HospitalInspections.org

Based on medical record review, policy and procedure review, document review, and staff interview the hospitals Director of Nursing failed to provide oversight and develop nursing policies and procedures which directed nursing staff to provide patient skin/wound care based on professional nursing standards of care (A-385). The hospital's supervisory registered nurse failed to ensure nursing staff follow established wound care policies to assess, monitor and document wound care (A-395). The nursing staff failed to develop a comprehensive plan of care for pressure ulcer prevention and treatment (A-396).

The cumulative effect of the systemic failure to identify patient skin breakdown, development of pressure ulcers and the need for continuous management and treatment of pressure ulcers based on national accepted standards, which include the need to develop patient plans of care has the potential to adversely affect all compromised patients.

The Hospital reported a census of 22 patients with 20 records chosen for review. Based on medical record review, policy and procedure review, document review, staff interview the hospitals Director of Nursing failed to provide oversight and develop nursing policies and procedures which directed nursing staff to provide patient skin/wound care based on professional nursing standards of care for 1 of 1 patient (Patients #1) who developed a hospital acquired pressure ulcer.

Findings include:

- Review on 9/18/13 of the "Job Description" titled "Director of Nursing" describes the Directors job function as, "A key member of the professional staff who assumes leadership accountability. Oversees care and activities based on policies, procedures standards and regulatory bodies ..."

- Policy review on 9/17/13 titled "Wound and Dressing Care", Number: NUR 6.11, Reviewed/revised date: 9/11/12, states nurses should be knowledgeable of the dressing and wound care needs of the patient ... Procedures 1) Total assessments will be done on admission and daily. 2) Any wound will be documented on the computerized wound assessment. 3) Specific dressing types may be ordered by the physician ...."

- Patient #1's medical record review on 9/16/13 to 9/17/13 revealed an admission date of 7/10/13 with a primary diagnosis of valvular heart disease (severe aortic stenosis with severe tricuspid regurgitation and mild to moderate mitral regurgitation). Patient #1 was scheduled on 7/11/13 to have a procedure to replace their aortic valve and coronary artery bypass grafting. Patient #1 developed a "stage I left buttock decubitus (pressure ulcer)" on 7/14/13 which deteriorated to a stage 2 decubitus on 7/16/13. Patient #1's record lacked consistent documentation of the wound assessment that included measurement of the size, depth, and surrounding tissue. Patient #1's medical record lacked evidence nursing staff notified the physician of the stage 1 and stage 2 pressure ulcer or obtained physician orders to treat the deteriorating wound. Patient #1's medical record lacked a plan of care for skin integrity and implementation for wound care interventions.

- Review on 9/17/13 of the policy titled "Wound and Dressing Care" revealed the policy failed to direct nursing staff to follow wound care guidelines based on a nationally accepted nursing standards of practice. The policy failed to include pressure ulcer identification, on going assessment for the prevention, treatment and interventions for patients at risk for development of pressure ulcers. The policy failed to direct nursing to assess the patient and notify the physician of changes in patient skin condition, the development of pressure ulcers, deteriorations of wounds, and obtain physician orders for the treatment of the wounds. The policy failed to direct nursing staff to develop a plan of care for patients with skin breakdown and wound care.

- Administrative Nurse staff A, B, and C interviewed on 9/17/13 at 3:00pm acknowledged the wound care policy lacked directions to follow wound care guidelines based on nationally accepted nursing standards of practice. Nurse staff A verified the policy lacked pressure ulcer identification, treatment and interventions for patients at risk for development of pressure ulcers, direction to notify the physician in changes in patient skin condition, development of pressure ulcers, deterioration of wounds and to obtain physician orders for treatment of the wounds. Staff A verified the policy lacked direction to ensure nursing staff developed a plan of care for patients with skin break down and wound care.

The Hospital reported a census of 22 patients with 20 medical records chosen for review. Based on medical record review, policy and procedure review, and staff interview the hospital's supervisory registered nurse failed to ensure nursing staff follow established wound care policies to assess, monitor and document wound care for 1 of 1 patients (patient #1) that developed a stage I/II pressure sore.

