HospitalInspections.org

Based on observations, record review and interviews, for one of ten sample patients (Patient #1), the Facility failed to ensure that all registered nurses caring for Patient #1 supervised and evaluated the nursing care to prevent pressure ulcers for Patient #, who was admitted to the Facility on 8/7/14 without pressure ulcers and then developed right and left heel pressure ulcers.

The Admission Nursing Assessment, dated 8/7/14, indicated that Patient #1 had no pressure ulcers upon admission.

Post-Operative Orders, dated 8/7/14, indicated Patient #1 was ordered for Thrombo Embolic Deterrent Stockings (TEDS) (stockings placed on the legs to help prevent formation of deep vein thrombosis (blood clots) postoperatively or during periods of immobility, also known as anti-embolism stockings). The Post-Operative Orders for TEDS indicated no instructions for the wear or care of the stockings.

Family Member #1 was interviewed at 11:15 A.M. on 10/1/14. Family Member #1 said Patient #1 complained of burning in the backs of his/her feet and Patient #1's compression leg stockings appeared to be to tight.

The Hospital's policies and procedures related to Nursing Practice Guideline for Patients with Potential Risk for Impaired Skin Integrity indicated that a Braden Risk Assessment (an assessment tool used to determine a patient's risk for developing pressure ulcers) was to be performed at least every 24 hours. The Hospital policy and procedure indicated that a score of 18 or less indicates a patient at risk to develop a pressure ulcer).

Nursing Progress Notes, dated 8/8/14-8/22/14 indicated a range of Braden Scores from 13-20.

The Policy and Procedure indicated a turning/repositioning schedule should be initiated with a frequency of at least every 2 hours for a patient in bed with the purpose of relieving or redistributing pressure and the patient's heels should be suspended off the bed surface, consider the use of waffle boot(s) (air-filled splints that hug the feet, ankles and calves and float the heel off the surface) to provide pressure relief to the lower legs and heels.

The Policy and Procedure indicated if the the risk of impaired skin integrity was related to friction (skin rubbing against another surface) than a special assessment of the elbows and heels were to be performed and those areas were to be moisturized with ointment twice a day or barrier wipes daily.

The Surveyor interviewed Nurse #1 at 7:45 A.M. on 10/6/14. Nurse #1 said that Patient #1 always had his/her TED stockings and compression boots on. Nurse #1 said she implemented pressure relieving measures such as elevating Patient #1's heels off the mattresses by placing a towel roll behind Patient #1's heels.

Nurse #1's Nursing Notes, from 7:00 P.M. on 8/7/14 to 7:00 A.M. on 8/8/14 and from 7:00 P.M. on 8/8/14 to 7:00 A.M. on 8/9/14 indicated that interventions for the prevention of heel ulcers such as elevating heels off the surface of the bed mattress were not documented as being implemented.

The Surveyor interviewed Nurse #2 at 7:40 A.M. on 10/2/14. Nurse #2 said Patient #1 had TED stockings and compression boots on. Nurse #2 said she did not exactly recall whether or not she checked the skin on Patient #1's heels and said she was not aware of any protocol to remove the TED stocking from Patient #1's legs. Nurse #2 said she placed a towel roll under Patient #1's heels when Patient #1 was in bed.

There was no nursing policy to guide nursing staff to remove and reapply TED stockings at least daily.

Nurse #2's Nursing Notes, dated 8/9/14 and 8/10/14, from 7:00 A.M. through 7:00 P.M., indicated Patient #1 was assessed to be at risk for altered skin integrity. However, pressure reduction interventions such as keeping the heels elevated off of the bed mattress was not documented as being implemented. Friction reducing interventions such as moisturize the heels with ointment twice a day or barrier wipes, as required by policies and procedures were not documented as being implemented.

The Surveyor interviewed Nurse #3 at 3:15 P.M. on 10/2/14. Nurse #3 said he remembered Patient #1 and remembered that he kept Patient #1's heels up and off the mattress with pillows and blankets. Friction reducing interventions such as moisturize the heels with ointment twice a day or barrier wipes daily, as required by policies and procedures were not documented as being implemented.

Nurse #3's Nursing Notes, dated 8/11/14 and 8/12/14 from 7:00 A.M. through 7:00 P.M. indicated that Patient #1 was assessed to be at risk for skin breakdown. The only skin assessment documented was the right knee. However, no pressure reduction interventions were documented as being implemented such as keeping the heels elevated off of the bed. Friction reducing interventions such as moisturize the heels with ointment twice a day or barrier wipes daily, as required by policies and procedures were not documented as being implemented.

The Surveyor interviewed Physical Therapist #2 at 9:30 A.M. on 9/2/14. Physical Therapist #2 said on 8/13/14 he was providing physical therapy to Patient #1 and noticed Patient #1's heel were reddened and the skin was non blanchable. Physical Therapist #2 said he reported his finding to the nurse and the physician.

A Nursing Note, dated 8/13/14, indicated Patient #1 had a right heel pressure ulcer that measured to be 4 centimeter (cm) x 4 cm. The pressure ulcer was described as a deep tissue injury (DTI) (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) that was described as purple and painful. The Nursing Note indicated that Patient #1 also had a left heel pressure ulcer that measured 4 cm x 3.5 cm that was described as having a reddened area and within the reddened area, there was a DTI that measured 1 cm x 1 cm.

