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Based on clinical record review and interview the facility failed to take actions aimed at improvement and to conduct appropriate and accurate root cause analysis. This failure has the potential to affect all patients at risk for developing pressure ulcers. A systemic failure of staff to follow the facility's standard of care for skin assessments affected 1 of 10 sampled patients (Patient # 10).

The findings include:

Review of Patient # 10 ' s clinical record was conducted on 09/20/11. Patient # 10 was admitted to the facility on 08/10/11 with the diagnosis, status post motor vehicle accident, passenger in rollover vehicle. Patient # 10 developed an avoidable pressure ulcer while hospitalized, based on staff failure to accurately implement the developed and established Care Plan, and to follow the facility's standards of practice.
The initial assessement records for 08/10/11 does not document any record or evidence of patient #10 having pressure ulcers at the time of admission. As of 08/18/11 the record documents the patient does not have any pressure ulcers. A Critical Care Flowsheet dated 08/19/11 documents the discovery that Patient #10 has one pressure ulcer to the left chin and one pressure ulcer to the left chest region.
Interview with the Director of Critical Care Services was conducted on 09/20/11 at 1:56 PM. The Director explained she is aware of the pressure ulcer found on patient # 10. She stated, the incident was investigated and the two nurses who took care of the patient on 08/18/11 and 08/19/11, did not follow the plan of care and the facility standard of practice and the cervical collar was not removed completely. She stated during her investigation she found out the nurses did not follow the policy and the nurses involved received disciplinary actions. She stated the wounds healed and wound care evaluated the wounds immediately. The Director stated she provided education to all of her staff and provided a copy of the meeting topics and sign in sheet.

Interview with the Clinical Educator (CE) was conducted on 09/20/11 at 2: 06PM. The Clinical Educator stated the nurses sign an attestation every shift documenting they have followed the standards of practice. She stated the hospital conducted an investigation into the development of patient #10's pressure ulcers, and they questioned the nurses who took care of the patient in the previous twenty four hours. There were two nurses involved. The CE sated "the nurses documented the Collar was removed and/or skin assessment was completed in different areas of the flow sheet, in addition to completing the attestation form at the end of their shift attesting to following the facility's standard of practice. She stated the nurses documented on the assessments in the section noted Function mobility, collar brace every eight hours. The section titled comfort is completed; a check mark for bath means a complete bed bath was given and therefore, according to the facility's standard of practice, means a complete skin assessment was done. In the interdisciplinary care plan under skin, in the section titled incisions and wounds, the nurses have a "yes" or "no" section related to skin. For patient #10, this section "documents skin intact and cervical collar checked with every position changed". The CE stated when the facility conducted their investigation the nurses were questioned regarding removing the collar and performing skin assessments and they both admitted to removing the collar" partially". She stated the wound was discovered when placing the tracheotomy.

Interview with Registered Nurse (RN # 1), who provided care for patient #10, was conducted on 09/20/11 at 2:43 PM. She stated she took care of Patient # 10 on 08/18/11, the day before the pressure ulcer was discovered and acknowledged she did not follow hospital policy by not removing the cervical collar completely. She stated she did not assess the patient as good as she should have. The patient's daughter was in the room and she did not turn the light on.
Interview with Registered Nurse (RN # 2), who also provided care for patient #10 was conducted on 09/21/11 at 11: 05 AM. He stated he discovered the decubitus ulcer while assisting the physician with the tracheotomy. He stated the collar was removed at around noon time for the procedure. During the interview with RN #2, the stated the day in question, was "odd", the physician scheduled the procedure for the morning, but then the procedure got rescheduled twice. RN # 2 stated he did not take the collar off as he was expecting the collar to be discontinued. He stated he recalled the patient preferred to have his head turn towards the left side and unless you removed the collar completely, the location of the ulcer was not visible. RN # 2 stated he did not receive disciplinary actions and he was told in the general staff meeting to be more diligent with skin assessments.
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Interview with RN # 3 was conducted on 09/21/11 at 12:16 PM. The nurse stated she took care of patient # 10 the day before the pressure ulcer was discovered and acknowledged she did not look under the collar. She acknowledged she did not follow the policy regarding assessments. The nurses stated the policy is to remove the collar once a shift. At this time the Clinical Educator who was present during the interview stated the policy is to do a complete head to toe assessment every four hours in the intensive care setting. The RN#3 said she was suspended for a day and she received education regarding the policy during her counseling and during the staff meeting.

