician's exam of Patient #1's skin revealed that Patient #1 had "Extensive pressure ulcers over right posterior shoulder, R hip and R ankle".

Per record review, the nursing physical assessment of a patient's skin evaluated the following:
"Integumentary Symptoms", "Skin Temperature", "Skin Moisture", "Skin Turgor", "Skin Color", "Skin Problem", "Skin Texture", and "Skin Problem Stage".

The nursing admission skin assessment for Patient #1 from 5/26/20 at 6:52 PM, showed an "Area of Concern"; and identified the following:
"Right thigh" "Stage 2 ulcer" "Ulceration"
"Right hip" "pressure area with blister" "Reddened"
"Right Shoulder" "Pressure Area" "Reddened"
"Left Shoulder" "Pressure Area" "Reddened"
"Left Lateral Back" "Pressure Area" "Reddened"
"Left Chest/Breast" "Excoriation" "Reddened"
"Right Ankle" "Pressure Area" "Reddened"

On 5/26/20 at 9:27 PM the skin assessment read,
"Right shoulder" "pressure area open"
"Left shoulder" "Pressure Area"
"Left Lateral Back" "Abrasion
At the time of this skin assessment, there was no assessment of the patient's right thigh, right hip, right ankle, and left chest/breast and/or the skin problem stage.

Per review of a nursing admission progress note for Patient #1 from 5/26/20 at 7:15 PM, it read, "skin issues noted especially on right side of body and mepliex's (type of absorbent dressing) were placed over pressure areas and over open area to" his/her "right hip, right thigh, left lateral back, and right ankle, other pressure areas noted to the left shoulder and large bruising area to the right shoulder."

Per review of a physician's order for Patient #1 from 5/27/20 at 6:44 AM it read, "Wound Care Consult" Reason for Exam "Extensive pressure wounds". A second physician's order from 5/27/20 at 3:34 PM, read, "Dressing Change Q3D" (every three days). The "Wound Care/Dressing Instructions" read, " For the right shoulder and right hip/buttock area, RN(Registered Nurse) recommends wound care as follows: remove old dressing, cleanse with normal saline or wound wash, pat dry, apply skin prep to periwound skin, cover with optifoam (type of dressing that promotes wound healing) bordered foam dressing. Change 2 times a week and as needed to maintain dressing integrity. RN left the right ankle area open to air as it is almost healed, althouh if it worsens or begins to drain, the above protocol should be used. RN would also recommend that patient a home care referral be placed for skilled nursing to ensure wounds are healing and change dressings."

On 5/27/20 at 10:16 AM the skin assessment read,
"Right Thigh" "Decubitus" "Reddened"
"Right Hip" "Pressure Area" "Reddened"
"Right Shoulder" "Pressure Area" "Reddened"
"Left Shoulder" "Pressure Area" "Reddened"
"Left Lateral Back" "Pressure Area" "Reddened"
"Left Chest/Breast" "Excoriation"
"Right Ankle" "Pressure Area" "Reddened"
On 5/27/20 at 8:00 PM the skin assessment read, "Area of Concern"; however, there was nothing further documented about the patient's skin.

Per record review, the nursing wound/incision assessment evaluated the following:
"Wound", "Wound Type", "Dressing Status", "Drainage Amount", "Drainage Description", "Drainage Odor" "General Appearance", 'Wound Bed Greatest Portion" Wound Bed Lesser Portion", "Surrounding Tissue", "Topical Solution, Irrigant" "Primary Dressing", and "Secondary Dressing".

On 5/27/20 at 6:00 PM the nursing wound/incision assessment for Patient #1 identified the following:
"Right Thigh" "Pressure Ulcer" "Changed" "optifoam (type of dressing that promotes wound healing)"
"Right Hip" "Pressure Ulcer" "Changed" "Optifoam"
On 5/27/20 at 9:50 PM the wound/incision assessment read,
"Right Shoulder" "blister-intact" "None" "Asymptomatic"
"Right Ankle" "Dry & Intact"
"Right Thigh" "Abrasion" "Changed" "Moderate" "Serosanguinous" "Clean/Dry, Reddened" "Yellow (Slough)" "Red (Granulation), Shiny" "Bright Red" "optifoam"
"Right Hip" "Abrasion" "Dry & Intact"

Per review of a nursing progress note from 5/27/20 at 6:35 PM, "Patient is alert to self, and place .....does not know current situation and has limited recall about the events leading to admission, wound care nurse in to assess patient, see new orders, but continue to treat with optifoam and turning and positioning and monitoring for any DTI's (Deep Tissue Injuries) that open which may happen."

On 5/28/20 at 10:11 AM the skin assessment read,
"Right Thigh" "Skin Tear" "Potential"
"Right Hip" "Skin Tear" "Potential"
"Right Shoulder" "Skin Flap" "Potential"
"Left Shoulder" "Bruise"
"Left Lateral Back" "Bruise"
"Left Chest/Breast" "Bruise"
"Right Ankle" "Bruise"
On 5/28/20 at 10:11 AM the wound/incision assessment read,
"Right Shoulder" "Skin Tear" "Dry & Intact" "None" "Elastic Bandage"
"Right Ankle" "Skin Tear" "Dry & Intact" "None" "Elastic Bandage"
"Right Thigh" "Skin Tear" "Dry & Intact" "None" "Elastic Bandage"
"Right Hip" "Skin Tear" "Dry & Intact" "None" "Elastic Bandage"

On 5/28/20 at 12:09 AM a nursing progress note read, "patient is alert, oriented to self. wounds documented, optifoam replaced on right thigh d/t coming off. moderate amount of drainage noted on bandage". At 4:30 PM, "scattered ecchymosis and skin tears to R side of body and back."

On 5/29/20 at 2:43 AM the skin assessment read,
"Right Thigh" "Abrasion"
"Right Hip" "Abrasion"
"Right Shoulder" "Abrasion"
"Left Shoulder" "Abrasion"
"Left Lateral Back" "Abrasion"
"Left Chest/Breast" "Abrasion"
"Right Ankle" "Abrasion"
On 5/29/20 at 10:40 AM,
"Right Thigh" "Skin Tear" "Reddened"
"Right Hip" "Skin Tear" "Reddened"
"Right Shoulder" "Skin Tear" "Reddened"
"Left Shoulder" "Bruise" "Reddened"
"Left Lateral Back" "Bruise" "Reddened"
"Left Chest/Breast" "Blister" "Potential"
"Right Ankle" "Skin Tear" "Reddened"
On 5/29/20 at 3:39 AM,
"Right Shoulder" "Skin Tear"
"Right Ankle" "Skin Tear"
"Right Thigh" "Skin Tear"
"Right Hip" "Skin Tear"

On 5/29/20 at 10:40 AM the wound/incision assessment read,
"Right Shoulder" "Skin Tear" "Dry & Intact" "None" "optifoam"
"Right Ankle" "Skin Tear" "Dry & Intact" "None" "optifoam"
"Right Thigh" "Skin Tear" "Dry & Intact" "None" "optifoam"
"Right Hip" "Skin Tear" "Dry & Intact" "None" "optifoam"

On 5/30/20 at 9:08 AM, the skin assessment indicated an "Area of Concern" with no further documentation.

On 5/30/20 at 9:57 AM the wound/skin assessment read,
"Right Ankle" "Dry & Intact" "None" "Mepilex"
"Right Thigh" "Skin Tear" "Changed" "Minimal" "Serous" "Purple" "Mepilex"
"Right Hip" "Skin Tear" "Minimal" "Serous" "Purple" "Mepilex"
At 10:01 AM it read,
"Left Hip" "Abrasion" "Dry & Intact" "Mepilex"
"Left Buttocks" "Skin Tear" "Dry & Intact" "None" "Asymptomatic" "Mepilex"
At 10:29 AM,
"Right Shoulder" "Skin Tear" "Changed" "Serous" "Purple" "Mepilex"
At 10:31 AM it read,
"Right Upper Medial Shoulder" "Blister" "Changed" "Serous" "Purple" "Mepilex"

On 5/30/20 at 4:42 AM a nursing progress note read, "confused, oriented to self .... extensive bruises, skin tears right side". At 5:05 PM, "Multiple skin tears on R side of body and 1 on L buttock. Noted another blister-surrounded-by-ecchymosis on R anterior shoulder; Mepilex applied". At 10:05 PM, "Oriented to self, following commands, pleasant, scattered numerous wounds/bruises."

