HospitalInspections.org

Based on observation, interview, record review, and policy review, the provider failed to ensure nursing staff:
*Assessed and documented the description and measurement of the wound according to the standards of practice for one of one sampled patient (1).
*Followed policy and procedures for wound and skin impairment care for one of one sampled patient (1) who had been re-admitted to the facility from another hospital with multiple skin issues. Findings include:

1. Observation and interview on 1/11/16 at 3:30 p.m. with patient 1 revealed she:
*Was lying on her right side in bed.
*Was unsure as to why she was in the hospital.
*Had fallen at home and had a stroke.
*She had a pair of blue heel protector boots lying in her chair in her room.
*Had some skin issues on her heels and her back.

Observation on 1/11/16 at 4:45 p.m. of patient 1 in her room revealed she was lying in bed without her heel protector boots on.

Review of patient 1's electronic medical record (EMR) from 12/9/15 through 12/16/15 revealed:
*She had been admitted for observation on 12/9/15 after being brought to the hospital by ambulance.
*She was confused and slightly disorientated.
*The actual circumstances of her incident at home were unclear.
*On 12/10/15 she was admitted to acute care.
*Her diagnoses included:
-Insulin dependent diabetes mellitus.
-She had a history of left-sided acute-on-chronic subdural hematoma (bleed on the brain).
*The current diagnoses after her admission were as follows:
-Confusion with fall.
-Elevated white count (elevation can indicate an infection).
-Dehydration.
-Diabetes with hyperglycemia (high blood sugar).
*There had been no documentation of any open areas or skin concerns by either the nursing staff or the physicians involved in her acute care stay from 12/10/15 through 12/16/15.
*She had been a patient at the hospital until 12/16/15 when she was transferred to another larger hospital by ambulance for a diagnosis of bacteremia (bacterial infection).

Review of patient 1's history and physical from her acute hospital stay from 12/10/15 through 12/16/15 revealed:
*The chief complaint was bacteremia.
*She was positive for a stroke.
*There had been no skin concerns noted.
*A magnetic resonance imaging (MRI) completed on 12/14/15 had indicated a small infarction in the posterior medial right frontal lobe (stroke).
*Had a methicillin sensitive staphylococcus aureus (blood stream infection) of unknown etiology (unsure where the infection originated).
*She had a new right frontal lobe cerebral vascular accident (CVA).
*She had sepsis secondary to the bacteremia, insulin dependent diabetes, and altered mental state.
*She was treated with intravenous (IV) antibiotics and returned to the provider on 12/21/15.

Review of patient 1's 12/21/15 history and physical revealed:
*She had been re-admitted to the facility for a swing bed stay due to the need for IV antibiotics.
*She had developed a small pressure ulcer on her coccyx (tailbone area) as well as both heels that was likely due to her immobility.
*The plan included:
-Admission to swing bed.
-Continuing occupational, physical, and speech therapy.
-Continuing her IV antibiotic twice daily for twenty-eight days.
-The certified nurse practioner was doubtful the patent could return to her home.
*There had been no documentation on the treatment or intervention of the current pressure ulcers on the patient's coccyx and both of her heels.

Review of patient 1's physician's orders from 12/21/15 through 1/7/16 revealed:
*On 12/21/15 at 7:55 p.m. physical therapy (PT) and occupational therapy (OT) evaluation and treatment. Venelex apply topically three times daily for wound care.
*On 12/21/15 at 8:00 p.m. skin breakdown prevention, and wound/incision intermediate.
*On 12/28/15 at 11:30 a.m. Mycelex cream 1% (percent) apply to the inner thigh and perineal rash twice daily (BID). May also use Seazorb powder BID as needed for moisture.
*On 12/31/15 at 9:40 a.m. Mycostatin powder apply topically TID (three times daily). Please keep peri-area, groin, and abdominal folds as dry as possible. Econazole 1% cream. Apply to affected area TID.
*On 1/4/16 at 11:01 a.m. Specify order consult with Dr. (surgeon's name) on 1/6/16 to left heel blister.

