HospitalInspections.org

Based on record review and interview the facility failed to ensure that nursing care plan is kept current by ongoing and periodic assessment and reassessments of patients are conducted and that care and treatment decisions are based on the patient's identified needs as evidenced by failure to prevent the development of pressure ulcers and to provide the nursing care to prevent worsening of the pressure ulcer in 1 of 3 sampled patients (#3).

Based on record review and interview the facility failed to prevent the development of pressure ulcers and to provide the nursing care to prevent worsening of the pressure ulcer in 1 of 3 sampled patients (#3).

The findings include:


Review of sample patient #1 record reveals an admission date of 11/13/09 with a diagnosis of respiratory distress. Documentation upon arrival reveals patient was brought into the emergency department with multiple decubitus ulcers and "appeared to be septic." Emergency room nurse documents on 11/13/09 at 2016 that the sacral and heel wounds have been photographed and referred to wound care team. Further review will show documentation of wound care by both the wound care physician and wound care nurses.

Review of sample patient #2 reveals an admission date of 11-13-09 with a diagnosis of history of schizophrenia and chronic abdominal wound. Further review of documentation reveals that the patient has a "colostomy with a poor healing wound." The documentations shows that photographs were taken and the patient was followed by wound care team from the date of admission. On 11/23/09 the documentation reveals that the wound has healed.

Review of sample patient #3 reveals an admission date of 11/19/09 with a diagnosis of acidosis. The patient was received in the emergency room via rescue complaining of depressed mental status and was noted to have a low blood sugar. Documentation in the emergency room reveals that the patient was found to have no wounds on initial assessment (11/19/09.) The daily nurse notes from 11/19/09 to 11/27/09 show "skin intact." On 11/28/09 the nurse note reads "redness noted around the sacral are and perineum." On 11/29/09 the RN writes "Stage I redness noted at the back and sacral area and perineal area. Skin cream protectant applied to affected area and to decubitus-prone area." Daily Assessment dated 11/30/09 reads "Stage I sacrum." Daily Assessment note dated 12/1/09 reads " Stage 2 to sacrum and left buttocks." On 12/14/09 the attending physician note states "sacral decubitus." The first note in the record for the wound care physician is dated 12/15/09. In this note the wound care physician measures two wounds, one on the sacrum measuring 2.5(l)x3.6(w)x0.21(d) and the right buttocks measuring 1.0(l)x1.5(w)x0.21(d). The same wound care note dated 12/15/09 states "has early nosocomial decubitus."
Interview with Director of CCU and wound care nurse (employee #1) on 1/13/10 at 3:54pm reveals that the plan for wound care is early intervention. The wound care RN states that the floor nurse that identifies redness of the skin is to notify the primary physician and request permission to contact the wound care physician. Once the primary physician gives an order to consult the wound care physician the wound care physician will write orders for the wound care nurse to follow. A wound care nurse will then see the patient every 7 to 10 days. The wound care RN is shown patient sample #3's chart and confirms with the surveyor that the patient was not seen by wound care until 12/14/10 and has no explanation for why the patient was not seen earlier. The wound care RN states that if the floor nurse does not report findings and the primary physician does not make the consult the wound care team would have no way of knowing the patient requires the wound teams care. The Director of CCU is also unable to explain why the patient was not consulted before 12/14/10.

On 1/14/10 at 12:30p.m. the wound care RN brought the surveyor documentation that reveals on 12/1/09 the wound care nurse did weekly rounds in the critical care unit. The document has patient #3 listed with a hospital acquired Stage II sacral left ischium pressure ulcer. The treatment area reads "Baza protective cream; turn q 2 hrs; off load sacrum/heels, obtain consult." The wound care RN states that the nurse listed on the document is the nurse that was asked to obtain the consult. The surveyor asked the wound care RN to explain what had happened that a consult was requested on 12/1/09 and the patient was not consulted until 12/15/09. The wound care RN said that weekly rounds are made by a wound care nurse to every patient in the critical care unit. If the patient has redness or breakdown the wound care nurse will ask the floor nurse to notify the primary physician and receive a consult order for wound care. The wound care RN explains that the floor nurse must not have followed through and received the consult order as requested. An explanantion could not be provided by the wound care RN or the Director of Clinical Quality Improvement for why the pateint was able to go 14 days without someone noticing that the wound care team had not been consulted.


The above findings were shown to the CEO, CNO, Director of Clinical Quality Improvement and the Wound Care RN. They stated that a policy regarding wound care consults would be put in to effect immediately.