On 5/31/20 at 7:54 AM, the skin assessment indicated an "Area of Concern" with no further documentation.

On 5/31/20 at 9:30 AM the wound/incision assessment read,
"Right Upper Medial Shoulder" "DTI with blister" "Dry & Intact" "None" "Optifoam"
"Left Hip" "Ruptured Blister" "None" "Draining" "Purple" "Saline Irrigant" "Optifoam"
"Left Buttocks" "Ruptured Blister" "Changed" "None" "Optifoam"
"Right Shoulder" "DTI with ruptured blister" "Changed"
"Right Ankle" "Pressure injury" "Changed" "None" "Asymptomatic" "Optifoam"
"Right Thigh" "DTI with ruptured blister" "Changed" "Minimal" "Serous" "None/Absent" "Draining" "Purple" "Saline Irrigant" "Optifoam"
"Right Hip" "DTI with ruptured blister" "Changed" "Minimal" "Serous" "Purple" "Saline Irrigant" "Optifoam"

On 6/1/20 at 8:35 PM the skin assessment read,
"Right Thigh" "dsg intact and dry"
"Right Hip" "dsg dry and intact"
"Right Shoulder" "Blister"
"Right Ankle" "dsg dry and intact"

On 6/1/20 at 9:35 PM the wound/incision assessment read,
"Right Upper Medial Shoulder" "Abrasion" "Dry & Intact"
"Left Hip" "abrasion/blister" "Dry & Intact"
"Left Buttocks" "abrasion/blister" "Dry & Intact"
"Right Shoulder" "Abrasion" "Dry & Intact"
"Right Ankle" "Abrasion" "Dry & Intact"
"Right Thigh" "Abrasion" "Dry & Intact"
"Right Hip" "Abrasion" "Dry & Intact"

On 6/1/20 at 5:51 PM a nursing progress note read, "many DTI's with blisters are covered with Optifoams"

On 6/3/20 at 11:55 AM the wound/incision assessment read,
"Right Upper Medial Shoulder" "2 mepilex in place" "Dry & Intact"
"Left Hip" "Redness"
"Left Buttocks" "2 mepilex in place" "Dry & Intact"
"Right Ankle" "small scab"
"Right Hip" "large mepilex in place" "Minimal" "Sanguineous"

On 6/3/20 at 5:05 AM a nursing progress note read, "foam dsgs (dressings) in place. all dry and intact".

On 6/3/20 at 3:02 PM, the Swing Bed admission nursing skin assessment for Patient #1 identified "Area of Concern":
"R hip" "heart shape mepilex in place"
"R ankle" "dry scab"
"left buttocks" "2 Mepilex in place"
"Right Shoulder" "2 Mepilex in place"

On 6/3/20 at 3:32 PM a nursing progress note read, "Dressings to R shoulder and R hip/Buttock areas changed per MD orders. Patient tol procedure well".

Upon further review of nursing progress notes, on 6/4/20 at 4:16 PM, "Patient showered today and all Optifoam dressings changed. The DTI's and blisters look better with the purple now turned to red". On 6/7/20 at 10:53 AM, "Dressing changes to R shoulder and R hip/buttock done at 10:30. Pt tol well. Very small amt serous drainage from all wounds. Wounds appear to be smaller than last time (4 days ago) when seen by this nurse". On 6/9/20 at 6:43 PM, "changed" his/her "dressings this afternoon, every single dressing had a small amount of green drainage."

On 6/12/20 at 11:53 AM, a wound/incision assessment read,
"Right Buttocks" "Changed" "Moderate" "sanguinous, green" "Draining" "Asymptomatic" "Mepilex"
"Right Hip" "Changed" "None" "Asymptomatic" "Mepilex"
"Right Shoulder" "Changed" "Minimal" "Sanguineous" "Draining" "Asymptomatic" "Mepilex"

On 6/12/20 at 5:22 PM a nursing progress note read, "Dressings to R Buttocks/R Hip and R Shoulder changed today. Significant amount of drainage noted to large R buttock/hip dressing-odorous and sanguinous/dark green tinted. Other dressings with minimal to no drainage."

On 6/15/20 at 6:29 AM a nursing progress note read, "Mepilexes dry and intact. R. hip dressing has moderate drainage but is intact and secure-dressings d/t be changed on day shift today". At 6:19 PM, "Declined dressing change to R hip/buttocks/shoulder area, offered multiple times, patient kept wanting to 'do it later'. Moderate drainage noted to large pressure area to R hip/buttocks area". On 6/16/20 at 2:43 AM, "Dressings changed to pressure areas on right posterior shoulder and right hip. Large amount of purulent drainage on old dressings; very foul odor from right hip dressing. New Mepilex borders applied to all sites."

Per review of the discharge nursing skin assessment from 6/17/20 at 9:03 AM it read,
"R hip" "Abrasion" "Draining" "Mepilix" "Moist"
"Right Shoulder" "Abrasion" "Clean/Dry" "mepilex" "Moist"

On 6/17/20 at 11:55 PM a nursing progress note read, "Patient has dressings to right shoulder and right hip that are clean, dry and intact. Shadowing of drainage noted on right hip sacral dressing. Dressing change due to tomorrow, per orders. Wound care supplies and instructions sent in discharge packet with patient."

3. Per review of a physician's progress note from 6/20/20, Patient #3 had a past medical history of dementia (A chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning.), hypertension, decubitus ulcer (pressure sore), and hyperlipidemia. S/He presented to the ED with an altered mental status. Patient #3 went out to sit in the car and had refused to get out. The patient had been in the car for approximately 40 minutes, then his/her family member was able to get him/her out of the car. At that time, the ambulance was called, as s/he became almost unresponsive with a temperature of 105.9. The patient as found to have bilateral infiltrates (fluid) on his/her chest x-ray and a possible urinary tract infection. The physician's exam of the patient's skin revealed "Small coccygeal pressure ulcer with intact skin present on admission."

The nursing admission skin assessment for Patient #3 from 6/20/20 at 8:03 PM, showed an "Area of Concern"; and identified the following:
"left buttock" "Pressure Area" "Potential"
"Right forearm" "Skin Tear"
"Right hand" "Skin Tear"
"Right Hip" "Bruise"

Per review of a nursing progress note for Patient #3 on 6/20/20 at 10:19 PM, "The patient ...was admitted .... with Heat Stroke. See admission general and physical assessments."

On 6/21/20 at 10:29 AM, the skin assessment read,
"Right Hip" "Bruise"
"Left buttock" "Pressure Area"
"Right forearm" "covered with mepilex"
"Right hand" "covered with mepilex"
"Right shin" "covered with mepilex"

The nursing discharge skin assessment from 6/21/20 at 12:35 PM read,
"Right Hip" "Bruise"
"Left buttock" "Pressure Area"
"Right forearm" "Skin tear"
"Right hand" "Skin tear"
"Right shin" "Mepilex"

Per review of a nursing progress note for Patient #3 on 6/21/20 at 4:13 AM, "Turned and repositioned side to side with 2 assist ...Alert, easily responsive." At 1:54 PM, "Patient alert to self, appropriate and cooperative .... discharge education provided .... updated medication list and new prescription."

4. Per review of a physician's progress note from 6/16/20, Patient #4 had a history of diabetes, benign prostatic hyperplasia with obstructive voiding symptoms (enlarged prostate that can cause difficulty urinating), chronic indwelling catheter, hypertension, and hyperlipidemia. The patient was treated at the hospital 6/6/20 to 6/10/20 for a blood infection caused by bacteria in the urine. S/He was discharged to a nursing facility and was receiving antibiotics by mouth. The patient was transferred to the ED due to a low-grade fever, blood and blood clots in his/her urine, pain with urination, and bladder spasms. The patient complained of severe pain from the bladder spasms and requested that that indwelling catheter be removed. The patient was alert and able to provide a clear, coherent history. The physician's exam of the patient's skin revealed "some ecchymosis on the dorsum of" his/her "left hand."

The nursing admission skin assessment for Patient #4 from 6/16/20 at 4:55 PM, showed an "Area of Concern"; and identified the following:
"Left Buttock" "pressure ulcer" "Potential"
On 6/16/20 at 11:01 PM the skin assessment read,
"Left Buttock" "Pressure Area" "Ulceration"

Per review of a nursing progress note from 6/16/20 at 5:20 PM, "Patient has an open area to" his/her "left buttocks and dressing was done in ED. Dressing is clean dry and intact. See admission general and physical assessments." At 11:03 PM, "PU on left buttock covered with optifoam gentle. small amount of sanguinous drainage noted from wound."

