HospitalInspections.org

Based on interview and clinical record review, the facility failed to ensure the nursing staff developed, kept current and implemented a nursing care plan for each patient, for 3 of 3 patient records reviewed, Patient #1, #2 and #3. The facility failed to ensure consistent nursing documentation, current care plans reflecting the patients' conditions or changes related to pressure ulcer risks, and failed to ensure timely implementation of interventions for pressure ulcer prevention, for the 3 sampled patients.

The findings include:

1. Review of the facility policy for Wound Care Protocol/Pressure Ulcer Prevention and Treatment Protocol included the following:
The Braden Scale is used to document skin breakdown risk on all in/out patients and is is included on the nursing forms. If the total score results in the Skin Risk Category of 17 or above = no risk, continue to score each shift; 16 or less = at risk of developing pressure ulcers, interventions required. A score of 15 or 16 = low risk; 13 or 14 = moderate risk; and 12 or less = high risk.
On page 2, the protocol notes the box under 'Skin Risk Category' is be checked if it is identified the patient is at risk for acquiring, or has an existing pressure ulcer or impaired skin integrity. The plan of care is to be completed and updated regularly, The Pressure Ulcer Prevention (PUP) Interventions are to be initiated on all patients at risk for or have an existing pressure ulcer; the Interventions are printed from EZ-ID and placed with 'The Plan of Care' on the patient's bedside chart. Nursing Interventions included: monitor skin, check bony prominences and maintain hygiene (keep clean & dry) ..., minimize skin injury due to friction and shearing forces ...use proper positioning, transferring and turning techniques, turn patients that are unable to turn self every 2 hours, do not drag patient when pulling up in bed, positioning devices such as pillows or foam wedges should be used to keep bony prominences from direct contact with any surface ..., maintain head of bed at 30 degrees or less with knees slightly bent ...., educate patient to shift weight every 30 minutes to 1 hour while sitting in chair ..., never use donut type devices ....
The Pressure Ulcer Documentation and Treatment Record is to be initiated if a pressure ulcer is discovered ...at any time during hospitalization ...to be completed daily ... each pressure ulcer must have its own form. Pressure Ulcers must be uniformly described in order to establish a baseline, to evaluate interventions ...to ensure accurate assessment of the progress toward healing ...
Description is as follows:
Stage I = intact skin with non-blanchable redness;
Stage II = partial thickness skin loss involving epidermis and/or dermis, ulcer is superficial and presents as abrasion, blister or shallow crater;
Stage III = full thickness tissue loss, Subcutaneous fat may be visible ...slough may be present but does not obscure the depth of tissue loss, there may be undermining or tunneling;
Stage IV = full thickness tissue loss with exposed bone, tendon, muscle, slough or eschar may be present on some of the wound bed, often with undermining or tunneling;
Unstageable = full thickness tissue lose in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, black) in the wound bed; AND Suspected Deep Tissue Injury = purple or maroon localized area of discolored skin or blood-filled blister due to damage of underling soft tissue from pressure and/or shear, the area may be preceded by tissue that is painful, firm, boggy, warmer or cooler as compared to adjacent tissue.
Photographic Wound Documentation is completed on all pressure ulcers and wounds that need to have their progress followed ....completed on admission, discovery and weekly ...; AND The Lamb's Book (Lets All Maintain Better Skin) is located on all nursing units ...and includes all established wound care guidelines and products used ... "
Review of the PUP interventions revealed interventions as listed in the policy including "turning and position every 2 hours and more often if needed", and prompt initiation of PUP interventions for all patients at risk for skin breakdown. There were additional interventions listed in the PUP.

Interview with the Risk Manager at approximately 2:15 PM on 4/15/10 revealed the Braden Scale is completed on each 12 hour shift by nursing in the Intensive Care Units for pressure ulcer risk and interventions should be implemented based on the Braden Scale results.


Review of the clinical record for Patient #1 revealed the patient was admitted on 2/25/2010, and had open heart surgery on 2/26/2010. Further review of the clinical record during the tour of the facility on the morning of 4/15/10 with the nurse revealed the patient developed 4 wounds recently while in ICU-B. The nurse stated he was the nurse who first documented them on 4/3/2010. The nurse stated the night nurse discovered the wounds and he did the documentation on the day shift (the record revealed no nursing documentation of wounds for the night of 4/3/2010). Further interview with the nurse revealed the patient has been heavily sedated, had minimal turning allowability, poor nutrition, plus has massive vascular issues.

