HospitalInspections.org

Based on interviews and record reviews, the hospital failed to ensure Registered Nurses (RN's) evaluated and provided treatment for 1 of 10 patients (Patient #1's) altered skin integrity to the sacrum and/or coccyx identified on admission to Hospital A on 07/15/13.

Findings Included:

Hospital A:

(Patient #1's) ED (emergency department) physician note dated 07/15/13 timed at 20:37 PM, reflected, "Tiny skin split...sacrum..."

The 07/17/13 patient progress note timed at 13:45 PM, reflected, "Wife at bedside...states patient has a small healing ulcer on his coccyx and that she put DuoDerm on when he was admitted and wishes to have us address this if necessary...information given to nurse..."

The 07/17/13 decubitus body picture timed at 17:45 PM, reflected, "Redness coccyx..."

The 07/23/13 patient progress note timed at 07:35 AM, reflected, "Skin condition intact..."

The 07/23/13 decubitus body picture timed at 07:35 AM, reflected, "Whole sore unstageable, blanchable reddened bottom..." No documentation was found which indicated treatment was applied to the pressure ulcer to the sacrum and/or coccyx. (Patient #1) discharged 07/23/13 to Hospital B.

The physician orders dated 07/15/13 through 07/23/13 reflected no treatment orders for the wound to (Patient #1's) sacrum and/or coccyx.

Hospital B's progress note dated 07/24/13 timed at 18:45 PM, for (Patient #1) reflected, "Initial asssessment performed by...wound nurse...deep tissue injury to coccyx, linear shaped lighter purple discoloration to bilateral gluteus...sloughing epidermis at coccyx site...site measures 10.0 (cm) by 2.0 cm...probable depth involvement...xenaderm ointment to deep tissue injury twice daily...side to side positioning..."

On 03/14/13 at 01:00 PM, Personnel #1 was interviewed. Personnel #1 was asked to review (Patient #1's) medical record. Personnel #1 verified the medical record did not contain any documentation which indicated treatment was provided to (Patient #1's) coccyx and/or sacrum.

On 03/18/14 at 09:41 AM, Personnel #4 was interviewed. Personnel #4 stated she could not provide the surveyor nursing education and/or competency regarding pressure ulcer prevention for the nursing personnel.

The policy and procedure entitled, "Pressure Ulcer Prevention and Management" with a revision date of 06/10 reflected, "The pressure ulcer prevention and treatment program will include...identifying pressure ulcers at the time of admission, informing the physician of need for wound care...education programs for staff..."

The policy and procedure entitled, "Patient assessment/Reassessment with an origination date of 03/10 reflected, "Purpose...to ensure each patient's physical status is assessed to determine the patient's care needs and to ensure patient's changing needs are reassessed in response to treatment and care provided...information generated via a patient's assessment will be integrated with other disciplines to identify and prioritize the patient's need for care and treatment..."

Based on interviews and record reviews, Hospital A failed to ensure 1 of 10 patients (Patient #1's) necessary medical record information was provided to Hospital B which addressed (Patient #1's) altered skin integrity which was identified on admission to Hospital A on 07/15/13.

Findings Included:

Hospital A:

(Patient #1's) ED (emergency department) physician note dated 07/15/13 timed at 20:37 PM, reflected, "Tiny skin split...sacrum..."

The 07/17/13 decubitus body picture timed at 17:45 PM, reflected, "Redness coccyx..."

The 07/23/13 decubitus body picture timed at 07:35 AM, reflected, "Whole sore unstageable, blanchable reddened bottom..."

The physician orders dated 07/23/13 timed at 08:45 AM, reflected, "Discharge to rehabilitation today...follow-up with primary care physician one week after rehabilitation discharge..." No documentation was found which indicated Hospital B was informed regarding (Patient #1's) altered skin integrity.

On 03/14/13 at 01:00 PM, Personnel #1 was interviewed. Personnel #1 said she could not find any documentation in the case management notes and transfer documentation which indicated Hospital B (Patient #1) was transferred to was informed (Patient #1) had altered skin integrity.

The Medical Staff Rules and Regulation with an approval date of 04/17/13 reflected, "The discharge summary shall concisely include...final diagnosis, evaluated and treated during encounter...hospital course...medical care, treatment and services provided and how patient responded to care, treatment...provisions for follow-up care...complications and all other treated diagnosis and procedures shall be recorded in full...additional diagnosis must also be recorded which may exist prior to the admission of the patient or develop after the patient's admission..."