HospitalInspections.org

Based on interview and record review the hospital failed to ensure 1 of 2 patients reviewed [Patient #1] had a braden scale assessment completed on admission and further failed to notify the physician and provide treatment when skin changes were found to Patient #1's coccyx. Patient #1 was discharged 11/1/09 with an unstageable pressure ulcer to the coccyx.

Findings included:

The physician progress notes dated 10/26/09 reflected Patient #1 was admitted with, "sub acute cerebrovascular accident, hypertension, atrial fibrillation and coronary artery disease..."

The nursing admission history and assessment dated 10/25/09 reflected, "integumentary assessment within defined parameters and braden skin assessment was not completed...the patients skin temperature, color, turgor,texture was left blank...the comment section reflected has bruises on knees and legs..."

The patient intervention documentation dated 10/26/09 to 10/30/09 reflected the following:

The note dated 10/26/09 timed at 0900 reflected, "friction and sheer potential problem, braden skin score 15 (at risk), skin risk interventions....at 1505 patient unable to retain education secondary to disorientation and decreased cognitive status (dementia/CVA) daughter at bedside and educated on swallowing evaluation, aspiration precautions and signs of ceasing po intake...at 1705 admitted to ICU from 4 north, status post hemorrhagic stroke...at 1730 skin turgor loose, texture paper thin, impaired skin integrity and abscess noted to coccyx. The braden skin score was 14 (moderate risk)...at 2015 coccyx noted to have boney protrusion from previous history of fall...at 2100 braden skin score was 11 (high risk)...on 10/27/09 at 0106...impaired skin integrity, wound not present and no pressure ulcer, nutrition probably inadequate, friction and shear potential problem...on 10/28/09 at 0800 pressure ulcer present, location coccyx, skin protectant, tissue appearance red, edges attached, no drainage, off loading with pillow...patient broke tailbone years ago...coccyx wound old and scarred...at 1330 the ET wound assessment...pressure ulcer to coccyx, product allevyn, 4 cm (centimeters) length by 2 cm wide, tissue white eschar, irregular shape, unstageable...envision low airloss mattress...surface ordered, photo, daughter states this is secondary to fracture to this area and it is always dry, appears today eschar has built up...the area does not have much padding...on 10/30/09 follow up visit done, wound bed has mostly pale tissue partly debrided exposing pink skin. Periwound skin is slightly macerated. Aquacel AG applied to wound bed covered with allevyn foam..."

The wound care treatment orders dated 10/28/09 timed at 1355 reflected, "envision low air loss surface, turn every two hours, offload heels, apply waffle boots, skin barrier cream, call wound nurse or physician if wound worsens, allevyn to coccyx, change Monday, Wednesday and Friday and prn (as needed). No further orders were found which addressed the abscess found initially on 10/26/09.

The nutrition assessment dated 10/28/09 timed at 1056 reflected, "abrasion right upper back, diet order mechanical soft, ground meat, cardiac with gravy, thin liquids, intake 50%...continue to follow for diet tolerance and need for supplements...risk level moderate." No further documentation was found indicating dietary supplementation was added related to the pressure ulcer located on Patient #1's coccyx. The nutritional assessment was completed prior to the wound care nurses assessment.

The physician progress notes dated 10/25/09 to 11/1/09 reflected the following documentation:

The 10/29/09 note timed at 11:00 AM reflected, "complains of coccyx pain." No further documentation was found in the physician progress notes which addressed the pressure ulcer to Patient #1's coccyx.

The physician discharge summary dated 11/21/09 reflected the discharge diagnosis was, "right basil ganglia ischemic cerebrovascular accident with a secondary hemorrhagic conversion, hypertension, chronic atrial fibrillation, anemia, history of coronary artery disease and dyslipidemia." No documentation was found on the discharge summary indicating Patient #1 had an unstageable pressure ulcer to the coccyx.

On 02/25/10 at 1400 Staff #7 was asked to review Patient #1's inital nursing assessment, physician progress notes, skin assessment and braden scale. Staff #7 verified the RN did not do a complete skin assessment and braden scale. Staff #7 further stated the only physician documentation found was when Patient #1 complained of coccyx pain. Staff #7 stated all patients should have a complete skin assessment and braden scale when admitted.

On 02/25/10 at 3:00 RN #9 was interviewed. RN #9 was asked by the surveyor how the wound nurse is involved in the patients care. RN #9 stated the wound nurses are notified by computer entry and/or phone call. RN #9 stated Patient #1 should have had complete skin assessment and braden scale when admitted.

