HospitalInspections.org

Based on document review, medical record review and staff interview, the hospital failed to ensure the medical staff enforced its own bylaws by not prescribing dietitian recommendations for therapeutic dietary supplements for patients with skin issues in two (2) of two (2) medical records (patient #1 and 2) reviewed. This has the potential to negatively impact all patient care by patients not receiving nutrients needed for adequate skin healing. Findings include:

1. Beckley Appalachian Regional Hospital Medical Staff Bylaws, last revised 2/10, states in part, Appendix I. Article V. Medical Orders...4. Orders For Specific Procedures...(c) Therapeutic diets shall be prescribed by the attending practitioner in written orders on the patient's chart. Orders for diets must be specific.

2. Review of the medical record for Patient #1 revealed the patient was admitted on 3/14/10 with a reddened area on the buttocks/lower back area and with very limited mobility. On 3/16/10, the reddened area developed into a Stage II wound and a Dietary Consult was ordered. The Registered Dietitian evaluated the patient in the morning of 3/16/10 and recommended dietary supplements three (3) times daily. Further review of the medical record revealed no documented evidence the physician considered the recommendation or ordered the recommended dietary supplements until 3/23/10. The patient was discharged 4/1/10.

3. Review of the medical record for Patient #2 revealed the patient was admitted on 3/22/10 with a Braden Score of 8 which is High Risk. The Registered Dietitian evaluated the patient the day of admission and recommended dietary supplements three (3) times daily. Further review of the medical record revealed no documented evidence the physician considered the recommedation or ever ordered the recommended dietary supplements. The patient was discharged on 3/31/10.

4. During an interview with the Medical Director of the Behavioral Science Center in the morning of 5/18/10, the Medical Director stated the expectation is the physician is to follow the dietitian's recommendations and write the orders.

5. During an interview in the morning of 5/20/10 with the Unit Manager and Clinical Nurse Manager of the Behavioral Science Center, the medical records were reviewed and they both agreed with the above findings.

Based on document review, medical record review and staff interview, the hospital failed to ensure the Behavioral Science Center registered nurses (RNs) follow hospital policy regarding the prevention of further skin breakdown in four (4) of four (4) closed medical records (patients #1, 2, 3 and 4) of patients admitted with skin issues reviewed. This has the potential to negatively impact all patient care by not preventing pressure ulcers in patients more susceptible or preventing worsening of already present pressure ulcers. Findings include:

1. Beckley Appalachian Regional Hospital (BARH) Skin & Wound Care Program Manual, last revised 1/2007, states in part "...The purpose of the ARH Skin/Wound Care Program is to enhance and facilitate the uniform delivery of quality patient care by establishing skin and wound care policies, procedures, protocols and resources...To serve as reference, define standards for performance and to assist the staff in achieving consistency in clinical practice...To describe duties and responsibilities of caregivers and to establish the basis of consistent and effective delivery...Upon admission, each patient will have a risk assessment completed utilizing the Braden Risk Assessment Scale to identify potential for alteration in skin integrity...Depending upon the risk score, the appropriate Skin Care Prevention Protocol will be implemented... Moderate Risk 13-14...Skin Hygiene and Inspection...Bathe daily...Keep local areas of skin clean, dry and free of body wastes, perspiration and wound drainage...Inspect the skin daily for signs and symptoms of breakdown and note any changes from the admission assessment on nurses' notes... Activity/Mobility...Establish and record an individualized turning schedule if the patient is immobile...Intervals may vary from 30 minutes to 2 hours. Evaluate the skin after each turning interval. If there is non-blanchable redness, increase the frequency of turning... High Risk 12 or less... Skin Hygiene and Inspection...Bathe daily...Keep local areas of skin clean, dry and free of body wastes, perspiration and wound drainage...Inspect the skin twice daily for signs and symptoms of breakdown and note any changes from the admission assessment on nurses' notes... Activity/Mobility...Establish and record an individualized turning schedule if the patient is immobile...Intervals may vary from 30 minutes to 2 hours. Evaluate the skin after each turning interval. If there is non-blanchable redness, increase the frequency of turning."

