HospitalInspections.org

Based on record reviews and interviews, the hospital failed to protect and promote patient rights for 3 of 3 patients (Patient #13, #14, and #15), in that,

1) Patient #13, #14, and #15 did not have consistent turns to relieve pressure on the buttocks during the admission;

2) Patient #13's, #14's and #15's wounds were not photographed to document the assessment upon admission/discovery, weekly and prior to discharge;

3) Patient #14's wounds were not assessed upon admission on 6/09/14;

4) Patient #14's wound care consult was not completed within 24 hours; and

5) Patient #15's record had no documentation of any nutrition (meals, supplements and/or tube feedings) provided to Patient #15 from 12/09/13 through 12/16/13 at 8:00 PM.

Cross Reference to Tag A-0144

Based on record reviews and interviews, the hospital failed to provide care in a safe setting for 3 of 3 patients (Patient #13, #14, and #15), in that,

1) Patient #13, #14, and #15 did not have consistent turns to relieve pressure on the buttocks during the admission;

2) Patient #13's, #14's and #15's wounds were not photographed to document the assessment upon admission/discovery, weekly and prior to discharge;

3) Patient #14's wounds were not assessed upon admission on 6/09/14;

4) Patient #14's wound care consult was not completed within 24 hours; and

5) Patient #15's record had no documentation of any nutrition (meals, supplements and/or tube feedings) provided to Patient #15 from 12/09/13 through 12/16/13 at 8:00 PM.

FINDINGS INCLUDED
1) Turns:
The 7/07/14 through 7/15/14 turn documentation for Patient #13 was reviewed. Some turns were documented but turns were not documented to consistently show every 2 hour turns.

During the electronic record review for Patient #13 on 8/14/14 at 1:00 PM, Personnel #4 confirmed the above findings and stated, "the patients are to be turned every two hours and it should be documented."

The 6/09/14 through 6/17/14 turn documentation for Patient #14 was reviewed. Some turns were documented but turns were not documented to consistently show every 2 hour turns.

During the electronic record review for Patient#14 on 8/14/14 at 9:10 AM, Personnel #4 confirmed the above findings.

The 12/09/13 through the 1/27/14 turn documentation for Patient #15 was reviewed. Some turns were documented but turns were not documented to consistently show every 2 hour turns.

During the electronic record review for Patient #15 on 8/15/14 at 8:45 AM, Personnel #4 confirmed the above findings.

2) Photographs:
Patient #13 was hospitalized from 7/07/14 through 7/15/14. There was one photograph of Patient #13's wound on 7/07/14. The wound documentation indicated, "7/07/14...Right Buttock...Yellow slough...Full thickness...Blanchable...Size (cm) (L x W): 5 X 4..." There were no photographs to document the wound for 7/14/14 or prior to discharge on 7/15/14.

During the electronic record review for Patient #13 on 8/14/14 at 1:00 PM, Personnel #4 confirmed the above findings.

Patient #14 was hospitalized from 6/09/14 through 6/17/14. There were no photographs to document the wound on admission. There was one photograph of Patient #14's wound taken on 6/10/14. The wound documentation indicated the buttocks (they were circled) and noted, "Stage IV...Size (cm) (L x W): 6 x 6 Depth (cm): 2 Tunneling (cm): 1cm Undermining (cm): 1 cm..." There were no photographs to document the wound prior to discharge on 6/17/14.

During the electronic record review for Patient #14 on 8/14/14 at 9:10 AM, Personnel #4 confirmed the above findings.