The Nursing Notes, dated 8/14 and 8/15/14, indicated Patient #1's left and right heel ulcer were described as purple.

The Nursing Note, dated 8/20/14, indicated Patient #1's right heel ulcer was a large black dry area and the skin remains intact. The note indicated Patient #1's left heel ulcer was described as nickel size black area and the skin remains intact. The measurements of the pressure ulcers were not documented. The note indicated a wound consult was ordered.

The Wound Care Specialist Consult, dated 8/20/14, indicated Patient #1's right heel pressure ulcer measured 3.5 cm x 4.5 cm; the pressure ulcer was a DTI and the skin was described to be soft, intact and black in color. The Consult indicated that Patient #1 had a DTI of the left heel that measured 2 cm x 2 cm and the skin was described to be intact and black.

The Nursing Progress Note, dated 8/21/14 at 5:15 P.M. indicated that Patient #1's pressure ulcers were not assessed and no pressure relieving interventions were documented.

Patient #1's Hospital Discharge Patient Care Referral, dated 8/22/14, indicated Patient #1 had a left and right heel ulcers. The left heel ulcer was described as a DTI and measured 4.5 cm x 4.0 cm and was described to be purple. Patient #1's right heel ulcer was described as a DTI and measured 2.2 cm by 2.0 cm and was described to be red. However, this information was inconsistent with the Wound Consult assessment performed on 8/20/14.

The Nursing Progress Note, dated 8/22/14, at 9:40 A.M. indicated Patient #1's heel ulcers were described as black and were unstageable (skin thickness loss in which actual depth of the ulcer is completely obscured).

Patient #1 was transferred from the Hospital to a rehabilitation facility on 8/22/14.

The rehabilitation facility's admission nursing assessment, dated 8/22/14 indicated Patient #1's heel ulcers were described as deep tissue injuries.

The Rehabilitation Facility's Physician Wound Consult, dated 9/2/14, indicated that Patient #1 had bilateral unstageable heel ulcers that were Hospital acquired. The pressure ulcer on Patient #1's right heel measured 5 cm x 1 cm and the skin was described as black, dry eschar (dead). The note indicated Patient #1's left heel ulcer measured 2 cm x 1.8 cm and was described as having black dry eschar. Both ulcers were described as non tender.

The Surveyor interviewed Non Sampled Patient #11 during a tour of the surgical unit at 11:40 A.M. on 10/2/14. Non Sampled Patient #11 who had a right knee replacement surgery said she/he had surgery three days ago and no nurse had removed her TED stockings to inspect the skin of his/her feet and heels.

Based on observations, record review and interviews, for one of ten sample patients (Patient #1), the Facility failed to ensure that all registered nurses caring for Patient #1 supervised and evaluated the nursing care to prevent pressure ulcers for Patient #, who was admitted to the Facility on 8/7/14 without pressure ulcers and then developed right and left heel pressure ulcers.

The Admission Nursing Assessment, dated 8/7/14, indicated that Patient #1 had no pressure ulcers upon admission.

Post-Operative Orders, dated 8/7/14, indicated Patient #1 was ordered for Thrombo Embolic Deterrent Stockings (TEDS) (stockings placed on the legs to help prevent formation of deep vein thrombosis (blood clots) postoperatively or during periods of immobility, also known as anti-embolism stockings). The Post-Operative Orders for TEDS indicated no instructions for the wear or care of the stockings.

Family Member #1 was interviewed at 11:15 A.M. on 10/1/14. Family Member #1 said Patient #1 complained of burning in the backs of his/her feet and Patient #1's compression leg stockings appeared to be to tight.

The Hospital's policies and procedures related to Nursing Practice Guideline for Patients with Potential Risk for Impaired Skin Integrity indicated that a Braden Risk Assessment (an assessment tool used to determine a patient's risk for developing pressure ulcers) was to be performed at least every 24 hours. The Hospital policy and procedure indicated that a score of 18 or less indicates a patient at risk to develop a pressure ulcer).

Nursing Progress Notes, dated 8/8/14-8/22/14 indicated a range of Braden Scores from 13-20.

The Policy and Procedure indicated a turning/repositioning schedule should be initiated with a frequency of at least every 2 hours for a patient in bed with the purpose of relieving or redistributing pressure and the patient's heels should be suspended off the bed surface, consider the use of waffle boot(s) (air-filled splints that hug the feet, ankles and calves and float the heel off the surface) to provide pressure relief to the lower legs and heels.

The Policy and Procedure indicated if the the risk of impaired skin integrity was related to friction (skin rubbing against another surface) than a special assessment of the elbows and heels were to be performed and those areas were to be moisturized with ointment twice a day or barrier wipes daily.

The Surveyor interviewed Nurse #1 at 7:45 A.M. on 10/6/14. Nurse #1 said that Patient #1 always had his/her TED stockings and compression boots on. Nurse #1 said she implemented pressure relieving measures such as elevating Patient #1's heels off the mattresses by placing a towel roll behind Patient #1's heels.

