HospitalInspections.org

Based on policy review, medical record review, and staff interview the hospital's nursing staff failed to supervise and evaluate patient care by failing to implement skin breakdown prevention measures for 3 of 5 sampled patients at increased risk for skin breakdown (#7, #6, and #12).

The findings include:

Review of current hospital policy entitled "Skin Integrity Assessment - Adult and Specialty Bed" dated 09/09/1997 and reviewed 08/18/2010 revealed, "PURPOSE: To identify patients with an alteration or potential for alteration in skin integrity related to pressure and other contributing skin breakdown factors. Initiate treatment or protocol for alteration based on the stage of the ulcer....GUIDELINES: 1. On admission, the Braden Risk Assessment Scale is completed as part of the Nursing Admission Assessment. 2. A complete skin assessment is completed on admission....3. If the Braden score is 16 or below the nurse initiates the Skin Breakdown Prevention Protocol....4. If the patient has skin breakdown, the nurse initiates the Pressure ulcer/Wound Care Protocol...."

Review of current hospital protocol entitled "Skin Breakdown Prevention Protocol" reviewed 07/15/2010 revealed, "Initiate Skin Breakdown Prevention Protocol for Braden Score 16 or Less per Nursing Assessment: Pressure Reduction: Establish turning schedule. Turn patient at least every 2 hours....float heels off of bed using a pillow underneath calves, or use waffle boots....If patient develops Pressure Ulcer/Skin Breakdown: Initiate Pressure Ulcer/Wound Care Protocol...."