Patient #15 was hospitalized from 12/09/13 through 3/12/14. There was no wound on admission. The wound developed during the stay. On 12/18/13 at 8:00 PM, the nurse note stated "wound present." There was no photograph to document the wound upon discovery. There were photographs to document the wound on 12/27/13, 1/09/14, 2/10/14 and 2/12/14. The wound documentation indicated, "sacrum/coccyx/left buttock...12/27/13 (picture date)...opaque (intact fluid filled blister)...purple/maroon/deep hues of red (or blood filled blister)...Stage II, Blister...non-blanchable...Size (cm) (L x W): 8 x 8..." The wound documentation indicated, "Sacrum...1/09/14...purple/maroon/deep hues of red (or blood filled blister)...unstageable...partial thickness...non-intact...(no measurements included)..." The wound documentation indicated, "Sacrum...2/06/14...Yellow (slough)...unstageable...Boggy...non-intact...(no measurements included)...Exudate: Serosanguineous..." The wound documentation indicated, "Sacrum...2/10/14 (picture date)Yellow (slough)...unstageable...Boggy...non-intact...bumpy...non-blanchable......(no measurements included)...Serosanguineous...Purulent...moderate..." The wound documentation indicated, "Sacrum...2/12/14 (picture date)...Exposed Muscle/Tendon/Bone...Stage IV...Non-intact...Non-blanchable...Size (cm) (L x W): 11.0 x 10.0...Depth (cm): 5.0 cm Undermining (cm): 4 cm..."
There was no photograph to document the wound weekly. There were no photographs for 1/03/14, 1/17/14, 1/24/14, 1/31/14, 2/21/14, 2/28/14, 3/07/14, or 3/12/14 prior to discharge.

During the electronic record review for Patient #15 on 8/15/14 at 8:45 AM, Personnel #4 confirmed the above findings.

During a telephone conference, multiple interviews were completed on 8/18/14 starting at 2:00 PM and ending at 2:51 PM. Personnel #16 was asked about the hospital's policy in regard to completing the assessment within 24 hours, photographing the wound weekly until healed. Personnel #16 said she knew the policy and the nurses complete the wound care and photographs. Personnel #16 said, "no. The wounds were not photographed weekly by staff."

3) Admission Assessment:
The 6/09/14 at 5:40 PM Nurse "Admission Assessment" for Patient #14 stated, "Pressure ulcer #2 location: Lt (left) Heal...Comment: Unseen at this time..." The dressing was not removed and the wound was not assessed upon admission.

During the electronic record review for Patient #14 on 8/14/14 at 9:10 AM, Personnel #4 confirmed the above findings and said, "the nurse should have undressed the wound and assessed it."

4) Wound Care Consult:
The 6/09/14 "History and Physical" for Patient #14 stated, "...wound care consult will be obtained."

Patient #14's wound care consult assessment was not completed within 24 hours of the consult.

During the electronic record review for Patient #14 on 8/14/14 at 9:10 AM, Personnel #4 confirmed the above findings.

5) Meals:
There was no documentation of any nutrition (meals, supplements and/or tube feedings) provided to Patient #15 from 12/09/13 through 12/16/13 at 8:00 PM.

During the electronic record review for Patient #15 on 8/15/14 at 8:45 AM, Personnel #4 confirmed the above findings.

The 07/2012 "Patient's Rights and Responsibilities" policy required, "affirm a basic operating philosophy that the observance of certain patients' rights and responsibilities will contribute to more effective patient care and greater satisfaction of the patient...The patient has the right to considerate care...recognition of personal dignity..."

Based on record reviews and interviews, the hospital failed to have an organized nursing service that provided nursing care for 3 of 3 patients (Patient #13, #14, and #15), in that,

1) Patient #13, #14, and #15 did not have consistent turns to relieve pressure on the buttocks during the admission;

2) Patient #13's, #14's and #15's wounds were not photographed to document the assessment upon admission/discovery, weekly and prior to discharge;

3) Patient #14's wounds were not assessed upon admission on 6/09/14;

4) Patient #14's wound care consult was not completed within 24 hours; and

5) Patient #15's record had no documentation of any nutrition (meals, supplements and/or tube feedings) provided to Patient #15 from 12/09/13 through 12/16/13 at 8:00 PM.

