HospitalInspections.org

Based on findings from document review and interview, in 1 of 1 medical record (MR) reviewed, the nursing care provided to a patient, as documented, did not meet generally accepted standards of care. Specifically, despite the patient's risk for developing pressure ulcers, identified upon admission, nursing staff did not implement all appropriate interventions. Additionally, the nursing documentation in this case was incomplete and varied widely in descriptions of the patient's pressure ulcers, and did not consistently describe accurate Skin Risk Assessment scores.

Findings include:

-- Per review of Patient A's MR, on 2/5/10 at 1400 the admission nurse (Registered Nurse/RN #1) documented on the Pressure Ulcer Wound Assessment section of the 24 hour flowsheet: "pink, intact skin, stage 1 pressure ulcer on the coccyx #3 skin barrier applied".. He/she assigned the patient a score of 13, moderate risk, on the Skin Risk Assessment scale, subscored as follows:
* Sensory Perception = 3, confused
* Moisture = 2, frequently moist
* Activity = 2, chair fast
* Mobility = 2, very limited
* Nutrition = 2, probably inadequate
* Friction & Shear = 2, slides occasionally in bed

-- Per review of the hospital's policy entitled "Skin and Pressure Ulcer Protocol," last revised 12/08, it describes interventions for specific subscale scores (from the determination of a patient's risk to develop a pressure ulcer(s) during hospitalization) as follows:

Sensory Perception score of 3:
* Turn and position every 2 hours, reassess for red areas
* Wedge foam cushion if OOB (out of bed)
* Elevate heels off bed
* Consider heel protector "boot"

Moisture score of 2 or 3:
* Offer bedpan/urinal with each turning
* Air dry skin folds
* Use gauze pads in skin folds as needed
* Assess for fungal infections or excoriated areas

Activity score of 2:
* Suggest PT/OT evaluation
* OOB for meals as tolerated
* Elevate heels in bed with pillow or heel boot
* Hoyer lift as needed

Mobility score of 1 or 2:
* Turn and reposition every 2 hours
* Check for areas of redness
* Range of Motion to unaffected limbs every shift and as needed
* Elevate heels off bed
* Consider specialty bed

Nutrition score of 2:
* Daily weights
* Manage contributing factors: e.g. nausea, constipation, dentition, and pain
* Consult with Registered Dietician

Friction and Shear of 1 or 2:
* Elevate foot of bed 30 degrees when HOB elevated
* Use slip sheet to assist with movement
* Use transfer mats when moving patient up in bed.
* OOB for meals when possible.
* Pad bony prominences

-- In Patient A's MR, RN #1 documented the following interventions in the Skin Risk Assessment section:
* Turn and Position every 2 hours
* Head of bed elevated to 30 degrees or less
* Use lift pads
* Elevate heels off bed
* Pillow between bony prominences
* Protective barrier every 8 hours and after each incontinence
* Assist with feedings
* Transfer mats

However, despite description in Patient A's MR of the presence of a Stage 1 pressure ulcer upon admission, there is no documentation indicating a specialty mattress was applied. Further, despite the policy above requiring consultation with a Registered Dietician (RD) for a nutrition subscore of 2, there is no documentation that such consultation was initiated.

-- Per continued MR review, only 6 1/2 hours following RN #1's admission assessment of Patient A's skin, at 2030 RN #2 assigned the patient a skin risk assessment score of 14, moderate risk, and documented in the narrative section of the nursing progress notes "skin care given; duoderm to DTI (deep tissue injury) area on coccyx...patient repositioned on left side."

Characteristics, including measurements of the DTI were not documented. Also, the MR does not indicate a speciality mattress was applied or that a consultation with an RD was initiated.

-- On 2/6/10 RN #3 documented a subscore of 4 (rarely moist) for Moisture on the Skin Risk Assessment form. However, the remaining subscores and the Pressure Ulcer Wound Assessment flowsheet were not completed. RN #3 documented on the Record of Hourly Rounds that the patient was rounded on every 2 hours; however, documentation that the patient was repositioned is lacking. Also, description of the DTI observed and the duoderm applied on 2/5/10 was not documented.

-- On 2/7/10 RN #4 documented a score of 17, mild risk, on the Skin Risk Assessment form and "no current problems" on the Pressure Ulcer Wound Assessment flowsheet. However, RN #4 also documented in his/her narrative note "reddened coccyx, cream applied." The score of 17 was inaccurate (see interview findings further below). Again, the DTI observed and duoderm applied on 2/5/10 were not described. Further, there is no indication the patient was turned and repositioned every 2 hours, that a specialty mattress was applied or that consultation with an RD was initiated.

This manner of incomplete and inconsistent documentation of Patient A's skin assessments and skin care interventions continued for the remainder of the patient's hospitalization.

--Per interview of RN #2 on 4/2/10 at 3:15 p.m., on 2/5/10 the skin on the patient's coccyx was intact but had a purple/maroon color; he/she documented this as a DTI, applied duoderm to prevent skin breakdown and repositioned the patient on his left side. The patient was restless and able to reposition himself, though he/she acknowledged not documenting this on the Record of Hourly Rounds section of the MR.

-- Per interview of RN #4 on 4/12/10 at 2:30 p.m., on 2/7/10 he/she assessed the patient's skin and documented a reddened coccyx for which he/she applied moisture barrier cream. During review of Patient A's MR, RN #4 acknowledged that he/she incorrectly assigned the patient a score of 17, mild risk, on the Skin Risk Assessment. He/she acknowledged assigning a score of 3 (slightly limited) for mobility when the patient was more appropriate for a 2 (very limited), a score of 3 (no apparent problem) for friction and shear when a 2 (slides occasionally) would have been more appropriate as the patient needed frequent repositioning. RN #4 also acknowledged that, given these factors, he/she should have, but did not assign the patient a score of 13-14, moderate risk, on the Skin Risk Assessment in the MR. RN #4 stated that he/she repositioned the patient with pillows every 2 hours, including elevating his heels, but acknowledged not documenting this in the MR.