HospitalInspections.org

Based on document review, medical record (MR) review and interview, 1 of 2 MRs reviewed of patients at risk for pressure ulcer development (Patient #1) lacked nursing documentation regarding turning and positioning, skin breakdown preventative measures, and consistent skin and wound assessments. These lapses could increase patients' risk for skin breakdown.

Findings include:

-- Per review of the hospital's policy and procedure (P&P) titled "Skin Integrity Protocol (Acute Care)/Swing Bed," dated 10/2019, it indicated all acute inpatients should be assessed by a registered nurse (RN) for risk of skin breakdown using the Braden Scale on admission and at least daily. Those whose Braden Scale score is 18 or less are considered at risk for skin breakdown. The Braden Scale for Pressure Sore Risk (Braden scale) requires scoring of patient risk factors. Prevention protocols for at risk patients include (e.g., observe skin daily and document, when in bed, turn and reposition at least every two hours, utilize pillows, when in chair, assist patient with position changes, limit out of bed to 1-2 hour intervals, heels must be elevated completely off bed surface, consider need for pressure reduction device in bed and chair, use heel and elbow protector to reduce friction, etc.) Staff are instructed to document wound assessment, wound care and interventions.

-- Per review of Patient #1's MR, she was a 96-year-old who presented to the hospital on 10/10/19 with chief complaint of overall weakness and a 2-day history of cough, fever, shortness of breath and chills. Her admitting diagnosis was pneumonia, sepsis, hypoxia and acute respiratory failure.

Her care plan indicated she was high risk for impaired skin integrity related to extreme of age, immobility, poor nutrition, mechanical forces, poor circulation, altered sensation, and incontinence. The care plan instructed staff to monitor for redness, skin tears, abrasions, lesions, shearing and friction skin damage.

On 10/12/19 Patient #1's skin assessment indicated her skin was intact except for an abrasion. Her Braden scale score on 10/12/19 at 3:58 am was 18 (at risk for skin breakdown).

On 10/12/19 at 8:45 pm, Patient #1 fell and suffered a hip fracture. After the fall and injury, her Braden score on 10/13/19 decreased to a 12.

From 10/12/19 through 10/21/19 the MR lacked documentation of consistent turning and positioning every two hours. For example:

- 10/14/19 at 10:00 am Patient #1 was in semi fowlers position (position in which a patient is lying on their back with the head and torso raised between 15 and 45 degrees). At 2:57 pm patient remained in semi fowlers, and at 6:07 pm patient remained in semi fowlers position.
- 10/18/19 at 12:10 am, MR reveals patient on her left side. At 2:50 am, patient remained on left side. At 5:20 am patient still on left side.

Also, the MR lacked documentation of consistent repositioning when Patient #1 was in a chair. For example:

-10/16/19 at 12:00 pm, Patient #1 was resting in chair. At 1:48 patient was resting in chair and at 2:16 pm patient remains in chair. There is no documentation that patient was repositioned while in chair.

Documentation also showed that Patient #1's heel were only elevated once on 10/14/19 at 4:28 am until 10/21/19.

Additionally, documentation of the patient's skin stated the only skin impairment from 10/15/19 to 10/17/19 was surgical wound to right hip. Documentation from 10/17/19 - 10/21/19 revealed the following;

-10/17/19 at 8:20 am, skin assessment indicates dry sterile dressing to right hip and pannus (an apron of skin or fat).
-10/18/19 at 4:40 pm, skin WNL.
-10/19/19 at 1:13 am, generalized bruising, dressing to right hip.
-10/19/19 at 9:57 pm, incision, 2 dressings on right hip, both dry and intact.
-10/20/19 at 8:19 pm, 2 Aquacel dressings dry and intact to right groin and hip.
-10/21/19 at 10:54 am, the MR indicated Patient #1 had 3 new pressure ulcers; unstageable heels with blisters, mepilex (wound dressing) to sacral area.

These 3 new pressure areas were hospital acquired pressure ulcers.

-- During interview of Staff A, Chief Nursing Officer on 7/29/20 and during exit conference on 8/4/20, these findings were acknowledged.

Based on document review and interview, the hospital did not have a formal written policy and procedure (P&P) to outline their additional practices implemented to address COVID-19 cleaning procedures between COVID-19 positive/presumptive patient rooms.

Findings include:

-- Per review of hospital's P&P titled "Cleaning Environment: Patient Equipment and Medical Devices," dated 8/25/16, it did not describe a COVID-19 specific cleaning process for COVID-19 positive/presumptive patient rooms.

-- Per interview of Staff B, Infection Preventionist, on 7/29/20 at 4:15 pm, he/she confirmed there was no COVID-19 specific cleaning P&P.