HospitalInspections.org

Based on document review and interview the facility failed to provide supervision, assessment and intervention for 1of 1 patient.


On 10/7/2010 at 9:30 AM, a review of Patient #1 medical record revealed the patient was admitted to the hospital on 8/14/2010 for a fractured right hip. While in the hospital the patient developed two (2) decubiti. The first decubitus was located on the bilateral buttock. On 8/17/2010 between 3:30-4:00 AM a nurse aid turned the patient over during a bath and found a fracture bed pan (fracture pan)improperly positioned beneath the patient #1. The fracture pan was positioned with the elevated portion of the pan beneath the fractured hip rather than the slender portion beneath the hip. The fracture pan was positioned under the patient by an unknown person, at an unknown time during a 12 hour shift. When the fracture pan was removed the imprint of the pan left a horse shoe shaped mark on the bilateral buttock. The skin adhered to the fracture pan and a portion of the skin was removed with the pan. The second decubitus, located on the left heel, was first identified in the nurses documentation under "other neuro" on 8/18/2010 as "left heel red/purple no open areas" On 8/19/2010 in "Other skin" " Deep purple area noted to left heel Heel protectors in place". The patient was discharged on 8/24/2010.
Further review of the patient record revealed, once the decubitus on the buttock and heel were identified the nursing staff failed to implement the skin care protocols that were approved by the medical staff. The care plan documented in the patient record on 8/14/2010 instructs the nurse to Notify Physician of the need for SKIN CONSULT if the Braden Scale Results are less than 16, & Complete ANATOMICAL Skin Assessment, as needed. The Braden Scale for 8/14/2010-8/18/2010 was documented as 13-14 respectively (Moderate Risk) and on 8/19/2010-8/20/2010 the Braden Scale was 10-12 respectively (High Risk). There was no documentation the physician was notified at the time of the incident and no Anatomical skin assessment documented in the patient's medical record. There was not a nursing assessment of the patient's bilateral buttock wound, until 8/24/2010, the date of discharge. There was no nursing assessment documented on the heel wound at all. The nursing documentation reveals a colloidal dressing was in use on the buttock, however the skin protocol manual indicated a foam dressing would be used. There was no treatment documented for the Right heel wound and no intervention other than provide heel protectors. Nursing documentation from 8/14/2010-8/19/2010 reveals Bed position "HOB UP" for every 2 hour check.

Further review of nursing documentation for 8/15/2010-8/18/2010 reveals the patient ate only one meal a day and consumed only 25%. From 8/19/2010-8/24/2010 nursing documentation reveals the patient ate only 2 meals a day and consumed 50% or less of the meal. Only one meal is documented greater than 50% consumption. There is no nursing documentation that the dietician was made aware of the decubiti or the poor intake. In fact on 8/23/2010 the nursing case management/discharge plan documents the patient as independent in eating, even though the ICU nursing assessment history report documentation for nutrition identifies the patient's eating as "total assist" on 8/19/2010 and "assisted" from 8/20/2010 -8/24/2010. There is no documentation of nutritional intervention or teaching for the patient or the family.

An interview with employee #1 on 8/7/2010 at 9:30 AM revealed she was aware of the incident.