HospitalInspections.org

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Based on document review and interview, the facility failed to monitor action aimed at Quality Improvement of patients at risk for pressure ulcer, to ensure measurable improvement.

Review of the Hospital Pressure Ulcer data for the four quarters (January to December) of 2018 revealed the hospital pressure ulcer index as follows:
1st Quarter = 2.30
2nd Quarter = 2.78
3rd Quarter = 3.42
4th Quarter = 2.14

The facility has not met the goal of Pressure Ulcer Index (1.88) established by National Database of Nursing Quality Indicators (NDNQI).

There was no documented evidence on how the facility is monitoring the effectiveness of action plans for each quarter.

During interview with Staff A, RN/Chief Nursing Officer and Staff X, Assistant Vice President of Quality Management on 4/18/19 at 10:20 am, they acknowledged that the goals to reduce hospital acquired pressure ulcers have not been met.

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Based on medical record review, document review, and interview, in 7 of 12 medical records reviewed, nursing staff failed to timely identify patients at risk for pressure ulcers and develop a nursing care plan for the prevention, and the management of patients with pressure ulcers in accordance with its policies and procedures (Patient #s 1, 2, 3, 7, 8, 9 and 10).

This failure may have placed patients at risk for developing pressure ulcers.

See Tag: 0396

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Based on medical record review, document review, and interview, in 7 of 12 medical records reviewed, nursing staff failed to timely identify patients at risk for pressure ulcers and develop a nursing care plan for the prevention, and the management of patients with pressure ulcers in accordance with its policies and procedures (Patient #s 1, 2, 3, 7, 8, 9 and 10).

This failure may have placed patients at risk for developing pressure ulcers.

Findings include:

Review of the Facility's policy on "Standard of Practice for Prevention and Treatment of Pressure Ulcers/Non-Pressure ulcer wounds", revised 6/16, documented the following:

"All patients receive skin assessment and completion of Braden Ulcer Pressure Ulcer Risk Assessment on admission and completed daily by day shift;
If Braden Score is 18 or less and/or mobility is less than 4, initiate Skin Care Bundle which include positioning and turning every 2 hours and initiating use of bedside clock ...Use pillows under calves to float heels;
Initiate a Wound Care Specialist referral for patients with Stage II pressure ulcer or greater. The patient will be assessed by the Wound Care Specialist within 72 hours;
Patients with a history of pressure ulcers Stage II or greater, Braden Score 18 or less and Nutrition Score less than or equal to 2 on the Braden, are identified as being Nutritional High Risk and will receive Nutritional Assessment in 24 hours. The nurse will enter the Nutrition High Risk Score in the EMR system on admission"

Review of medical record for Patient #1 identified: A 39 year - old male with a history of Crohn's disease who presented to the Emergency Department, (ED) on 12/12/18 and found to have bowel perforation. The patient underwent an emergency surgery on 12/12/18.

The initial nursing admission assessment on 12/13/18 at 2:00 am, documented that the patient's skin was intact. The Braden score (The Braden score is a Pressure Ulcer Risk Assessment tool, a score of 18 or less is a risk for pressure ulcer development) was 22, which indicated the patient was not at risk. The patient was identified as a high nutrition risk due to malnutrition, albumin level was 2.1 (Normal range is 3.5 -5.5) and being on a mechanical ventilator.

On 12/20/18 at 11:30 am, Wound /Ostomy consultant documented that the patient had blister wounds to his left and right groin. The Braden score was 12, which indicated the patient was a high risk for pressure ulcer development. Wound care treatment was ordered, and recommendation was noted for frequent turning and re-positioning from side to side using a tortoise positioner. The patient was placed on a Low air loss mattress.

A follow up assessment by the Wound/Ostomy Nurse on 1/9/19 at 11:00 am, documented that the patient developed hospital acquired pressure ulcers, stage 3 on the sacrum, left and right lateral feet and left and right lateral lower cleaves.

On 2/21/19, the Wound/Ostomy nurse noted additional pressure ulcers to buttocks and the bottom of both feet. Wound care treatment continued.

On 2/26/19, the patient was medically cleared and was discharged home with home care services.

Review of the Braden Pressure Ulcer Risk Assessment completed on 12/13/19, that scores the patient's sensory perception, moisture, activity, mobility, nutrition, and friction/shear revealed that the patient was not scored correctly for activity, and nutrition. On "Activity", the nurse scored the patient "4- Walks Frequently", when the patient was intubated and Bed bound. The nurse assessed the patient's nutrition as adequate with a score of "3", when the patient was one day post-surgery and was not receiving nutrition. The patient's risk for developing pressure ulcer was not identified.

There was no documented evidence that the patient's pressure ulcer risk was assessed daily as per the facility policy. After the initial pressure risk assessment on 12/13/18, a reassessment conducted on 12/20/18, revealed a Braden score of 12. Subsequently, the Braden Pressure Ulcer Risk Assessment was conducted by the Wound/Ostomy nurse on 12/26/18, 1/9/19, 1/18, 1/25, 1/30, 2/12 and 2/1/19.