Cross Reference to Tag A-0395

Based on interview and record reviews, the hospital failed to ensure Registered Nurses (RN's) evaluated, prevented, and provided treatment for 3 of 3 patients (Patient #13, #14, and #15) who had altered skin integrity identified during the admission, in that,

1) Patient #13, #14, and #15 did not have consistent turns to relieve pressure on the buttocks during the admission;

2) Patient #13's, #14's and #15's wounds were not photographed to document the assessment upon admission/discovery, weekly and prior to discharge;

3) Patient #14's wounds were not assessed upon admission on 6/09/14;

4) Patient #14's wound care consult was not completed within 24 hours; and

5) Patient #15's record had no documentation of any nutrition (meals, supplements and/or tube feedings) provided to Patient #15 from 12/09/13 through 12/16/13 at 8:00 PM.


FINDINGS INCLUDED

1) Turns:
The 7/07/14 through 7/15/14 turn documentation for Patient #13 was reviewed. Some turns were documented but turns were not documented to consistently show every 2 hour turns.

During the electronic record review for Patient #13 on 8/14/14 at 1:00 PM, Personnel #4 confirmed the above findings and stated, "the patients are to be turned every two hours and it should be documented."

The 6/09/14 through 6/17/14 turn documentation for Patient #14 was reviewed. Some turns were documented but turns were not documented to consistently show every 2 hour turns.

During the electronic record review for Patient #14 on 8/14/14 at 9:10 AM, Personnel #4 confirmed the above findings.

The 12/09/13 through the 1/27/14 turn documentation for Patient #15 was reviewed. Some turns were documented but turns were not documented to consistently show every 2 hour turns.

During the electronic record review for Patient #15 on 8/15/14 at 8:45 AM, Personnel #4 confirmed the above findings.

2) Photographs:
Patient #13 was hospitalized from 7/07/14 through 7/15/14. There was one photograph of Patient #13's wound on 7/07/14. The wound documentation indicated, "7/07/14...Right Buttock...Yellow slough...Full thickness...Blanchable...Size (cm) (L x W): 5 X 4..." There were no photographs to document the wound for 7/14/14 or prior to discharge on 7/15/14.

During the electronic record review for Patient #13 on 8/14/14 at 1:00 PM, Personnel #4 confirmed the above findings.

Patient #14 was hospitalized from 6/09/14 through 6/17/14. There were no photographs to document the wound on admission. There was one photograph of Patient #14's wound taken on 6/10/14. The wound documentation indicated the buttocks (they were circled) and noted, "Stage IV...Size (cm) (L x W): 6 x 6 Depth (cm): 2 Tunneling (cm): 1cm Undermining (cm): 1 cm..." There were no photographs to document the wound prior to discharge on 6/17/14.

During the electronic record review for Patient #14 on 8/14/14 at 9:10 AM, Personnel #4 confirmed the above findings.

Patient #15 was hospitalized from 12/09/13 through 3/12/14. There was no wound on admission. The wound developed during the stay. On 12/18/13 at 8:00 PM, the nurse note stated "wound present." There were no photographs to document the wound upon discovery. There were photographs to document the wound on 12/27/13, 1/09/14, 2/10/14 and 2/12/14. The wound documentation indicated, "sacrum/coccyx/left buttock...12/27/13 (picture date)...opaque (intact fluid filled blister)...purple/maroon/deep hues of red (or blood filled blister)...Stage II, Blister...non-blanchable...Size (cm) (L x W): 8 x 8..." The wound documentation indicated, "Sacrum...1/09/14...purple/maroon/deep hues of red (or blood filled blister)...unstageable...partial thickness...non-intact...(no measurements included)..." The wound documentation indicated, "Sacrum...2/06/14...Yellow (slough)...unstageable...Boggy...non-intact...(no measurements included)...Exudate: Serosanguineous..." The wound documentation indicated, "Sacrum...2/10/14 (picture date)Yellow (slough)...unstageable...Boggy...non-intact...bumpy...non-blanchable......(no measurements included)...Serosanguineous...Purulent...moderate..." The wound documentation indicated, "Sacrum...2/12/14 (picture date)...Exposed Muscle/Tendon/Bone...Stage IV...Non-intact...Non-blanchable...Size (cm) (L x W): 11.0 x 10.0...Depth (cm): 5.0 cm Undermining (cm): 4 cm..."
There were no photographs to document the wound weekly. There were no photographs for 1/03/14, 1/17/14, 1/24/14, 1/31/14, 2/21/14, 2/28/14, 3/07/14, or 3/12/14 prior to discharge.