On 6/17/20 at 7:19 PM the skin assessment read,
"Left Buttock" "open area" "Ulceration"
On 6/17/20 at 10:26 PM the skin assessment read,
"Right buttock" "Abrasion" "Reddened"
"Left Buttock" "Pressure Area" "Ulceration"
On 6/18/20 at 3:30 PM the skin assessment read,
"Right buttock" "shearing"
"Left buttock" "Pressure Area" "Ulceration"
On 6/18/20 at 10:15 PM the skin assessment read,
"Right buttock" "Pressure Area" "Ulceration"
"Left Buttock" "Pressure Area" "Ulceration"

On 6/18/20 at 10:06 PM and 10:09 PM the nursing wound/incision assessment on read,
"Right Buttocks" "Pressure Ulcer" "Changed" "None" "Optifoam dressing"
"Left Buttocks" "Pressure Ulcer" "Dry & Intact" "None" "optifoam gentle"

Per review of a nursing progress note for Patient #4 on 6/18/20 at 1:13 AM, "During routine skin care pt noted to have abrasion on left buttock which is painful with care." S/He "also has an open area on left buttock. Optifoam dressing to left buttock changed." At 6:24 PM, "Mepilex on left buttock intact. Open areas on right buttock noted. Barrier cream applied."

On 6/19/20 at 11:20 AM the skin assessment read,
"Right buttock" "Pressure Area"
"Left Buttock" "Pressure Area"

On 6/19/20 at 11:16 AM the wound/incision assessment read,
"Right Buttocks" "Stasis Ulcer" "Dry & Intact" "None" "Clean/Dry" "Asymptomatic" "Mepilex"
"Left Buttocks" "Pressure Ulcer" "Dry & Intact" "None" "Clean/Dry" "Asymptomatic" "Mepilex"

The nursing discharge skin assessment from 6/19/20 at 6:18 PM read,
"Right buttock" "Pressure Area" "Clean/Dry" "Mepilex"
"Left Buttock" "Pressure Area" "Clean/Dry" "Mepilex"

Per review of a nursing progress note for Patient #4 on 6/19/20 at 5:14 AM, "Dressing to right buttock applied earlier in the evening ...Improvement in all skin compared to previous night". At 3:23 PM, "Pt alert & oriented, able to make needs known ...Skin care performed to groin and abd folds. Mepilex placed to L&R buttocks pressure areas."

For Patient #1 there was no evidence that the physician was notified on 6/9/20, 6/12/20, and 6/16/20 regarding the change in characteristics of his/her pressure ulcers and wounds. The above examples also show the lack of documentation, consistency, and knowledge/competency with identifying and assessing skin problems, pressure ulcers, wounds and their characteristics for Patient #1, Patient #3, and Patient #4.

Per interview on 10/5/20 at 1:30 PM with the Chief Nursing Officer (CNO), s/he stated that the hospital did not have a "wound nurse" on staff; however, six of the hospital nursing staff had been specially trained in wound care. S/He stated that the hospital had a contract to utilize the wound care services of the local Home Health Agency. S/He stated that s/he expected the nursing staff assess a patient upon admission and that if there were any wounds present, to "document what they look like, pictures if needed". S/He also stated that s/he would expect to see evidence of a "wound getting better and actions taken" if a wound was not improving.

Per interview on 10/5/20 at 4:22 PM with the Medical/Surgical Nurse Manager, s/he stated that the hospital policy was that the nursing staff completed a physical assessment of all body systems every twelve hours and that this assessment would include skin. If a "variance" in a patient's skin was identified this variance was expected to be documented in a wound assessment and/or a nursing progress note. S/He confirmed that there was an opportunity to improve and that the nursing staff did not adequately and/or accurately and completely document Patient #1's skin problems and pressure injury and wound characteristics.

On 10/6/20 at 2:47 PM and at 2:50 PM, the Medical/Surgical Nurse Manager additionally confirmed that for Patient #3 and Patient #4 the nursing staff did not adequately and/or accurately and completely document their skin problems and pressure injury and wound characteristics.

Per interviews on 10/5/20 through 10/7/20 with the CNO, Medical/Surgical Nurse Manager, and Director of Quality, they confirmed that there were no policies for pressure injury and wound assessment and care. The expectation was that the nursing staff were to utilize an online, evidence based site called clinical skills(https://www.elsevier.com/solutions/clinical-skills).

Per review of the reference,"retrieved on 10/7/20", "Skills: Pressure Injury and Wound-CE"
"Quick Sheet"

"6. Determine the organization-approved pressure injury (PI) or wound assessment tool and the required frequency of PI or wound assessment. 7. Check the practitioner's orders regarding PI or wound care. 8. Review the patient's last documented PI or wound assessment to use as a comparison for the current PI or wound assessment. 17. Examine the dressing for quality of drainage (color, consistency) and quantity of drainage (saturated, slightly moist, or no drainage). 20 .... assess key PI or wound characteristics. a. Anatomic location on the body b. Type of PI or wound c. Extent of tissue involvement d. Color, type, and percentage of tissue involved e. Length, width, and depth measured in centimeters f. Presence of undermining (tissue under a wound becomes eroded) at PI or wound edges, tunnels, or sinus tracts (narrow opening extending from a wound through soft tissue that creates a dead space where a potential abscess could form); measure and record depth and direction of each g. Amount, color, and consistency exudate (drainage) h. Presence of foul odor (assess after the PI or wound has been cleansed) 24. Review and compare previous PI or wound assessments to monitor the PI or wound healing. 30. Document the procedure in the patient's record." [Adapted from Perry, A.G. Potter, P.A., Ostendorf, W.R.(Eds.). (2018). Clinical nursing skills & techniques (9th ed.). St Louis: Elsevier]

Per review of the reference,"retrieved on 10/7/20", "Skills: Assessment: Pressure Injury: Treatment-CE"
"Quick Sheet"
"Alert"
"Accurate wound assessment requires competency-based education for the most accurate results of subjective data."
"5. Perform a comprehensive assessment of the patient to determine whether any risk factors are present that might delay wound healing. 10. Assess each pressure injury and the surrounding skin. a. Assign a pressure injury stage per the organization's practice. b. Determine the type of tissue in the wound bed by color (red, yellow, black). c. Approximate the percentage of each tissue type found in the wound bed. d. Determine whether signs or symptoms of infection are present. e. Assess the amount of exudate present. f. Measure the wound dimensions (length, width, depth) in centimeters. g. Determine the depth of tunneling or undermining. 13. Review the practitioner's order, as applicable for topical agent(s) and dressing. If the order is not consistent with established wound care guidelines or conflicts with the identified outcomes for the patient, review the order with the practitioner. 29. Report any signs and symptoms of infection to the practitioner. 31. Report any deterioration in pressure injury appearance to the nurse in charge or practitioner. 34. Document the procedure in the patient's record." [Adapted from Perry, A.G. Potter, P.A., Ostendorf, W.R.(Eds.). (2018). Clinical nursing skills & techniques (9th ed.). St Louis: Elsevier]




43524


2. Per review of patient #2's medical record it revealed s/he was admitted to the facility on 6/25/20 related to a diagnosis of advanced pancreatic cancer. A nursing note dated 6/25/20 at 06:50 noted that the patient had an Optifoam dressing in place on his/her coccyx for "2 small spots that were excoriated". There were no other descriptors or wound measurements provided in this note. There was a nurses note dated 6/25/20 at 09:29 that reported "Pinpoint pressure sore noted on pts L buttock. Mepilex in place, but was changed due to soiling dressing from using bedpan.", again there were no other descriptors or wound measurements provided in this note. This wound was not adequately assessed and documented per the facility's policy. Per interview on 10/5/20 at 1:30 PM with the Chief Nursing Officer (CNO), s/he stated that the hospital did not have a "wound nurse" on staff; however, six of the hospital nursing staff had been specially trained in wound care. S/He stated that the hospital had a contract to utilize the wound care services of the local Home Health Agency. S/He stated that s/he expected the nursing staff assess a patient upon admission and that if there were any wounds present, to "document what they look like, pictures if needed". S/He also stated that s/he would expect to see evidence of a "wound getting better and actions taken" if a wound was not improving.

