HospitalInspections.org

Based on review of the medical record, staff interview, and review of the facility's policy, the facility failed to ensure skin care needs were identified and addressed in a timely manner for 1 of 7 sample patients (#8) who required skin care interventions. In addition the facility failed to ensure adequate monitoring for the use and effectiveness of prn (as needed) pain medication for 3 of 8 sample patients (#7, #16, #20) who were administered prn pain medications. The findings were:

1. According to the medical record #8 patient was admitted to the hospital on 11/1/12 from another hospital. At that time, s/he had an unstageable pressure ulcer on the coccyx, and the diagnoses included chronic obstructive pulmonary disease, pneumonia, chronic kidney disease, fibromyalgia, osteoporosis and neuropathic pain. Review of the physician's documentation, dated 11/1/12, showed IV (intravenous) Vancomycin (antibiotic) was administered at the transferring hospital for treatment of pneumonia and it was to be continued at this facility. Review of the physician's orders, dated 11/2/12, showed Jouens (a skin care paste) was to be applied twice daily and as needed to the coccyx pressure ulcer and reddened areas on the groin, pannus, lower extremity folds, buttock, and chest. Review of the following physical therapy and nursing documentation showed the patient's impaired mobility was assessed during the first two days of admission. Physical therapist (PT) #1's initial evaluation, dated 11/2/12, showed the patient required total assistance with bed mobility and transfers. The case manager's documentation, dated 11/2/12, showed the patient required the assistance of two staff to transfer. PT #2's 11/3/12 therapy note revealed a mechanical lift was used because the patient was unable to complete a transfer to the wheelchair. According to the nursing notes, a urinary catheter was inserted on 11/3/12. According to the registered dietitian's documentation, protein supplements were added on 11/6/12 and 11/10/12 to address the patient's nutritional needs. Review of the wound care policy, effective 11/1/07, showed patients with Braden (a skin breakdown risk assessment tool) scores of 16 or less were high risk. Review of the 11/1/12 to 11/14/12 daily Braden assessments for this patient showed all but two of the scores were 16 or less. The following concerns were identified:
a. Review of the wound addendum/weekly update report showed assessments of the unstageable pressure ulcer on the coccyx were completed on 11/1/12, 11/6/12 and 11/13/12. All showed the "predominate" tissue was necrotic eschar (scabbed/ dried crusted) and the surrounding tissue was bright red. The size of the pressure ulcer increased from 2 centimeters (cm) x 0.5 cm on 11/1/12, to 2 cm x 1 cm on 11/6/12, and by 11/13/12 it had progressed to 3 cm x 1 cm. This review revealed zinc was added to the treatment but additional information regarding the evaluation of effective and ineffective measures that impact wound healing was lacking.
b. Review of the nurse's notes showed the patient's mattress was replaced with a Stat-3 Air Mattress (an air overlay mattress that provided increased pressure reduction) on 11/8/12 (eight days after the unstageable pressure ulcer was identified). Interview with the director of nursing operations on 2/15/12 at 8:30 AM revealed the previous mattress was not initially assessed for its impact on wound healing. She further stated the type of mattress was usually determined by how it helped the patient with transferring skills; therefore, the need for a mattress that provided increased pressure relief was not identified until 11/8/12.

2. Review of the medical record for patient #7 showed the patient had diagnoses that included sepsis (systemic inflammatory response to infection), diabetes, and respiratory failure. The patient reported pain levels of 7-10 on a scale of 1-10 (10 being the worst pain) from a right foot ulcer and right shoulder pain. Review of the 10/17/12 physician orders showed hydrocodone-APAP 15 milligrams (mg)/650 mg as needed every four hours for pain level of 5-10, not to exceed 4000 mg acetaminophen per 24 hours; hydrocodone-APAP 7.5 mg/325 mg as needed for pain level of 3-4, not to exceed 4000 mg acetaminophen per 24 hours; as well as oxycodone 5 mg every 4 hours prn for pain. Review of the 10/21/12 MAR (medication administration record) and prn intervention form showed 3 doses of hydrocodone-APAP 15 mg/650 mg were administered at 9:30 AM, 1:45 PM, and 5:45 PM without a follow-up assessment for effectiveness. In addition an assessment for effectiveness was not completed after staff administered 3 doses of oxycodone 5 mg at 7:30 AM, 11:45 AM, and 3:30 PM on the same date.

3. Review of the medical record for patient #16 showed the patient had diagnoses that included weakness and extremity pain. The patient reported pain levels of 3-10 on a 1-10 scale, with 10 being the worst pain. Review of the 11/5/12 physician orders showed Naproxen 250 mg every 6 hours as needed for pain. Review of the MAR and prn intervention form showed that Naproxen 250 mg was administered on 11/9/12 at 7:35 AM and again on 11/14/12 at 8:35 AM. Further review showed an assessment for effectiveness had not been completed for the two doses.

4. Review of the medical record for patient #20 showed the patient had diagnoses that included coronary artery disease, congestive heart failure, hypertension, and fractured right hip. The patient reported pain levels of 5-7 on a scale of 1-10 with 10 being the worst pain. Review of the 12/4/12 physician orders showed hydrocodone 15 mg/650 mg as needed for pain level of 5-10, not to exceed 4000 mg acetaminophen per 24 hours, and hydrocodone-APAP 7.5 mg/650 mg as needed for pain level of 3-4, not to exceed 4000 mg acetaminophen per 24 hours. Review of the MAR and prn intervention form showed that hydrocodone-APAP 7.5 mg/650 mg was administered on 12/11/12 at 9:38 AM and again on 12/12/12 at 4 PM. Further review showed an assessment for effectiveness had not been completed for the two doses.

5. Interview with the director of nursing operations on 2/15/13 at 9:15 AM revealed the facility had no specific policy related to pain management. She further stated pain assessments/reassessments were expected to be completed within 1 hour of medication administration. She verified the pain reassessments had not been completed for patients #7, #16 and #20.