Findings include:

- Medline plus defines and describes a pressure ulcer as an area of skin that breaks down when something keeps rubbing or pressing against the skin. Causes of pressure ulcers are when pressure on the skin reduces blood flow to the area. Without enough blood, the skin can die. An ulcer may form.

Pressure sores categorized as deep tissue injury may be purple or maroon. This may be an area of skin or blood-filled blister due to damage of soft tissue from pressure. The area around may be sore, firm, mushy, boggy, warmer, or cooler compared with tissue nearby.
Pressure sores are grouped by their severity. Stage I is the earliest stage. Stage IV is the worst.
Stage I: A reddened area on the skin that, when pressed, does not turn white. This is a sign that a pressure ulcer is starting to develop.
Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. ...

- Policy review on 9/17/13 titled "Wound and Dressing Care", Number: NUR 6.11, Reviewed/revised date: 9/11/12, states nurses should be knowledgeable of the dressing and wound care needs of the patient ... Procedures 1) Total assessments will be done on admission and daily. 2) Any wound will be documented on the computerized wound assessment. 3) Specific dressing types may be ordered by the physician. 4) The insertion site of all central lines and peripherally inserted catheters (PIC) will be inspected every 24 hours ..."

Administrative nursing staff A, B, and C reported nursing staff used the manufacture manual titled "Solutions Algorithms for Skin and Wound Care " by ConvaTec (the manufacture of their wound care supplies) for wound care guidelines. "Solutions" algorithms for wound care suggest A) "Medical diagnosis: acute or chronic wound, B) Nursing diagnosis: Skin integrity impaired or tissue integrity impaired. C) Goals of patient care is to reduce risk factors for new ulcer development and delaying healing of current wounds. Prevent wound complications and promote wound healing.

"Solutions Algorithms for Skin and Wound Care" tab Wound Assessment directed nursing staff to document the 13 key components of wound assessment are to include:
1. Identify location of wound,
2. Determine etiology of wound
3. Determine wound classification and/or stage
4. Measure size of wound
5. Measure depth of wound
6. Measure amount of wound tunneling and undermining
7. Assess wound bed
8. Assess wound exudate
9. Assess surrounding skin
10. Assess wound edges
11. Assess signs and symptoms of wound infection
12. Assess patient's pain
13. Document wound assessment.

- Patient #1's medical record review on 9/16/13 to 9/17/13 revealed an admission date of 7/10/13 with a primary diagnosis of valvular heart disease (severe aortic stenosis with severe tricuspid regurgitation and mild to moderate mitral regurgitation). Patient #1 was scheduled on 7/11/13 to have procedures to replace the aortic valve and coronary artery bypass grafting.

The admission assessment report dated 7/10/2013 2:19pm indicated that the patient had a Braden Scale for Risk (a tool used to indicate risk for developing a pressure ulcer) score of 22/23--No risk. Skin dry/warm; skin color normal for patient; mucosa moist/intact; turgor elastic; signs/symptoms none.

The record demonstrated sporactic wound assessments and lacked evidence of physician orders for the following treatments between 7/14/13 and 7/26/13 (the date of patient #1's discharge) a sample which includes:

Patient #1's medical record revealed Registered Nurse H documented a nursing assessment on the "Nursing Wound Report" dated 7/14/13 at 7:30am which initially identified a nosocomial stage 1 decubitus (Pressure ulcers, also known as decubitus ulcers) quarter size left buttock (between cheeks) with only top layer of skin off and erythemic (abnormal redness to skin due to capillary congestion as in inflammation).

Register Nurse H noted the patient also had 2 pressure areas intact, purplish bilateral coccyx region. She applied Aloe Vista spray and barrier cream and noted the area was dry and open to air.

Registered Nurse S on 7/15/13 at 4:34am noted the wound was cleansed with Carrington products and was trying to keep patient off their bottom with the site red and left open to air.

Registered Nurse I noted on 7/15/13 at 8:18pm the wound was cleansed during bath, Carrington barrier cream was applied to area with no change in wound from the initial assessment.