5. Per review of patient #6's medical record it revealed s/he was admitted to the facility on 10/3/20 related to a left subcapital femur fracture (hip fracture) due to a fall at home. On 10/5/20 patient #6 underwent a left total hip replacement. On 10/5/20 at 23:52 a skin assessment was completed and a reddened area was noted. On 10/7/20 at 13:01 a nurses note revealed patient #6 had "2 pea size open areas on [pronoun omitted] buttocks, - 1 on the left side of [pronoun omitted] gluteal cleft and 1 on the right of [pronoun omitted] gluteal cleft." There was no documentation of wound characteristics or dimensions.

A wound tracking sheet was noted in patient #6's medical record that was initiated on 10/5/20 specific to the patients coccyx area. The first entry was completed on 10/5/20 at 07:44 listing the wound as a "pressure area" that was described as "reddened", no other descriptors or wound measurements were provided. The second entry was completed on 10/5/20 at 20:00 listing the wound as a "pressure area" that was described as "reddened", no other descriptors or wound measurements were provided. The third entry was completed on 10/6/20 at 20:00 listing the wound as "Excoriation" that was described as "smooth" and "reddened". The last entry was completed on 10/7/20 at 08:00 listing the wound as a "pressure area" there were no other descriptors or wound measurements provided in this entry. This wound was not adequately assessed and the patients medical record was not accurate related to the type of wound.

During an interview on 10/5/20 at 4:22 PM with the Medical/Surgical Nurse Manager, s/he confirmed the hospital policy was that nursing staff complete a head to toe assessment every twelve hours which includes assessment of the skin. If a "variance" in a patient's skin was identified this variance was expected to be documented in a wound assessment and/or a nursing progress note.

During an interview on 10/7/20 at approximately 3:35 PM with the Director of Quality, s/he confirmed that accurate and complete documentation for patient #2 and patient #6 was not evident in the patients' medical records.

During interviews on 10/5/20 through 10/7/20 with the CNO, Medical/Surgical Nurse Manager, and Director of Quality, they confirmed that there were no policies for pressure injury and wound assessment and care. The expectation was that the nursing staff were to utilize an online, evidence based site called clinical skills(https://www.elsevier.com/solutions/clinical-skills).

The reference, "retrieved on 10/7/20", used as hospital policy "Skills Assessment: Pressure Injury and Wound - CE Quick Sheet" states on page 2, #20 the following:
"Using the organization-approved assessment tool, assess key PI or wound characteristics.
a. Anatomic location on the body
b. Type of PI or wound
c. Extent of tissue involvement
d. Color, type, and percentage of tissue involved
e. Length, width, and depth measured in centimeters......."

Based on staff interview and record review the CAH failed to ensure that skin, pressure ulcer and wound care was provided in accordance with patients needs by qualified, competent staff for 3 of 10 patients reviewed (Patient #1, Patient #3, Patient #4). Findings include:

1. Per record review, Patient #1 was admitted to the hospital on 5/26/20. On 6/3/20, Patient #1 was discharged to a Swing Bed (The patient swings from receiving acute-care services and reimbursement to receiving skilled nursing (SNF) services and reimbursement.) and was waiting for placement in a nursing facility. On 6/17/20, Patient #1 was discharged from the hospital to a residential care facility. On 6/18/20, Patient #1 was readmitted to the hospital for evaluation and treatment of several wounds.

Per review of a physician's progress note from 5/26/20, Patient #1 had a history of alcohol abuse, peripheral vascular disease,(A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs.), heart failure, hypertension (high blood pressure), hyperlipidemia (A high concentration of fats in the blood.), gastro-esophageal reflux disease (A digestive disease in which stomach acid or bile irritates the food pipe lining.), anxiety, and depression. Patient #1 presented to the Emergency Department (ED) after being found on the floor at home by a neighbor. S/He was lying on his/her right side next to a dresser that had been knocked over. Patient #1 was alert but unable to recall any events leading to his/her fall. S/He had a history of frequent falls; and had been discharged from a nursing facility on 5/20/20 after recovering from sacral fractures. Patient #1's ED course showed acute kidney injury (A condition in which the kidneys suddenly can't filter waste from the blood.), elevated troponin level(shows damage to the heart muscle possibly indicating a heart attack.), altered mental status (confusion), leukocytosis (elevated white blood cell count), new onset atrial fibrillation (irregular heart beat), and intractable back pain. The physician's exam of Patient #1's skin revealed that Patient #1 had "Extensive pressure ulcers over right posterior shoulder, R hip and R ankle".

Per record review, the nursing physical assessment of a patient's skin evaluated the following:
"Integumentary Symptoms", "Skin Temperature", "Skin Moisture", "Skin Turgor", "Skin Color", "Skin Problem", "Skin Texture", and "Skin Problem Stage".

The nursing admission skin assessment for Patient #1 from 5/26/20 at 6:52 PM, showed an "Area of Concern"; and identified the following:
"Right thigh" "Stage 2 ulcer" "Ulceration"
"Right hip" "pressure area with blister" "Reddened"
"Right Shoulder" "Pressure Area" "Reddened"
"Left Shoulder" "Pressure Area" "Reddened"
"Left Lateral Back" "Pressure Area" "Reddened"
"Left Chest/Breast" "Excoriation" "Reddened"
"Right Ankle" "Pressure Area" "Reddened"

On 5/26/20 at 9:27 PM the skin assessment read,
"Right shoulder" "pressure area open"
"Left shoulder" "Pressure Area"
"Left Lateral Back" "Abrasion
At the time of this skin assessment, there was no assessment of the patient's right thigh, right hip, right ankle, and left chest/breast and/or the skin problem stage.

Per review of a nursing admission progress note for Patient #1 from 5/26/20 at 7:15 PM, it read, "skin issues noted especially on right side of body and mepliex's (type of absorbent dressing) were placed over pressure areas and over open area to" his/her "right hip, right thigh, left lateral back, and right ankle, other pressure areas noted to the left shoulder and large bruising area to the right shoulder."

Per review of a physician's order for Patient #1 from 5/27/20 at 6:44 AM it read, "Wound Care Consult" Reason for Exam "Extensive pressure wounds". A second physician's order from 5/27/20 at 3:34 PM, read, "Dressing Change Q3D" (every three days). The "Wound Care/Dressing Instructions" read, " For the right shoulder and right hip/buttock area, RN(Registered Nurse) recommends wound care as follows: remove old dressing, cleanse with normal saline or wound wash, pat dry, apply skin prep to periwound skin, cover with optifoam (type of dressing that promotes wound healing) bordered foam dressing. Change 2 times a week and as needed to maintain dressing integrity. RN left the right ankle area open to air as it is almost healed, althouh if it worsens or begins to drain, the above protocol should be used. RN would also recommend that patient a home care referral be placed for skilled nursing to ensure wounds are healing and change dressings."

On 5/27/20 at 10:16 AM the skin assessment read,
"Right Thigh" "Decubitus" "Reddened"
"Right Hip" "Pressure Area" "Reddened"
"Right Shoulder" "Pressure Area" "Reddened"
"Left Shoulder" "Pressure Area" "Reddened"
"Left Lateral Back" "Pressure Area" "Reddened"
"Left Chest/Breast" "Excoriation"
"Right Ankle" "Pressure Area" "Reddened"
On 5/27/20 at 8:00 PM the skin assessment read, "Area of Concern"; however, there was nothing further documented about the patient's skin.

Per record review, the nursing wound/incision assessment evaluated the following:
"Wound", "Wound Type", "Dressing Status", "Drainage Amount", "Drainage Description", "Drainage Odor" "General Appearance", 'Wound Bed Greatest Portion" Wound Bed Lesser Portion", "Surrounding Tissue", "Topical Solution, Irrigant" "Primary Dressing", and "Secondary Dressing".

On 5/27/20 at 6:00 PM the nursing wound/incision assessment for Patient #1 identified the following:
"Right Thigh" "Pressure Ulcer" "Changed" "optifoam (type of dressing that promotes wound healing)"
"Right Hip" "Pressure Ulcer" "Changed" "Optifoam"
On 5/27/20 at 9:50 PM the wound/incision assessment read,
"Right Shoulder" "blister-intact" "None" "Asymptomatic"
"Right Ankle" "Dry & Intact"
"Right Thigh" "Abrasion" "Changed" "Moderate" "Serosanguinous" "Clean/Dry, Reddened" "Yellow (Slough)" "Red (Granulation), Shiny" "Bright Red" "optifoam"
"Right Hip" "Abrasion" "Dry & Intact"

Per review of a nursing progress note from 5/27/20 at 6:35 PM, "Patient is alert to self, and place .....does not know current situation and has limited recall about the events leading to admission, wound care nurse in to assess patient, see new orders, but continue to treat with optifoam and turning and positioning and monitoring for any DTI's (Deep Tissue Injuries) that open which may happen."

