HospitalInspections.org

Based on review of policy, medical record review, facility billing report, and staff interviews facility staff failed to identify a hospital acquired pressure ulcer for 1 of 1 patient's (Patient #4).

The findings included:

Review of facility policy titled Event Reporting last revised on 11/2019 revealed "...Reportable Event: Generalized as anything that occurs outside of the expected course of treatment...or outside the usual and expected course of daily activities/procedures...that does, or could cause injury, illness or death...PROCEDURE: 1. The Electronic Safety Event Management System is utilized by all employees and staff to report any actual or "near miss" events, including but not limited to, those events deemed in this policy as "reportable."...3. The following are required general reportable events/event types...Skin Integrity Events / Pressure Ulcers..."

Review of facility policy titled Wound Care and Management last revised 03/2019 revealed "... Definitions: ...C. Pressure Ulcer: a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction ...C. Stage II Pressure Ulcer: Partial thickness as well as loss of epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater ...PROCEDURE: ...2. Skin assessment is completed on admission to unit and each shift by assigned nurse. Wounds/skin integrity alterations should be noted and documented ...DOCUMENTATION: 1. The presence of a wound or skin integrity alteration is documented in the electronic medical record; including the appearance of the wound, the treatment, and the response to the treatment. Wound appearance documentation is inclusive of the following. Location of the wound ...Size: All measurements are made in metric units ...Vague descriptors to indicate size ...are not used..."

Review of Medical Record for Patient #4 revealed a 71-year-old female who presented to the ED (emergency department) on 06/12/2020 for complaints of nausea, vomiting and history of a UTI (urinary tract infection) currently on Bactrim (antibiotic for UTI). Patient was admitted on 06/13/2020 with a diagnosis of an AKI (acute kidney injury), and a UTI with a past medical history of CVA (cerebral vascular accident (stroke)), diabetes, obesity, urinary retention with a chronic foley. Review of History and physical dated 06/13/2020 at 1514 revealed "...extremities: bilateral (both) legs wrapped in compression wraps, cyanosis (pale blue in color), 2+ distal pulses ..." Review of Adult Admission Assessment dated 06/13/2020 at 0449 revealed no assessment of patients lower extremities skin condition. Review of Adult Shift focus assessment by RN (registered nurse) #1 dated 06/13/2020 at 0800 revealed " ...Wound Assessment ... Wound Location: Bilateral lower extremities dressing not removed by this nurse..." Review of provider progress note dated 06/14/2020 at 1205 revealed "...Extremities: BL (bilateral) pressure wraps, cyanosis, 2+ distal pulses. Review of Nurses note dated 06/15/2020 at 2242 revealed "...EDEMA NOTED TO BLE (bilateral lower extremities), LEGS WRAPPED IN COBAN (Self adherent wrap). WOUND TO SACRUM CLEANED AND BARRIER CREAM APPLIED ..." Review of Nursing note dated 06/16/2020 at 0800 " ...SKIN WARM AND DRY. COLOR PALE. PICTURES OF SACRUM AND BUTTOCK TAKEN. 2 AREAS OF BREAKDOWN NOTED. OPTIFOAM PLACED ON AREAS. DRESSING TO BOTH LOWER LEGS INTACT..." Nursing note dated 06/17/2020 1622 revealed "...asked to remove UNA boots (type of compression leg wrap for swelling) and I cut them off patient refuses to let me slide them out... Review of Nursing note by RN #2 dated 06/17/2020 revealed "...CNA and I removed UNA boot pt wouldn't let dayshift remove, very large blister on left heel..." Review of care plans for patient #2 revealed no care plans related to impaired skin integrity, or wounds. Review of MD (Medical Doctor) #2 Progress note revealed "...the blister on the left foot was drained under aseptic conditions. Place (sic) is to be dressed. Will place fluid bed under foot to prevent any stress worsening..." Review of Discharge summary dated 06/21/2020 at 1055 revealed discharge instructions on a cardiac diet, activity as tolerated, PT (physical therapy) and OT (occupational therapy), and blood sugar checks. Review revealed no discharge instructions related to wound care treatment.

