HospitalInspections.org

A. Based on document review and interview, it was determined for 1 of 3 (Pt. #1) clinical records reviewed of patients who developed pressure ulcers, the hospital failed to identify pressure ulcers on daily reassessments.

Findings include:

1. Hospital policy titled, "Documentation in the Medical Record by Nursing Personnel (revised 9/07)" required, "Nursing personnel are required to document: 1. the initial patient assessment, evaluation and reassessment,"

1. The clinical record of Pt. #1 was reviewed on 12/16/13. Pt. #1 was an 81 year old male admitted on 8/30/13 with the diagnosis of psychosis. Daily nurse reassessment notes from 8/31/13 to 9/8/13 indicated the skin was intact. The nurse reassessment note dated 9/9/13 at 3:10 PM included, " unstageable sacral wound, seen by MD (MD#1) - for wound consult. "

The wound care nurse progress note dated 9/10/13 at 7:30 PM included, " assessed patient coccyx pressure ulcer. Stage III, 5.5 by 3.5 by 0.1 centimeter..."

2. The nurse coordinator (E#3) was interviewed on 12/16/13 at 2:30 PM. E#3 was the nurse who identified the pressure ulcer. E#3 stated, " I turned the patient to his side to check his skin because I was told there was some slight redness on his buttocks. When I first looked, I did not see anything, but them I spread the buttock cheeks. I saw, what I would call an unstageable pressure ulcer. " E#3 notified the attending and placed a call to the wound nurse for consult.

3. The wound nurse (E#6) was interviewed on 12/17/13 via telephone at 11:00 AM. E#6 stated she had received a call for a wound consult and saw the patient on 9/10/13. E#6 saw the wound and staged it as a " stage III " . E#6 stated, " The wound was probably present for some time, could have even been there on admission. You had to actually separate the butt cheeks to see the wound. The patient was not cooperative with any type of care, so that was difficult to do. "

B. Based on document review and interview, it was determined for 1 of 3 (Pt. #1) clinical records reviewed of patients at nutritional risk upon admission, the hospital failed to ensure nursing entered a dietary consult.

Findings include:

1. Hospital policy titled, "Admission assessment (revised 9/07)" required, "The assessment of each patient's physical, psychological, social and behavioral functioning is done to determine the need for the type of treatment, care and services to be provided."

2. The admission "Nursing Assessment form (revised 8/11)" required, "F. Nutrition screening: Any positive responses triggers an immediate dietary referral."

3. The clinical record of Pt. #1 was reviewed on 12/16/13. Pt. #1 was an 81 year old male admitted on 8/30/13 with the diagnosis of psychosis. The admission nursing assessment included Pt. #1 had an unexplained weight loss of more than 10 pounds in the past month and difficult chewing. A dietary referral was not made.

4. The registered dietician (E#1) was interviewed on 12/16/13 at 1:45 PM. E#1 evaluated Pt. #1 after receiving a referral because of a pressure ulcer on 9/10/13. When E#1 was asked about referral upon admission, E#1 responded, " there should have been a consult on admission. "

Based on document review and interview, it was determined for 3 of 5 (Pt. #1, 2 and 9) clinical records reviewed of patients with a low Braden score or developed a pressure ulcer during hospitalization, the hospital failed to ensure skin integrity was included in the care plan.

Findings include:

1. Hospital policy titled, "Admission assessment (revised 9/07)" required, "The assessment of each patient's physical, psychological, social and behavioral functioning is done to determine the need for the type of treatment, care and services to be provided."

2. Hospital policy titled, "interdisciplinary Treatment Plan (revised 9/12)" required, "The Master treatment plan shall be developed ... and included problems identified in the admission assessment, reassessment..."

3. The admission "Nursing Assessment form (revised 8/11)" required, "Braden Skin Breakdown Assessment: If risk score is moderate (13 - 14) or high (12 or less), complete skin breakdown treatment plan."

4. The clinical record of Pt. #1 was reviewed on 12/16/13. Pt. #1 was an 81 year old male admitted on 8/30/13 with the diagnosis of psychosis. Pt. #1 had a Braden score of 13 (moderate risk). A skin breakdown treatment plan was not initiated until 9/9/13 (after pressure ulcer developed).

5. The clinical record of Pt. #2 was reviewed on 12/17/13. Pt. #2 was an 84 year old female admitted on 9/2/13 with the diagnosis of depressive disorder. Pt. #2 had a Braden score of 12 (high risk). A skin breakdown treatment plan was not initiated.

6. The clinical record of Pt. #9 was reviewed on 12/17/13. Pt. #9 was an 88 year old male admitted on 9/9/13 with the diagnosis of psychosis. Pt. #9 developed a pressure ulcer on the buttocks on 9/16/13. Skin integrity was not added to the care plan.

7. During an interview on 12/16/13 at 2:15 PM, the Director (E#2) stated a plan of care is developed for each patient based on admission findings and is updated as needed.