On 5/28/20 at 10:11 AM the skin assessment read,
"Right Thigh" "Skin Tear" "Potential"
"Right Hip" "Skin Tear" "Potential"
"Right Shoulder" "Skin Flap" "Potential"
"Left Shoulder" "Bruise"
"Left Lateral Back" "Bruise"
"Left Chest/Breast" "Bruise"
"Right Ankle" "Bruise"
On 5/28/20 at 10:11 AM the wound/incision assessment read,
"Right Shoulder" "Skin Tear" "Dry & Intact" "None" "Elastic Bandage"
"Right Ankle" "Skin Tear" "Dry & Intact" "None" "Elastic Bandage"
"Right Thigh" "Skin Tear" "Dry & Intact" "None" "Elastic Bandage"
"Right Hip" "Skin Tear" "Dry & Intact" "None" "Elastic Bandage"

On 5/28/20 at 12:09 AM a nursing progress note read, "patient is alert, oriented to self. wounds documented, optifoam replaced on right thigh d/t coming off. moderate amount of drainage noted on bandage". At 4:30 PM, "scattered ecchymosis and skin tears to R side of body and back."

On 5/29/20 at 2:43 AM the skin assessment read,
"Right Thigh" "Abrasion"
"Right Hip" "Abrasion"
"Right Shoulder" "Abrasion"
"Left Shoulder" "Abrasion"
"Left Lateral Back" "Abrasion"
"Left Chest/Breast" "Abrasion"
"Right Ankle" "Abrasion"
On 5/29/20 at 10:40 AM,
"Right Thigh" "Skin Tear" "Reddened"
"Right Hip" "Skin Tear" "Reddened"
"Right Shoulder" "Skin Tear" "Reddened"
"Left Shoulder" "Bruise" "Reddened"
"Left Lateral Back" "Bruise" "Reddened"
"Left Chest/Breast" "Blister" "Potential"
"Right Ankle" "Skin Tear" "Reddened"
On 5/29/20 at 3:39 AM,
"Right Shoulder" "Skin Tear"
"Right Ankle" "Skin Tear"
"Right Thigh" "Skin Tear"
"Right Hip" "Skin Tear"

On 5/29/20 at 10:40 AM the wound/incision assessment read,
"Right Shoulder" "Skin Tear" "Dry & Intact" "None" "optifoam"
"Right Ankle" "Skin Tear" "Dry & Intact" "None" "optifoam"
"Right Thigh" "Skin Tear" "Dry & Intact" "None" "optifoam"
"Right Hip" "Skin Tear" "Dry & Intact" "None" "optifoam"

On 5/30/20 at 9:08 AM, the skin assessment indicated an "Area of Concern" with no further documentation.

On 5/30/20 at 9:57 AM the wound/skin assessment read,
"Right Ankle" "Dry & Intact" "None" "Mepilex"
"Right Thigh" "Skin Tear" "Changed" "Minimal" "Serous" "Purple" "Mepilex"
"Right Hip" "Skin Tear" "Minimal" "Serous" "Purple" "Mepilex"
At 10:01 AM it read,
"Left Hip" "Abrasion" "Dry & Intact" "Mepilex"
"Left Buttocks" "Skin Tear" "Dry & Intact" "None" "Asymptomatic" "Mepilex"
At 10:29 AM,
"Right Shoulder" "Skin Tear" "Changed" "Serous" "Purple" "Mepilex"
At 10:31 AM it read,
"Right Upper Medial Shoulder" "Blister" "Changed" "Serous" "Purple" "Mepilex"

On 5/30/20 at 4:42 AM a nursing progress note read, "confused, oriented to self .... extensive bruises, skin tears right side". At 5:05 PM, "Multiple skin tears on R side of body and 1 on L buttock. Noted another blister-surrounded-by-ecchymosis on R anterior shoulder; Mepilex applied". At 10:05 PM, "Oriented to self, following commands, pleasant, scattered numerous wounds/bruises."

On 5/31/20 at 7:54 AM, the skin assessment indicated an "Area of Concern" with no further documentation.

On 5/31/20 at 9:30 AM the wound/incision assessment read,
"Right Upper Medial Shoulder" "DTI with blister" "Dry & Intact" "None" "Optifoam"
"Left Hip" "Ruptured Blister" "None" "Draining" "Purple" "Saline Irrigant" "Optifoam"
"Left Buttocks" "Ruptured Blister" "Changed" "None" "Optifoam"
"Right Shoulder" "DTI with ruptured blister" "Changed"
"Right Ankle" "Pressure injury" "Changed" "None" "Asymptomatic" "Optifoam"
"Right Thigh" "DTI with ruptured blister" "Changed" "Minimal" "Serous" "None/Absent" "Draining" "Purple" "Saline Irrigant" "Optifoam"
"Right Hip" "DTI with ruptured blister" "Changed" "Minimal" "Serous" "Purple" "Saline Irrigant" "Optifoam"

On 6/1/20 at 8:35 PM the skin assessment read,
"Right Thigh" "dsg intact and dry"
"Right Hip" "dsg dry and intact"
"Right Shoulder" "Blister"
"Right Ankle" "dsg dry and intact"

On 6/1/20 at 9:35 PM the wound/incision assessment read,
"Right Upper Medial Shoulder" "Abrasion" "Dry & Intact"
"Left Hip" "abrasion/blister" "Dry & Intact"
"Left Buttocks" "abrasion/blister" "Dry & Intact"
"Right Shoulder" "Abrasion" "Dry & Intact"
"Right Ankle" "Abrasion" "Dry & Intact"
"Right Thigh" "Abrasion" "Dry & Intact"
"Right Hip" "Abrasion" "Dry & Intact"

On 6/1/20 at 5:51 PM a nursing progress note read, "many DTI's with blisters are covered with Optifoams"

On 6/3/20 at 11:55 AM the wound/incision assessment read,
"Right Upper Medial Shoulder" "2 mepilex in place" "Dry & Intact"
"Left Hip" "Redness"
"Left Buttocks" "2 mepilex in place" "Dry & Intact"
"Right Ankle" "small scab"
"Right Hip" "large mepilex in place" "Minimal" "Sanguineous"

On 6/3/20 at 5:05 AM a nursing progress note read, "foam dsgs (dressings) in place. all dry and intact".

On 6/3/20 at 3:02 PM, the Swing Bed admission nursing skin assessment for Patient #1 identified "Area of Concern":
"R hip" "heart shape mepilex in place"
"R ankle" "dry scab"
"left buttocks" "2 Mepilex in place"
"Right Shoulder" "2 Mepilex in place"

On 6/3/20 at 3:32 PM a nursing progress note read, "Dressings to R shoulder and R hip/Buttock areas changed per MD orders. Patient tol procedure well".

Upon further review of nursing progress notes, on 6/4/20 at 4:16 PM, "Patient showered today and all Optifoam dressings changed. The DTI's and blisters look better with the purple now turned to red". On 6/7/20 at 10:53 AM, "Dressing changes to R shoulder and R hip/buttock done at 10:30. Pt tol well. Very small amt serous drainage from all wounds. Wounds appear to be smaller than last time (4 days ago) when seen by this nurse". On 6/9/20 at 6:43 PM, "changed" his/her "dressings this afternoon, every single dressing had a small amount of green drainage."

On 6/12/20 at 11:53 AM, a wound/incision assessment read,
"Right Buttocks" "Changed" "Moderate" "sanguinous, green" "Draining" "Asymptomatic" "Mepilex"
"Right Hip" "Changed" "None" "Asymptomatic" "Mepilex"
"Right Shoulder" "Changed" "Minimal" "Sanguineous" "Draining" "Asymptomatic" "Mepilex"

On 6/12/20 at 5:22 PM a nursing progress note read, "Dressings to R Buttocks/R Hip and R Shoulder changed today. Significant amount of drainage noted to large R buttock/hip dressing-odorous and sanguinous/dark green tinted. Other dressings with minimal to no drainage."

