HospitalInspections.org

Based on record review and interview, staff failed to perform skin assessments, interventions, and evaluations to prevent skin breakdown in 1 of 10 medical records reviewed (Patient (Pt) #1), in a total of 10 medical records reviewed.

Findings Include:

Review of policy and procedure titled, "Nursing Patient Assessment, Documentation, Care Planning, Learning Assessment and Patient Education" last reviewed 04/04/2023 revealed the following:
-"A Full Patient Assessment will be performed and documented...At least once during a Regular Shift (greater than 4 hours, less than or equal to 12 hours)."
-"The RN (Registered Nurse) is responsible for the documentation of a nursing assessment used to determine the patient's current condition and response to treatment interventions."
-"Patient's not progressing and/or declining should have care plan note identifying the barriers and any changes to interventions and plan of care."
-"Assessment findings that fall outside of WDL (within defined limits or normal findings) values will be documented for affected body system by adding the specific assessment rows as required to completely document the assessment findings."
-"Body system interventions in the applicable flow sheets will be documented at the time the intervention is performed..."
-"Progress notes are written to indicate when the patient is not progressing as expected in response to the plan of care."
-"Examples of when progress notes are needed: 1. Patient is not progressing and the note should include barriers to progression and any interventions and/or changes to the plan of care..."
-"Provider Notification Documentation: needs to occur using the provider notification section of the vital signs flow sheet whenever a provider is notified."

Review of policy and procedure titled, "Wound, Wound Care, Treatment, Assessment, Dressing, Pressure Ulcer" last reviewed 07/29/2022 revealed the following:
1. "A head to toe skin assessment will be conducted as follows: 1. Every Shift; 2. With a change in the patients condition or wound condition."
2. "A focused wound assessment will be completed for any wound identified in the basic skin assessment: 2. With every dressing change. a) With each dressing change, the wound will be observed for developments that may indicate the need for a change in treatment (e.g.,wound deterioration...); 3. Upon discovery; 4. With significant changes in the wound condition."
3. "A decline in the wound status will be reported to the provider."
4. "RN to utilize Wound/Skin Guidelines to implement prevention strategies and initiate wound treatments."

Review of Pt #1's Critical Care Admission History & Physical (H & P) dated 03/16/2023 at 8:17 PM revealed that Pt #1 was initially admitted on 02/07/2023 to the MICU (Medical Intensive Care Unit) for Hypernatremia (high sodium level in the blood) and altered mental status; Pt #1 was transferred to another acute care hospital (per family A's request) on 06/10/2023 (4 months in hospital). Per H & P, Pt #1 is a 26 year old with a past medical history significant for primary CNS (central nervous system) lymphoma (cancer of the lymph nodes), diabetes mellitus type 1, and End Stage Renal Disease status post combined kidney and pancreas transplant in 2021.

Review of Pt #1's Certified Wound Nurse Consult note dated 04/13/2023 at 4:17 PM, revealed the "Reason for Consult" was for recommendations for care of Pt #1's "Skin tear R (right) inguinal (groin) area and perineum (skin between the anus and genitals)." "Activity" documentation revealed, "Dependent on staff for cares/repositioning"; "Incontinent of bowel"; "Incontinent of bladder." Wound Care progress notes revealed, "Excessive moisture to perineal area d/t (due to) urinary/bowel incontinence." Per Wound Care Recommendations, staff should cleanse the wound, pat dry, apply Desitin cream topically, and then cover with a non-adherent mesh gauze dressing, 3 times daily and as needed. Wound Care progress notes revealed the Preventative Measures include but are not limited to, Repositioning Pt #1 every two hours while in bed. Per Wound Care notes, "...Please re-consult if wound status declines or new skin issues arise."

