HospitalInspections.org

15036

Based on interview, record review, and policy review, the provider failed to ensure:
*Physician notification was completed for one of one sampled patient (4) who developed a wound underneath a Bledsoe boot and a redden area on the buttock.
*The physician order was clarified to include the frequency, duration, and care for one of one sampled patient (4) with a Bledsoe boot.
*The status of skin issues were documented for two of ten sampled patients (4 and 6) with alterations in skin integrity.

It was determined the hospital program was ineffective in the areas of communication between nursing staff, physicians, and service departments for physician notifications when a change in the patient's skin condition occurred; order clarification for the use of an orthopedic device; between orthopedic and hospitalist services for patient assessment when an orthopedic medical device was used; and staff documentation of identified skin wounds. The quality of care issues cited in A385 supports the hospital program ineffectiveness.

Findings include:

1a. Interview and review with nurse manager H on 4/11/18 at 8:10 a.m. and again on 4/12/18 at 1:28 p.m. of patient 4's medical record revealed:
*She had been admitted on 3/11/18 and discharged on 3/30/18.
*She had multiple complex medical problems including pneumonia, sepsis, gastrointestinal bleeding, and acute kidney injury.
*On 3/14/18 while ambulating to the bathroom she experienced rectal bleeding and was lowered to the floor.
*On 3/15/18 a right ankle x-ray was ordered due to complaints of right ankle pain.
-The radiology report indicated a right ankle fracture.
*On 3/15/18 the physician ordered "Bledsoe boot RLE [right lower extremity]". No additional instructions were provided by the physician with that order.

Interview and review on 4/11/18 at 8:10 a.m. and again on 4/12/18 at 1:28 p.m. with nurse manager H of patient 4's wound/incision intervention record revealed:
*Thirteen altered skin integrity issues were assessed by nursing staff.
*On 3/20/18 a wound/incision intervention record was initiated for the right ankle, that was five days after the application of the Bledsoe boot.
*On 3/20/18 at 9:24 p.m. the nurse identified a scabbed area on the right ankle.
-The scabbed area was described as black, raised, no drainage, crusted, and intact.
*There was no documentation the physician/practitioner had been notified of the right ankle scabbed area.
*On 3/25/18 at 11:06 a.m. the right ankle wound was described as an opened skin tear, pink and red in color, raised, crusted, intact, and a small amount of reddish colored drainage.
*On 3/25/18 at 8:49 p.m. the right ankle wound was described as scabbed, black, raised, crusted, intact, dry, and no drainage.
*From 3/25/18 to the patient's discharge on 3/30/18 the right ankle wound had been described as scabbed, black, raised, crusted, intact, dry, and without drainage.

Interview on 4/10/18 at 1:40 p.m. with registered nurse (RN) A revealed:
*Should a boot have been ordered by the physician she would have removed the boot, assessed the skin all the way around, and washed and dried the area as needed.
*The boot might be ordered as two hours on and two hours off.
*The boot would have been taken off during the day if the patient was up in the chair. It "need to be taken off to give the skin a break."

Interview on 4/10/18 at 2:10 p.m. with RN B revealed:
*A patient with an opened wound staff could obtain a consult from the wound team.
*Once the wound nurse had evaluated the patient those orders would have been followed.
*Wounds were assessed per physician orders. For boots circulation checks would have been completed every four hours unless the patient was post surgery, then assessment done every hour.
*Walking boot would have been taken off to check for sores.

Interview and medical record review on 4/11/18 at 1:52 p.m. with physician C regarding patient 4 revealed:
*If staff noticed a change in the patient's condition the physician should have been notified.
*For skin breakdown the physician would have wanted to have been notified.

Interview and medical record review on 4/11/18 at 1:10 p.m., on 4/11/18 at 3:35 p.m., and 4/11/18 at 3:47 p.m. with nurse manager H regarding patient 4's right ankle wound revealed:
*She had been contacted by the receiving facility the patient had arrived with a large opened area on the right ankle that was foul smelling. If the wound was scabbed over a foul smell might not have been noticed by staff at the time of their assessment.
*The skin breakdown was caused by the boot.
*There had to have been an opened area before the scab formation.
*She was unable to locate documentation regarding an opened area prior to the scab formation.
*She had reviewed all hospitalist progress notes and was unable to locate physician notification or physician documentation on the right ankle wound.
*The expectation was nursing notified the physician, documented notification, physician assessed the area, and change treatment if appropriate.
*The physician had ordered "Bledsoe boot RLE". The physician's order had no additional instructions for frequency, duration, or care.
*There was no hospital policy specific to physician notification. The notification depended on what was happening with the patient and the severity of the condition.

