HospitalInspections.org

The Critical Assess Hospital (CAH) Senior Behavioral Health Unit (SBH) reported a census of 10 patients. Based on record review, document review and staff interview the CAH failed to ensure nursing staff supervised and evaluated the nursing care needs for 1 of 10 sampled patients (Patient #1) admitted.
The failure to supervise, evaluate and treat patients identified at admission with pressure ulcers and evaluate further skin breakdown for development of wounds had the potential to affect all patients admitted to the CAH's SBH unit who were at risk for skin breakdown.

Findings include:

- Policy titled, "Decubitus Ulcer Prevention, revised date of 08/06/08", reviewed on 10/21/14 directed nursing staff to prevent and treat pressure sores. Nursing's responsibility is to record treatment in nursing chart and all pertinent observations including depth and size of ulcer. The policy directed equipment to be use included heel protector and alternating pressure pad.

- Patient #1' medical record review revealed an admission date of 7/17/14 with a diagnosis of vascular dementia with psychosis, aneurysm, diabetes mellitus and hypertension (high blood pressure). Review on 10/20/14 of the SBH " Inpatient Nursing Assessment " dated 7/17/14 revealed nursing staff documented a " D. Decubitus...Stage I and II " on the back coccyx area of patient #1. The medical record lacked documentation of the appearance and size of the decubitus stage I and II ulcers. The record lacked treatment orders, daily assessments that included the appearance and size of the ulcers or a daily plan to treat the skin ulcers. On 7/26/14, the 2nd shift nursing staffs assessment documented a "Friction/Sheer problem. Nursing staff documented under "Integumentary, heel wound." The medical record lacked treatment orders and daily nursing assessments that included appearance and size of the heel wound or a daily plan to treat the wound.

Administrative staff A interviewed on 10/21/14 at 3:30pm acknowledged nursing staff failed to document the appearance and size of patient #1's skin ulcers at admission and failed to document treatment for the coccyx's ulcers. Staff A verified nursing staff failed to document the initial appearance, size and treatment of the heel wound found nine days after patient #1's admission and failed to provide treatment for the heel wound.

The Critical Assess Hospital (CAH) Senior Behavioral Health Unit (SBH) reported a census of 10 patients. Based on record review, document review and staff interview the CAH failed to ensure nursing staff developed a nursing plan of care and keep it current for 1 of 10 patients (Patient #1) sampled and identified at admission with the risk for skin impairment (breakdown).

The failure to update treatment plans as patient conditions change and identify newly developed skin breakdown and wounds had the potential to affect all patients admitted to the SBH unit who were at risk for skin breakdown.

Findings include:

- Policy titled "Medical Record Documentation ...Plan of Treatment, Review Date: 5/22/12", reviewed on 10/21/14 directed the nurse to initiate the comprehensive treatment plan within eight hours of admission, integrate the evaluations and assessment into the patient specific plan of care. Nursing reviews the plan at least weekly or when any major change in patient condition occurs. Nursing is to complete a written progress note at least once every shift.

- Patient #1's medical record review revealed an admission date of 7/17/14 with a diagnosis of vascular dementia with psychosis, aneurysm, diabetes mellitus and hypertension (high blood pressure). Review on 10/20/14 of the SBH "Inpatient Nursing Assessment" dated 7/17/14 revealed nursing staff documented a "D. Decubitus ...Stage I and II" on the coccyx area of patient #1. Nursing staff initiated a treatment plan dated 7/8/14 for "Problem Number 2" impaired skin integrity that identified poor tissue perfusion, pressure sores, poor skin turgor and excessive wetness and contact with body excretions/secretions due to incontinence. The treatment plan intervention listed keep head of bed at or below 30 degree angle, do a skin assessment every shift, apply transparent adhesive dressing to high risk areas, utilize pressure relief/reduction device ..., and Document patient and spouse response and level of understanding ... The record review lacked documentation on the treatment plan of the appearance and size of the decubitus stage I and II ulcers, treatment and interventions initiated, and the daily assessments and treatment sheet. On 7/26/14 the 2nd shift nursing staff assessment documented a " Friction/Sheer 1 problem". Nursing staff documented under, "Integumentary, heel wound." The medical record lacked an updated treatment plan that included interventions and treatments for the newly developed heel wound.

Administrative staff A interviewed on 10/21/14 at 3:30pm acknowledged nursing staff failed to specifically identify and update the ongoing treatment plan for patient #1's coccyx's ulcers during their hospitalization. Staff A verified nursing staff failed to initiate a treatment plan with interventions for the heel wound identified on 7/14/14.