Review of facility records regarding the occurrence revealed the following:
The facility identified contributing factors: event severity moderate. Primary cause staff competency/education. Specific causes policies and procedures not followed. Individuals involved are noted. Wound Nurse confirmed unstageable wound. Final disposition, no adverse event; final disposition on 09/20/11 treatment provided. Corrective actions noted: wound protocol and enforced existing policy.

Based on clinical record review and staff interview the facility failed to ensure quality nursing care is provided to each patient in accordance with established standards of practice for the delivery of nursing care. This failure affected 1 of 10 sampled patients (Patient # 10).

The findings include:


Review of the clinical record for Patient # 10 conducted on 09/20/11, revealed the Patient 10 was admitted to the facility on 08/10/11 with a diagnosis of status post motor vehicle accident; passenger in rollover vehicle.
Physician admitting orders dated 08/10/11 document, admit patient to trauma service, critical condition, consult neurosurgery. Bed rest, logroll only every two hours and reposition right side back to left side, do not remove cervical collar until cleared by neurosurgery. Collar care twice a day, neurological checks every hour one hour, nothing by mouth. Vent settings per trauma attending.
History & Physical dated 08/10/11 document, " This is a 70 year old male who was unrestrained passenger in the back of SUV. He was thrown into the rear of the section of the SUV. He was trauma alerted to the hospital for respiratory distress. The patient arrived immobilized on transport board with a cervical collar in place. The plan of care documents the patient will be admitted to Intensive Care unit for ongoing resuscitation and then alert management, he will be maintained on spine precautions with Velcro only " .
The Critical Care Flowsheet dated 08/18/11 document Patient # 10 has no pressure ulcers, however the Critical Care Flowsheet dated 08/19/11 documents the discovery that Patient # 10 has one pressure ulcer to the left chin and one pressure ulcer to the left chest region.
Physician Orders dated 08/19/11 document a request for consultation from the wound care nurse for chin wounds.
The wound/skin consult assessment dated on 08/19/11 documents the consult was received to evaluate chin wounds. The assessment/treatment notes, " Patient lying in bed, on Ventilator. Patient had been wearing vista C-collar when removed, wound of left jaw line and left upper chest noted. Wound on jaw line measures 1 cm by 3 cm. Wound is 100% covered with yellow and gray slough. Patient with facial hair growth. Wound on left upper chest near clavicle. On left upper chest near center and yellow slough around edges. Approximately 50 % of pink, 50 % yellow. Both wounds are unstageable pressure ulcers. No drainage at this time for either wound. Jaw line wound is very soft. Cleaned with saline and patted dry. Mepilex border placed on left chest wound, Foley catheter secured in place." The Recommendations documented is: left jaw line unstageable pressure ulcer, clean with normal saline solution and pat dry. Check with physician regarding Santyl versus surgical debridement. Left upper chest wound, unstageable pressure ulcer: clean with normal saline solution and pat dry. Mepilex border dressing. Change every three days and as needed. Check with physician for Santyl versus surgical debridement.

Interview with the Director of Critical Care Services was conducted on 09/20/11 at 4:56 PM. The Director explained she is aware of the pressure ulcer found on patient # 10. She stated, the incident was investigated and the two nurses who took care of the patient on 08/18/11 and 08/19/11, did not follow the plan of care and the facility standard of practice and the cervical collar was not removed completely. She stated during her investigation she found out the nurses did not follow the policy and the nurses involved received disciplinary actions. She stated the wounds healed and wound care evaluated the wounds immediately. The Director stated she provided education to all of her staff and provided a copy of the meeting topics and sign in sheet.

