HospitalInspections.org

Based on Policy & Procedure review, medical record review, and patient interview the hospital failed to ensure plans of care were fully developed and followed to prevent patients from developing pressure ulcers in 3 out 10 patients reviewed.
Findings include:
On 4-13-2010 at 12:30 PM interview with pt. #1 revealed pt. #1 cannot speak, instead he uses a communication board and points to pictures, letters, single words or phrases. Surveyor asked pt. #1 if he was aware of the skin breakdown, pt. #1 pointed to " yes " . Pt. #1 was asked if he felt this was caused from not being turned enough, pt. #1 pointed to " yes " . Pt. #1 was asked if he felt it was caused from not being cleaned enough, pt. #1 pointed to " yes " . Pt. #1 expressed concern for going home, surveyor asked if the social worker was working with him and his concern, pt. #1 pointed to " yes " .

On 4-13-2010 at 2:10 PM interview with pt. #4 revealed " sometimes " the staff are timely in answering his call light. Pt. #4 explained he has been incontinent 2 times due to waiting so long for help. Pt. #4 is unsure how often they check his skin, and they only help him with repositioning when he asks for help. Pt. #4 was unaware of any open areas on his body. Pt. #4 does wear a neck collar that covers his chin, and entire neck making it impossible to turn his head from side to side.

On 4-14-2010 at 9:10 AM review of the Policy & Procedure (P&P) titled Skin Integrity Alteration-Potential/Actual was completed. The P&P states in part, " Assess integumentary system, conduct a comprehensive wound assessment including staging for patients with a pressure ulcer " , " assess per policy including the standard parameters and the following parameters as appropriate if skin integrity abnormality is noted. Location, Pattern, Color, Pressure Points, Abnormality Type, Periwound Color, Periwound Condition, wound edge, exudate amount, exudate type, exudate odor, wound status." These are the decriptors to be used during the assessments,

On 4-14-2010 at 9:30 AM pt. #1 ' s medical record was reviewed with Clinical Nurse Specialist, K. Pt. #1 was admitted on 3-3-2010 with a diagnosis of Cancer of the esophagus. Nursing skin assessments on 3-3-2010, and 3-4-2010 show no breakdown of skin. Skin assessment on 3-5-2010 shows a skin assessment that states, " red buttock, coccyx red ", no additional descriptors or staging was documented . Daily skin assessments on 3-6-2010 and 3-7-2010 show coccyx and buttock were red, no additional descriptors documented. On 3-8-2010 skin assessment shows a stage II ulcer on the left buttock measuring 1.0 cm, and a stage II ulcer on the right buttock measuring .50 cm, no additional descriptors were documented. Skin assessment dated 3-9-2010 shows a stage II ulcer on the coccyx that measures 1.50 cm. Additional skin assessment on 3-9-2010 shows a tear on pt. #1 ' s scrotum, no additional descriptors were documented. Daily skin assessments from 3-9-2010 through 3-15-2010 show Sensi cream was used on the ulcers and no change in the size of the ulcers, no additional descriptors were documented. Skin assessment on 3-16-2010 shows a stage II ulcer on the coccyx measuring 1.0 cm, stage II ulcer on left buttock measuring 1.50 cm and a stage II ulcer on the right buttock measuring .50 cm. Daily skin assessments from 3-17-2010 through 3-21-2010 show no change in the ulcer sizes or the treatments. Skin assessment dated 3-22-2010 shows the left and right buttock, and coccyx are stage III ulcers. VASHE solution is ordered . Daily skin assessments from 3-23-2010 through 3-28-2010 show no change in the size or staging of pt. #1 ' s pressure ulcers. Skin assessment dated 3-29-2010 shows one ulcer measuring 3.50 cm long, 7.50 cm wide and 1.0 cm deep. Daily skin assessments from 3-30-2010 through 4-5-2010 show no change in the size or staging of the wound. Skin assessment dated 4-6-2010 shows one ulcer measuring 6.0 cm in length, 7.0 cm wide, and 1.0 cm deep. This assessment does not contain staging information. Daily skin assessments from 4-7-2010 through 4-11-2010 show no change in size, no staging information and no change in the treatments. Skin assessment on 4-12-2010 shows a new treatment order for Dakins solution.Care planning was to include full integumentary assessments, assessments from 3-16-2010 to 4-12-2010 did not have descriptors documented.


On 4-14-2010 at 2:45 PM review of medical record for pt. #4 revealed pt. #4 was admitted to the hospital with a diagnosis of metastatic lung cancer on 3-25-2010. Skin assessments were completed at admission and daily. Initial skin assessment on 3-25-2010 showed no open areas. Skin assessment dated 4-8-2010 showed redness on the neck and chin underneath the medical device pt. #4 had to wear, no staging or additional descriptors were documented. Skin assessment dated 4-12-2010 showed pt. #4 had a stage II wound on the chin that measured .30 cm long, .20 cm wide, no additional descriptors were documented.Care planning was to include full integumentary assessments, no additional descriptors were documented.


On 4-14-2010 at 1:50 PM review of medical record for pt. #8 revealed pt. #8 was admitted to the hospital on 2-21-2010 with a diagnosis of difficulty breathing. Skin assessment on 2-21-2010 showed no areas of skin breakdown. Skin assessment dated 3-5-2010 showed pt. #8 developed a stage II ulcer on the right buttock that measured .40 cm long, .30 cm wide, no additional descriptors were documented. Daily skin assessments from 3-6-2010 through 4-12-2010 show no change in the ulcer, no decriptors were documented.Care planning was to include full integumentary assessments, no additional descriptors were documented.
The above medical record findings were confirmed by Clinical Nurse Specialist K, during the review.


On 4-14-2010 at 4:28 PM Vice President A had no additional information to offer.