HospitalInspections.org

1. Based on the policy review, medical records review and interviews with staff, the hospital failed to identify when patients are at risk for developing pressure ulcers. This was observed in 2 of 10 medical records, note in P1's & P2's medical records.

Failure to achieve consistency in assessing, documenting and staging patients pressure ulcers does not ensure that safe nursing practices will provide the appropriate skin care management to the patient.

Findings:

1. On 11/30/2010 the investigator reviewed the nursing service Skin Care Policy. The policy was revised on 07/2008 by administration. The policy documented that patients who currently had or have skin breakdown are identified and a comprehensive skin care program is implement by the multidisciplinary team.

2. Review of P1's medical record on 12/01/2010 determined that on 09/26/2010 the patient was admitted from the Emergency Department ED to the Intensive Care Unit ICU. Review of the ED physician's medical screening exam documented that the 55-year-old patient was transported by ambulance to the ED because the family members noted the patient could not remember things. The documentation noted the patient had a long history of multiple sclerosis with seizure disorder. The patient's mental status did improve while in the ED. The ED physician documented on the patient's history and physical report that the patient had a right heel pressure ulcer that was healed. The ED physician's medical exam documentation revealed the patient's diagnosis included altered level of consciousness, severe sepsis and urinary tract infection.

3. Review of the ICU nursing skin assessments documentation on 09/26/2010 at 23:30 determined that the patient had no skin breakdown on his/her heels, on coccyx or buttock areas. The nurse documented that patient's Braden Skin score measured between the parameters of 13-15. The nursing documented on the assessment flow sheet that patient was turned every 2 hours and was on an air bed to prevent pressure ulcers. The family member brought in the patient's right heel boot to prevent another pressure ulcer from developing on right foot.

4. On 09/29/2010, nursing documented the patient was transferred to PCU Progressive Care Unit, located on the 10th floor. Review of the nursing assessment flow sheet dated 10/02/2010 at 12:31 (on Saturday) revealed that patient's right foot heel boot was discontinued because patient had developed a translucent blister on the right heel. The nurse's flow sheet assessments dated 10/03/2010 at 20:40 (on Sunday) revealed the patient had developed a non-stageable pressure ulcer to the right heel. The nursing identified that patient's right heel pressure ulcer measured at 5 cm in length by 5 cm in width.

5. On Monday 10/04/2010 the nurse transferred the patient to the Medical/Dialysis Unit, located on the 4th floor. The nurse assessed and documented on the skin assessment flow sheet that patient's right heel had a blister. The patient's right and left heels were floated off the bed. At 09:00 the wound care nurse was contacted to assess the patient's right heel. The wound care nurse saw the patient and documented the patient had a fluid fill blister, located at the plantar part of the heel with mild erythema. The pressure on the right heel was relieved by using a heel lift boot. The patient was not to bear weight on the heel but could toe touch when transferring.

6. Also, nursing staff made an entry on the assessment flow sheet documenting the patient developed new sacral pressure ulcers at the right and left sacral areas. This was discovered after the patient was turned that morning. The wound care nurse also assessed the sacral buttocks areas. The wound care nurse identified the right buttock had developed a stage II pressure ulcer and left buttocks developed a stage I pressure ulcer. The nurses transferred the patient on 10/06/2010 at 15:00 to the Rehabilitation Unit for further care.

7. Review of the wound care team documentation determined the patient's pressure ulcers were assessed twice a week on the Rehabilitation Unit. The patient was discharged on 10/30/2010 to home with home health agency services. The Rehabilitation's physician's discharge plan summary included a referral to a local home health agency for continuous wound care to be given to patient's right heal and right buttocks pressure ulcers.

8. During an interview on 11/30/2010 with the nursing managers from ICU, PCU, and Medical/Dialysis Unit. The managers discussed that (during the weekend) if a nurse
can't determine what stage the patient's pressure ulcer is, the nurse identifies the pressure ulcer as non-stageable and implements the appropriate skin care interventions i.e. floating the patient's heels off the bed. The nurse manager of PCU explained that during the weekend the wound care nurses are not available for staff consultation. The staff nurse has to wait until the following Monday morning in order to get help in assessing the patient's skin care issues.

9. During an interview with the two wound care nurses they confirmed that they worked Monday-Fridays during the day shift. Both wound care nurses reported they knew this patient and confirmed this patient was at risk for skin care issues. They reported this patient used a wheelchair at home and damaged his/her right foot causing the right heel pressure ulcer. This patient was seen in the outpatient wound care clinic several months for treatment regarding the right heel pressure ulcer. They continued to report the patient's history causes the patient to have poor circulation problems that supports skin breakdown.

10. On 12/03/2010, the investigator interviewed the Rehabilitation nursing team. The nursing manager confirmed that new pressure ulcers had developed during this patient's hospitalization. The patient's right foot ulcer did expand into the middle of the foot because of edema issues. The patient did develop black firm eschar that covered the right heel pressure ulcer.

11. Review of P2's medical record on 12/03/2010 determined the 83 year-old patient was admitted on 11/27/2010 to the medical unit. The patient experienced abdominal surgery 6 weeks ago and complaint of pain at the incisional area. Review of the nursing assessment flow sheet documentation revealed the following:
1.The initial nurse made an entry on the assessment flow sheet dated 11/27/2010 at 13:10 and at 17:14. The nurse identified the patient had a pressure ulcer at the coccyx area, it was non-stageable and no other skin characteristic were documented regarding the pressure ulcer. 2. A second nurse assessed the patient's pressure ulcer on 11/27/2010 at 20:00 (4 hours later after the initial assessment was made) and documented the coccyx ulcer was a stage I pressure ulcer and it was red.

12. On 11/28/2010 at 00:20 and at 04:00 the second nurse continued to document that patient's coccyx ulcer was a stage I pressure ulcer and it was red. Review of the nursing skin assessment flow sheet documentation done at 08:00-16:00 determined the initial nurse continued to document that patient's coccyx pressure ulcer was non-stageable. Also, the second nurse at 20:00 continued to document the coccyx area was a stage I pressure ulcer and it was red. The progress notes did not reveal that the two nurse's contacted the nursing manager or wound care nurse for assistant in identifying the type of pressure ulcer the patient had.

13. During an interview on 12/03/2010 with the Quality Care Coordinator confirmed that nursing needed more training in assessing patient's wound care needs. Nursing service revealed that patient's skin care documentation was inconsistent in identifying patient's skin care needs. S/he also confirmed that nursing service needed to find away to better assist nursing staff with wound care consultation services during the weekends.