On 6/15/20 at 6:29 AM a nursing progress note read, "Mepilexes dry and intact. R. hip dressing has moderate drainage but is intact and secure-dressings d/t be changed on day shift today". At 6:19 PM, "Declined dressing change to R hip/buttocks/shoulder area, offered multiple times, patient kept wanting to 'do it later'. Moderate drainage noted to large pressure area to R hip/buttocks area". On 6/16/20 at 2:43 AM, "Dressings changed to pressure areas on right posterior shoulder and right hip. Large amount of purulent drainage on old dressings; very foul odor from right hip dressing. New Mepilex borders applied to all sites."

Per review of the discharge nursing skin assessment from 6/17/20 at 9:03 AM it read,
"R hip" "Abrasion" "Draining" "Mepilix" "Moist"
"Right Shoulder" "Abrasion" "Clean/Dry" "mepilex" "Moist"

On 6/17/20 at 11:55 PM a nursing progress note read, "Patient has dressings to right shoulder and right hip that are clean, dry and intact. Shadowing of drainage noted on right hip sacral dressing. Dressing change due to tomorrow, per orders. Wound care supplies and instructions sent in discharge packet with patient."

2. Per review of a physician's progress note from 6/20/20, Patient #3 had a past medical history of dementia (A chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning.), hypertension, decubitus ulcer (pressure sore), and hyperlipidemia. S/He presented to the ED with an altered mental status. Patient #3 went out to sit in the car and had refused to get out. The patient had been in the car for approximately 40 minutes, then his/her family member was able to get him/her out of the car. At that time, the ambulance was called, as s/he became almost unresponsive with a temperature of 105.9. The patient as found to have bilateral infiltrates (fluid) on his/her chest x-ray and a possible urinary tract infection. The physician's exam of the patient's skin revealed "Small coccygeal pressure ulcer with intact skin present on admission."

The nursing admission skin assessment for Patient #3 from 6/20/20 at 8:03 PM, showed an "Area of Concern"; and identified the following:
"left buttock" "Pressure Area" "Potential"
"Right forearm" "Skin Tear"
"Right hand" "Skin Tear"
"Right Hip" "Bruise"

Per review of a nursing progress note for Patient #3 on 6/20/20 at 10:19 PM, "The patient ...was admitted .... with Heat Stroke. See admission general and physical assessments."

On 6/21/20 at 10:29 AM, the skin assessment read,
"Right Hip" "Bruise"
"Left buttock" "Pressure Area"
"Right forearm" "covered with mepilex"
"Right hand" "covered with mepilex"
"Right shin" "covered with mepilex"

The nursing discharge skin assessment from 6/21/20 at 12:35 PM read,
"Right Hip" "Bruise"
"Left buttock" "Pressure Area"
"Right forearm" "Skin tear"
"Right hand" "Skin tear"
"Right shin" "Mepilex"

Per review of a nursing progress note for Patient #3 on 6/21/20 at 4:13 AM, "Turned and repositioned side to side with 2 assist ...Alert, easily responsive." At 1:54 PM, "Patient alert to self, appropriate and cooperative .... discharge education provided .... updated medication list and new prescription."

3. Per review of a physician's progress note from 6/16/20, Patient #4 had a history of diabetes, benign prostatic hyperplasia with obstructive voiding symptoms (enlarged prostate that can cause difficulty urinating), chronic indwelling catheter, hypertension, and hyperlipidemia. The patient was treated at the hospital 6/6/20 to 6/10/20 for a blood infection caused by bacteria in the urine. S/He was discharged to a nursing facility and was receiving antibiotics by mouth. The patient was transferred to the ED due to a low-grade fever, blood and blood clots in his/her urine, pain with urination, and bladder spasms. The patient complained of severe pain from the bladder spasms and requested that that indwelling catheter be removed. The patient was alert and able to provide a clear, coherent history. The physician's exam of the patient's skin revealed "some ecchymosis on the dorsum of" his/her "left hand."

The nursing admission skin assessment for Patient #4 from 6/16/20 at 4:55 PM, showed an "Area of Concern"; and identified the following:
"Left Buttock" "pressure ulcer" "Potential"
On 6/16/20 at 11:01 PM the skin assessment read,
"Left Buttock" "Pressure Area" "Ulceration"

Per review of a nursing progress note from 6/16/20 at 5:20 PM, "Patient has an open area to" his/her "left buttocks and dressing was done in ED. Dressing is clean dry and intact. See admission general and physical assessments." At 11:03 PM, "PU on left buttock covered with optifoam gentle. small amount of sanguinous drainage noted from wound."

On 6/17/20 at 7:19 PM the skin assessment read,
"Left Buttock" "open area" "Ulceration"
On 6/17/20 at 10:26 PM the skin assessment read,
"Right buttock" "Abrasion" "Reddened"
"Left Buttock" "Pressure Area" "Ulceration"
On 6/18/20 at 3:30 PM the skin assessment read,
"Right buttock" "shearing"
"Left buttock" "Pressure Area" "Ulceration"
On 6/18/20 at 10:15 PM the skin assessment read,
"Right buttock" "Pressure Area" "Ulceration"
"Left Buttock" "Pressure Area" "Ulceration"

On 6/18/20 at 10:06 PM and 10:09 PM the nursing wound/incision assessment on read,
"Right Buttocks" "Pressure Ulcer" "Changed" "None" "Optifoam dressing"
"Left Buttocks" "Pressure Ulcer" "Dry & Intact" "None" "optifoam gentle"

Per review of a nursing progress note for Patient #4 on 6/18/20 at 1:13 AM, "During routine skin care pt noted to have abrasion on left buttock which is painful with care." S/He "also has an open area on left buttock. Optifoam dressing to left buttock changed." At 6:24 PM, "Mepilex on left buttock intact. Open areas on right buttock noted. Barrier cream applied."

On 6/19/20 at 11:20 AM the skin assessment read,
"Right buttock" "Pressure Area"
"Left Buttock" "Pressure Area"
On 6/19/20 at 11:16 AM the wound/incision assessment read,
"Right Buttocks" "Stasis Ulcer" "Dry & Intact" "None" "Clean/Dry" "Asymptomatic" "Mepilex"
"Left Buttocks" "Pressure Ulcer" "Dry & Intact" "None" "Clean/Dry" "Asymptomatic" "Mepilex"
The nursing discharge skin assessment from 6/19/20 at 6:18 PM read,
"Right buttock" "Pressure Area" "Clean/Dry" "Mepilex"
"Left Buttock" "Pressure Area" "Clean/Dry" "Mepilex"

Per review of a nursing progress note for Patient #4 on 6/19/20 at 5:14 AM, "Dressing to right buttock applied earlier in the evening ...Improvement in all skin compared to previous night". At 3:23 PM, "Pt alert & oriented, able to make needs known ...Skin care performed to groin and abd folds. Mepilex placed to L&R buttocks pressure areas."

For Patient #1 there was no evidence that the physician was notified on 6/9/20, 6/12/20, and 6/16/20 regarding the change in characteristics of his/her pressure ulcers and wounds. The above examples also show the lack of documentation, consistency, and knowledge/competency with identifying and assessing skin problems, pressure ulcers, wounds and their characteristics for Patient #1, Patient #3, and Patient #4.

Per interview on 10/5/20 at 1:30 PM with the Chief Nursing Officer (CNO), s/he stated that the hospital did not have a "wound nurse" on staff; however, six of the hospital nursing staff had been specially trained in wound care. S/He stated that the hospital had a contract to utilize the wound care services of the local Home Health Agency. S/He stated that s/he expected the nursing staff assess a patient upon admission and that if there were any wounds present, to "document what they look like, pictures if needed". S/He also stated that s/he would expect to see evidence of a "wound getting better and actions taken" if a wound was not improving.

Per interview on 10/5/20 at 4:22 PM with the Medical/Surgical Nurse Manager, s/he stated that the hospital policy was that the nursing staff completed a physical assessment of all body systems every twelve hours and that this assessment would include skin. If a "variance" in a patient's skin was identified this variance was expected to be documented in a wound assessment and/or a nursing progress note. S/He confirmed that there was an opportunity to improve and that the nursing staff did not adequately and/or accurately and completely document Patient #1's skin problems and pressure injury and wound characteristics.

