HospitalInspections.org

Based on policy review, medical record review, record review from long term care facility, observation and interview, the facility failed to ensure nursing staff assessed a patient's wound, implemented preventative measures to avoid further skin breakdown, notified the physician of an existing decubitus ulcer and obtained a physician's order for wound care treatment for 1 of 3 (Patient #2) sampled patients.

The findings included:

1. Review of the facility's "DECUBITUS ULCER, CARE AND PREVENTION" policy revealed, "...PURPOSE: To prevent and/or effectively treat pressure areas and/or tissue destruction...RISK FACTORS...All patients who are bedridden or chair bound who have difficulty repositioning themselves...Decreased mental status...Moisture...Incontinence...Nutritional Deficits...PREVENTATIVE MEASURES ...Inspect the skin at least daily with documentation of assessment results ...Use devices that totally relieve pressure on the heels ...Use eggcrate mattress, sheepskin, heelprotectors, pillows and wedges as necessary ...STAGING AND TREATMENT OF DECUBITUS ULCERS...STAGE II...TREATMENT...Flush with saline solution and air dry - apply skin barrier (DUODERM) and change every 3-5 days...STAGE III...Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia...TREATMENT...Eggcrate mattress...If clean, follow same treatment as for stage II...If dirty, treatment prescribed by physician...DOCUMENTATION...Assessment and reassessment of skin integrity noting presence of any reddened areas with nursing interventions and response. Assessment and reassessments of wound noting stage, diameter and depth in centimeters noting presence of signs and symptoms of healing infection, increase in diameter or depth. Document nursing interventions and response..."

2. Medical record review for Patient #2 revealed an admission date of 4/2/18 with diagnoses which included Aspiration Pneumonia, Chronic Obstructive Pulmonary Disease, Respiratory Distress, Hypotension, Dementia, Diabetes Mellitus, Chronic Kidney Disease Stage 3, Protein Calorie Malnutrition, Cerebrovascular Accident and Coronary Artery Disease. Patient #2 was discharged from the facility on 4/23/18.

The "INITIAL INTERVIEW" dated 4/2/18 revealed, "...Pt [Patient] has stage III decub [decubitus] to coccyx area..."

The "Unisex Body" documentation dated 4/2/18 revealed, "...Location: coccyx...Date First Observed: 04/02/18...Stage 2 possible 3...approx. [approximately] 7 cm [centimeters] in size..." There was no documentation the 7 cm was the length or width of the wound. There was no documentation for the depth of the wound, the surrounding tissue, the condition of the wound bed or if there was any drainage.

The "PATIENT PROGRESS NOTES" dated 4/16/18 at 12:40 PM revealed, "...Area to coccyx noted to be leaking with foul odor..."

The "PATIENT PROGRESS NOTES" dated 4/17/18 at 9:22 PM revealed, "...Open to air coccyx area. Drainage: small amount serosang [serosanguineous] drainage..."

The "PATIENT PROGRESS NOTES" dated 4/19/18 at 8:33 PM revealed, "...gross excoriation of bilat [bilateral] buttocks c [with] Stage III wound to coccyx c sanguinous [sanguineous] drainage noted and red areas to bilat hips..."

The "PATIENT PROGRESS NOTES" dated 4/20/18 at 8:08 PM revealed, "...wound on coccyx open to air with mild yellow/bloody drainage..."

The "LABORATORY - COMPARATIVE REPORT" dated 4/20/18 revealed, "...COLLECTED...4/17/18 1228 [12:28 PM]...RESULTED...4/20/18...CULTURE WOUND...Result 1...Heavy growth...Providencia stuartii A..."

The "Discharge Instructions" dated 4/23/18 revealed, "...Wound coccyx 5cm's with eschar, rt [right] hip 2 cm's stage two..."

Medical record review for Patient #2 from Nursing Facility #1 dated 4/23/18 at 7:40 PM revealed the wound to the coccyx was assessed as a Stage IV and the wound to the right hip was assessed as a Stage 3. A communication form dated 4/24/18 revealed, "...Res [resident]...c [with] Stage IV to coccyx 5.5 [cm] x [by] 6.0 [cm] x 0.4 cm...50% eschar, 50% red tissue. Surrounding skin extremely excoriated...Stage III to R [right] greater trochanter 3.0 [cm] x 6.0 [cm] x 0.2 cm...90% pink 10% yellow..."

During an interview in the conference room on 9/13/18 at 10:28 AM, the Director of Nursing (DON) stated the admitting nurse should document any wounds, and the nursing staff should reassess the wounds each shift. The DON stated the nurse should assess and measure the wound and document the results.

During an interview in the Regulatory Compliance Officer's office on 9/13/18 at 12:40 PM, the Regulatory Compliance Officer confirmed Patient #2's wounds to the coccyx and right hip were not appropriately assessed.

There was no documentation by the nursing staff at the facility for the assessment of the complete measurements for Patient #2's coccyx wound, and there was no description of the wound bed until 4/23/18. There was no description of wound drainage except on 4/16/18 at 12:40 PM, 4/17/18 at 9:22 PM, 4/19/18 at 8:33 PM and 4/20/18 at 8:08 PM. There was no documentation for the assessment of the complete measurements for Patient #2's wound to the right hip.

3. The "INITIAL PHYSICAL ASSESSMENT" dated 4/2/18 revealed, "...Level of Consciousness: Drowsy, Confused...Hand Grips: Left sided weakness...Skin Condition: breakdown noted area of coccyx approx 7cm in diameter, LUE [left upper extremity swollen] and redden [reddened]...Gait: Non-ambulatory...Weakness: Generalized body weakness/aches...Skeletal Assessment: stiff weak..."