There was no documented evidence of a nursing care plan for the prevention and management of pressure ulcers. The patient's treatment and response to treatment were not documented.


Review of the medical record for Patient #2 identified a 94- year old, Nursing Home resident who was evaluated in the Emergency Department on 3/29/19. The ED nurse on 3/29/19 at 7:54 PM documented two Stage 2 pressure ulcers to buttocks, and open wounds to both lower extremities.

A physician order on 3/30/19 at 6:54 AM, documented: Implement Skin Care Bundle.
The initial nursing admission assessment on 3/30/19 at 10:00 AM described the patient's skin condition as ecchymotic (Skin discoloration due to escape of blood into the tissues from ruptured blood vessels) areas all over the body with a sacral redness. The Braden Score was 13, indicating he was a high risk for developing pressure ulcers.
On 4/3/19 4:00 PM, the Wound Consultant documented: Community acquired Wound #1, Right Sacrum 3.5x2x0.2 Stage III with associated dermatitis; Community acquired Wound #2, Left Sacral-Gluteal 4x2x0, not staged; Community acquired Wound #3, Bilateral Peri-anal areas.

On 4/4/19 at 12:12 PM, Physician's order documented a Triad Hydrophylic (Zinc oxide based) wound dressing to Bilateral Perianal areas every eight (8) hours and as needed.

On 4/16/19, wound treatment for the right and left sacral pressure ulcers were ordered.

There was no documented evidence of a comprehensive pressure ulcer assessment on admission to the medical unit on 3/30/19. The description of the patient's pressure ulcers, including the location, stages, and other characteristics were not documented.
Nurse's Notes with Plan of Care dated 3/30/19 through 4/15/19 did not document a nursing care plan for the care and management of the patient's pressure ulcers. There was no documented evidence that turning and positioning, and the use of pressure relieving devices were implemented.

There were delays in the treatment of the patient's pressure ulcers; orders for wound treatment of the bilateral perianal area was written on 4/4/19, five days after admission. The wound care and treatment for the right and left sacral pressure ulcers were ordered on 4/16/19, seventeen days after admission.


Patient # 3 is a 54-year-old male, who presented to the ED on 11/21/18 with a complaint of severe abdominal pain and decreased appetite. The patient's past medical diagnosis included Cancer with metastasis.
The Initial Nursing Assessment note dated 11/22/18 at 3:45 pm, documented that patient's skin was intact, and the patient Braden Score was 20, which indicated the patient was not at risk.

The Initial note by the Wound Care Nurse Consultant dated 11/30/18 at 2:25 pm, documented a new Braden score of 14. The patient was identified with a stage 2, sacrum ulcer 1.5 cm x 1.0 cm x 0.2 cm. Wound treatment was recommended.

On 12/7/18 at 8:00 am, the patient was re-assessed by the Wound care nurse, and documented a stage 3 sacral ulcer that measured 1.5 cm x 1 cm x 0.2 cm.

There was no documented evidence that the patient's pressure ulcer risk was assessed daily as per the facility's policy. After the initial pressure risk assessment on 11/22/18, a reassessment was conducted eight days after, on 11/30/18, at this time, the patient was identified with a stage 2 pressure ulcer.

There was no documented evidence that a nursing care plan was developed for the prevention of pressure ulcer Following the initiation of treatment for the sacral ulcer on 11/30/18, nursing care plan did not establish goals and document the patient's response to treatment.

Similar findings regarding timely identification of patients at risk for pressure ulcers and the delay in developing and implementing a care plan for the prevention and treatment of pressure ulcers were noted in medical records for Patient #s 7, 8, 9, and 10.

During interview with Staff I, RN and Staff K, RN Manager on 4/16/19 from 10:00 AM to 12:30 PM, staff acknowledged findings.

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Based on review of the personnel files and staff interviews, in 12 of 12 personnel files reviewed, the facility failed to ensure that the nursing staff received training on pressure prevention and management to meet the care needs of patients (Staff B, F, G, H, I, K, L, M, N, Q, S, and V).

This failure to may lead to inadequate prevention and management of patients with pressure ulcers.

Findings include:

Review of the nursing personnel file for Staff B, RN revealed no documented evidence that the nursing staff received training on pressure ulcer assessment, care and management.

Similar findings were noted for personnel files for Staff F, G, H, I, K, L, M, N, Q, S, and V.

During interview with Staff Y, RN Instructor, on 4/18/19 at 11:00 AM, staff explained that a new pressure ulcer program was rolled out in October 2018; however, not all nurses have been trained.
Staff Y was unable to show evidence in the personnel files that the staff completed the training.

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Based on medical record review, document review and staff interview, in 6 of 7 medical records reviewed, the hospital failed to conduct timely nutrition reassessment and provide adequate calories and protein to meet the needs of patients with pressure ulcer (Patient # 1,2,3,4,5,8).