1. Closed medical record review for Patient #7 revealed a 40 year-old female that was admitted to the 2-South nursing unit on 07/25/2010 with a diagnosis of sepsis (systemic infection) from a skilled nursing facility. Record review revealed the patient had a history of anoxic encephalopathy (brain damage due to lack of oxygen) that developed following a cardiac arrest in May 2009 and had been in a persistent vegetative state since then. Record review revealed the patient was bedridden. Review of the admission nursing assessment dated 07/25/2010 at 0645 revealed the patient's skin was intact upon admission with no evidence of breakdown. Further review of the admission nursing assessment revealed the patient's Braden Score was 14 (increased risk for skin breakdown) and "Skin Breakdown Prevention Orders Activated - Yes". Review of the physician orders revealed the physician dated and signed "Skin Breakdown Prevention Protocol" on 08/05/2010 at 1645 (11 days after the patient was assessed to be at increased risk for skin breakdown and the nurse documented the orders were activated). Record review revealed the first documentation that patient's heels were floated off the bed on 07/30/2010 at 0830 (5 days after the patient was assessed to be at increased risk for skin breakdown). Record review revealed no documentation the patient was turned every 2 hours on the following dates:
? 07/25/2010 from 0645 to 1600 (9 hours and 15 minutes);
? 07/25/2010 from 2013 to 07/26/2010 at 0048 (4 hours and 35 minutes);
? 07/26/2010 from 0830 to 07/27/2010 at 0030 (16 hours);
? 07/27/2010 from 0030 to 0935 (9 hours and 5 minutes);
? 07/27/2010 from 0935 to 2013 (10 hours and 38 minutes);
? 07/27/2010 from 2013 to 07/28/2010 at 0415 (8 hours and 2 minutes);
? 07/28/2010 from 0415 to 07/29/2010 at 0430 (24 hours and 15 minutes);
? 07/29/2010 from 0430 to 1600 (11 hours and 30 minutes);
? 07/29/2010 from 1600 to 2255 (6 hours and 55 minutes);
? 07/29/2010 from 2255 to 07/30/2010 at 0830 (9 hours and 35 minutes);
? 07/30/2010 from 0830 to 07/31/2010 at 1230 (28 hours);
? 07/31/2010 from 1230 to 2130 (9 hours);
? 07/31/2010 from 2130 to 08/01/2010 at 1415 (16 hours and 45 minutes);
? 08/01/2010 from 1415 to 08/02/2010 at 0400 (13 hours and 45 minutes);
? 08/02/2010 from 0400 to 08/03/2010 at 0730 (27 hours and 30 minutes);
? 08/03/2010 from 1530 to 08/04/2010 at 0721 (15 hours and 51 minutes); and
? 08/04/2010 from 1230 to 08/05/2010 at 0900 (20 hours and 30 minutes).
Review of nurse's notes from the time of admission through 08/05/2010 revealed documentation the patient's skin was intact with no evidence of breakdown. Review of nurse's notes dated 08/05/2010 at 0846 revealed, "Patient has pressure sore on left heel." Record review revealed on 08/05/2010 at 0846 the nurse requested a Wound Care Nurse referral. Record review revealed the Wound Care Nurse (WOCN) evaluated the patient on 08/06/2010. Review of a WOCN note dated 08/06/2010 at 1046 revealed, "pt (patient) is very contracted pt and it will be very difficult to keep feet from recieving pressure from the bed, as a result there is a deep tissue injury on the lt (left) heel lt side of foot, rt (right) small toe and rt great toe....I suggest foam cradles to attempt to pressure relieve and Mepilex AG between the toes." Record review revealed the next documentation the patient's heels were floated off the bed was on 08/13/2010 at 1015 (8 days after skin breakdown was found on the patient's feet). Further record review revealed no documentation the patient was turned every 2 hours on the following dates (after the patient was found to have skin breakdown):
? 08/05/2010 from 0900 to 1942 (10 hours and 42 minutes);
? 08/05/2010 from 1942 to 08/07/2010 at 1730 (45 hours and 48 minutes);
? 08/07/2010 from 1730 to 08/08/2010 at 1200 (18 hours and 30 minutes);
? 08/08/2010 from 1200 to 08/09/2010 at 0051 (12 hours and 51 minutes);
? 08/09/2010 from 0051 to 0459 (4 hours and 8 minutes);
? 08/09/2010 from 0459 to 08/10/2010 at 1030 (29 hours and 31 minutes);
? 08/10/2010 from 1030 from 1030 to 08/11/2010 at 1100 (24 hours and 30 minutes);
? 08/11/2010 from 1100 to 2000 (9 hours);
? 08/11/2010 from 2000 to 08/12/2010 at 1430 (18 hours and 30 minutes);
? 08/12/2010 from 1430 to 2000 (5 hours and 30 minutes);
? 08/13/2010 from 0600 to 1015 (4 hours and 15 minutes);
? 08/13/2010 from 1015 to 08/15/2010 at 1544 (53 hours and 29 minutes);
? 08/15/2010 from 1544 to 08/16/2010 at 0040 (8 hours and 56 minutes);
? 08/16/2010 from 0040 to 0440 (4 hours);
? 08/16/2010 from 0622 to 1420 (7 hours and 58 minutes);
? 08/16/2010 from 1420 to 2000 (5 hours and 40 minutes);
? 08/17/2010 from 0001 to 0430 (4 hours and 29 minutes);
? 08/17/2010 from 0700 to 1600 (9 hours); and
? 08/17/2010 from 1600 to 2000 (4 hours).
Record review revealed the patient's Braden Score ranged between 6 and 15 throughout the hospitalization. Review of nurse's notes dated 08/18/2010 at 0900 revealed, "Patient has pressure sore on left heel and to both feet. Patients left fourth toe edematous with pus....Pressure Ulcer...Stage 2...Left heel...." Record review revealed on 08/18/2010 the patient was discharged to a Long Term Acute Care hospital.

Interview on 12/15/2010 at 1515 with the Wound Care Nurse revealed Skin Breakdown Prevention Protocol should immediately be implemented for all patients with Braden Scores of 16 or less. Interview revealed patients that were at increased risk for skin breakdown must be turned every 2 hours and should have their heels floated off the bed, either with pillows or waffle boots. Interview revealed Patient #7 was at increased risk for skin breakdown. Interview revealed the Wound Care nurse evaluated the patient after she developed skin breakdown on her feet. Interview revealed staff apply waffle boots to the patient's feet to prevent pressure.