On 02/26/09 Staff #10 was asked by the surveyor to review Patient #1's medical record and explain what dietary intervention she provided for the patient. Staff #10 stated she saw Patient #1 before the wound nurse. Staff #10 explained she was going to follow up in five days but the patient was discharged, she stated at the time of her review the patient was eating. Staff #10 said the dietician writes recommendations and leaves a note for the physican. Staff #10 stated she was unaware Patient #1 had a pressure ulcer. Staff #10 stated dietary was available everyday and if she was aware of the wound she could of evaluated the patient again.

On 02/26/10 at 1214 MD #14 was interviewed. MD #14 was asked to review Patient #1's physician discharge summary. MD #14 stated he did not see any documentation which addressed Patient #1's pressure ulcer.

The policy entitled, "Pressure Ulcer Prevention/Management Program dated 08/15/1997" reflected, "The braden pressure ulcer risk assessment is used with all admitted patients and reviewed at regular intervals...the registered nurse completes a risk analysis on all inpatients as part of the initial assessment...if the patient scores less than 18 on the risk analysis, a nutritional assessment is conducted...if the prevention protocol is not effective or if a pressure ulcer is present, the nursing staff or therapy staff who discover a pressure area notifies the physician and consults wound care nurse via order entry, to assess and provide recommendations...the braden scale prevention protocol attachment "A" to this policy reflected, "At risk (15-18), frequent turning...protect heels, manage moisture, nutrition and friction and shear...moderate risk (13-14), turning schedule, use foam wedges for 30 degree lateral positioning, pressue reduction surface, increase protein intake, supplement with multi-vitamin, should have vitamin A, C and E, act quickly to alleviate deficits, consult dietician..."

Based on interview and record review, the hospital failed to ensure the physician discharge summary for 1 of 2 patient records reviewed [Patient #1's] addressed a pressure ulcer acquired to the coccyx during Patient #1's hospitalization.

Findings Included:

1) The physician progress notes dated 10/26/09 reflected Patient #1 was admitted 10/25/09 with, "sub acute cerebrovascular accident, hypertension, atrial fibrillation and coronary artery disease...and discharged 11/1/09."

The patient intervention documentation dated 10/26/09 to 10/30/09 reflected the following:

The note dated 10/26/09 timed at 1705 admitted to ICU from 4 north, status post hemorrhagic stroke...at 1730 skin turgor loose, texture paper thin, impaired skin integrity and abscess noted to coccyx...at 1330 the ET wound assessment...pressure ulcer to coccyx, product allevyn, 4 cm (centimeters) length by 2 cm wide, tissue white eschar, irregular shape, unstageable...envision low airloss mattress...surface ordered....on 10/30/09 follow up visit done, wound bed has mostly pale tissue partly debrided exposing pink skin. Periwound skin is slightly macerated. Aquacel AG applied to wound bed covered with allevyn foam..."

The wound care treatment orders dated 10/28/09 timed at 1355 reflected, "envision low air loss surface, turn every two hours, offload heels, apply waffle boots, skin barrier cream, call wound nurse or physician if wound worsens, allevyn to coccyx, change Monday, Wednesday and Friday and prn (as needed). The orders were noted to be signed by Patient #1's physician.

The 10/29/09 neurologist progress note timed at 11:00 AM reflected, "complains of coccyx pain." No further documentation was found in the physician progress notes which addressed the pressure ulcer to Patient #1's coccyx.

The physician discharge summary dated 11/21/09 reflected the discharge diagnosis was, "right basil ganglia ischemic cerebrovascular accident with a secondary hemorrhagic conversion, hypertension, chronic atrial fibrillation, anemia, history of coronary artery disease and dyslipidemia." No documentation was found on the discharge summary indicating Patient #1 had an unstageable pressure ulcer to the coccyx.

On 02/26/09 at 11:47 AM, RN #3 was asked to review the physician discharge summary. RN #3 validated no documentation was found addressing Patient #1's pressure ulcer to the coccyx.

On 02/26/10 at 1214 MD #14 was interviewed. MD #14 was asked to review Patient #1's physician discharge summary. MD #14 stated he did not see any documentation which addressed Patient #1's pressure ulcer.

The hospital policy dated 06/28/05, entitled, "continuum of care plan" reflected, "the referral, transfer, discharge, or discontinuation of services process is based on the patient's assessed needs and the hospital capabiltiy to provide the needed care and services..."