Findings include:

The facility policy titled "Documentation of Screening, Assessments, Reassessments and Nutrition Counseling in the Medical Record" last revised November 20, 2017 noted that patients who have Protein-Calorie Malnutrition (PCM) or are at high risk for developing PCM should have a follow-up within 4 days after an assessment.

Review of facility document on 4/16/19 titled "Nutrition Therapy Guideline for Adult Patients with Pressure Ulcers/Wounds" notes that Nutritional provisions may be adjusted based on individual patient needs and clinical judgement. Nutritional recommendation for total calories and protein for each stage of pressure ulcer was noted.

Review of medical record for Patient #1 identified: A 39-year-old with history of Crohn's disease underwent surgery

Initial nutrition assessment on 12/13/18 at 3:05 pm noted the patient's blood albumin was 2.1 (normal level 3.5-5.5). The patient was at high risk for malnutrition due to poor oral intake and his NPO (nothing by mouth) status. Nutrition requirements calculated for the patient was 1775 calories and 88 grams of Protein. Current weight was 71.168 kilogram.

Nutrition reassessment on 12/17/18, noted a new diet order on 12/15/18 that provided 1404 Calories and 73 grams Protein.

Nutrition Reassessment on 12/20/18, noted patient has severe protein calorie malnutrition and was currently tolerating feeds.

On 1/25/19 the patient was identified with two, stage 2, and two stage 3 pressure ulcers.
On 1/26/18, the patient's blood albumin decreased to 1.8.

Nutrition reassessment on 12/27/18, seven days later noted that the patient was on a Regular diet (finger foods) with Pro-Stat, a protein supplement, 30 ml/day. The patient's appetite was poor.

There was no documented evidence that the patient received a nutrition reassessment every four days for patients at risk for malnutrition. The intervals between assessment were from 4-11 days from 12/13/18 to 2/26/19. In addition, nutrition reassessments did not include patient's current weight necessary for calculation of the patient's nutritional needs.

Patient #2 is a 94-year-old admitted to the hospital on 3/31/19 from the nursing home with a Stage 2 sacral pressure ulcer.

The initial nutrition assessment on 3/31/19 documented a nutrition risk level 5 (This level notes that patient is at low or moderate risk for malnutrition and should be followed up within 7 days).

Dietitian next nutrition reassessment was on 4/9/19, 9 days later, notes that patient blood albumin on 4/8/19 was 2.5 and the patient was now at high risk for malnutrition. Nutrition estimated requirement was 1520 calories and 84 grams Protein. The patient's current diet provided 1152 calories and 53 grams protein.

Nutrition reassessment of 4/14/19, five days later noted diet remained the same.

There was no documented evidence that nutrition reassessments for high risk patients were conducted every four days as per facility's policy and procedure for reassessments. Nutrition reassessments were conducted between five to nine days apart.

There was no documented evidence the dietician increased the patients diet to meet his nutritional needs calculated on 3/31/19. Subsequent nutrition reassessments from 4/9/19 to 4/18/19 noted that the patient's diet remained unchanged at 1152 calories and 53 grams protein, less than his nutrition need. The patient's weight status needed for calculation of his diet was not revised and documented. In addition, the patient's pressure ulcer progressed from a stage 2 to a stage 3 on 4/14/19 with no changes in the patient's nutrition requirements.


Patient #3 is a 54-year-old who was admitted on 11/21/18 for management of his severe abdominal pain. Medical history indicated carcinoma with metastases.

The initial nutrition assessment on 11/23/18, noted the patient was within ideal body weight. The patient however was identified at high risk for protein-calorie malnutrition due to his NPO (nothing by mouth) status.

A nutrition reassessment on 11/27/18, noted the patient was on a Cardiac-2 gm sodium diet but was refusing to eat.

There was no recommendation provided by the Dietitian to promote food consumption by the patient. There was no documentation of patient participation in meal planning to determine food preferences, meal pattern, and alternate route of feeding.

Nutrition reassessment 12/2/18 (5 days later) noted that the patient had a stage 2 pressure ulcer. There was no evidence that recommendation concerning the means to promote food intake by the patient was provided in the assessment.

The Dietitian's last nutrition reassessment of the patient on 12/6/18 notes patient is eating minimally. Recommend oral supplement of "Ensure Clear".

The recommendation did not document patient's preference and the amount of nutrition the supplement would provide

The patient's current food intake did not meet patient nutritional needs. Alternate feeding route was not recommended to the physician.

Wound and Ostomy Consult Note on 12/7/18, 5 days later notes Sacrum pressure ulcer stage 3.

There was no documented evidence in the reassessments of revisions to the patient's nutritional requirements.

Similar findings were noted for Patients #s 4, 5 and 8, who were identified at high nutrition risk but were not assessed every four days.

During interview with Staff M, Dietician on 4/16/19 at 11:00 pm, she acknowledged findings.