Interview with RN #3 on 03/17/2021 at 1058 revealed all incidents were to be reported in the facilities incident reporting system. Interview revealed that after the incident report was put in, that RN would notify the nurse manager, and house supervisor of an incident.

Interview on 03/17/2021 at 1324 with RN #2 revealed there was no incident report filed related to Patient #4's pressure ulcer development during June 2020 admission.

Interview on 03/18/2021 with RN #2 at 1128 revealed there was no tracking of hospital acquired pressure ulcers. Interview revealed facility had no way to identify a hospital acquired pressure ulcer unless it was identified by coding.

Interview on 03/18/2021 at 1440 with CNO (Chief Nursing Officer) #2 and Nurse Director #1 revealed that Senior leadership and organizational goals determine what metrics to monitor. Interview revealed that incident reports and trends could be monitored if a trend was identified. Interview revealed that Patient #4's wound identified on 06/20/2020 should have been photographed per policy and reported in the incident reporting system. Interview confirmed that facility policies were not followed.

Interview on 03/18/2021 with RN #2 at 1618 revealed that Patient #4 developed a pressure ulcer during the June 2020 admission per facility policy definition of a Stage II pressure ulcer. Interview revealed the billing report from June 2020 did not identify Patient #4 with a pressure ulcer. Interview confirmed Patient #4 had an unidentified hospital acquired pressure ulcer.

Based on review of facility policy, medical record review, and staff interview revealed nursing staff failed to initiate and maintain a care plan for 2 of 3 patients admitted with wounds (Patient #4 and Patient #14).

The findings included:

Review of facility policy titled Patient Care plan last revised on 02/2018 revealed "...Care Plan: A document developed after the patient assessment that identifies a. the nursing diagnoses to be addressed... PROCEDURE OR PROCESS: ... 3. The Nursing Care Plan is based on and reflects the findings of the initial nursing assessment and input of other disciplines as appropriate and outlines the patient's goals and as appropriate includes physiological and psychosocial factors... 4. The Nursing Care Plan is based on an assessment of the patient's nursing care needs and includes development of the following. Appropriate patient specific goals. Nursing interventions in response to identified needs... 6. The plan of care is maintained and updated based upon ongoing assessments of the patient's needs, the patient's response to interventions, and changes in the patient's condition ..."

1. Review of Medical record for Patient #14 revealed a 72-year-old female admitted on 01/03/2021. Review of "HISTORY AND PHYSICAL REPORT" revealed patient #14 admitted inpatient for " ...recurrent UTI's (urinary tract infection) ... Urinalysis was strongly suggestive of infection ... PAST MEDICAL HISTORY: 1. UTI, recurrent. 2. Bilateral heel decubitus, diabetic foot ulcers. 3. Sacral ulcer, stage III. 4. Left hip ulcer, decubitus ...". Review of "ADULT ADMISSION ASSESSMENT" revealed " ... PATIENT HAS BOOTS ON FEET BILATERALLY WITH DRESSINGS. ... WOUND ASSESSMENT: Wound location: SACRUM Type : Pressure Ulcer ... Wound Location: LEFT HIP Type: pressure ulcer Drain: wound vac (special dressing to pull drainage from wound) ... Wound Location: HEELS BILATERALLY Type: Pressure ulcer ... Dressing: WRAPPED WITH KERLIX AND BANDAGE ..." Review of care plans revealed care plans in place related to Acute pain, infection risk, and potential for injury. Review revealed no care plan in place related to patient #14's impaired skin integrity. Review of "DISCHARGE SUMMARY" revealed " ... Service Date: 01/03/21 (sic) ... Final Diagnosis 1. COVID-19 2. Seizure 3. UTI ... Condition EXPIRED ... Hospital Course ... The family decided to make her comfort care at that point in time and hospice was supposed to see her today but the patient did not make it. She expired and was pronounced dead at 1203 ..." Review of patient information revealed " ... Encounter Information ... Discharge Date 01/11/2021 14:20 Discharge Disposition: EXPIRED IN HOSPITAL OR SNF ..."

Interview on 03/17/2021 at 1304 With Nurse Director #1 revealed there was no care plan related to skin integrity for patient #14. Interview revealed that facility policy was not followed.