On 10/6/20 at 2:47 PM and at 2:50 PM, the Medical/Surgical Nurse Manager additionally confirmed that for Patient #3 and Patient #4 the nursing staff did not adequately and/or accurately and completely document their skin problems and pressure injury and wound characteristics.

Per interviews on 10/5/20 through 10/7/20 with the CNO, Medical/Surgical Nurse Manager, and Director of Quality, they confirmed that there were no policies for pressure injury and wound assessment and care. The expectation was that the nursing staff were to utilize an online, evidence based site called clinical skills(https://www.elsevier.com/solutions/clinical-skills).

Per review of the reference,"retrieved on 10/7/20", "Skills: Pressure Injury and Wound-CE"
"Quick Sheet"

"6. Determine the organization-approved pressure injury (PI) or wound assessment tool and the required frequency of PI or wound assessment. 7. Check the practitioner's orders regarding PI or wound care. 8. Review the patient's last documented PI or wound assessment to use as a comparison for the current PI or wound assessment. 17. Examine the dressing for quality of drainage (color, consistency) and quantity of drainage (saturated, slightly moist, or no drainage). 20 .... assess key PI or wound characteristics. a. Anatomic location on the body b. Type of PI or wound c. Extent of tissue involvement d. Color, type, and percentage of tissue involved e. Length, width, and depth measured in centimeters f. Presence of undermining (tissue under a wound becomes eroded) at PI or wound edges, tunnels, or sinus tracts (narrow opening extending from a wound through soft tissue that creates a dead space where a potential abscess could form); measure and record depth and direction of each g. Amount, color, and consistency exudate (drainage) h. Presence of foul odor (assess after the PI or wound has been cleansed) 24. Review and compare previous PI or wound assessments to monitor the PI or wound healing. 30. Document the procedure in the patient's record." [Adapted from Perry, A.G. Potter, P.A., Ostendorf, W.R.(Eds.). (2018). Clinical nursing skills & techniques (9th ed.). St Louis: Elsevier]

Per review of the reference,"retrieved on 10/7/20", "Skills: Assessment: Pressure Injury: Treatment-CE"
"Quick Sheet"
"Alert"
"Accurate wound assessment requires competency-based education for the most accurate results of subjective data."

"5. Perform a comprehensive assessment of the patient to determine whether any risk factors are present that might delay wound healing. 10. Assess each pressure injury and the surrounding skin. a. Assign a pressure injury stage per the organization's practice. b. Determine the type of tissue in the wound bed by color (red, yellow, black). c. Approximate the percentage of each tissue type found in the wound bed. d. Determine whether signs or symptoms of infection are present. e. Assess the amount of exudate present. f. Measure the wound dimensions (length, width, depth) in centimeters. g. Determine the depth of tunneling or undermining. 13. Review the practitioner's order, as applicable for topical agent(s) and dressing. If the order is not consistent with established wound care guidelines or conflicts with the identified outcomes for the patient, review the order with the practitioner. 29. Report any signs and symptoms of infection to the practitioner. 31. Report any deterioration in pressure injury appearance to the nurse in charge or practitioner. 34. Document the procedure in the patient's record." [Adapted from Perry, A.G. Potter, P.A., Ostendorf, W.R.(Eds.). (2018). Clinical nursing skills & techniques (9th ed.). St Louis: Elsevier]

Per document review, the following content was part of the "PMC (Porter Medical Center) Clinical RN Annual Training 2020": "PMC Fire and Electrical Safety 2020", "PMC Fire Plan", "PMC Basic Ergonomics 2020", "PMC General Safety 2020", "PMC Hazardous Communication 2020", "PMC Patient Safety and Reporting 2020", "PMC Email Security Training/Phishing 2020", "PMC Security and Emergency Preparedness 2020", "PMC Suspected Abuse Reporting 2020", "PMC Suspected Abuse Reporting Policy 2020", "PMC Unsecure Medication", "PMC Blood Transfusion 2020", "PMC Blood Borne Pathogens Clinical 2020", "PMC Infection Control Clinical 2020", "PMC Organ and Tissue Donation 2020", PMC Restraint Training 2020", "PMC Compliance Training 2020", and "PMC Privacy Training 2020".

Per review on 10/7/20 of the document used for nursing orientation to the medical/surgical unit, for "Skin/Wound/Ostomy Assessment" the nurse, "Applies Intervention to Help in Healing Compromised Skin" "Verbalizes the Difference Between Sterile and Clean Dressing Changes" "Demonstrates Dressing Change:" "Sterile", "Clean", "Wet to Dry" "Assists Wound Care with Wound Vac Dressing Change".

Per review of the education files on 10/7/20 of four Registered Nurses who work on the Medical/Surgical Unit, 3 of the nurses were hired in 2019, one was hired in 2018, there was no evidence that any follow-up education/training for skin, pressure injury and wound assessment and care had been done since orientation.

Per interview on 10/5/20 at 4:22 PM with the Medical/Surgical Nurse Manager, s/he stated that if a nurse had a question about skin, pressure ulcer and wound assessment and care there was an educational reference that they could refer to. S/He stated that after the orientation period, if issues were identified "based on a need" then education was provided on the unit and/or by the clinical nurse educators to the nursing staff.

Per interview on 10/7/20 at 3:12 PM with the Medical/Surgical Nurse Manager, s/he stated that the nursing staff on the medical/surgical unit receive monthly newsletters that cover different educational topics. S/He confirmed at that time that s/he had "no documented competency for nursing staff for skills" which included wound care, other than during their initial orientation to the unit.

Per interview on 10/7/20 at 3:45 PM with a Clinical Nurse Educator, s/he stated that there were annual trainings that nurses were required to complete, some were regulatory driven, and some were needs based. S/He stated that the hospital did not "go by every RN needs training". The trainings were developed on a need basis and in "real time". S/he stated that in June of 2019 a "Skills Fair" was offered to staff that included many different tables of topics with content experts; however, it was not offered this year (2020). S/He also stated that the Unit Managers were responsible for unit specific competencies and training of staff on an ongoing basis.

Per review of the policy "Scope of Services-Medical-Surgical"-approved 4/19/19, it read, "The practice of Medical-Surgical nursing requires specialized knowledge and clinical skills to manage actual or potential health problems that affect individuals, their significant other(s), and the community. Medical-Surgical services are provided to our clients from pediatrics throughout the life span. The patient cliental served includes, but is not limited to: general medical, pre and post op surgery, orthopedics, progressive care, non-critical pediatrics, telemetry monitoring, end of life and outpatient infusion treatments when needed ... ....The Medical-Surgical Department uses numerous nursing, diagnostic and therapeutic modalities to facilitate care." Some of the qualifications listed for a "Registered Nurse" were the following: "Valid Unrestricted Vermont RN license, BLS (Basic Life Support), upon hire, completion of hospital orientation, ongoing competencies and educational assignments, and assigned hospital education modules".

Based on staff interview and record review the CAH failed to ensure that records were complete and accurately documented for 4 of 10 patients reviewed (Patient #1, Patient #2, Patient #4, and Patient #6). Findings include:

1. Per review of a physician's progress note from 5/26/20, Patient #1 has a history of alcohol abuse, peripheral vascular disease,(A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs.), heart failure, hypertension (high blood pressure), hyperlipidemia (A high concentration of fats in the blood.), gastro-esophageal reflux disease (A digestive disease in which stomach acid or bile irritates the food pipe lining.), anxiety, and depression. Patient #1 presented to the Emergency Department (ED) after being found on the floor at home by a neighbor. S/He was lying on his/her right side next to a dresser that had been knocked over. Patient #1 was alert but unable to recall any events leading to his/her fall. S/He had a history of frequent falls; and had been discharged from a nursing facility on 5/20/20 after recovering from sacral fractures. Patient #1's ED course showed acute kidney injury, elevated troponin level, altered mental status, leukocytosis, new onset atrial fibrillation, and intractable back pain. The physician's exam of Patient #1's skin revealed that Patient #1 had "Extensive pressure ulcers over right posterior shoulder, R hip and R ankle".

