HospitalInspections.org

Based on interviews, documentation in 1 of 3 medical records reviewed of patients (Patient #3) with skin conditions, and review of policies and procedures, it was determined the hospital failed to ensure an individualized nursing plan of care was developed and kept current addressing all of the patient's skin conditions, and based on the assessment and identified needs of the patient in accordance with hospital policy and this regulation.

Findings include:

1. A policy titled "Plan of Care - Pre Epic," dated/reviewed 07/2011 reflected the following internal requirements: "The RN is accountable to develop and coordinate an individualized plan of care...The RN/LPN is accountable to evaluate and modify the patient's Plan of Care based on review of...Surveillance data...Patient response to therapeutic interventions and outcomes...Patient progress toward desired goals/outcomes...Interdisciplinary care team members' progress notes, orders, and recommendations...Managing the Patient's Plan of Care...If the patient is not progressing toward goals, the nurse will document a note to describe the barriers and update the plan as appropriate."

A policy titled "Universal: Adult - Pre Epic," revised 05/2011 reflected the following internal requirements: "...Upon assumption of care and with changes to the patient condition unless otherwise noted...Perform and document an individualized focused assessment. The frequency and comprehensiveness of assessments and interventions should be adequate to detect changes early enough in the course of the patient's stay to treat and/or allay undesirable outcomes."

A policy titled "Pressure Ulcers: Prevention - Pre Epic," revised 09/2012 reflected the following internal requirements: "...Observe the skin for pressure damage caused by medical devices...Develop an individualized care plan for...Braden Score of [less than or equal to] 18...Consider additional factors which increase risk:..excessive skin moisture." The policy required an individualized plan of care for all patients. An addendum to the policy (Addendum A) was a "Braden Scale for Predicting Pressure Sore Risk." The Braden scale reflected that a total score of less than or equal to 9 = severe risk; a total score of 10-12 = high risk; a total score of 13-14 = moderate risk; and a total score of 15-18 = mild risk."

2. An interview was conducted with Interviewee D on 05/02/2013 at 1615. Interviewee D stated he/she was the nurse assigned to care for Patient #3 during the day shift on 02/11/2013, 02/12/2013 and 02/16/2013. He/she stated the patient had an elastic abdominal binder in place during all of those shifts. On 02/12/2013, the night shift nurse reported that the patient had a "skin tear" on his/her thoracic area. The patient's abdominal tubes had been leaking so they were discussing ways they could clean and manage the binder. The night shift nurse had placed a gauze dressing between the binder and the patient's skin to try to protect it. Interviewee D stated he/she noticed skin breakdown on the patient's back on 02/12/2013. He/she stated the skin breakdown "appeared to be an abrasion from the binder." Interviewee D stated the binder was approximately nine inches wide, and the abrasion was underneath the binder. Interviewee D was asked whether or not the patient's physician was informed of the skin breakdown. Interviewee D stated he/she should have notified the patient's physician of the skin breakdown, but he/she did not. He/she stated the physician was aware on "Saturday [02/16/2013]," but he/she did not know when or how the physician was informed. He/she acknowledged there was no documented assessment or care plan addressing how to manage the patient's skin with the abdominal binder in place. He/she acknowledged there should have been a care plan developed.

An interview was conducted with Interviewee B on 05/02/2013 at 1600. He/she stated that Patient #3 had an abdominal binder, and acknowledged the patient developed a wound underneath the binder while at the hospital. Interviewee B stated "We did not look at the patient in a holistic manner" and "We did not consider the curvature of [his/her] back and how that may impact [his/her] skin." He/she acknowledged there was no individualized plan of care developed to address how staff should manage the patient's skin with the abdominal binder in place.

3. The medical record for Patient #3 was reviewed. The patient was admitted to the hospital on 02/03/2013 with a chief complaint of aspiration. The patient had a history of severe cerebral palsy. He/she had a gastrostomy tube (G-tube, a tube inserted through the abdomen to the stomach to deliver nutrition/hydration) and a jejunostomy tube (J-tube, a tube inserted through the abdomen to the small intestine to deliver nutrition/hydration).

The record reflected the patient was at high risk for skin breakdown. The patient was quadriplegic, kyphotic (abnormal curvature of the spine resulting in a protuberance of the upper back) and scoliotic (abnormal lateral curvature of the spine). The history and physical dated 02/03/2013 reflected the patient had a seizure disorder, severe contractures of both upper and lower extremities, and was incontinent of urine. Record review reflected the patient's abdominal tube(s) were leaking fluids and the patient was experiencing fevers which increased the risk of excess moisture on the patient's skin. The patient was also nonverbal and required total assistance for care.

Physician orders dated 02/04/2013 at 1222, 02/08/2013 at 0730 and 02/11/2013 at 1722 reflected an abdominal binder (an elasticized wrap applied around the lower part of the torso) was ordered. The physician orders did not include directions addressing care of the patient's skin in relation to the use of the binder such as when the binder may need to be changed, cleaned and/or removed for skin checks.

The record reflected the patient had an abdominal binder in place during the hospital stay. For example, nurse flowsheets dated 02/03/2013 at 1820, 02/04/2013 at 1938 and 02/05/2013 at 0801 reflected "Dressing [Intervention]...[abdominal] binder." Nurse progress notes dated 02/09/2013 at 2200 reflected the patient's tube feeding was leaking a large amount and his/her abdominal binder was "replaced."

Documentation on daily Braden skin risk scales for 02/03/2013 through 02/16/2013 reflected the patient had a "low score" (high risk for skin breakdown) and his/her skin was "reddened."

Nurse flowsheets dated 02/11/2013 at 2100 reflected the patient had a "skin tear" located on his/her "Trunk #3...back." Nurse flowsheets dated 02/12/2013 at 0835 reflected the "skin tear" on the patient's back was "pink red" and "open raw/denuded."

Nurse progress notes dated 02/12/2013 at 1519 reflected "[Patient's] J-tube continues to leak...skin is dry and sloughs off easily..." Nurse progress notes dated 02/13/2013 at 1733 reflected the patient had loose stools and his/her J-tube continued to leak.

Nurse flowsheets dated 02/14/2013 at 0825 reflected the patient had a "skin tear" located on his/her "Trunk #3...back." The skin tear was "pink red" and "open raw/denuded."

Nurse flowsheets dated 02/15/2013 at 1444 reflected "[Additional wound description]...superficial area open bottom portion of skin tear. some [sic] bruised areas surrounding open area...Periwound dry peeling skin on back..."

Nurse flowsheets dated 02/16/2013 at 0740 again reflected the patient had a "skin tear" on his/her "Trunk #3...back." The nurse flowsheets reflected the patient also had a "red" and "dry moist scratch/[excoriation]" on his/her "Trunk #6...posterior back."

The physician's discharge summary dated/transcribed on 02/13/2013 at 1629, and the addendum to the discharge summary dated/transcribed on 02/16/2013 were reviewed. Although the discharge summary addressed the patient's skin surrounding the abdominal tubes, it did not include documentation regarding the skin breakdown on the patient's back.

Review of the record reflected it lacked documentation of an individualized assessment and plan of care addressing the patient's risk for skin breakdown to his/her back in relation to the use of the abdominal binder, in accordance with hospital policy and this regulation.