HospitalInspections.org

Based on interview and record review, the facility failed to provide care and services to prevent the development of pressure ulcer, by failing to turn and reposition per skin and wound protocol for 1 of 10 sampled patients (#1).

Findings:

Patient #1 presented to the Emergency Department (ED) on 3/07/18 with a chief complaint of fever, shaking, chills, and decreased responsiveness. The "Emergency Provider Report" dated 3/07/18 read, "Patient was seen for a checkup 2 days ago at [another medical center]...requires total care by his son, d/t [due to] diminished ambulation along with dementia. This AM the son found him lying in bed in a contorted position, acutely febrile, with diminished alertness and shallow irregular breathing. Pt (patient) was brought to ER [ED] by EMS (Emergency Medical service) as a SEPSIS alert. He is usually incontinent of urine and stool." The "Focused PE (physical exam)" showed the patient's skin was "clammy". The "Emergency Patient Record" showed that patient #1's skin was "warm, dry and intact. No complaints of lesions, rash, wounds, bruises, petechiae or abrasion."

On 5/30/18 at 8:32 AM in a telephone interview, patient #1's relative said, when patient #1 was admitted to the hospital on 3/07/18, he did not have a pressure ulcer. On 3/14/15 he reported patient #1 was discharged home, from the hospital, at about 4 PM. Two hours later when he and the home health aide was changing the patient, he observed two open areas on the patient's buttocks. Patient #1's relative said he reported this to the risk manager at the hospital. He said the hospital did not turn and reposition patient #1 as they should, to help prevent the bed sores.

The Admission/Shift Assessment dated 3/07/18 and 3/14/18 showed that patient #1 had a generalized bruise to both his arms, and had "intact skin no open areas". The Discharge Summary dated 3/14/18 did not show any documentation regarding the condition of patient #1's skin.

Patient #1 was readmitted to the hospital on 3/15/18 at 10:57 AM. The "Emergency Provider Report" dated 3/15/18 read, "Patient was discharged yesterday from this facility with a week long stay for altered mental status and sepsis, and presents today sent from home by the son for new bed sores on his buttocks patient states that was not there before his admission....On the right buttock is a stage II decubitus with a brawning of the left posterior buttocks."

Review of documentation for positioning for the period 3/09/18-3/14/18 showed that patient #1 was turned and repositioned (T/R) on the following dates/times: 3/09/18 at 5:48 AM, 8:10 AM, 10 AM, and 1:41 PM;
3/10/18: none; 3/11/18 at 3:19 PM and 8:25 PM; 3/12/18 at 6:07 PM; 3/13/18 at 11:59 AM and 10:38 PM; and 3/14/18 at 10:37 AM.

For the period 3/07-13/18: Positioning aids were not documented from 3/07-11/18, and on 3/13/18. On 3/12/18, "Present/Exists" was documented in the medical record.

On 5/30/18 at 2:44 PM, the Cardio/neuro 3W/PCU (progressive care unit) manager said, patient #1 was admitted to her units on both admission 3/07/18 and 3/15/18. His first admission was to 3W, and the second admission was to the PCU. She said wounds were discussed with the interdisciplinary team daily, but wounds did not "come up" for pateint #1 until his readmission on 3/15/18. The manager said she could not say that patient #1's pressure ulcer happened at the hospital during his first admission, since the facility did not have documentation regarding the patient's buttocks on admission, and proper documentation was not done throughout the patient's hospital stay.

The activity form for turning and repositioning (T/R) was reviewed with the manager who verified that documentation showed that patient #1 was not turned and repositioned every two hours as per hopsital protocol.

The Policy and Procedure "Skin and Wound Care Policy" effective 5/16/2017, read, "To provide guidelines that promote continuity of care as it relates to the prevention and management of a patient at-risk for development of pressure injuries....A skin assessment will be performed for each patient on admission, on every shift, on transfer to a different unit....Assessment for moisture induced irritation, maceration, or denudement are included in the skin assessment and reassessment process....Assessment/reassessment of the integumentary system is done daily and every shift if a wound is present....The patient is turned at least every 2 hours and more frequently if necessary....Patients on any type of specialty mattress must be turned every 2 hours unless documented as medically contraindicated....Heels are suspended off the bed surface....The skin is inspected and any devices removed every shift and as needed for pressure areas and findings are documented."

