HospitalInspections.org

Based on medical record review, interviews and review of policy and procedure the hospital failed to conduct a head to toe skin audit for Patient Identifier (PI) # 1 on admission, daily and at discharge. The hospital also failed to consistently implement interventions to promote wound healing and prevent wound deterioration. As a result of this deficient practice, PI # 1 developed an in-house pressure ulcer and/or possible deep tissue injury.

This affected PI # 1, one of ten sampled patients.

Findings Include:


I. Medical Record Review Patient :

Admission Date: 11/28/16

Initial Physical Assessment (Nursing) on 11/28/16 at 17:45:
Admitted to swing bed with diagnosis of left hip replacement. Alert and able to make some needs known..."Silvalone dressing intact to left hip. Incision clean and intact with 29 staples...No redness to buttocks. TED hose on bilateral lower legs (designed to prevent the formation of deep vein thrombosis and pulmonary embolisms through the application of graduated compression. vitalitymedical.com).

History and Physical: PI # 1 (Electronically signed by CRNP, Certified Registered Nurse Practitioner, on 12/4/16) includes:

History of Present Illness: Admitted to our Swing Bed Program...after undergoing a Left hip Hemiarthoplasty on 11/22/16 (only one half of the hip joint is replaced - the top of the femur by a metal implant, orthoanswer.org).

Physical Examination:

Musculoskeletal/Extremity: Very weak. Difficulty sitting on side of bed. Has dressing Left hip with removal showing staples with incision looking well. No signs of infection or drainage.

Progress Note: 12/5/16; Amended 12/6/16:

Physical Examination:
"Has Stage I pressure ulcer wound developed Left heel foot."

A photograph of a wound was given to the surveyor 2/28/17 at 3:20 PM. There was no patient name, date, wound description and or measurements documented on the photograph. Staff reported it was a photograph of PI # 1's left heel reportedly taken on 12/8/16.

A review of the Nursing Notes 12/7/16 through 12/15/16 revealed no documentation of a pressure ulcer to PI # 1's left heel.

The exception was a Progress Note documented by the CRNP on 12/13/16 the revealed: "Has Stage I pressure ulcer wound developed Left heel foot."

12/16/16:
On 12/16/16 at 5:21 AM the Nursing Note revealed, "Left heel discolored and soft to touch, but intact."

The Nursing Note dated 12/16/16 at 5:34 AM revealed, "Necrotic (dead tissue) area to back of left heel. Not open, but is black and soft to touch."

12/17/16:
On 12/17/16 at 5:38 AM the Nursing Note revealed, "Left heel discolored and soft to touch, but intact."

The note, amended at 5:55 AM revealed, "L (Left) heel with Stage II decubitus ulcer. Purple color; soft area; not open."

On 12/17/16 at 5:42 PM the Nursing Note revealed no documentation regarding the ulcer to PI # 1's left heel.

12/18/16:

The Nursing Note dated 12/18/16 at 5:11 AM revealed, Pain to heel. Ultram (pain medication) given.
There was no documentation about PI # 1's heel.

The Nursing Note dated 12/18/16 at 5:26 PM revealed no documentation about PI # 1's heel.

Discharge Summary - Electronically signed by CRNP on 12/27/16:
"Stage 1 Pressure Ulcer Left heel foot."


II. Policy and Procedures:

A). Integumentary (Skin) System Assessment, Reference Number 1121:

- An assessment of the integumentary system is performed on all patients at the beginning of every shift, throughout that shift as needed.

- Assess the function of the skin, such as intactness, temperature regulation, sensation, pain, etc...

- Perform daily skin care and as needed.

- Identify patients at risk for impaired skin integrity...

- Document all pertinent data...

- Perform appropriate wound care per physician's order...

- Identify the following complications and interventions appropriately and document:

1. Altered skin integrity....
2. Impaired physical mobility...


B). Pressure Ulcer Prevention Program Reference Number 1172:

Definition: The PUPA (National Pressure Ulcer Advisory Panel) defines a pressure ulcer as, "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..."

Pressure Ulcers can occur whenever pressure has impaired circulation to tissue... Pressure ulcers develop when soft tissues are compressed between a bony prominence and the surface of an object, i.e., mattress, chair...


Pressure ulcers are described as:

Suspected Dee Tissue Injury:

- Purple or maroon in color, localized area of intact skin or blood filled blister due to damage of underlying soft tissue

- The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to the adjacent tissue.

- ...Evolution of the injury may be include a thin blister over a dark wound bed. The wound may evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue...


Stage I: Non-blanchable erythema of intact skin...Discoloration of skin, warmth, edema, pain or itching may be indicators of pressure ulcers. These indicators will be evident after the pressure on the area has been removed for 30-45 minutes.


Stage II: Partial thickness skin loss involves the dermis...A superficial open ulcer with a red-pink wound bed. No slough or bruising...Presents as an abrasion, intact or open serum filled blister or shallow crater...

Stage III: Full thickness skin loss...

Stage IV: Full tissue loss...


III. Interviews:

During an interview on 3/1/17 at 1:05 PM, Employee Identifier (EI) # 1, Staff RN who admitted PI # 1, stated she did not recall if she removed PI #1's TED hose (designed to prevent the formation of deep vein thrombosis and pulmonary embolisms through the application of graduated compression, vitalitymedical.com) to assess the condition of PI # 1's heels/skin during the initial nursing assessment.

During an interview on 3/2/17 at 1:58 PM, Employee Identifier (EI) # 2, Director of Patient Care Services, was asked to clarify the expectations for an admission skin assessment for patients by nursing staff. EI # 2 stated, "A head to toe assessment without clothes," is the expectation. When asked if the staff RN who preformed PI # 1's initial skin assessment should have removed the patient's hose EI # 2 said, "yes."

EI # 2 also confirmed the expected interventions for nursing staff if a pressure ulcer is identified during a patient's hospitalization. Interventions include measuring, photographing, notifying the physician, documentation of the wound and surrounding tissue, odor and tunneling, etc. EI # 2, Director of Patient Care Services, also questioned if PI # 1's wound was identified correctly by staff. According to EI # 2, PI # 1's wound may have been a deep tissue injury versus a pressure ulcer.