HospitalInspections.org

Based on document review and interview, the facility failed to ensure that nursing staff implemented an updated Nursing Care Plan (NCP) for 1 of 4 (#11) patients with inpatient stays longer than three days, resulting in increased potential for skin break down. Findings include:

On 4/3/14 at approximately 1000, review of patient #11's medical record with staff #J and #K revealed that the patient was admitted on 11/11/13 through 11/21/13 for repair (on 11/13/13) and post-operative recovery of a right hip fracture. The 'Nursing Progress Notes' dated 11/12/13 documented "no wounds on her back or bottom." The Braden Skin Assessment score upon admission was documented at 13 in the 'Flowsheet Data' of 11/12/13. Braden Skin Assessment scores assessed twice a day, from 11/12/13 through 11/18/13, were documented at 13 and 14 (below 18). The facility policy and procedure on skin risk assessment titled 'Pressure Ulcers', No. 330, dated 10/23/12 documented: "If the Braden scale is 18, or less, place patient on Pressure Ulcer Prevention Precautions...Turning/repositioning, Prevention measures i.e. popliteal support, Mepilex border sacrum should be documented on doc Flowsheet or progress notes." (sic)

Interview with Nurses #M and #Q, on 4/3/14 at approximately 1130, revealed that a Braden score of 13 did not trigger any additional skin integrity interventions to prevent skin break down. It was noted on patient #11's NCP that 'Skin Integrity' was not addressed in the NCP until 11/18/13. When queried about pressure relieving mattress or bed, Nurse #Q stated, "We need to go through our Manager to get an order for that."

Further review of the NCP, "Nurse Progress Notes", and "Flowsheets" with Nurse Manager #L, on 4/3/14 at approximately 1530, verified that the patient had developed wounds on the back and coccyx on 11/16/13. The NCP documented "Problem: Pain, Altered Mobility" and the plan was to turn the patient every two hours during that time period. It was verified with Nurse Manager #L, on 4/3/14 at approximately 1630, that every two hour turning was not consistently documented. Additionally, other pressure ulcer interventions for the patient's back and coccygeal areas were not documented from 11/13/13 through 11/16/13.