Review of Patient #1 initial plan of care from admission on 2/26/2010 revealed an initial plan of care dated 2/25/2010 which had no identified Skin Integrity problem; this section was left blank.
Review of the plan of care dated 2/27/2010 revealed documentation of the following:
Problem = Skin Integrity;
Goals = maintain or improve during stay, negative for redness, improvement of skin since admission and surgical wound intact with no redness, swelling or drainage;
Plan of Care = Braden Scale every shift; and
Problem Status = unchanged (u) with date of 2/28/2010. There were no other interventions identified for the prevention of pressure ulcers. The nurses signed that the care plan is reviewed by nursing daily and/or with change in patient condition.
Review of the plan of care dated 3/24/2010 revealed the following:
Skin Integrity was checked, the same goals as previous were in place, the Plan of Care Interventions included: Braden scale every shift, implement wound protocol if needed (see Lamb's book), if positive for redness and/or breakdown see skin care sheet, and if positive for redness, swelling, or drainage see nurses notes; and
Problem Status was documented as: 4/3 = u, 4/5 = u, 4/8 = u, and 4/11 = u. Under the Care Plan being signed daily, the last dates were 4/10, 4/12, 4/13, 4/14 and 4/15/10. There were no changes documented as being made to the skin integrity interventions on the plan of care up to 4/15/2010.

Review of nursing documentation for 4/3/2010 (no time documented on form) matching documentation by the night nurse on 4/3/2010 noting "see Pressure Sore Documentation Sheet" revealed the following:
(1). right mid-thoracic - Stage UTD (unable to determine), measures 6cm X 2cm
(2). right gluteal fold - Stage UTD at 4.5cm X 3.5cm, serous drainage, undermining, dressing change 'no' .
(3). left buttock - Stage UTD measures 10cm X 9cm, undermining, serous drainage, dressing change 'no' .
(4). right buttock - Stage UTD, measures 5cm X 5cm, undermining, serous drainage, dressing change 'no' .
For each of these wounds, the nurses documented "yes" to Plan of care updated, but there were no additional interventions noted to the plan of care. This was reviewed with the Risk Manager who agreed the plan of care was not updated to reflect pressure sore development.

The chart was reviewed for wound documentation with the nurse while on tour in the ICU-B at approximately 11AM on 4/15/10. The following was revealed related to the nurse's identified documentation (day shift):
On 4/3/2010, the patient acquired the following wounds:
(1). Mid-Thoracic/upper spine area - 6cm X 2 cm,
(2). Right gluteal area/buttock - 5cm X 5cm,
(3). Left gluteal/buttock - 10cm X 9cm; deep tissue injury
(4). Right gluteal fold - 4.5cm X 3.5cm; deep tissue injury.

On 4/14/2010, these wounds measured at:
(1). Mid-Thoracic/upper spine area - 8cm X 3cm, eschar.
(2). Right gluteal area/buttock - 4cm X 3cm (improving per the nurse)
(3). Left gluteal/buttock - 11cm X 7cm, eschar, black
(4). Right gluteal fold - 6cm X 4cm, eschar, black.