Interview on 12/15/2010 at 1530 with the Nurse Manager the 2-South nursing unit revealed nursing staff must assess patients for risk of skin breakdown by utilizing the Braden Score upon admission and each following shift. Interview revealed Skin Breakdown Prevention Protocol should immediately be implemented for all patients with Braden Scores of 16 or less. Interview revealed when the nurse implemented the protocol she placed a copy of a pre-printed order sheet (that contained the protocol) on the patient's medical record and the physician signed the orders when he/she came in. Interview revealed sometimes the orders were placed in the record, but not signed by the physician for several days. Interview revealed patients that were at increased risk for skin breakdown must be turned every 2 hours and have their heels floated off the bed.. Interview revealed Patient #7 was at increased risk for skin breakdown. Interview confirmed there was no available documentation the patient was turned every 2 hours during her hospitalization. Interview revealed, "I just found out today that the CNAs had a place to document turning in the chart....This is a good opportunity to educate staff."

2. Closed medical record review for Patient #6 revealed a 76 year-old female that was admitted on 08/01/2010 from a skilled nursing facility with diagnoses of acute respiratory failure, urinary tract infection with sepsis (systemic infection), and history of chronic obstructive pulmonary disease. Record review revealed the patient was bedridden. Review of the admission nursing assessment dated 08/01/2010 at 2011 revealed the patient had a Stage 1 pressure ulcer on her sacrum upon admission. Record review revealed the nurse requested a Wound Care Nurse referral upon admission. Review of the nurse's admission skin assessment revealed, "Healed pressure area sacrum with skin tear." Further review of the admission nursing assessment revealed the patient's Braden Score was 11 (increased risk for skin breakdown) and "Skin Breakdown Prevention Orders Activated - Yes". Review of the physician orders revealed the physician dated and signed "Skin Breakdown Prevention Protocol" on 08/05/2010 (no time) (4 days after the patient was assessed to be at increased risk for skin breakdown and the nurse documented the orders were activated). Record review revealed the Wound Care Nurse (WOCN) evaluated the patient on 08/02/2010. Review of a WOCN note dated 08/02/2010 at 1416 revealed, "Pt (patient) has a small skin tear on sacrum, there is some discoloration from scarring from healed stage 4 pressure ulcer. Pt is co (complaining of) severe pain in the buttocks area, but there is no visible reason for the pain." Record review revealed the first documentation that patient's heels were floated off the bed on 08/04/2010 at 0959 (3 days after the patient was assessed to be at increased risk for skin breakdown). Record review revealed no documentation the patient was turned every 2 hours on the following dates:
? 08/01/2010 from 2011 to 08/02/2011 at 0900 (12 hours and 49 minutes);
? 08/02/2010 from 0900 to 08/03/2010 at 0900 (24 hours);
? 08/03/2010 from 1030 to 08/04/2010 at 0730 (21 hours);
? 08/04/2010 from 1630 to 2001 (3 hours and 31 minutes);
? 08/04/2010 from 2001 to 08/05/2010 at 0000 (3 hours and 59 minutes);
? 08/05/2010 from 0000 to 0830 (8 hours and 30 minutes);
? 08/05/2010 from 1430 to 2000 (5 hours and 30 minutes);
? 08/06/2010 from 2200 to 08/10/2010 at 1030 (79 hours and 30 minutes);
? 08/10/2010 from 1030 to 2328 (12 hours and 58 minutes); and
? 08/10/2010 from 2328 to 0600 (6 hours and 32 minutes).
Record review revealed the patient's Braden Score ranged between 10 and 15 throughout the hospitalization. Record review revealed on 08/11/2010 the patient was discharged to a skilled nursing facility.