Review of patient 1's nursing documentation from 12/15/15 and 12/16/15 prior to being transferred to another hospital for further treatment revealed:
*12/15/15 at 8:11 p.m.
-"PT [patient] HAS MANY SMALL SCABS OVER ENTIRE BODY PT STATES SHE PICKS AT PLACES ON HER SKIN AND THEY BECOME OPEN AND THEN PICKS THE SCABS SO THEY ARE HARD TO HEAL."
-The right elbow had scratches and had a small amount of brown colored drainage, and there had been a mild odor. A Tegaderm dressing had been applied to the weeping area of the elbow.
*There were no other skin concerns documented.
*12/16/15 at 5:50 a.m. there had been a skin integrity/risk assessment completed by the nurse that indicated the following:
-The patient was occasionally moist.
-She was chairfast (she was in her chair frequently and not mobile).
-She was very limited in her mobility (being able to move around independently).
-She had a potential problem with friction and shearing of the skin.
*The interventions were the following:
-Skin care products.
-Dressings.
-Activity as ordered.
-The patient's total score (a specific scoring system) was fifteen (mild to moderate risk for developing pressure ulcers).
*12/16/15 at 7:35 a.m. "PT HAS MANY SMALL SCABS OVER ENTIRE BODY PT STATES SHE PICKS AT PLACES ON HER SKIN AND THEY BECOME OPEN AND THEN PICKS THE SCABS SO THEY ARE HARD TO HEAL."
-Right elbow had a small amount of brownish drainage with odor from the drainage.
-Tegaderm (dressing) with patch applied to this weeping area of her elbow.
-"Tegaderm with patch applied to left elbow per pt request. Area dry but prone bumps on arm rest."

Review of patient 1's nursing documentation from 12/21/15 through 1/2/16 revealed:
*12/21/15 at 6:50 p.m."Pt. arrives to inpatient swing bed from [name of the hospital transferring from] post-fall, post-cva, and for IV abx [antibiotic] X (times) 28 days for septicemia."
*There were current open skin areas (no description as to the location or size of the open areas were documented on the assessment).
*12/21/15 at 7:30 p.m.:
-There was a left heel blister. The blister was intact and dark red. The wound was documented as present on admit. There was no dressing and was open to air. Venelex was to have been applied bid.
-The right elbow had a skin tear.
-The left elbow had a skin tear and had a dressing that was dry and intact.
-The coccyx area was described as having an ulcer, pink, red, open, and moist. There was a scant amount of yellow drainage. Venelex was applied bid. There was no dressing, and the wound was left open to air.
*There had been no nursing documentation in regards to the measurements or staging of the above mentioned wounds until 12/27/15.
*12/27/15 at 7:30 p.m.:
-The left heel blister was intact and dark red, with no drainage, was open to air, and was present on admit.
-The coccyx area ulcer was described as pink, red, open, and moist. There was a scant amount of yellow drainage, and there was an odor. The area was open to air, and Venelex was applied bid.
*12/27/15 at 10:22 p.m. The coccyx area ulcer was described as red, open, white, moist, and a stage II (partial thickness loss of dermis [skin]presenting as a shallow open ulcer with a red or pink wound bed, without slough [dead skin]. May also present as an intact or open/ruptured serum [fluid]-filled blister). Drainage amount was scant and there was an odor. Present on admit. "12/27 aqua cell ag and extra thin duoderm applied." "VENELEX NOT APPLIED BECAUSE DUODERM IN PLACE."
*No further staging on measurements noted in the nursing documentation until 1/1/16.
*1/1/16 at 9:15 a.m.:
-"Perineum [private area] is pink, red, moist with no drainage. Econazole and nystatin powder applied to this and surrounding areas."
-Left heel blister is now black, intact, brown, with no drainage.
-The left and right elbows are healing.
-The coccyx area ulcer is pink, red, open, moist, and a stage II, there is a small amount of sanguineous drainage. Aquacel Ag/veriva dressing applied.
*At 1/2/16 at 9:07 a.m.:
-Perineum was pink, red, and had inflammation (swelling). Econazole and nystatin powder had been applied to the area.
-Left heel had a blister that was intact, black, brown, and the patient had been admitted with this blister.
-"MEDICATION CREAM APPLIED TO WOUND, COVERED WITH ACE WRAP, HEEL PROTECTORS IN PLACE."
-Right elbow healed.
-Left elbow was now red, open, moist, and there was a small amount of sanguineous drainage. Dressing was intact to the area. The nurse charted that a Tegaderm dressing and a pad was applied to the right elbow, but the right elbow had been healed in the previous charting.
-Coccyx pressure ulcer was pink, red, open, moist, and the first measurement was now 10.0 centimeter (cm) long and 9.0 cm wide. The ulcer was a stage II. The drainage had been described as sero-sanguinous, and there was no odor. There was an Aquacel Ag and versiva dressing applied to the area.
*The above measurement was the first documented measurement since the patient's admission on 12/21/15. That was twelve days since her admission with the pressure ulcer to the coccyx. There was no documentation of the heel wounds or the elbow wounds in the nursing documentation records.
*There was no documentation in the physician's progress notes in regards to the progress of the wounds or changes in treatments during the hospitalization time from admission on 12/21/15 through 1/2/16.