Interview with the Clinical Educator (CE) was conducted on 09/20/11 at 2: 06PM. The Clinical Educator stated the nurses sign an attestation every shift documenting they have followed the standards of practice. She stated the hospital conducted an investigation into the development of patient #10's pressure ulcers, and they questioned the nurses who took care of the patient in the previous twenty four hours. There were two nurses involved. The CE sated "the nurses documented the Collar was removed and/or skin assessment was completed in different areas of the flow sheet, in addition to completing the attestation form at the end of their shift attesting to following the facility's standard of practice. She stated the nurses documented on the assessments in the section noted Function mobility, collar brace every eight hours. The section titled comfort is completed, a check mark for bath means a complete bed bath was given and therefore, according to the facility's standar of practice means a complete skin assessment was done. In the interdisciplinary care plan under skin section, titled incisions and wounds, the nurses have a yes or no section related to skin which "documents skin intact and cervical collar checked with every position changed". The CE stated when the facility conducted their investigation the nurses were questioned regarding removing the collar and performing skin assessments and they both admitted to removing the collar" partially". She stated the wound was discovered when placing the tracheotomy.

Interview with Registered Nurse (RN # 1), who provided care for patient #10, was conducted on 09/20/11 at 2:43 PM. She stated she took care of Patient # 10 on 08/18/11, the day before the pressure ulcer was discovered and acknowledged she did not follow hospital policy by not removing the cervical collar completely. She stated she did not assess the patient as good as she should have. The daughter was in the room and she did not turn the light on.

Interview with Registered Nurse (RN # 2), who also provided care for patient #10 was conducted on 09/21/11 at 11: 05 AM. He stated he discovered the decubitus ulcer while assisting the physician with the tracheotomy. He stated the collar was removed at around noon time for the procedure. During the interview with RN #2, the stated the day in question, was "odd", the physician scheduled the procedure for the morning, but then the procedure got rescheduled twice. RN # 2 stated he did not take the collar off as he was expecting the collar to be discontinued. He stated he recalled the patient preferred to have his head turn towards the left side and unless you removed the collar completely, the location of the ulcer was not visible. RN # 2 stated he did not receive disciplinary actions and he was told in the general staff meeting to be more diligent with skin assessments.
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Interview with RN # 3 was conducted on 09/21/11 at 12:16 PM. The nurse stated she took care of patient # 10 the day before the pressure ulcer was discovered and acknowledged she did not look under the collar. She acknowledged she did not follow the policy regarding assessments. The nurses stated the policy is to remove the collar once a shift. At this time the Clinical Educator who was present during the interview stated the policy is to do a complete head to toe assessment every four hours in the intensive care setting. The RN#3 said she was suspended for a day and she received education regarding the policy during her counseling and during the staff meeting.

Review of the facility policy titled " Assessment and Reassessment Plan " revealed the policy specifies the following, Nursing Services: at the time of admission the initial assessment is the responsibility of the registered Nurse. The initial assessment will be completed as soon as possible. Documentation of patient reassessment is unit specific, critical care unit ' s reassessment time of every four hours and as needed. The assessment includes skin integumentary/Integrity/Ulcer risk assessment.
Review of the policy Standard of Care/Practice-Critical Care revealed Standard of Care related to skin integrity, to perform Braden skin assessment upon admission, with any change in condition and every assessment. Initiate and maintain preventive measures, keep skin clean and dry and prevent pressure friction and shearing forces on skin.

Unit specific Standard of Care/Practice, Documentation/Assessment notes a complete head to toe assessment will be completed every four hours, or more frequently, as necessary. If changes are observed, with subsequent patient reassessments, the nurse will document these changes in CPCS at the time of the occurrence. All trauma documentation is to be completed on the trauma flow sheet; the only exceptions that need to be in CPCS are as follows: Patient admission history and physical, education, restraints and attestation of standards of care.

RN #2 and RN#3 who are knowledgeable of the facility's standards of practice relating to skin integument assessments documented the completion of care and services they did not provide. While disciplinary action and education inservice has been provided, no evidence was found or provided to substantiate a "causal anlysis was conducted and a evaluation of the circumstances that contributes to the ability to violate the policy was made; nor is there evidence the facility identified and monitored other patients who are potentially at risk of having the same negative occurrence.