Interview on 12/15/2010 at 1515 with the Wound Care Nurse revealed Skin Breakdown Prevention Protocol should immediately be implemented for all patients with Braden Scores of 16 or less. Interview revealed patients that were at increased risk for skin breakdown must be turned every 2 hours and should have their heels floated off the bed, either with pillows or waffle boots. Interview revealed Patient #6 was at increased risk for skin breakdown.

Interview on 12/15/2010 at 1345 with a Nursing Performance Improvement Coordinator revealed the Coordinator reviewed Patient #6's medical record. Interview confirmed the first available documentation that the patient's heels were floated off the bed was on 08/04/2010 at 0959 (3 days after the patient was assessed to be at increased risk for skin breakdown). Further interview confirmed there was no available documentation the patient was turned every 2 hours during her hospitalization.






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3. Open medical record review, during tour of the 2-South Nursing Unit on 12/15/2010 at 1330, for Patient #12 revealed a 91 year-old female that was admitted on 12/12/2010 with a diagnosis of respiratory difficulty and urinary tract infection. Record review revealed the patient was admitted with a sacral (base of spine) bed sore and a necrotic area (dying tissue) on the sole of her left foot. Record review revealed the patient's morning and evening "Braden Scores (skin breakdown risk assessment)" were 12 and 14, respectively, on 12/12/2010 (increased risk for skin breakdown); 15 and 12, respectively, on 12/13/2010 (increased risk for skin breakdown); and 11 and 11, respectively, on 12/14/2010 (increased risk for skin breakdown). Electronic medical record review revealed "Skin Breakdown Prevention Orders Activated - Yes". Paper medical record review revealed a blank "Skin Breakdown Prevention Protocol" order sheet on the front of the chart, without patient specific parameters checked and without a physician's signature (3 days after the patient was assessed to be at increased risk for skin breakdown and the nurse documented the orders were activated). Record review revealed no documentation the patient was turned every 2 hours or that heels were floated off the bed between 12/12/2010 at 1700 to 12/14/2010 at 0000.

Interview with a staff nurse on 12/15/2010 at 1335, during unit tour and electronic/paper medical record review, revealed the electronic record incorrectly showed a "Skin Breakdown Prevention Protocol" was in place for Patient #12. Interview confirmed the paper chart contained a blank "Skin Breakdown Prevention Protocol" sheet. Interview revealed the protocol was not in place until the nurse obtained an order (written or verbal) from the physician. Further interview revealed a physician ordered "Skin Breakdown Prevention Protocol" was required to obtain special skin care products from the pharmacy. Interview revealed patients with Braden Scores =16 should have physician signed "Skin Breakdown Prevention Protocol" orders in the medical record. Interview confirmed Patient #12 had Braden Scores =16 and had skin breakdown upon admission. Interview revealed Patient #12 should have had an active "Skin Breakdown Prevention Protocol" in place on 12/12/2010. Interview confirmed there was no available documentation of a physician signed "Skin Breakdown Prevention Protocol" for the patient. Further interview confirmed there was no available documentation the patient had been turned every 2 hours or had her heels floated off the bed between 12/12/2010 at 1700 to 12/14/2010 at 0000.

Interview on 12/15/2010 at 1530 with the Nurse Manager the 2-South nursing unit revealed nursing staff must assess patients for risk of skin breakdown by utilizing the Braden Score upon admission and each following shift. Interview revealed Skin Breakdown Prevention Protocol should immediately be implemented for all patients with Braden Scores of 16 or less. Interview revealed when the nurse implemented the protocol she placed a copy of a pre-printed order sheet (that contained the protocol) in the patient's medical record and the physician signed the orders when he/she came in. Interview revealed sometimes the orders were placed in the record, but not signed by the physician for several days. Interview revealed patients that were at increased risk for skin breakdown must be turned every 2 hours and have their heels floated off the bed.


NC00068368