During the electronic record review for Patient #15 on 8/15/14 at 8:45 AM, Personnel #4 confirmed the above findings.

During a telephone conference, multiple interviews were completed on 8/18/14 starting at 2:00 PM and ending at 2:51 PM. Personnel #16 was asked about the hospital's policy in regard to completing the assessment within 24 hours, photographing the wound weekly until healed. Personnel #16 said she knew the policy and the nurses complete the wound care and photographs. Personnel #16 said, "no. The wounds were not photographed weekly by staff."

3) Admission Assessment:
The 6/09/14 at 5:40 PM Nurse "Admission Assessment" for Patient #14 stated, "Pressure ulcer #2 location: Lt (left) Heal...Comment: Unseen at this time..." The dressing was not removed and the wound was not assessed upon admission.

During the electronic record review for Patient #14 on 8/14/14 at 9:10 AM, Personnel #4 confirmed the above findings and said, "the nurse should have undressed the wound and assessed it."

4) Wound Care Consult:
The 6/09/14 "History and Physical" for Patient #14 stated, "...wound care consult will be obtained."

Patient #14's wound care consult assessment was not completed within 24 hours of the consult.

During the electronic record review for Patient #14 on 8/14/14 at 9:10 AM, Personnel #4 confirmed the above findings.

5) Meals:
There was no documentation of any nutrition (meals, supplements and/or tube feedings) provided to Patient #15 from 12/09/13 through 12/16/13 at 8:00 PM.
During the electronic record review for Patient #15 on 8/15/14 at 8:45 AM, Personnel #4 confirmed the above findings.

During a telephone conference, multiple interviews were completed on 8/18/14 starting at 2:00 PM and ending at 2:51 PM. Personnel #17 was asked about the findings of no documentation of the patient receiving meals, supplements and/or tube feedings from 12/09/13 through 12/16/13 at 8:00 PM. Personnel #17 said the patient was ordered a Cardiac diet on 12/09/13 and trays go to the patient as ordered. Personnel #17 said the nursing staff were to document the meal consumption. Personnel #17 said when she evaluated Patient #15, she saw that the nurses had not documented meals received/consumed. When asked if she had "made note" of this in Patient #15's record, Personnel #17 said, "no."


The 06/2013 "Assessment, Prevention, Treatment, and Photographing of Skin Breakdown, and Notification of Enterstomal Therapy" policy required, "...assess the skin integrity on admission, each shift, and with any significant change in the patient's condition...in order to plan appropriate measures for the prevention or the treatment of skin breakdown. The nurse will photograph all existing pressure ulcers and wounds during admission assessment and weekly until healed and any new pressure ulcers or wounds noted during the course of hospitalization...All dressings should be removed upon initial admission, for assessment including wound VAC (vacuum assisted closure) dressings...The patient can expect maintenance of intact skin while hospitalized...consultation by the WOCN (Wound, Ostomy and Continence Nurse) will occur within a 24 hour period or one business day after weekends or holidays..."

The revised 03/(20)12 "Wound Care Protocols" required, "photograph, measure, stage, and document wounds and pressure ulcers at the time of initial assessment and weekly...reduce pressure over affected areas; turn and support with pillows at least every 2 hours..."