Interview on 03/18/2021 at 1053 with Nurse Director #1 revealed care plans auto populate into the electronic medical record based on the nurse's admission and subsequent assessments. Interview revealed that the nurses were able to pull the populated care plan into the chart or dismiss the care plan.

Interview on 03/18/2021 at 1440 with CNO (chief nursing officer) #2 and Nurse Director #1 revealed that the expectation for nursing staff is that a care plan would be added to the patient plan of care. Interview revealed if a patient presented with or developed an abnormal skin assessment that there would be a new care plan added. Interview revealed facility policy was not followed.

2. Review of Medical Record for Patient #4 revealed a 71-year-old female who presented to the ED (emergency department) on 06/12/2020 for complaints of nausea, vomiting and history of a UTI (urinary tract infection) currently on Bactrim (antibiotic for UTI). Patient was admitted on 06/13/2020 with a diagnosis of an AKI (acute kidney injury), and a UTI with a past medical history of CVA (cerebral vascular accident (stroke)), diabetes, obesity, urinary retention with a chronic foley. Review of History and physical dated 06/13/2020 at 1514 revealed " ...extremities: bilateral (both) legs wrapped in compression wraps, cyanosis (pale blue in color), 2+ distal pulses ..." Review of Adult Admission Assessment dated 06/13/2020 at 0449 revealed no assessment of patients lower extremities skin condition. Review of Adult Shift focus assessment by RN #1 dated 06/13/2020 at 0800 revealed " ...Wound Assessment ... Wound Location: Bilateral lower extremities dressing not removed by this nurse ..." Review of provider progress note dated 06/14/2020 at 1205 revealed " ...Extremities: BL (bilateral) pressure wraps, cyanosis, 2+ distal pulses. Review of Nurses note dated 06/15/2020 at 2242 revealed " ...EDEMA NOTED TO BLE (bilateral lower extremities), LEGS WRAPPED IN COBAN (Self adherent wrap). WOUND TO SACRUM CLEANED AND BARRIER CREAM APPLIED ..." Review of Nursing note dated 06/16/2020 at 0800 " ...SKIN WARM AND DRY. COLOR PALE. PICTURES OF SACRUM AND BUTTOCK TAKEN. 2 AREAS OF BREAKDOWN NOTED. OPTIFOAM PLACED ON AREAS. DRESSING TO BOTH LOWER LEGS INTACT ..." Nursing note dated 06/17/2020 at 1622 revealed "...asked to remove UNA boots (type of compression leg wrap for swelling) and I cut them off patient refuses to let me slide them out ... Review of Nursing note by RN #2 dated 06/17/2020 revealed "...CNA and I removed UNA boot pt wouldn't let dayshift remove, very large blister on left heel..." Review of care plans for patient #2 revealed no care plans related to impaired skin integrity, or wounds. Review of MD (Medical Doctor) #2 Progress note revealed "...the blister on the left foot was drained under aseptic conditions. Place (sic) is to be dressed. Will place fluid bed under foot to prevent any stress worsening..." Review of Discharge summary dated 06/21/2020 at 1055 revealed discharge instructions on a cardiac diet, activity as tolerated, PT (physical therapy) and OT (occupational therapy), and blood sugar checks. Record review revealed there was no care plan related to impaired skin integrity for Patient #4.

Interview on 03/17/2021 at 1304 With Nurse Director #1 revealed there was no care plan related to skin integrity for patient #4. Interview revealed there were no provider orders for wound care for patient #4. Interview revealed that facility policy was not followed.

Interview on 03/18/2021 at 1053 with Nurse Director #1 revealed care plans auto populate into the electronic medical record based on the nurse's admission and subsequent assessments. Interview revealed that the nurses were able to pull the populated care plan into the chart or dismiss the care plan.

Interview on 03/18/2021 at 1440 with CNO (chief nursing officer) #2 and Nurse Director #1 revealed that the expectation for nursing staff is that a care plan would be added to the patient plan of care. Interview revealed if a patient developed a change in skin assessment that there would be a new care plan added. Interview revealed facility policy was not followed.