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Based on record review and interview, the hospital failed to ensure the registered nurse (RN) supervised and evaluated each patient's care by failing to implement the Dermal Wound-Partial Thickness Protocol for Patient #1 after the development of blisters. (Stage II decubitus). Further there was no documented evidence of ongoing nursing assessments of the numbers, location, staging and measurement of the blisters for 1 of 1 patient with blisters out of a total of 7 sampled patients. Findings:

The medical record for Patient #1 was reviewed. Patient #1 was admitted to the hospital on 04/ 21/10 for a left total knee replacement and discharged on 04/26/10. Review of the Interdisciplinary Progress Notes dated 04/21/10 revealed Patient #1 was received to the Medical Surgical Unit on 04/21/10 at 1345 (1:45pm) with continuous passive motion (CPM) to the left knee, hemovac drainage, foley catheter and epidural catheter in place. Further documentation revealed the following in part:
04/23/10 900 (9am) Spoke with (name of Dr, S5, Anesthesiologist) to remove epidural and set up for a PCA (Patient Controlled Analgesia pump)
1310 (1:10pm) Dr. S5 present to remove epidural;
1900 (7pm) Encouraged to use PCA, discussed with MD pts anxiety and buttocks blisters.
2000 (3pm) Skin care given to blisters on L buttocks, antifungal applied to groin.
2215 (5:15pm) CPM decreased to 0/50 due to anxiety, repositioned for comfort.
04/24/10 2pm Physical Therapy (PT) Note: Pt will be positioned on R side lying position in order to release pressure from blisters on buttocks area.
1945 (7pm) Allowed CPM to stay off to allow pt to turn on side secondary to blisters (caused by epidural tubing taped) applied barrier Cream to buttocks with blisters.
0200 (2am) Pt verbalized understanding for need of CPM but still requested it be removed. Removed CPM and placed on floor.
04/25/10 1330 (1:30pm) Verbalized importance of placing L knee to CPM as ordered. Pt refused at this time. States that machine rubs against blisters on bottom. Cream applied to areas.
1830 (6:30pm) Offered to place CPM to L knee. Pt refused. Assisted to turn to side. Cream applied to blistered areas.
1925 (7:25pm) CPM not on pt. Pt. refused to allow CPM back on. Stated was flexing her knee to music and it allowed her to be off her buttocks & not lying flat in bed. Plexi pulses also off-stated she did not need those on, that she move enough. Explained importance of both CPM and plexi pulses.
1950 (7:50pm) Applied cream to blisters on buttocks. (Skin protectant cream)
0015 (12:15am) CPM still off per patient request. Plexi pulses not in use.
0358 (3:58am) CPM remains off & plexi pulses remain off.
04/26/10 1600 (4pm) Pt leaving now with family.

Review of the Physician Progress Record dated 04/23/10 at 6:00 pm revealed in part, "Nurse notified me of patient developing a "blister"on the buttock. Local care ordered. Review of the Physician Orders date 04/23/10 6pm revealed in part, "Encourage patient to aerate buttock to prevent blister. Local care to blister PRN."

Review of the Nursing Assessment dated 04/21/10, patient's day of admit, revealed a Braden Scale of 20 indicating no risk for skin breakdown.

Review of the Patient Care Flow Sheets from admit to discharge revealed the patient was turned every 2 hours.

Review of the Wound Nurse Initial Evaluation dated 04/26/10 10:15am revealed a friction wound of the left buttocks, questionable tape irritation wound to R inner thigh and blister wound to left knee near surgical incision. Recommendations for cleaning agent were mild soap and water and primary dressing Skintegrity.

Review of photographs #4010299 dated 04/26/10 14:25 (2:25pm) revealed multiple open areas on the left buttocks and the surveyor was unable to determine the size, color, length, width and depth of the open areas. Further there was a blister noted on left knee near the surgical site.

Review of the Plan of Care revealed Skin integrity-Pressure Ulcer interventions were implemented on 04/26/10.

Review of the Dermal Wounds- Partial Thickness Protocol presented as the hospitals current protocol for wound care was reviewed. Documentation revealed the following in part:
"Goal: to protect skin breakdown, prevent further skin breakdown and promote healing
Indication: Stage I and Stage II pressure ulcers, traumatic wounds, and superficial burns
Assessment/Documentation: location, size, stage (for pressure ulcers only), partial thickness (for all other ulcers), depth, wound edges, necrotic tissue (if any), amount of drainage, surrounding tissue.
Stage I Pressure Ulcer: Non-blanchable erythema (redness) of intact skin, the heralding lesion of skin ulceration. Discoloration of skin, warmth or hardness may also be indicators. VS Spans surface is unbroken but inflamed.
Stage II Pressure Ulcer: Partial thickness skin loss involving epidermis and/or dermis. The wound is superficial and presents clinically as an abrasion, blister, or shallow crater. The outer layer of skin is broken, red and painful. There may be a blistering and drainage.
SUPPLIES NEEDED:
1. Non sterile gloves- universal precautions
2. Disposable absorbent pad- to protect linens
3. Gauze-for wiping
4. Wound measuring guide- to measure wound
5. Sea Clens AF Wound Cleaner- for wound cleaning
6. Dressings: DuoDERM Extra this, CombiDERM ACD or Versiva
7. Aquacel Hydrofiber dressing- to absorb excess of drainage (Aquacel Ag, for infected wounds)
8. AllKare protective barrier wipe- to prep skin under adhesive dressing, if needed
9. AllKare adhesive remover -wipe to remove adhesive from dressing
Procedure: 6. A: Dermal Wounds-Dry to Scant drainage: Choose a DuoDERM extra Thin dressing to allow a 1 ? inch margin around entire wound. Mold to area for 30-40 seconds. Leave in place for 3-5 days unless loose or leaking. Change at least every 7 days."

