HospitalInspections.org

Based on facility policy review, medical record review, and interview, the facility failed to prevent the development of pressure ulcers for one patient (#1) of three patients reviewed.

The findings included:

Patient #1 was admitted to the facility on 7/2/15 with diagnoses including Streptococcal Septicemia, Malnutrition, Paraplegia, and Anemia.

Review of facility policy Assessment of Patient Global Policy, last reviewed on 11/2013, revealed "...each shift a reassessment is completed in order to reassess the patient's condition..."

Review of facility policy Pressure Ulcer Prevention and Management, last reviewed on 3/2014, revealed "...an RN [Registered Nurse] or LPN [Licensed Practical Nurse]...will assess each patient's skin status for presence of impaired skin integrity every shift...assess skin each shift...document...TED [specialized stockings to prevent development of blood clots in legs] hose are removed every shift for skin inspection..."

Medical record review of a physician's order dated 7/2/15 revealed "...TEDs Bilateral Knee High..."

Medical record review of a nurse's shift assessment dated 7/2/15 at 7:45 PM revealed "...skin...dry...warm...pale...Braden skin daily assessment...score total 14...level 2...moderate risk...use of pillows to relieve pressure points...turned every 2 hours and as needed...equipment in use...TED hose..."

Medical record review of a physician's progress note dated 7/3/15 revealed "...SKIN...no rash, no mass, no lesions..."

Medical record review of a nurse's shift assessment dated 7/4/15 at 8:00 AM revealed "...skin...warm...pale...Braden skin daily assessment...score total 10 to 12...level 3 (high risk)...turned more frequently than every 2 hours...pillows to elevate pressure points...equipment in use...TED hose..."

Medical record review of a nurse's shift assessment dated 7/5/15 at 7:49 PM revealed "...skin...warm...pale...Braden skin daily assessment...score total...13 to 14...(moderate risk)...use of pillows to relieve pressure points...turned every 2 hours and as needed...pt refuses TEDS...Left Heel...pt states sores on feet from TEDS...type of finding...Pressure Ulcer...Color of Wound Red...Right Heel...pt states sores on feet from TEDS...type of finding...Pressure Ulcer...Color of Wound Red..."

Medical record review of a physician's progress note dated 7/6/15 revealed "...He is receiving skin damage from thromboembolism deterrent hose..."

Medical record review of a nurse's note dated 7/7/15 at 11:30 PM revealed "...bil [bilateral] LE [lower extremities] floated...pt [patient] does have wounds on bil feet...no drainage noted..."

Medical record review of a nurse's note dated 7/8/15 at 7:30 AM revealed "...wounds...bilateral heels and ankles...pictures taken and placed in chart...heels firm and bruised...heels floated on foam wedges..."

Interview with the Director of Acute Care on 1/26/16 at 10:25 AM, in the conference room, revealed "...sorry to say but he developed the skin ulcers from the TED hose...the mother would take the TED hose off...it was very clear his pressure ulcers were from the TED hose...we had several huddles with the staff about this...the staff wasn't verifying the mother was really removing them...on Saturday [7/4/15] he had red spots and by Sunday [7/5/15] he had breakdown...sores on both feet were identified...the one on heel was the worse one...TEDS were removed...pressure areas were elevated...when the nurse found them...the mother said he didn't want them on and she had removed them..."

Interview with RN #1 on 1/26/16 at 10:56 AM, in the conference room, revealed "...he wasn't able to do anything for himself...he had a care giver in his room all the time...it was a family member...the wounds on his feet was a big surprise...I thought the family was removing them...it was toward the evening [7/5/15] when I discovered them...I told the charge nurse...we would keep his feet off the bed after that...his feet were boney...the TED hose put pressure on boney prominences...we don't want this to happen ever again...we do skin assessments every shift...take TED hose off and leave off a couple of hours...then put them back on...pictures were taken..."

Interview with the Director of Acute Care on 1/26/16 at 12:30 PM, in the conference room, confirmed the facility failed to follow facility policy and failed to do complete skin assessments each shift. Further interview confirmed the facility failed to remove the TED hose each shift, which caused the patient to develop pressure ulcers to both feet.