HospitalInspections.org

Based on findings from medical record (MR) review, facility document review and interviews, the quality assurance performance improvement program does not consistently measure and analyze the occurrence of all pressure ulcers in the hospital.

Findings include:

--Per MR review, a patient (Patient A) developed a stage 3 pressure ulcer during the course of her hospitalization from 2/10/14 to 3/7/14.

--Per review of the hospital's incident reports for the past 12 months (7/2013 - 7/2014) only one incident report was submitted for a pressure ulcer and it was related to a patient's nasogastric (NG) tube. It did not involve Patient A.

--Per the hospital's policy and procedure titled "Reporting of Significant Occurrence," last revised 3/2013, any occurrence that has an undesirable and unintended effect on an individual patient's condition or poses a real or potential hazard to patients should be reported to appropriate supervisor, manager or director. (Such occurrence would include a stage 3 pressure ulcer.)

--During interview on 8/19/14 at 4:00 pm with the Vice President of Nursing Operations, the findings above were acknowledged.

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Based on findings from medical record (MR) review, facility document review and interview, lapses were identified in bedside nursing care and/or MR documentation, and in the Nursing Department policies and procedures (P&Ps), as follows:

1) In 3 of 3 MRs reviewed for patients needing pressure ulcer prevention measures (Patients A, B and C), nursing did not document sufficient turning and repositioning (T&P). Hospital P&P addressing pressure ulcer prevention measures was not complete;

2) In 1 of 6 MR reviewed involving patients who wore TED (antiembolic) stockings (Patient A), the patient developed a stage 2 pressure ulcer from use of the TED stockings;

3) Seven (7) nursing staff interviewed regarding use of TED stockings and sequential air compression devices (SCDs) described 5 variations in procedures for use of these patient care interventions. The guidance document the hospital used for embolic prevention measures was not complete, and the hospital lacked its own P&P in the matter.

Findings regarding (1) above include:

--Per MR review, Patient A was admitted to the hospital with a reddened sacrum which developed into a stage III pressure ulcer. Documentation in Patient A's MR indicated there were times when she was not T&P every 2 hours (e.g., during the 3/1/14 day shift, the 3/4/14 night shift, the 3/5/14 day shift).

--Per MR review, Patient B was at risk for skin breakdown - his Braden Scale scores ranged from low to moderate risk. An abrasion on his sacrum was documented on 8/12/14. Nursing also documented the need to T & P the patient every 2 hours. However documentation that the patient was T & P every 2 hours was not consistent (e.g., no T & P documented on 8/13/14, T & P only documented once on 8/15/14).

--Per MR review, Patient C was at risk for skin breakdown - his Braden Scale scores ranged from moderate to very high risk. However, nursing staff did not consistently document that Patient C was T & P every 2 hours. For example, from 12:17 am on 8/17/14 to 12:00 pm on 8/18/14, nursing staff documented T & P at intervals ranging from every 3 to 4.5 hours. The patient developed a Stage II pressure ulcer on the sacrum during the hospitalization.

--Per review of the hospital's P&P titled "Skin, Tissue Trauma and Pressure Ulcer Protocol," last revised 4/2011, it described nursing pressure ulcer prevention measures but did not direct nursing staff to document the position the patient was placed in each time repositioned. Also, other than when a patient is initially admitted to the hospital with an existing pressure ulcer, the P&P did not contain instructions regarding how often nursing staff should document periodic reassessments of a pressure ulcer (e.g., at least weekly).

Findings regarding (2) above include:

--Per review of Patient A's MR, on 2/28/14 nursing documented, "Skin consultation requested on this 94 year old woman for linear red area media lower extremities just below knees...suspect TEDs might be the cause. Skin intact with one area on right and two areas on left..." Additional nursing documentation on 3/7/14 noted "she has marks to left posterior calf - pressure ulcer stage 2 from TEDs."

Findings regarding (3) above include:

--During interviews of the following 7 nursing staff, they described 5 variations in procedures for use and removal of TED stockings and SCDs:

Per interview on 8/18/14 at 10:45 am with Staff #1, TED stockings are removed every shift and the patient's skin is inspected. SCDs are removed once a shift and remain on until a patient is independent and mobile. The patient wears the SCDs at night.

Per interview on 8/18/14 at 11:10 am with Staff #2, TED stockings are removed every shift and the patient's skin is assessed. SCDs are on all the time when a patient is in bed and are removed to assess a patient's skin if they are on bedrest.

Per interview on 8/18/14 at 11:40 am with Staff #3, SCDs are taken off when bathing a patient and the nurse assesses the patient's skin. If a patient is on bedrest SCDs are removed every 4 hours (variation #1).

Per interview on 8/18/14 at 2:15 pm with Staff #4, TED stockings and SCDs are removed every 8 hour shift for one hour then reapplied. He/she would report to the next shift that the TED stockings and SCDs would need to be taken off in a 12 hour shift.

Per interview on 8/19/14 at 9:55 am with Staff #5, TED stockings are removed at night (variation #2) and reapplied in the morning after assessing a patient's skin. SCD's are on when a patient is in bed and out of bed (OOB) until the patient is ambulating independently.

Per interview on 8/19/14 at 10:45 am with Staff #6, TED stockings and SCDs are removed every shift. If the patient is post operative the physicians want TED stockings on all the time. SCDs are on 2 hours and off 2 hours (variation #3), on at night and per physician orders. TED stockings are off at night (variation #2 repeated).

Per interview on 8/19/14 at 12:00 pm with Staff #7, TED stockings are removed every 12 hours (variation #4) to rest the legs for 1 hour and then reapplied. SCDs are on at night when a patient is in bed and off when OOB (variation #5).

--During interview of the VP of Nursing Services on 8/19/14 at 1:15 pm, he/she indicated the nursing service uses a document titled "Mosby's Skills, Antiembolic Stockings and Sequential Compression Devices Quicksheet," to provide guidance to the nursing staff in the use of TED stockings and SCDs. Per review of this document during the interview, it lacked instructions regarding timeframes for wearing and periodic removal of the TED stockings and SCDs. The VP of Nursing Services acknowledged this finding and the finding that the hospital had not developed its own P & P providing instructions for use of TED stockings and SCDs.

--During interviews with the VP of Nursing Services, beginning on 8/18/14 and concluding on 8/19/14 at 4:00 pm, all findings above under sections (1) (2) and (3) were acknowledged.