2. Review of the medical record for Patient #1 revealed the patient was admitted on 3/14/10 with a reddened area on the buttocks/lower back area and with very limited mobility. The Braden Score was considered High Risk. However, further review of the medical record revealed inconsistent documented turning of the patient by the nursing staff on every day of the patient's stay. Most of the documentation was self-turning by the patient, few were the actual position the staff turned the patient, multiple documentations of the patient being left for multiple hours sitting in a chair and some was no documented evidence of any turns at all. The patient did develop a Stage II pressure wound on the reddened area documented on 3/16/10. Also there was no documented evidence of the patient receiving a bath on 3/21/10 and 3/29/10. The patient was discharged on 4/1/10.

3. Review of the medical record for Patient #2 revealed the patient was admitted on 3/22/10 with a Braden Score of 8 which is High Risk. Further review of the patient's medical record revealed the Registered Nurses' (RN's) notes documenting the patient was a total patient care; however there was inconsistent documentation of turns of the patient throughout the entire stay. The patient was discharged on 3/31/10.

4. Review of the medical record for Patient #3 revealed the patient was admitted on 3/6/10 and discharged on 3/18/10. Further review of the medical record revealed no documented evidence of the patient receiving a bath on 3/7/10, 3/10/10 and 3/17/10. Review of the RN's documented notes revealed the patient was total care for grooming and hygiene.

5. Review of the medical record for Patient #4 revealed the patient was admitted on 3/12/10 with a yeast infection of the skin from under the breast down to the thighs with open sores. RN documentation revealed the patient was able to complete hygiene with maximum assist and was able to walk very short distances with assistance. There were also documented physician orders for skin care and nystatin to affected areas twice daily. Further review of the medical record revealed no documented evidence of any turning of the patient during the entire stay and documented evidence of skin care/bath only once a day. The patient was discharged on 3/19/10.

6. During an interview in the morning of 5/20/10 with the Unit Manager and Clinical Nurse Manager of the Behavioral Science Center, the medical records were reviewed and they both agreed with the above findings.

Based on medical record and staff interview, the hospital failed to ensure the Behavioral Science Center nursing staff appropriately updated the nursing care plans for skin issues in three (3) of four (4) medical records reviewed of patients with altered or risk for altered skin integrity (patient #1, 2 and 4). This has the potential to negatively impact all patient care by not maintaining or improving the skin condition and/or preventing further breakdown of compromised skin of patients. Findings include:

1. Review of the medical record for Patient #1 revealed the patient was admitted on 3/14/10 with a reddened area on the buttocks/lower back area and with very limited mobility. The Braden Score was considered High Risk. Further review of the medical record revealed Altered Skin Integrity was added to the patient's Nursing Care Plan, however, the nursing interventions were only Consult Dietary, Consult Physical Therapy and Wound Care as Ordered. The patient did develop a Stage II pressure wound on the reddened area documented on 3/16/10. The patient was discharged on 4/1/10.

2. Review of the medical record for Patient #2 revealed the patient was admitted on 3/22/10 with a Braden Score of 8 which is High Risk. Further review of the patient's medical record revealed the Registered Nurses' (RN's) notes documenting the patient was a total care; however, Risk for Altered Skin Integrity was not added to the Nursing Care Plan. The patient was discharged on 3/31/10.

3. Review of the medical record for Patient #4 revealed the patient was admitted on 3/12/10 with a yeast infection of the skin from under the breast down to the thighs with open sores. RN documentation revealed the patient was able to complete hygiene with maximum assist and was able to walk very short distances with assistance. There were also documented physician orders for skin care and nystatin to affected areas twice daily. Further review of the medical record revealed Altered Skin Integrity was not added to the Nursing Care Plan. The patient was discharged on 3/19/10.

4. During an interview in the morning of 5/20/10 with the Unit Manager and Clinical Nurse Manager of the Behavioral Science Center, the medical records were reviewed and they both agreed with the above findings.