Review of Pt #1's Daily Cares flow sheets (Body Position) from 04/13/2023 through 04/28/2023 revealed the following documentation of staff repositioning Pt #1:
-Nursing staff documented repositioning Pt #1 on 4/13/2023 at 10:15 AM; there was no documented evidence of repositioning Pt #1 again until 6:27 PM (8 hours and 12 minutes later) (should be every 2 hours as per Wound Care Nurse consult).
-Nursing staff documented repositioning Pt #1 on 04/14/2023 at 6:28 PM; there was no documented evidence of repositioning Pt #1 again until 10:45 PM (3 hours and 7 minutes later).
-Nursing staff documented repositioning Pt #1 on 04/15/2023 at 3:38 PM; there was no documented evidence of repositioning Pt #1 again until 9:46 PM (6 hours and 8 minutes later).
-Nursing staff documented repositioning Pt #1 on 04/15/2023 at 9:46 PM; there was no documented evidence of repositioning Pt #1 again until 04/16/2023 at 9:26 PM (11 hours and 20 minutes later).
-Nursing staff documented repositioning Pt #1 on 04/18/2023 at 1:12 AM; there was no documented evidence of repositioning Pt #1 again until 9:27 AM (8 hours and 15 minutes later).
-Nursing staff documented repositioning Pt #1 on 04/19/2023 at 4:00 PM; there was no documented evidence of repositioning Pt #1 again until 8:30 PM (4 hours and 30 minutes later).
-Nursing staff documented repositioning Pt #1 on 04/21/2023 at 4:05 PM; there was no documented evidence of repositioning Pt #1 again until 10:20 PM (6 hours and 15 minutes later).
-Nursing staff documented repositioning Pt #1 on 04/22/2023 at 2:08 AM; there was no documented evidence of repositioning Pt #1 again until 8:55 AM (6 hours and 47 minutes later).
-Nursing staff documented repositioning Pt #1 on 04/23/2023 at 1:21 AM; there was no documented evidence of repositioning Pt #1 again until 5:58 PM (4 hours and 39 minutes later).
-Nursing staff documented repositioning Pt #1 on 04/24/2023 at 3:43 AM; there was no documented evidence of repositioning Pt #1 again until 10:35 AM (6 hours and 52 minutes later).
-Nursing staff documented repositioning Pt #1 on 04/25/2023 at 12:04 PM; there was no documented evidence of repositioning Pt #1 again until 3:13 PM (3 hours and 9 minutes later).
-Nursing staff documented repositioning Pt #1 on 04/26/2023 at 9:13 AM; there was no documented evidence of repositioning Pt #1 again until 3:00 PM (5 hours and 47 minutes later).
-Nursing staff documented repositioning Pt #1 on 04/27/2023 at 3:29 PM; there was no documented evidence of repositioning Pt #1 again until 9:25 PM (5 hours and 56 minutes later).

Review of Pt #1's Skin/Wound nursing flow sheets revealed that a right Buttocks wound was first identified on 04/18/2023 at 9:00 AM. Review of the Wound flow sheet documentation from 04/18/2023 through 05/10/2023 revealed that an assessment/intervention for the Buttocks wound was not documented as being completed every shift as per policy on 04/18/2023, 04/19/2023, 04/22/2023, and 05/03/2023.

Review of Pt #1's Skin/Wound nursing flow sheets for the Right Buttocks Wound revealed, from 04/18/2023 to 05/04/2023, Pt #1's Buttocks Wound Site Assessment documentation revealed "Dry, Intact, pink." Review of the Buttocks Wound Site Assessment documentation from 05/05/2023 through 05/10/2023 revealed that the Site Assessment changed to "Pink; Moist, Maceration (skin that looks soggy, feels soft, exposed to too much moisture), Painful"; and the wound "Closure" changed from "intact" to "Open/not approximated (wound edges not touching)."

Review of the Pt #1 Provider Notification flow sheets from 05/05/2023 through 05/10/2023 showed no documentation that the provider was notified of the decline in wound status as per policy.

Review of Pt #1's medical record revealed a Wound Care Consult order was not placed until 05/10/2023 at 10:54 AM; 5 days after nursing staff noticed a change/worsening condition of the right Buttocks wound. (Wound Care progress notes dated 04/13/2023 stated to "...Please re-consult if wound status declines or new skin issues arise.")

Review of the nursing progress notes from 05/05/2023 through 05/10/2023 revealed that there was no documentation of the nursing staff identifying barriers and changing the nursing interventions to address the worsening condition of the Buttocks wound as per policy.

Review of Pt #1's Certified Wound Nurse Consult Note dated 05/24/2023 at 3:50 PM, revealed that the "Reason for Consult" was for recommendations for care of "Other-Wound care to back/buttocks." Per Wound Care note, "Wounds not present on admission..."; "Wounds to Left Buttock...noted 5/24." Review of the Wound Care to Buttocks Recommendations revealed to; cleanse wound with Lotion Cleanser, pat dry, apply barrier cream, and cover with an oil-emulsion gauze dressing to prevent cream from adhering to clothing/bed linen. Per Wound Care recommendations, wound care should be performed daily and as needed for soiling.

Review of Pt #1's Left Buttocks Wound assessments documented on 06/04/2023 at 8:00 AM and 8:00 PM, 06/05/2023 at 8:00 AM and 8:00 PM, and 06/06/2023 at 9:04 AM, revealed that the "Dressing" assessments were documented as "Open to air". Per the Wound Care Consult recommendations, the Buttocks wound should be covered with an oil-emulsion gauze dressing after cleansing and applying barrier cream.

Per interview with Nurse Manager F on 07/11/2023 beginning at 9:31 AM, Manager F stated that staff should be documenting repositioning every 2 hours in "real time." Manager F stated that staff should be following Wound Care recommendations. Nurse Manager F agreed that nursing staff should consult Provider when skin condition/injury worsens or is not improving with current treatment; per Nurse Manager F, the Wound Care consult must be ordered by the Provider. Manager F stated that nursing wound assessments should be completed every shift.