Per review of a physician's progress note from 5/27/20, the physician's exam of Patient #1' skin showed, "Pressure wounds over right posterior shoulder, R hip and buttock and R ankle". There was no documented assessment and/or plan for the resident's pressure ulcer. Upon further review of a physician's order for Patient #1 on 5/27/20 it read, "Wound Care Consult" Reason for Exam "Extensive pressure wounds". Upon further review of a physician's order on 5/27/20 at 3:34 PM, it read "Dressing Change Q3D" (every three days). The "Wound Care/Dressing Instructions" read, " For the right shoulder and right hip/buttock area, RN recommends wound care as follows: remove old dressing, cleansed with normal saline or wound wash, pat dry, apply skin prep to periwound skin, cover with optifoam bordered foam dressing. Change 2 times a week and as needed to maintain dressing integrity. RN left the right ankle area open to air as it is almost healed, althouh if it worsens or begins to drain, the above protocol should be used. RN would also recommend that patient a home care referral be placed for skilled nursing to ensure wounds are healing and change dressings."

Per review of physician's progress notes for Patient #1 on 5/28/20, 5/29/20, 5/30/20, 5/31/20, 6/1/20, and 6/2/20; and a discharge summary from 6/3/20; there was no skin exam, assessment or plan of care for Patient #1's pressure ulcers.
Per interview on 10/5/20 at 4:31 PM with the Medical/Surgical Nurse Manager, s/he confirmed that there was no skin exam, assessment or plan of care for Patient #1's pressure ulcers. On 10/7/20 at 1:00 PM, during an interview with the Chief Medical Officer (CMO) s/he also confirmed that the "provider documentation" was lacking for Patient #1 regarding pressure ulcer identification and plan of care.


3. Per review of a physician's progress note from 6/16/20, Patient #4 had a history of diabetes, benign prostatic hyperplasia with obstructive voiding symptoms (enlarged prostate that can cause difficulty urinating), chronic indwelling catheter, hypertension, and hyperlipidemia. The patient was treated at the hospital 6/6/20 to 6/10/20 for a blood infection caused by bacteria in the urine. S/He was discharged to a nursing facility and was receiving antibiotics by mouth. The patient was transferred to the ED due to a low-grade fever, blood and blood clots in his/her urine, pain with urination, and bladder spasms. The patient complained of severe pain from the bladder spasms and requested that that indwelling catheter be removed. The patient was alert and able to provide a clear, coherent history. The physician's exam of the patient's skin revealed "some ecchymosis on the dorsum of" his/her "left hand."

The nursing admission skin assessment for Patient #4 from 6/16/20 at 4:55 PM, showed an "Area of Concern"; and identified the following:
"Left Buttock" "pressure ulcer" "Potential"

On 6/16/20 at 11:01 PM the skin assessment read,
"Left Buttock" "Pressure Area" "Ulceration"

Per review of a nursing progress note from 6/16/20 at 5:20 PM, "Patient has an open area to" his/her "left buttocks and dressing was done in ED. Dressing is clean dry and intact. See admission general and physical assessments." At 11:03 PM, "PU on left buttock covered with optifoam gentle. small amount of sanguinous drainage noted from wound."

On 6/17/20 at 7:19 PM the skin assessment read,
"Left Buttock" "open area" "Ulceration"
On 6/17/20 at 10:26 PM the skin assessment read,
"Right buttock" "Abrasion" "Reddened"
"Left Buttock" "Pressure Area" "Ulceration"
On 6/18/20 at 3:30 PM the skin assessment read,
"Right buttock" "shearing"
"Left buttock" "Pressure Area" "Ulceration"
On 6/18/20 at 10:15 PM the skin assessment read,
"Right buttock" "Pressure Area" "Ulceration"
"Left Buttock" "Pressure Area" "Ulceration"

On 6/18/20 at 10:06 PM and 10:09 PM the nursing wound/incision assessment on read,
"Right Buttocks" "Pressure Ulcer" "Changed" "None" "Optifoam dressing"
"Left Buttocks" "Pressure Ulcer" "Dry & Intact" "None" "optifoam gentle"

Per review of a nursing progress note for Patient #4 on 6/18/20 at 1:13 AM, "During routine skin care pt noted to have abrasion on left buttock which is painful with care." S/He "also has an open area on left buttock. Optifoam dressing to left buttock changed." At 6:24 PM, "Mepilex on left buttock intact. Open areas on right buttock noted. Barrier cream applied."

On 6/19/20 at 11:20 AM the skin assessment read,
"Right buttock" "Pressure Area"
"Left Buttock" "Pressure Area"

On 6/19/20 at 11:16 AM the wound/incision assessment read,
"Right Buttocks" "Stasis Ulcer" "Dry & Intact" "None" "Clean/Dry" "Asymptomatic" "Mepilex"
"Left Buttocks" "Pressure Ulcer" "Dry & Intact" "None" "Clean/Dry" "Asymptomatic" "Mepilex"
The nursing discharge skin assessment from 6/19/20 at 6:18 PM read,
"Right buttock" "Pressure Area" "Clean/Dry" "Mepilex"
"Left Buttock" "Pressure Area" "Clean/Dry" "Mepilex"

Per review of a nursing progress note for Patient #4 on 6/19/20 at 5:14 AM, "Dressing to right buttock applied earlier in the evening ...Improvement in all skin compared to previous night". At 3:23 PM, "Pt alert & oriented, able to make needs known ...Skin care performed to groin and abd folds. Mepilex placed to L&R buttocks pressure areas."

Per review of the physician's discharge summary from 6/19/20 for Patient #4 there was no skin exam, assessment or plan of care for Patient #4's pressure ulcers. Per interview on 10/6/20 at 2:59 PM with the Medical/Surgical Nurse Manager, s/he confirmed there was no documentation on the discharge summary regarding Patient #4's pressure ulcers and recommendations for their care and treatment.


43524


2. Per review of patient #2's medical record it revealed s/he was admitted to the facility on 6/25/20 related to a diagnosis of advanced pancreatic cancer. A nursing note dated 6/25/20 at 06:50 noted that the patient had an optifoam dressing in place on his/her coccyx for "2 small spots that were excoriated". There were no other descriptors or wound measurements provided in this note. There was a nurses note dated 6/25/20 at 09:29 that reported "Pinpoint pressure sore noted on pts L buttock. Mepilex in place, but was changed due to soiling dressing from using bedpan.", there were no other descriptors or wound measurements provided in this note. This wound was not adequately assessed and the patients medical record was not accurate related to the type of wound.

4. Per review of patient #6's medical record it revealed s/he was admitted to the facility on 10/3/20 related to a left subcapital femur fracture (hip fracture) due to a fall at home. On 10/5/20 patient #6 underwent a left total hip replacement. On 10/5/20 at 23:52 a skin assessment was completed and a reddened area was noted. On 10/7/20 at 13:01 a nurses note revealed patient #6 had "2 pea size open areas on [pronoun omitted] buttocks, - 1 on the left side of [pronoun omitted] gluteal cleft and 1 on the right of [pronoun omitted] gluteal cleft." There was no documentation of wound characteristics or dimensions.

A wound tracking sheet was noted in patient #6's medical record that was initiated on 10/5/20 specific to the patients coccyx area. The first entry was completed on 10/5/20 at 07:44 listing the wound as a "pressure area" that was described as "reddened", no other descriptors or wound measurements were provided. The second entry was completed on 10/5/20 at 20:00 listing the wound as a "pressure area" that was described as "reddened", no other descriptors or wound measurements were provided. The third entry was completed on 10/6/20 at 20:00 listing the wound as "Excoriation" that was described as "smooth" and "reddened". The last entry was completed on 10/7/20 at 08:00 listing the wound as a "pressure area" there were no other descriptors or wound measurements provided in this entry. This wound was not adequately assessed and the patients medical record was not accurate related to the type of wound.

During an interview on 10/5/20 at 4:22 PM with the Medical/Surgical Nurse Manager, s/he confirmed the hospital policy was that nursing staff complete a head to toe assessment every twelve hours which includes assessment of the skin. If a "variance" in a patient's skin was identified this variance was expected to be documented in a wound assessment and/or a nursing progress note.

During an interview on 10/7/20 at approximately 3:35 PM with the Director of Quality, s/he confirmed that accurate and complete documentation for patient #2 and patient #6 was not evident in the patients' medical records.

The reference, "retrieved on 10/7/20", used as hospital policy "Skills Assessment: Pressure Injury and Wound - CE Quick Sheet" states on page 2, #20 the following:
"Using the organization-approved assessment tool, assess key PI or wound characteristics.
a. Anatomic location on the body
b. Type of PI or wound
c. Extent of tissue involvement
d. Color, type, and percentage of tissue involved
e. Length, width, and depth measured in centimeters......."