Registered Nurse J noted on 7/16/13 at 6:01am that they applied barrier cream.

Registered Nurse K on 7/16/2013 at 7:49pm noted the wound as a quarter size stage 2 sore that they had kept clean and dry all day. They noted they repositioned the patient every 2 hours.

Registered Nurse M documented on 7/17/13 at 4:06pm patient #1's wound as a stage 2 pressure ulcer on buttocks they applied barrier cream. Staff M noted they applied barrier cream, kept the area clean and dry and repositioned the patient every 2 hours.

Registered Nurse J on 7/18/13 at 4:47am noted the skin remains intact as described (no description of wound on note), barrier creme applied and turned the patient every 2 hours.

Registered Nurse N on 7/18/13 at 3:00pm noted an open wound to buttocks that is purple at the coccyx area. Staff N noted the wound was red, open to air, applied barrier cream and kept the patient on their sides turning frequently.

Registered Nurse O on 7/19/13 at 1:34am documented the patient's buttock reddened with small open areas that was dry and open to air. They applied barrier cream and assisted in turning the patient.

Registered Nurse P on 7/19/13 at 2:40pm noted the patient had red blistered areas to bilateral buttocks and 2 purple reddish areas to coccyx area that they cleansed and applied cream to the area leaving open to air.

Registered Nurse O on 7:40pm noted the area as reddened with small open areas upper buttock area. Staff O applied barrier cream note the wound as dry and open to air.

Registered Nurse O on 7/20/13 at 9:20pm noted the wound was a dry small open area they applied barrier cream to and left open to air.

Registered Nurse D on 7/21/12 at 8:15am noted the wound was open to air.

Registered Nurse J on 7/22/13 at 0:12am noted they applied barrier cream and/or spray protectant spray as needed and left the wound open to air.

Registered Nurse M on 7/22/13 at 7:33pm noted the wound as red, applied barrier cream this morning and applied spray this afternoon per the patients request and was open to air.

Registered Nurse Q on 7/23/13 at 11:22am noted the wound was open to air.

Registered Nurse T noted on 7/23/13 at 8:34pm noted the wound was open to air.

Registered Nurse R noted on 7/24/13 at 6:37pm the wound was red and changed the dressing using a duoderm dressing.

Registered Nurse R on 7/26/13 at 11:02am noted the wound was red with a duoderm dressing.

The record identified the presence of patient #1's hospital acquired pressure ulcer and failed to demonstrate continuous management and treatment of national accepted standards for pressure ulcers between 7/14/13 and 7/26/13 (the date of patient #1's discharge).

The patient's daily flow sheets dated 7/10/13-7/14/2013 lacked evidence of documentation on the body graphic indicating the location and descriptive statement of for example: incisions, decubiti (pressure ulcers), medical devices (IVs, catheters, chest tubes), and bruises.

The daily flow sheet dated 7/15/2013 indicated an introducer (large IV to infuse fluids), oxygen, two chest tubes, chest and leg incisions, urinary catheter, and sequential compression devices (pump used to prevent blood clots) and lacked documentation of the decubitus ulcer documented on the Nursing Wound Report on 7/14/13.

The patient's daily flow sheets dated 7/16/13-7/25/13 lacked evidence of documentation on the body graphic indicating the location and descriptive statement of for example: incisions, decubiti (pressure ulcers), medical devices (IVs, catheters, chest tubes), and bruises.

Administrative staff A, B, and C interviewed on 9/17/13 at 3:00pm acknowledged patient #1's medical record lacked evidence of physician notification and physician orders for skin breakdown and pressure ulcer treatment. Administrative staff A stated the physicians would not want nursing staff calling for wound care orders after working hours and nurses are responsible to identify and treat pressure ulcers as they occur during their shift. Administrative nursing staff A verified nursing staff are to follow the guidelines of the manufacture for treating pressure ulcers. Administrative nursing staff A, B, and C verified nursing failed to complete the required 13 components for wound assessment, continued monitoring, documentation and provide nursing interventions to prevent skin breakdown and pressure ulcers; failed to notify the physician of the presence of pressure ulcers; and failed to obtain an order for treatment of the hospital acquired pressure ulcer.

