HospitalInspections.org

Based on observation, interviews, the review of medical records and other documents, it was determined the facility failed to develop and implement an individualized care plan to assure that the care needs of patients at risk for developing pressure ulcers are met. Specifically, nursing staff failed to implement and document preventive measures for patients at risk for developing pressure ulcers and those with pressure ulcers. This finding was noted in 4 of 12 applicable patient records reviewed (Patient #1, #2, #3 and #4).

Findings include:

1) Patient #1 is a 68-year-old female who presented to the facility on 6/2/14 and was admitted to the Intensive Care Unit on 6/3/14 for management of elevated blood pressure and urinary tract infection. The initial nursing assessment on 6/3/14 notes the patient was mildly contracted and immobile and had a Braden score (the Braden Scale is a tool for assessing risk of developing a pressure ulcer) less than 13 which placed her at high risk for skin impairment. Although the patient was placed on an air mattress and had arrived with intact skin, and was given nutritional support via tube feedings, she developed pressure ulcers on the right sacrum on 6/13/14; the coccyx on 6/17/14; and on 6/23/14, a left heel, right buttock and ankle ulcers were identified.

The Braden Scale assessment score scale:
· Very High Risk: Total Score 9 or less
· High Risk: Total Score 10-12
· Moderate Risk: Total Score 13-14
· Mild Risk: Total Score 15-18
· No Risk: Total Score 19-23

Nursing staff failed to maintain the patient's skin integrity by implementing a consistent protocol of turning and positioning every two hours as is required by the facility's Pressure Ulcer Prevention Protocol. For example, the "Care Interventions flow sheet" for 6/10/14 noted the patient was turned at 6:48 AM, followed by a turn at 11:08 AM, and at 7:52 PM.

A pattern of inconsistent treatment and staging of pressure ulcers was noted among care providers. For example, on 6/18/14 an area of concern noted as a blister was documented without noting the site and stage of the ulcer as well as the treatment protocol that was initiated. The pressure ulcer on the right sacrum was not evaluated on 6/19/14 and the stage was not noted on 6/20/14, 6/21/14, and 6/22/14. The pressure ulcer on the left heel was not staged on 6/23/14.

Patient #1 was readmitted to the facility on 9/20/14 for evaluation of low-grade fever and respiratory condition. During tour of the inpatient unit SLB6 with Staff #2 on 2/25/14 at approximately 1:45 PM, Patient #1 was observed in bed in left lateral position. Staff #2 stated the patient was non-verbal, she has severe contraction of the upper and lower extremities, and she is dependent in activities of daily living. The patient had multiple pressure sites including left foot ulcers that was bandaged and the right heel was opened to air.

At interview with Staff #2 on 9/25/14 at approximately 1:50 PM, regarding pressure ulcer preventive measures that was implemented for the patient, she stated that in addition to the pressure-relieving mattress, nursing staff use pillows or heel pads to off-load patient's heels. The patient however was not wearing heel pads and her heels were not elevated as indicated in the patient's plan of care.


2) Patient #2 is an 81 year-old female with multiple medical conditions including arthritis and bilateral knee replacement. The patient was admitted on 9/24/14 with complaints of multiple falls at home in the last few months.

During tour of an inpatient unit (SLB6) on 9/25/14 at approximately 2:00 PM, Patient #2 was observed in bed in supine position. The patient's heel was inspected with Staff #2 and it was noted she had a non-blanchable redness (stage I pressure ulcer) to the left heel that was confirmed by Staff #2.

The initial nursing assessment of the patient on 9/24/14 at 6:40 PM identified the patient at risk for pressure ulcers evidenced by a Braden score of 17. The skin assessment on admission revealed a healed coccyx pressure ulcer. However, the nursing care plan developed on 9/24/14 did not specify the pressure ulcer preventive measures that were to be implemented and did not include an established turning and reposition schedule for the patient.

At interview with Staff #2 on 9/25/14 at approximately 2:00 PM, she acknowledged the patient did not have heel pads and stated, the patient's nurse would be informed to apply heel pads while the patient is in bed. Staff #2 stated, the patient is repositioned every two hours, but there are no established schedules for repositioning the patient.

Review of medical record revealed repositioning of the patient was not consistently documented.


3) Patient #3 is a 70-year-old male with multiple medical conditions that was evaluated in the Emergency Department on 8/13/14 and diagnosed of hemorrhagic stroke. The patient required intubation and sedation on admission. The initial nursing assessment on 8/13/14 at 11:00 PM notes the patient's skin was within normal limit and no pressure ulcers. However, during the admission course, the patient developed a right buttock Stage II pressure ulcer on 8/31/14, a medial sacral stage II on 9/9/14 and a deep tissue injury to the left heel on 9/17/14.

The Care Activity record revealed the patient was not repositioned every two hours as prescribed by the facility's protocol. Although heel elevation was consistently documented in the patient's record, a deep tissue injury developed on the left heel.


4) Patient #4 is an 85-year-old male with past medical history that includes Cerebrovascular Accident (Stroke) and heart disease. The patient was admitted on 9/11/14 for evaluation of respiratory status.

The initial nursing assessment on 9/12/14 at 1:30 AM notes a stage IV pressure ulcer on the medial sacrum 10 centimeter (cm) x 12 centimeter (cm) x 2 centimeter (cm), and a right heel stage I pressure ulcer 0.5 centimeter (cm) x 0.5 centimeter (cm). The patient was noted to be a high risk for developing additional pressure ulcers evidenced by pressure ulcer score of 14 (facilities internal scoring mechanism).

There was no evidence the patient's heels were consistently elevated as prescribed by the facility's protocol. A new pressure ulcer was identified on the patient's left heel on 9/24/14.

In a document titled "Pressure Ulcer Update, August 2013" provided by the facility on 9/30/14, measures to be implemented for patients at risk included elevation and padding of bony prominences.

At interview with Staff #2 on 9/26/14 at 2:30 PM, she stated, unit nurse managers are responsible for monitoring the implementation of pressure ulcer prevention and treatment protocol.

However, it was observed there was no effective plan in place to ensure that patients at risk for developing pressure ulcers received timely preventive measures and that their turning schedules are tracked to assure timely implementation.









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