Prior to documentation of the development of the four (4) wounds on 4/3/2010, review of the nursing notes revealed documentation of the nursing plan of care as follows:
3/24/2010 8:00 AM - no documentation about skin condition or plan (area was blank)
3/24/2010 7:30 PM - documented "skin intact", no plan checked off, Braden scale was 10 (day shift) indicating high risk, and 10 (evening/night shift) which per the facility protocol would indicate interventions required; less than 16 = intervention required is written on the nursing notes. There was no documentation of interventions implemented.
3/25/2010 7:35 AM - documented "skin intact" and no interventions, Braden scale was 12.
3/25/2010 7:30 PM - documented 'pressure ulcer prevention protocol in place' (See above under policy). Braden scale = 12.
3/26/2010 8:00 AM - documented Skin Intact, no interventions. Braden scale = 10; 12:44 PM - went to Operating Room (OR); 4:00 PM - returned from OR, patient on ventilator, sedated.
3/26/2010 7:15 PM - documented Skin Intact, no interventions. Braden scale = 10. Cream applied to back.
3/27/10 7:40 AM - Pressure Ulcer Prevention Protocol in place (PUPPP), Braden scale = 16, did not tolerate feeding tube well, TPN will be re-started tonight.
3/27/2010 7:00 PM - no skin documentation (blank) but pressure ulcer prevention protocol in place, "see Pressure Ulcer Documentation Sheet" (unable to locate this sheet). The nursing narrative notes documented the patient was re-positioned every 2 hours. Braden scale = 16.
3/28/2010 7:50 AM - no documentation of skin condition but Pressure Ulcer Prevention Protocol in Place; and the nurse documented the patient was re-positioned every 2 hours. Braden scale = 15.
3/28/2010 7:00 PM - documented skin intact, Braden scale = 13. No interventions documented.
3/29/2010 7:30 AM - documented skin intact, Braden scale = 13. No interventions documented.
3/29/2010 7:00 PM - documented skin intact, Braden scale = 10. No interventions documented.
3/30/2010 7:30 AM - documented skin intact, Braden scale = 13. No interventions documented.
3/30/2010 8:00 PM - documented skin intact, Braden scale =13. No interventions documented.
3/31/2010 8:00 AM - documented Skin intact and Pressure Ulcer Prevention Protocol in Place (PUPPP). Nursing narrative documented related to PICC (percutaneous intravenous central catheter) line, and NG (nasogastric) tube feeding/residual. Braden scale = 10.
3/31/2010 8:00 PM - documented Skin intact and Pressure Ulcer Prevention Protocol in place Braden scale = 10.
4/1/2010 7:15 AM - no skin documentation but PUPPP. Braden scale = 9.
4/1/2010 8:00 PM - No documentation related to skin integrity in check-box and no interventions; the nursing narrative documented at 8:15 PM, "large deep appearing ecchymotic regions to upper back and bilateral buttocks. Skin intact though ecchymotic areas appear deep to superficial". At 6 AM, vitals stable, weak cough, sedation remains..." There was no documentation of physician notification of the wound to back or ecchymotic areas to buttocks. Braden scale = 11.
4/2/2010 8:00 AM - section for Skin, Skin intact = not checked off but PUPPP and see Pressure Ulcer (PU) Documentation sheet was checked. This Documentation Sheet was not available for review. Braden scale = 9. At 10 AM the nurse documented the physician was in to see patient; at 2 PM the nurse documented the patient was repositioned.
4/2/2010 8:00 PM - no documentation of skin condition interventions in check-boxes. The nursing narrative documented at 8 PM, " large ecchymotic regions to bilateral buttocks, and upper back - skin appears intact, charge RN day-shift aware of potential skin breakdown. At 1:00 AM (4/3/10), charge RN aware of imminent skin breakdown to bilateral buttocks - large dark ecchymotic regions buttocks and upper back. Barrier lotion applied. Turned often..." Braden scale = 11. No documentation of special equipment used.
4/3/2010, 8:00 AM - PUPPP and PU Documentation Sheet checked and "see notes" which revealed:
(1) Mid-Thoracic/upper spine area - 6cm X 2 cm,
(2) Right gluteal area/buttock - 5cm X 5cm,
(3) Left gluteal/buttock - 10cm X 9cm; deep tissue injury, and
(4) Right gluteal fold - 4.5cm X 3.5cm; deep tissue injury.
Review of the nursing narrative notes at 4:00 PM revealed, the "patient was placed on a Clinitron bed for wound on buttocks". Braden scale = 9.
4/3/2010 7:30 PM - no box check for skin intact or interventions, only "See PU documentation sheet". TPN (nutrition) started at 9 PM per nursing documentation. Braden scale = 8.
4/4/2010 8:00 AM - the nurse documents Skin intact, PUPPP and "see PU documentation sheet". Braden scale = 8. There was documentation of the wounds with measurements. Braden scale = 8.
4/4/2010 7:00 PM - documented PUPPP and documented wound measurements with sloughing to each wound. Braden scale = 13...under the Braden scale, the nurse circled 'skin intact' and checked PUPPP and "see PU Documentation sheet".
4/5/2010 8:00 AM - documented PUPPP and "see PU documentation sheet, on Clinitron Bed". Braden scale = 12.
4/5/2010 8:00 PM - same as 8 AM, Braden scale = 11.
4/6/2010 8:00 AM - same as 4/5/2010, Braden scale = 13.
4/6/2010 7:30 PM - See PU documentation sheet only, on Clinitron Bed, Braden scale = 11.
The nursing documentation continues the same - sometimes documenting PUPPP and sometimes not; on 4/9/2010, the nurse documented Skin Intact but interventions in place; Braden scale was 12/12. On 4/10/10, the nurse documented Skin Intact, PUPPP, Braden scale 11/11. On 4/14/2010, the 4 wounds remained and measured:
(1) Mid-Thoracic/upper spine area - 8cm X 3cm, eschar,
(2) Right gluteal area/buttock - 4cm X 3cm (improving per the nurse);
(3) Left gluteal/buttock - 11cm X 7cm, eschar, black; and
(4) Right gluteal fold - 6cm X 4cm, eschar, black.

Review of the physician orders revealed there were no identified orders for the wounds until 4/3/2010 with an order for "Xerofoam dressing changes daily" but the order does not identify which wounds. (The patient also had a chest wound from a surgical site). The initial skin changes per the nursing documentation started on 4/1/2010.