The hospital identified a census of 22 patients with 20 medical records chosen for review.
Based on medical record review, policy and procedure review, and staff interview the nursing staff failed to develop a comprehensive plan of care for pressure ulcer prevention and treatment for 1 of 1 patients (patient #1) that developed a stage I/II pressure sore.

Failure to identify patient skin breakdown, development of pressure ulcers and the need for continuous management and treatment of pressure ulcers based on national accepted standards, which include the need to develop patient plans of care has the potential to adversely affect all compromised patients.

Findings include:

- Entrance conference on 9/16/13 at 10:30am surveyors requested Nursing patient plan of care policy from nursing administration staff A, B and C, and made a second request on 9/17/13 at 4:30pm. Surveyors made phone requests for the Nursing plan of care policy and 9/18/13 at 9:56am and at 10:59am and the hospital failed to provide the policy.

The hospital faxed a policy on 9/18/13 at 12:07pm titled, "Documentation" policy.

The hospital's "Documentation" policy reviewed on 9/18/13 at 1:00pm revealed page 4 of 4 noted "Revision History" dated "9/18/13 Added Nursing Plan of Care section." The hospital lacked evidence of a patient plan of care to direct nursing staff on when and how to develop and reassess individualized patient plan of care to meet patient's specific needs including pressure ulcer treatments.

- Medline plus defines and describes a pressure ulcer as an area of skin that breaks down when something keeps rubbing or pressing against the skin. Causes of pressure ulcers are when pressure on the skin reduces blood flow to the area. Without enough blood, the skin can die. An ulcer may form.

- Patient #1's medical record reviewed on 9/16/13 and 9/17/13 revealed an admission date of 7/10/13 with diagnosis of valvular heart disease (decreases blood flow in the heart). Patient #1 underwent a heart bypass surgery on 7/11/13.

Patient #1's nursing wound report revealed the following pressure ulcer and skin breakdown concerns:

1. Nursing wound report dated 7/14/13 revealed Registered Nurse H at 7:30am documented "Shift report of existing decubiti, quarter size left buttocks (between cheeks), stage 1 only top layer of skin erhythemic (abnormal redness of the skin due to capillary congestion such as in inflammation) Also 2 pressure areas intact, purplish bilateral coccyx region."

2. Nursing wound report dated 7/16/13 revealed Registered Nurse K at 5:49pm documented "quarter size stage 2 sore"...

3. Nursing wound report dated 7/17/13 revealed Registered Nurse M at 4:06pm documented "stage 2 pressure ulcer on buttocks"...

4. Nursing wound report dated 7/18/13 revealed Registered Nurse N at 3:00pm documented "open wound to buttocks, purple at coccyx area,.."

5. Nursing wound report dated 7/19/13 revealed Registered Nurse O at 1:34am documented "patient buttock reddened with small open area."

6. Nursing wound report dated 7/19/13 revealed Registered Nurse P at 2:40pm documented "red blistered areas to bilateral buttocks and 2 purple reddish areas to coccyx area,.."

7. Nursing wound report dated 7/20/13 revealed Registered Nurse O at 9:20pm documented "small open area."

Patient #1's medical record revealed a plan of care dated 7/10/13. Review of patient #1's plan of care on 9/16/13 lacked evidence of a plan of care for patient #1's pressure ulcer, and lacked evidence of nursing interventions to assess and treat patient #1's pressure ulcer and skin breakdown.

Patient #1's medical record from admission on 7/10/13 to discharge on 7/26/13 revealed the record lacked evidence of a patient plan of care for impairment of skin integrity.

Administrative nursing staff A, B, and C interviewed on 9/17/13 at 3:00pm reviewed patient #1's medical record. Administrative nursing staff A, B, and C reported the medical record lacked evidence of a plan of care to assess, and treat patient #1's pressure ulcer and skin breakdown. Administrative nursing staff A, B, and C stated the nursing staff failed to ensure patient #1 had an individualized plan of care.