The "PATIENT PROGRESS NOTES" dated 4/2/18 revealed, "...13:18 [1:18 PM]...Sensory Perception: Slightly limited...Moisture: Constantly moist...Activity: Bedfast/Confined to Bed...Mobility: Very limited position changes...Nutrition: NPO...Friction and Shear: Frequently slides down in bed or chair...Total Score 8 [Braden Scale score of 9 or less signifies very high risk for skin breakdown]...20:30 [8:30 PM]...Skin Condition...Fragile/Thin..."

The "PATIENT PROGRESS NOTES" dated 4/6/18 at 9:15 PM revealed, "...Deformity: Contracture of the: LLE [left lower extremity]..."

The "PATIENT PROGRESS NOTES" dated 4/12/18 at 6:00 PM revealed, "...Heel protectors re [regarding]: Stage I nonblanchable pressure areas noted to bilat heels..."

The "PATIENT PROGRESS NOTES" dated 4/14/18 at 9:22 PM revealed, "...heel protectors applied..."

The "PATIENT PROGRESS NOTES" dated 4/19/18 at 8:33 PM revealed, "...Bilat heels c soft pinkened areas..."

Observations in the supply room on 9/13/18 at 12:10 PM revealed an eggcrate mattress and heel protectors were stored in the supply room.

During an interview in the conference room on 9/13/18 at 10:28 AM, the DON stated nursing staff used an eggcrate mattress and heel protectors for patients with a potential for skin breakdown. The DON confirmed an eggcrate mattress and heel protectors were available to the patients.

There was no documentation the nursing staff used an eggcrate mattress for Patient #2 to help prevent further skin breakdown. There was no documentation the nursing staff used heel protectors for Patient #2 except on 4/12/18 at 6:00 PM and 4/14/18 at 9:22 PM to help relieve pressure on the heels.

4. The "INITIAL INTERVIEW" dated 4/2/18 revealed, "...Pt has stage III decub to coccyx area..."

Physician #2's progress note dated 4/14/18 revealed, "...Trophic ulcer both gluteal region upper part c gr [grade] II pressure sores 3 cm x 2 cm R side & [illegible] 3 gr over L [left] side..."

During an interview in the conference room on 9/13/18 at 11:35 AM, Nurse #1 stated she believed the physician did know about Patient #1's wound when admitted to the facility, because she assumed the physician reviewed the nurses' documentation.

During a phone interview on 9/14/18 at 10:10 AM, Nurse Practitioner #1 stated she nor Physician #1 was aware of Patient #2's coccyx wound until Physician #2 documented on the wound on 4/14/18.

There was no documentation the nursing staff notified any provider of Patient #2's coccyx wound from 4/2/18-4/14/18 (12 days).

5. The "PATIENT PROGRESS NOTES" dated 4/6/18 at 4:21 AM revealed, "...dressing applied to coccyx area per nursing home orders s [without] collagen [collagen] D/T [due to] no collegin [collagen] on unit at this time...dressing needs to be changed daily according to nursing home orders..."

The "PATIENT PROGRESS NOTES" dated 4/8/18 revealed, "...11:15 [AM] Coccyx wound covered with clean/dry dressing...21:51 [9:51 PM]...pressure wound to coccyx area with clean dry dressing applied..."

The "PATIENT PROGRESS NOTES" dated 4/12/18 at 6:00 PM revealed, "...Stage III decubitus coccyx area. Cleansed c normal saline and foam dressings applied. Covered c ABD [abdominal] pad and secured c tape..."

During an interview in the conference room on 9/13/18 at 10:28 AM, the DON stated the admitting nurse should get an order for wound care treatment if the physician has not written any orders.

During an interview in the Regulatory Compliance Officer's office on 9/13/18 at 12:40 PM, the Regulatory Compliance Officer confirmed there was no physician's order for wound care treatment from 4/2/18-4/14/18.

There was no documentation of a physician's order for wound care treatment from 4/2/18-4/14/18.

Based on medical record review, facility document review and interview, the facility failed to ensure drugs and biologicals were administered as ordered by a physician for 1 of 3 (Patient #2) sampled patients.

The findings included:

1. Medical record review for Patient #2 revealed an admission date of 4/2/18 with diagnoses which included Aspiration Pneumonia, Chronic Obstructive Pulmonary Disease, Respiratory Distress, Hypotension, Dementia, Diabetes Mellitus, Chronic Kidney Disease Stage 3, Protein Calorie Malnutrition, Cerebrovascular Accident and Coronary Artery Disease. Patient #2 was discharged from the facility on 4/23/18.

The "INITIAL INTERVIEW" dated 4/2/18 revealed, "...Pt [Patient] has stage III decub [decubitus] to coccyx area..."

A physician's order dated 4/14/18 revealed, "...Air dry trophic ulcer for 2 hrs [hours]...Cleanse c [with] betadine mixed sterile H2O [water] & [and] apply gentamycin [gentamicin] cream & normogel [Normlgel] & cover c mepeplex [Mepilex dressing]...Q [every] day..."

The medication administration record (MAR) and patient progress notes dated 4/14/18-4/23/18 revealed there was no documentation the gentamicin cream or Normlgel was administered as ordered.

2. Review of the facility's "Patient Account Detail" dated 4/14/18-4/23/18 revealed Patient #2 was not charged for the gentamicin cream.

3. During a phone interview on 9/14/18 at 10:04 AM, Pharmacist #1 confirmed there was no record or documentation Patient #2 received gentamicin cream. Pharmacist #1 stated Patient #2 could only receive gentamicin cream from the pharmacy in the hospital.