HospitalInspections.org

Based on policy review, medical record review and staff interview the hospital's nursing staff failed to supervise and evaluate patient care by failing to: turn a patient every two hours for 1 of 2 sampled patients at moderate to high risk for skin breakdown (Patient #3); assess a wound each shift per policy for 1 of 3 sampled patients with a wound (Patient #3) and assess pain per policy for 1 of 4 sampled patients (Patient #3).

The findings include:

Review of current hospital policy entitled "Guidelines for Documenting Risk Assessment, Pressure Sores, Wounds and Incisions" dated 02/2009 revealed, "Policy: Record every shift a risk assessment and skin assessment on every inpatient....skin alteration assessments are documented on patients when these are present....Wound assessments are completed on patients when these are present....Documentation:...Risk Assessment...Identify Risk Factors for skin breakdown for the patient using the Braden Scale....For adults, a score of 18 or less indicates the patient is at moderate to high risk for skin breakdown and prevention measures should be implemented...."

Review of current hospital policy entitled "Adult Pressure Ulcer PREVENTION Guideline" dated 02/2009 revealed, "Basics of Prevention and Interventions....Reposition at least every two hours in bed...."

Review of current hospital policy entitled "Pain Management" dated 06/2008 revealed, "Pain assessment:...Before, during, and after any known pain-producing event....Pain assessment is documented...pre and post-procedures...."

Open medical record on 01/06/2010 review for Patient #3 revealed a 62 year-old female that was admitted on 08/31/2009 with congestive heart failure, diabetes mellitus and morbid obesity. Record review revealed physician documentation on 09/12/2009 that the patient's primary diagnosis was changed to acute and chronic respiratory failure. Record review revealed the patient's Braden Scale score was 12 upon admission (moderate to high risk for skin breakdown). Review of admission nurse's notes dated 08/31/2009 at 1215 revealed documentation of a pen-sized open area on the patient's sacrum (wound). Record review revealed the patient was bedridden throughout the admission. Record review revealed no documentation that the patient was turned every 2 hours during the following shifts: 09/07/2009 through 09/09/2009 - 7P (1900 - 0700); 09/12/2009 - 7A (0700 - 1900); 09/13/2009 - 7P; 09/28/2009 - 7A and 7P; 09/29/2009 - 7P; 09/30/2009 - 7A; 10/01/2009 - 7A and 7P; 10/02/2009 through 10/04/2009 - 7P; 10/05/2009 - 7A and 7P; 10/06/2009 - 7P; 10/08/2009 - 7P; 12/28/2009 and 12/29/2009 - 7A; 12/30/2009 and 12/31/2009 - 7P; 01/03/2010 - 7A and 01/04/2010 - 7P (24 of 76 shifts reviewed). Record review revealed no documentation that the nurse assessed the patient's sacral wound during the following shifts: 08/31/2009 - 7P; 09/01/2009 and 09/02/2009 - 7A; 09/12/2009 - 7A; 09/25/2009 and 09/26/2009 - 7P; 09/29/2009 and 09/30/2009 - 7A; 10/02/2009 through 10/04/2009 - 7P; 12/27/2009 and 12/28/2009 - 7A; 12/31/2009 and 01/01/2010 - 7A and 01/03/2010 - 7A (16 of 76 shifts reviewed). Review of the wound care nurse's notes dated 10/06/2009 at 1143 revealed, "Sacrum with unstageable pressure ulcer that measures 6cm (centimeters) x (by) 11cm and central portion covered with necrotic overlay, right buttocks portion is full thickness and pink....Impressions: 1) Start Santyl cream drsg (dressing) change to sacrum/buttocks, change once per day....Must keep turned and repositioned q (every) 2 hours...." Further record review revealed no documentation that the nurse assessed the patient's pain level before and after dressing changes on the following dates and times: 10/21/2009 at 1500; 10/22/2009 at 1200; 10/23/2009 at 0600; 10/28/2009 at 1100; 12/29/2009 at 1030 and 01/01/2010 at 2200 (7 of 12 dressing changes reviewed).

Interview on 01/07/2010 at 1200 with administrative nursing staff revealed a patient with a Braden Scale score of less than 18 was at high risk for skin breakdown and must be turned every 2 hours by nursing staff. Interview revealed nursing staff must assess all wounds at least once per shift. Interview revealed nursing staff must assess a patient's pain level before and after any know pain producing-event, such as a dressing change. Further interview confirmed there was no documented evidence that nursing staff turned Patient #3 every 2 hours on the following shifts: 09/07/2009 through 09/09/2009 - 7P (1900 - 0700); 09/12/2009 - 7A (0700 - 1900); 09/13/2009 - 7P; 09/28/2009 - 7A and 7P; 09/29/2009 - 7P; 09/30/2009 - 7A; 10/01/2009 - 7A and 7P; 10/02/2009 through 10/04/2009 - 7P; 10/05/2009 - 7A and 7P; 10/06/2009 - 7P; 10/08/2009 - 7P; 12/28/2009 and 12/29/2009 - 7A; 12/30/2009 and 12/31/2009 - 7P; 01/03/2010 - 7A and 01/04/2010 - 7P (24 of 76 shifts reviewed). Interview confirmed there was no documented evidence that nursing staff assessed the patient's wound during the following shifts: 08/31/2009 - 7P; 09/01/2009 and 09/02/2009 - 7A; 09/12/2009 - 7A; 09/25/2009 and 09/26/2009 - 7P; 09/29/2009 and 09/30/2009 - 7A; 10/02/2009 through 10/04/2009 - 7P; 12/27/2009 and 12/28/2009 - 7A; 12/31/2009 and 01/01/2010 - 7A and 01/03/2010 - 7A (16 of 76 shifts reviewed). Interview confirmed there was no documented evidence that nursing staff assessed the patient's pain level before and after dressing changes on 10/21/2009 at 1500; 10/22/2009 at 1200; 10/23/2009 at 0600; 10/28/2009 at 1100; 12/29/2009 at 1030 and 01/01/2010 at 2200 (7 of 12 dressing changes reviewed).


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