HospitalInspections.org

Based on document review, medical record (MR) review and interview, nursing care practices were not consistent with generally accepted standards of nursing practice. Specifically, 1) 3 of 4 MRs (Patients #3 - #5) reviewed of patients with skin breakdown lacked appropriate documentation of skin / wound assessments by a registered nurse (RN). 2) 2 of 2 MRs (Patients #3 and #7) reviewed of patients at risk for pressure ulcer development lacked documentation that appropriate preventative measures were implemented. 3) 2 of 3 MRs (Patients #3 and #4) reviewed of patients receiving pain medication, lacked reassessments of patient's pain or reassessments were not done timely. These lapses could increase patients' risk for skin breakdown and inadequate pain management

Findings regarding (1) include:

-- Review of the facility's policy and procedure (P&P) titled "NSG-SKIN Assessment, Reassessment and Wound Care Treatment," last revised 9/2019, indicated the following:
- Each admitted patient will receive a skin assessment by a registered nurse (RN) upon admission.
- Skin will be assessed daily.
- If a patient has wounds, wound assessment should include location, measurements, wound bed tissue (color, granulation, etc.), presence of necrotic tissue, any drainage amount (color , amount, consistency), undermining, skin around the wound.

-- Review of Patient #3's MR revealed, he presented to the emergency department (ED) on 8/22/19 at 5:00 pm with a right great toe abscess. An incision and drainage was done. He was admitted to the hospital. The skin and wound assessment done by an RN indicated he had a blackened blister on the left heel covered with mepitel (dressing), scabbed blister on the right heel covered with mepitel, and that dressing to right great toe was dry and intact. Patient #3 also had a skin tear on his right arm, buttocks sheared and open, covered with sacral dressing, ecchymosis and bruising. Multiple open areas on body. The wound assessment completed by an RN on 8/24/19 lacked the required elements per the P&P (e.g., measurements, wound bed tissue, presence of necrotic tissue, drainage, undermining, skin around the wound). The MR lacked RN skin assessment documenation on 8/26/19. (The skin assessment was completed by a licensed practical nurse [LPN]).

-- Review of Patient #4's MR revealed, she was admitted on 11/17/19 at 7:43 am with a diagnosis of pneumonia. Documentation by an LPN on 11/18/19 at 1:36 pm revealed Patient #4 had skin tears on both legs, skin was cleansed with normal saline, dried and dressed with mepilex. On 11/19/19 at 11:45 am, the LPN noted a small open area on outer shin and applied a mepilex. There was no RN documentation pertaining to Patient #3's skin breakdown.

-- Review of Patient #5's MR revealed she was admitted on 10/24/19 at 7:50 pm with a diagnosis of right foot ulcer and cellulitis. Prior to admission she was seen by a surgeon in the ED and had a debridement (removal of damaged tissue) done. The RN documented at 10:33 pm that the wound on top of right foot measured 6 centimeters (cm) x 4.5 cm and that there was serosanguinous (blood mixed with clear liquid) drainage so she changed the dressing.

Licensed practical nurse documentation on 10/28/19 at 3:11 pm revealed, he/she initiated the wound care flowsheet and documented ulcer/acute, no odor, 5 cm (length) 4 cm (wide) x 1 cm (deep), heavy serous drainage, smooth red tissue in center of wound with thick tan exudate, wound cleansed with normal saline, dressing applied. There was no new documentation of wound assessment by an RN.

-- During interview of Staff A, RN, Charge Nurse on 11/21/19 at 10:30 am, he/she indicated RNs don't usually see the patient's wounds after the initial admission assessment. The LPN does all wound care and dressings and then documents in the MR.

Findings regarding (2) include:

-- Review of the facility's policy and procedure (P&P) titled "NSG-SKIN Assessment, Reassessment and Wound Care Treatment," last revised 9/2019, indicated the following:
- Skin assessment should include the Braden Scale (risk assessment tool for pressure ulcer development, Mild Risk 15-18, moderate risk 13-14, high risk 10-12 and severe risk 9 and below).
- Appropriate preventative measure should be implemented based on Braden Scale score.
- Scores of 18 and below require additional preventative measures (e.g., turn and position every 2 hours, heel and elbow protectors, splints, pillows for support, etc.)

-- Review of Patient #3's MR revealed, on 8/22/19 at 8:58 pm, his Braden Scale score was 17 (mild risk). The patient's position was documented every 2 hours from 8/22/19 at 9:00 pm - 8/23/19 at 8:18 am (11 hours) as supine.

-- Review of Patient #7's MR revealed, on 11/21/19 at 10:54 pm, his Braden score was 14 (moderate risk). The patient's position was documented every 2 hours from 11/21/19 at 10:00 pm - 11/20/19 at 6:00 am (8 hours) as supine.

-- During interview of Staff B, Director Of Quality Assurance on 11/22/19 at 9:30 am, he/she acknowledged the above findings.

Findings regarding (3) include:

-- Review of the facilty's P&P titled "Clinical - Pain Assessment/Reassessment," last reviewed 5/22/18, indicated staff should select the appropriate pain scale for the patient (e.g., numerical pain rating scale from 0 - 10 [0-no pain, 10-severe pain]). After pharmological intervention pain should be reassessed within 30 minutes. Document the patient's response.

-- Review of Patient #3's MR revealed, on 8/22/19 at 10:02 am, he received acetaminophen and codeine for back pain documented as a level 5. Reassessment was documented at 2:37 pm as effective (4.5 hours later). Also on 8/23/19 at 7:44 pm, Patient #3's pain level was 5, acetaminophen and codeine were administered. No pain reassessment was documented. On 8/25/19 at 8:38 pm, Patient #3's pain level was 10, acetaminophen and codeine were administered. No pain reassessment was done.

-- Review of Patient #4's MR revealed, she received Tylenol 650 mg for back pain on 11/21/19 at 4:24 am, there was no documentation of pain level or reassessment of pain.

-- Per interview of Staff C, LPN on 11/21/19 at 2:30 pm, he/she documents on the flow sheet the level of pain the patient has. Reassessment should be done in 1 hour and documented on the flow sheet.

-- During interview of Staff D, Clinical Informatics Coordinator on 11/22/19 at 9:30 am, he/she acknowledged the above findings.