Review of patient 1's 12/21/15 care plan revealed:
*On 12/21/15: Impaired skin integrity was identified, and the physician had been notified. "Notify Dr [doctor] of any open areas on admission and document this in notes or Provider notification, then complete this intervention. Skin Breakdown Prevention Protocol: Skinbreak."
-There was no documentation in the patient's care plan for the frequency of turning or specific times.
*On 12/28/15: Dressing change to coccyx ulcer with the application of Aquacel ag (doubled up) to wound base cover. Change every two days.
*On 12/28/15: Continue to use medicated cream, avoid any pressure to heel/blister or up in chair. Use heel protectors while in bed or up in chair.

Interview with the director of nursing on 1/12/16 from 9:00 a.m. through 10:00 a.m. during the chart review time of patient 1's electronic medical record revealed:
*The assessment and measurements of the wounds should have been completed on admission.
*There should have been on-going documentation in regards to the progress of the wounds.
*She agreed with lack of documentation of those wounds it would have been difficult to identify the progress or worsening of those identified areas.
*She would have expected the nursing staff to follow the provider's policy and procedures and the professional nursing practice standards for the care and treatment of patient pressure ulcers.

Review of the provider's July 2011 Skin Care Intervention Guidelines revealed:
*"Follow the Braden Skin Care Intervention Guide for Skin Care. Skin integrity risk assessment will be done every day. Pressure reduction if bed or chair bound. Frequent turning with a planned schedule. Protect heels. Protect elbows and heels exposed to friction."

Review of the provider's February 2012 Documentation of Wound and Skin Impairments revealed:
*The objective of the policy and procedure was to properly assess, treat, and document on skin/wound impairments.
*"Skin/wounds impairments shall be documented on when first noticed in the Wound and Skin Meditech Intervention screens. Document that wound is present on admission. Wound Care nurse to assess within first 24 hours of admission. Wound staging to be done by wound care nurse.
*Documentation shall occur on the Wound/Incision Meditech Intervention screens once per 8 or 12 H [hour] shifts and/or with any change in wounds status including drgs [dressing]/reinforcements, or change in pressure ulcer state.
*Stage II, III, and IV, and non-stageable pressure ulcers need documentation of the wound measurements when first noted. Wounds need to be measured/assessed every seven days."

Review of the provider's September 2014 Skin Assessment and Care policy revealed:
*The purpose of the policy was to provide guidelines and direction for healthcare professionals in assessing and providing care and intervention to patients with skin issues and to prevent the development of skin issues.
*A full head-to-toe skin assessment would be completed on admission and a minimum of every twelve hours thereafter or if change in status to assess skin changes/breakdown.
*The Braden Pressure Ulcer Risk Assessment Tool would be completed upon admission and then daily.
*Reposition every two hours.
*Off-load potential affected bony prominences.
*Use elbow/heel protectors.
*Use protective dressing if indicated.