Nurse #1's Nursing Notes, from 7:00 P.M. on 8/7/14 to 7:00 A.M. on 8/8/14 and from 7:00 P.M. on 8/8/14 to 7:00 A.M. on 8/9/14 indicated that interventions for the prevention of heel ulcers such as elevating heels off the surface of the bed mattress were not documented as being implemented.

The Surveyor interviewed Nurse #2 at 7:40 A.M. on 10/2/14. Nurse #2 said Patient #1 had TED stockings and compression boots on. Nurse #2 said she did not exactly recall whether or not she checked the skin on Patient #1's heels and said she was not aware of any protocol to remove the TED stocking from Patient #1's legs. Nurse #2 said she placed a towel roll under Patient #1's heels when Patient #1 was in bed.

There was no nursing policy to guide nursing staff to remove and reapply TED stockings at least daily.

Nurse #2's Nursing Notes, dated 8/9/14 and 8/10/14, from 7:00 A.M. through 7:00 P.M., indicated Patient #1 was assessed to be at risk for altered skin integrity. However, pressure reduction interventions such as keeping the heels elevated off of the bed mattress was not documented as being implemented. Friction reducing interventions such as moisturize the heels with ointment twice a day or barrier wipes, as required by policies and procedures were not documented as being implemented.

The Surveyor interviewed Nurse #3 at 3:15 P.M. on 10/2/14. Nurse #3 said he remembered Patient #1 and remembered that he kept Patient #1's heels up and off the mattress with pillows and blankets. Friction reducing interventions such as moisturize the heels with ointment twice a day or barrier wipes daily, as required by policies and procedures were not documented as being implemented.

Nurse #3's Nursing Notes, dated 8/11/14 and 8/12/14 from 7:00 A.M. through 7:00 P.M. indicated that Patient #1 was assessed to be at risk for skin breakdown. The only skin assessment documented was the right knee. However, no pressure reduction interventions were documented as being implemented such as keeping the heels elevated off of the bed. Friction reducing interventions such as moisturize the heels with ointment twice a day or barrier wipes daily, as required by policies and procedures were not documented as being implemented.

The Surveyor interviewed Physical Therapist #2 at 9:30 A.M. on 9/2/14. Physical Therapist #2 said on 8/13/14 he was providing physical therapy to Patient #1 and noticed Patient #1's heel were reddened and the skin was non blanchable. Physical Therapist #2 said he reported his finding to the nurse and the physician.

A Nursing Note, dated 8/13/14, indicated Patient #1 had a right heel pressure ulcer that measured to be 4 centimeter (cm) x 4 cm. The pressure ulcer was described as a deep tissue injury (DTI) (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) that was described as purple and painful. The Nursing Note indicated that Patient #1 also had a left heel pressure ulcer that measured 4 cm x 3.5 cm that was described as having a reddened area and within the reddened area, there was a DTI that measured 1 cm x 1 cm.

The Nursing Notes, dated 8/14 and 8/15/14, indicated Patient #1's left and right heel ulcer were described as purple.

The Nursing Note, dated 8/20/14, indicated Patient #1's right heel ulcer was a large black dry area and the skin remains intact. The note indicated Patient #1's left heel ulcer was described as nickel size black area and the skin remains intact. The measurements of the pressure ulcers were not documented. The note indicated a wound consult was ordered.

The Wound Care Specialist Consult, dated 8/20/14, indicated Patient #1's right heel pressure ulcer measured 3.5 cm x 4.5 cm; the pressure ulcer was a DTI and the skin was described to be soft, intact and black in color. The Consult indicated that Patient #1 had a DTI of the left heel that measured 2 cm x 2 cm and the skin was described to be intact and black.

The Nursing Progress Note, dated 8/21/14 at 5:15 P.M. indicated that Patient #1's pressure ulcers were not assessed and no pressure relieving interventions were documented.

Patient #1's Hospital Discharge Patient Care Referral, dated 8/22/14, indicated Patient #1 had a left and right heel ulcers. The left heel ulcer was described as a DTI and measured 4.5 cm x 4.0 cm and was described to be purple. Patient #1's right heel ulcer was described as a DTI and measured 2.2 cm by 2.0 cm and was described to be red. However, this information was inconsistent with the Wound Consult assessment performed on 8/20/14.

The Nursing Progress Note, dated 8/22/14, at 9:40 A.M. indicated Patient #1's heel ulcers were described as black and were unstageable (skin thickness loss in which actual depth of the ulcer is completely obscured).

Patient #1 was transferred from the Hospital to a rehabilitation facility on 8/22/14.

The rehabilitation facility's admission nursing assessment, dated 8/22/14 indicated Patient #1's heel ulcers were described as deep tissue injuries.

The Rehabilitation Facility's Physician Wound Consult, dated 9/2/14, indicated that Patient #1 had bilateral unstageable heel ulcers that were Hospital acquired. The pressure ulcer on Patient #1's right heel measured 5 cm x 1 cm and the skin was described as black, dry eschar (dead). The note indicated Patient #1's left heel ulcer measured 2 cm x 1.8 cm and