Further review of Patient #1's medical record revealed no documented evidence the Dermal Wound-Partial Thickness Protocol was implemented for Patient #1 after the development of blisters. Further there was no documented evidence of ongoing nursing assessments of the numbers, location, staging and measurement of the blisters.

S1, RN Manager of Med/Surg was interviewed face to face on 06/01/10 at 2pm. S1 indicated the Wound Care Nurse consult was triggered on Friday 04/23/10 but the wound assessment was done on 04/26/10. The physician had ordered local care to the blister on 04/23/10 at 6:00 pm and the nurses had used a barrier cream to the area.
S3, RN WCC (Wound Care Certified) Wound Care Coordinator was interviewed face to face on 06/01/10 at 1pm. She indicated she was Wound Care Certified for 5 years. S3 indicated she assessed Patient #1 on 04/26/10 on the day of her discharge. Further the consult depends on the nursing assessment and the use of the Braden Scale. She added the wound was discovered on Friday 04/23/10 and she received the consult on Monday 04/26/10, as she does not work the weekends. S3 indicated when she assessed the wound there was no blister but there was an irregular area on the left buttocks not measurable and it looked like a friction injury. Further there was an inner thigh irritation possibly due to the tape of the foley catheter. She indicated she did not think the blister occurred from the epidural tape as there was no reason to put tape in that area. Further there was a blister at the surgical site at the left knee near the tape area. She further indicated she did not consider the wound to be a decubitus. S3 was again interviewed face to face on 06/02/10 at 10:15 AM. She reported she was present when the primary area nurse took pictures of Patient #1's buttocks on 04/26/10. S3 RN Wound Care further indicated she would classify the area on the patient's buttock as a friction/abrasion/wound. She added that the top layer of the skin was removed and when she assessed the wound it was 3 to 4 days old. After review of the photograph that was taken on 04/26/10 at 2:25 pm (14:25), she referred to the linear markings on the patient's skin. She added that the linear markings indicated the skin was pulled across another surface as in moving a patient. She reported she would not call the area on the left buttock a blister. She added that wounds occurring from friction have irregular borders and that wounds occurring from pressure have clearly defined margins. S3 RN Wound Care indicated she could not call this area on the left buttock a decubitus ulcer because it was not over a bony prominence nor was it from pressure. She repeated that she considered this area on the patient's left buttock to have occurred from friction. S3 reviewed the Dermal Wounds-Partial Thickness Protocol. She indicated the protocol does classify a blister as a Stage II decubitus and nurses should have followed the hospital Dermal-Partial Thickness Protocol for treatment of the wounds.

S4 RN was interviewed face to face on 06/01/10 at 1:45pm. She indicated she worked 7p /7a on Med/Surg for 4 years. S4 indicated she remembered Patient #1 and added the blisters looked like they followed the tape line from the epidural. Further a blister usually occurs between the thighs from the use of the CPM.
S1, RN Manager of Med/Surg was interviewed face to face on 06/01/10 at 2pm. S1 indicated the Wound Care Nurse consult was triggered on Friday 04/23/10 but the wound assessment was done on 04/26/10. The physician had ordered local care to the blister on 04/23/10 at 6pm and the nurses had used a barrier cream to the area.
S5, MD Anesthesiologist was interviewed face to face on 06/01/10 at 2:45pm. He reviewed the record for Patient #1. S5 indicated he uses microspore tape to hold the epidural catheter in place and the size of the patient determines how much tape he uses. Further the patient had not indicated she had a tape allergy. Further the epidural catheter stays in place for 2 days and he had removed Patient #1's catheter on 04/23/10. Further he had documented in his progress note the skin area at the epidural site was clean, dry and intact. S5 indicated there were no apparent blisters at the epidural site. Further tape is placed at the L4/L5 area and never put as low as the buttocks.

A face to face interview was held with S6 RN on 6/2/10 at 9:10 AM. She indicated that she worked the day shift and had 10 years of experience on the medical surgical unit. She indicated she did not remember the patient but after review of her notes, added that she remembered the tape in the patient's lumbar area that was irritating her skin. S6 RN reported that the irritated area was located at the site of the epidural tape used in surgery. She indicated there was documentation of blisters on the patient's buttocks in her note of 04/23/10 at 1900 (7pm) and she did not remember the numbers, appearance, and size which was not documented.

A face to face interview was held with S7 RN on 6/2/10 at 9:30 AM. She indicated that she worked nights and had 7 to 8 years on the medical surgical floor. She further indicated her documentation from the nurse's notes for Patient #1 revealed blisters on the left buttocks cheek. S7 RN reported she did not remember nor could she find documentation in the medical record of the care and/or the assessment she had given the patient for the blisters on the left buttock. She further indicated there was no documentation of the number of blisters or the size of the blisters. She indicated some of the abrasions could be from tape or sheering. She reported the patient had a trapeze above the bed and did not move much in an attempt to adjust her hips or with repositioning. S7 RN reported she was familiar with the wound protocol from the hospital and had applied a moisture barrier.