Based on record review and interview the facility failed to ensure that nursing care plan is kept current by ongoing and periodic assessment and reassessments of patients are conducted and that care and treatment decisions are based on the patient's identified needs as evidenced by failure to prevent the development of pressure ulcers and to provide the nursing care to prevent worsening of the pressure ulcer in 1 of 3 sampled patients (#3).

Based on record review and interview the facility failed to prevent the development of pressure ulcers and to provide the nursing care to prevent worsening of the pressure ulcer in 1 of 3 sampled patients (#3).

The findings include:


Review of sample patient #1 record reveals an admission date of 11/13/09 with a diagnosis of respiratory distress. Documentation upon arrival reveals patient was brought into the emergency department with multiple decubitus ulcers and "appeared to be septic." Emergency room nurse documents on 11/13/09 at 2016 that the sacral and heel wounds have been photographed and referred to wound care team. Further review will show documentation of wound care by both the wound care physician and wound care nurses.

Review of sample patient #2 reveals an admission date of 11-13-09 with a diagnosis of history of schizophrenia and chronic abdominal wound. Further review of documentation reveals that the patient has a "colostomy with a poor healing wound." The documentations shows that photographs were taken and the patient was followed by wound care team from the date of admission. On 11/23/09 the documentation reveals that the wound has healed.

Review of sample patient #3 reveals an admission date of 11/19/09 with a diagnosis of acidosis. The patient was received in the emergency room via rescue complaining of depressed mental status and was noted to have a low blood sugar. Documentation in the emergency room reveals that the patient was found to have no wounds on initial assessment (11/19/09.) The daily nurse notes from 11/19/09 to 11/27/09 show "skin intact." On 11/28/09 the nurse note reads "redness noted around the sacral are and perineum." On 11/29/09 the RN writes "Stage I redness noted at the back and sacral area and perineal area. Skin cream protectant applied to affected area and to decubitus-prone area." Daily Assessment dated 11/30/09 reads "Stage I sacrum." Daily Assessment note dated 12/1/09 reads " Stage 2 to sacrum and left buttocks." On 12/14/09 the attending physician note states "sacral decubitus." The first note in the record for the wound care physician is dated 12/15/09. In this note the wound care physician measures two wounds, one on the sacrum measuring 2.5(l)x3.6(w)x0.21(d) and the right buttocks measuring 1.0(l)x1.5(w)x0.21(d). The same wound care note dated 12/15/09 states "has early nosocomial decubitus."
Interview with Director of CCU and wound care nurse (employee #1) on 1/13/10 at 3:54pm reveals that the plan for wound care is early intervention. The wound care RN states that the floor nurse that identifies redness of the skin is to notify the primary physician and request permission to contact the wound care physician. Once the primary physician gives an order to consult the wound care physician the wound care physician will write orders for the wound care nurse to follow. A wound care nurse will then see the patient every 7 to 10 days. The wound care RN is shown patient sample #3's chart and confirms with the surveyor that the patient was not seen by wound care until 12/14/10 and has no explanation for why the patient was not seen earlier. The wound care RN states that if the floor nurse does not report findings and the primary physician does not make the consult the wound care team would have no way of knowing the patient requires the wound teams care. The Director of CCU is also unable to explain why the patient was not consulted before 12/14/10.

On 1/14/10 at 12:30p.m. the wound care RN brought the surveyor documentation that reveals on 12/1/09 the wound care nurse did weekly rounds in the critical care unit. The document has patient #3 listed with a hospital acquired Stage II sacral left ischium pressure ulcer. The treatment area reads "Baza protective cream; turn q 2 hrs; off load sacrum/heels, obtain consult." The wound care RN states that the nurse listed on the document is the nurse that was asked to obtain the consult. The surveyor asked the wound care RN to explain what had happened that a consult was requested on 12/1/09 and the patient was not consulted until 12/15/09. The wound care RN said that weekly rounds are made by a wound care nurse to every patient in the critical care unit. If the patient has redness or breakdown the wound care nurse will ask the floor nurse to notify the primary physician and receive a consult order for wound care. The wound care RN explains that the floor nurse must not have followed through and received the consult order as requested. An explanantion could not be provided by the wound care RN or the Director of Clinical Quality Improvement for why the pateint was able to go 14 days without someone noticing that the wound care team had not been consulted.


The above findings were shown to the CEO, CNO, Director of Clinical Quality Improvement and the Wound Care RN. They stated that a policy regarding wound care consults would be put in to effect immediately.