Review of the provider's professional nursing standards, Fundamental and Advance Nursing Skills, 3rd Edition, 2010, revealed:
*All assessments and procedures must be completely documented according to institutional policy.
*Record a detailed description of the assessment related to the chief concern.
*Record a detailed description of abnormalities.
*Describe in detail what the pressure area/ulcer looked like noting its location, color, size, shape, and drainage, and the depth of the tissue involved.
*Describe what procedure was done (wound care), what solutions or skin care were used, and how it was done, noting either aseptic or sterile technique per physician orders.
*Describe the client's response to the procedure and how the client tolerated it.
*Document what interventions were being done to decrease/limit pressure to bony prominences.
*Pressure ulcers could develop in unexpected places. Assess the whole client when determining pressure ulcer risk.
*The elderly experience the following effects of aging making them more prone to develop pressure ulcers:
-Less tissue between skin and bone.
-Dehydration.
-Limited mobility.
-Slower wound healing.
*Look at the client's skin especially the pressure areas at least every two hours, and reposition the client as often as you can.

Based on interview, record review, and policy review, the provider failed to ensure individual patient activities were documented in the electronic medical record for two of two sampled swing bed patients (1 and 2). Findings include:

1. Interview on 1/11/16 from 3:45 p.m. through 4:10 p.m. with patients 1 and 2 regarding activities revealed they could not recall any scheduled activities in their rooms.

Interview on 1/12/16 at 8:10 a.m. with registered nurse A in regards to activities for swing bed patients revealed:
*She was unaware of any scheduled routine activities for swing bed patients.
*Family visited often.
*The patients were asked if they wanted to attend activities in the long term care area.

Interview on 1/12/16 at 8:15 a.m. with licensed practical nurse B in regards to scheduled activities for swing bed patients revealed:
*She usually worked the night shift.
*She was filling in for another employee today.
*She was not aware of any scheduled activities that would have been initiated by the staff.
*The patients had a choice to go the the nursing home for activities.

Review of patient 1 and 2's electronic medical records revealed there was no documentation of participation in any scheduled activities. Patient 1 had been admitted to swing bed services on 12/21/15 and patient 2 had been admitted to swing bed services on 1/7/16.

Review of patient 1's 12/24/15 Swing Bed Nutritional-Activities-Social Services-Restorative Care Plan revealed:
*Provide activities of interest.
*Offer activity choices.
*Encourage participation.
*Monitor despondence (rejection or disinterest).
*Other: "Will come down when she can."
*The goal was for the patient to participate in activities of choice during hospitalization.
*There was no documentation the patient had been given an activities calendar.

Review of patient 2's 1/11/16 Swing Bed Nutritional-Activities-Social Services-Restorative Care Plan revealed:
*Provide activities of interest.
*Offer activity choices.
*Encourage participation.
*Monitor for despondence.
*"Calendar given."
*Other: "Will attend is [as] she can later."

Interview on 1/12/16 at 1:30 p.m. with activities coordinator C in regards to scheduled activities and the documentation of those activities for swing bed patients revealed:
*She had been employed in activities for two years.
*She had been offering activities to the swing bed patients.
*The patients usually refused the activity offered.
*She was unaware those activities or the refusal of those activities needed to have been documented in the patient's medical record.

Review of the provider's undated Activities for Swing Bed Residents policy revealed:
*The purpose of the policy was to: "Encourage swing bed residents to socialize and pursue interests similar to those prior to admission. Group activities are available in the Care Center Dining room. Independent activities of interest can be provided in rooms."
*A calendar of events would be given to each swing bed patient.
*Activity staff would discuss interests with patients.
*Complete swing bed resident (patient) individual care plan and encourage both group and one-to-one activities.
*Activities, (provider's name) staff, and Health Center nursing staff were jointly responsible to take residents to and from activities unless the resident was capable of going by themselves. Good communication between departments would be essential to make sure residents had the opportunity to attend activities.

Review of the provider's undated Individualized Activities for Care Center and Swing Bed Residents policy revealed:
*The purpose of the policy was to: "Provide stimulation or activity for the residents who are unable or unwilling to leave their room for other group activities and for those who require additional stimulation beyond what they receive through group attendance."
*The need for individualized activity would be determined by an activity assessment, care planning process, or change of condition.
*In determining the type of individualized visit needed, interests needs, and capabilities were considered. the length, type, and frequency of the activity would vary with the resident.