Interview and medical record review on 4/11/18 at 2:05 p.m. with RN D regarding patient 4's right ankle wound/incision intervention record documentation revealed:
*On 3/25/18 at 11:06 a.m. he had documented a right leg skin tear that was opened, pink in color, and had reddish colored drainage.
*"It looked like an open blister, little blood."
*He had "used saline to clean old blood," and then assessed for circulation.
*That area at the time of his assessment was not scabbed over or black in color.
*He thought he had notified the physician but did not know if he had documented notifying the physician.
*Physician notification depended on the severity of change. He would have to check the policy to see "if documentation of notification needed to be made."

Interview and medical record review on 4/11/18 at 2:45 p.m. with physician E regarding patient 4's right ankle wound revealed:
*He became involved in her care on 3/28/18.
*He was never notified by staff there was a skin issue underneath the right ankle boot.
*Typically staff notified physicians when there was a skin change.
*After she was discharged he was notified by the provider there was a problem with the right ankle.
*She was always up in the chair with the boot on when he visited.
*He did not remove the boot, it had been ordered by orthopedic, and he was not sure if he could take it off.
*There was no indication there was a problem with the right leg. There was no odor.

Interview and medical record review on 4/11/18 at 4:20 p.m. with RN F regarding patient 4's right ankle wound revealed:
*On 3/20/18 at 9:24 p.m. she initially identified the scabbed area on the right ankle.
*It was approximately dime size, black in color, raised, crusted, and had no drainage.
*"For the night shift would talk to physician if emergent."
*She had reported the information regarding the scab on to the day shift.
*The patient had very fragile skin.
*There should have been a sore first, then a scab.
*Scab area could have been healing.
*She removed the boot for assessments.
*With orthopedics it was not clear what should have been done, and some staff were afraid to remove the boot.

Interview on 4/12/18 at 1:43 p.m. with physician G regarding patient 4's right ankle wound revealed:
*She was the patient's primary physician for five days.
*She had not removed the boot, because she did not have training to remove the boot, and orthopedic surgeons did not like them to.
*She had assumed nursing staff had assessed the skin condition.
*She had not been notified by nursing about skin changes.
*The nurse would call the physician regarding skin changes; that was an expectation.

Review of the Bledsoe manufacturer's instructions for use revealed "The frequency and duration of use should be determined by your prescribing Healthcare professional."

b. Interview and review with nurse manager H on 4/11/18 at 8:10 a.m. and again on 4/12/18 at 1:28 p.m. regarding patient 4's buttock wound/incision intervention record documentation revealed:
*On 3/29/18 at 1:47 p.m. the nurse identified a reddened area.
-That area was described as being red, dry, intact, and a protective skin barrier cream had been applied.
*On 3/30/18 at 9:42 a.m. the buttock area continued to be red, dry, and with intact skin.
-There was no documentation the physician/practitioner had been notified regarding the reddened area on the buttocks.

c. Interview and medical record review on 4/11/18 at 8:10 a.m. and again on 4/12/18 at 1:28 p.m. with nurse manager H of patient 4's leg wound/incision intervention record documentation revealed:
*On 3/21/18 at 7:46 a.m. and at 9:00 p.m. a small skin tear on the left lower leg with reddish colored drainage.
-After that date and times no further documentation was noted on the wound/incision intervention record regarding the skin tear.
*On 3/26/18 at 2:14 p.m. a medial skin tear was noted on the leg.
-The documentation did not indicate right or left leg.
-From 3/29/18 through 3/30/18 no further documentation was noted on the wound/incision intervention record regarding the skin tear.

2. Interview and medical record review with nurse manager H on 4/12/18 at 1:00 p.m. of the wound/incision intervention record for patient 6 revealed:
*There were fourteen altered skin integrity issues that were assessed by nursing staff.
-The status of five of those skin issues could not be determined, as nursing staff had stopped documenting on those areas.
-Nursing staff had not documented if those areas had healed or were no longer a concern.
*On 3/21/18 at 7:30 p.m. a wound/incision intervention record had been initiated and revealed:
-An opened sore on the right side of the back that was present at admission on 3/11/18.
-Bruising on the right and left arms.
-Scratches on the right and left leg.
-Red spots on the right side of the back.
-Inflammation of the left forearm.

3. Review of the provider's March 2018 Skin Assessment and Care policy revealed:
*"A full head to toe skin assessment will be completed on admission (within 8 hours, or before transfer to another unit, as patient condition allows) and a minimum of every twelve hours thereafter or if change in status, to assess skin changes/breakdown.
*All skin issues present on admission will be documented in the Wound/Incision intervention.
*Areas of concern include all bony prominences, drains, and surgical sites.
*Consult WOC [wound ostomy care] for visibly impaired skin integrity."
*Scores two or less on any individual subscale required implementation of interventions.
*The policy did not address physician notification if skin breakdown was observed.