Based on interview and clinical record review, the facility failed to monitor and accurately document turning and repositioning to prevent the development of pressure ulcers for 1 of 10 sampled patients (#1).

Findings:

Patient #1 presented to the Emergency Department (ED) on 3/07/18 with a chief complaint of fever, shaking, chills, and decreased responsiveness. The "Emergency Provider Report" dated 3/07/18 read, "Patient was seen for a checkup 2 days ago at the [another medical center]. He requires total care by his son, d/t (due to) diminished ambulation along with dementia. This AM the son found him lying in bed in a contorted position, acutely febrile, with diminished alertness and shallow irregular breathing. Pt (patient) was brought to ER(Emergency Room) by EMS (Emergency Medical Services) as a SEPSIS alert. He is usually incontinent of urine and stool."

The "Focused PE (physical exam)" showed the patient's skin was "clammy". The "Emergency patient record" showed that patient #1's skin was "warm, dry and intact. No complaints of lesions, rash, wounds, bruises, petechiae or abrasion." The Admission/Shift Assessment dated 3/07/18 and 3/14/18 documented generalized bruise to bilateral arm and "intact skin no open areas".

The Activity form for turning and repositioning (T/R) from 3/09/18-3/14/18 showed the following: Patient #1 was T/R on 3/09/18 x 4 at 5:48 AM, 8:10 AM, 10 AM, and 1:41 PM, 3/10/18 x 0, 3/11/18 x 2 at 3:19 PM, and 8:25 PM, 3/12/18 x 1 at 6:07 PM, 3/13/18 x 2 at 11:59 AM, and 10:38 PM and on 3/14/18 x 1 at 10:37 AM .

On 5/30/18 at 2:44 PM the Cardio/neuro 3W/PCU (Progressive Care Unit) manager said, patient #1 was admitted to her units on both admission 3/07/18 and 3/15/18. His first admission was to 3W, and the second admission was to the PCU. The manager said daily shift assessments done by the nurses,covered skin assessment, and T/R was shared between the nurse and the nurse tech, and documented in the patient's electronic chart.

The activity form for T/R was reviewed with the manager who verified that documentation was not done every two hours per protocol. The manager said she "would hope for better documentation on a bedridden patient." The manager said the facility's expectation was that documentation for T/R should be completed every two hours, and in review there were some missed documentation, and a lot of missed opportunity for proper documentation and proper implementation of a T/R schedule for patient # 1. She said "nothing" was documented on the patient's first admission, and "very little" was documented during his first hospital stay.

The Cardio/neuro 3W/PCU manager said she could not say that patient #1's pressure ulcer happened at the hospital during his first admission,since the facility did not have documentation regarding the patient's buttocks on admission and no proper documentation throughout the patient's hospital stay. She verbalized that both nurses and nurse techs did not document per protocol.

On 5/30/18 at 3:05 PM, the chief nursing officer (CNO) said the facility recognized there was needed improvement on documentation, and assessment. She said the nurses and nurse techs did not document per protocol, so the facility did not know what patient #1's skin was like on his first hospital admission. The CNO said there was no documentation to support intact skin, or the presence of any skin breakdown.

The Policy and Procedure "Skin and Wound Care Policy" effective 5/16/17, read, "To provide guidelines that promote continuity of care as it relates to the prevention and management of a patient at-risk for development of pressure injuries....A skin assessment will be performed for each patient on admission, on every shift, on transfer to a different unit....Assessment for moisture induced irritation, maceration, or denudement are included in the skin assessment and reassessment process....Assessment/reassessment of the integumentary system is done daily and every shift if a wound is present....Findings are documented in the patient's medical record per documentation guidelines...."