In review of the nursing documentation, the wounds were acquired in the hospital and three had increased in size. The documentation was inconsistent relating to when the wounds initially developed, when the skin was intact or wounds present, and there was inconsistent documentation of the implementation of a Pressure Ulcer Preventive Protocol. Prior to the development of the 4 wounds with a lower than 16 risk scale for wound development, there was no documented preventative plan in place.

Interview with the Risk Manager at at approximately 12:15 PM on 4/15/10 revealed it was a concern of her's that the wounds were not identified for Patient # 1 until the wounds were staged at a Stage III or greater. She verbalized that no matter at what Stage the wounds are identified, or if the patient is at high risk, the Pressure Ulcer Protocol should become part of the plan of care. She further stated the Policy was not specific in what the nurses were to do at what Risk level on the Braden scale for pressure ulcer prevention.


2 Review of the clinical record for Patient #2 revealed the patient was admitted on 3/29/2010 with diagnosis of Wound Dehiscence to chest wall. The patient had a history of Diabetes, Chronic Obstructive Pulmonary Disease, Hypertension, and Coronary Artery Disease status post MI (myocardial infarction) with recent CABG (coronary artery bypass graft). Review of the plan of care for this patient revealed a plan of care was initialed on 4/1/2010 that included a Problem Area of Skin Integrity (check box) and handwritten 'wound vac to right groin from outside facility'; outcomes were documented; four (4) interventions listed had a check box, but none of these interventions were checked; and on 4/3/2010, the nurse documented under Status 'unchanged'.
Review of the nursing notes for 3/29/2010, revealed the Braden scale was 18 (17 or greater = no risk; 16 or less = at risk and interventions required). On 4/1/2010, 4/2, and 4/3, the nurse documented the Braden scale as 13 for each shift; on 4/4 = 15; on 4/5 = 14; on 4/6 = 16; on 4/7 & 4/8 = 18; 4/9 = 19; 4/10 = 16; 4/11 = 15/16; 4/12 = 18/15; 4/15 = 15/15 and on 4/14 = 17/16 on the scale.
Review of the nursing documentation revealed when the Braden scale for Patient #2 dropped to 13 on 4/1/2010, there was no plan of care documented as being implemented for this patient and the nurse documented 'skin intact' only. On 4/2/10 with a Braden scale of 13, the nurse did not document any skin condition (area left blank). On 4/3/10 at 8:00 AM, the nurse had no documentation related to skin integrity checked in the box. On 4/3/1020, at 7:30 PM, the nurse documented PUPPP and see PU documentation. On 4/4/2010, Braden scale was 15; there were no documented interventions in place. On 4/5, the skin integrity section was blank. On 4/6/2010, the nurse documented skin intact and PUPPP. On 4/10/10, the patient was in the ICU; there was no documentation of wound prevention interventions in place. The nurses documented the pressure sore risk of the patient, but failed to show documentation of the implementation of pressure ulcer prevention; and on 4/14/2010, the patient remained at Braden scale risk of 16, but with no documented interventions on the plan of care. The patient did not develop a pressure ulcer, but had other surgical wounds.

3. Review of the clinical record for Patient #3 revealed the patient was admitted on 3/28/2010, with diagnoses that included Pneumonia, Congestive Heart Failure and Hypoxia. The patient was admitted to ICU-A. The physician history and physical documented the patient had chronic obstructive pulmonary disease with acute exacerbation, bilateral pleural effusions and hypoxia.
Review of the Braden scale revealed a score of 17 or greater = no risk for wound development; 16 or below = at risk and interventions required.
On 4/4/2010, review of the nursing documentation revealed the patient was at risk for wound development (Braden scale of 11). The skin was intact, but there were no interventions documented as being put into place to prevent wound/pressure ulcer development. On 4/5/2010, the nurse documented skin intact and PUPPP. On 4/6 to 4/8/10 (day shift), the skin remained intact and Braden scale was 'no risk'. On 4/8/10 at 8:00 PM, the nurse documented a Braden scale of 13 and implemented PUPPP. On 4/9/2010, the notes had no skin integrity documentation. On 4/10/10, the Braden scale remained at 13; at 7:00 AM, there was no skin integrity documentation, and at 7:30 PM the documentation revealed Skin Intact only and no interventions (PUPPP) in place.
On 4/11/2010, the nurse documented a wound to the right and left buttock: "right buttocks with Stage II, no exudate, scant amount of drainage, and red around wound" and "left buttock with Stage II, no exudate, scant drainage, and red around wound". The nurse documented there was no dressing change and the plan of care is updated daily.
On 4/13/10 (day and night shift), the Braden scale was down to 12, the nurses documented in the nursing notes 'skin intact', but there were no documented interventions in place. On the wound sheet, the patient has a Stage II wound. On 4/14 and 4/15/2010, the nurse documented a Stage II pressure ulcer was present. There was no documentation of an updated plan of care for skin integrity.