HospitalInspections.org

Based on medical record review, review of the Pressure Prevention Protocol, Policy and Procedure and interviews, nursing staff failed to document consistent turning every two hours as ordered per Pressure Prevention Protocol of Patient Identifier (PI) # 1, a patient identified at risk for the development of pressure ulcers on admission and the presence of wounds to the coccyx and heel on admission. This affected one of ten records reviewed.

Findings include:

A review of the medical record revealed PI # 1 presented to the Emergency Department (ED) via EMS (Emergency Medical Services) on 5/18/15 with a chief complaint of respiratory distress's. PI # 1 was admitted to Medical Intensive Care (MICU) with diagnoses to include Acute on Chronic Respiratory Failure with Hypoxia and Bilateral Pleural Effusions.

According to the Wound Care notes dated 5/18/15 at 4:17 PM, PI # 1 had two wounds present on admission:

1). Unstageable pressure ulcer to the coccyx. (Full thickness skin or tissue loss - depth unknown. Actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed, www.npuap.org)

Measurement: 3.0 centimeters (cm) x 4.0 x 2.3 with undermining (erosion under the wound edges, www.woundsource.com). "Dark black gray" tissue noted with odor.

2). Right heel with Deep Tissue Injury. (Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Evolution may be rapid exposing additional layers of tissue even with optimal treatment, www.npuap.org).

Measurement: 0.8 cm. x 1.0 cm.

Braden Score: 11. (Braden Scale: a tool to help assess a patient's risk of developing a pressure ulcer using six criteria: sensory perception,
moisture, activity, mobility, nutrition, friction and shear, en.wikipedia.org).


Wound Care Orders/Treatment
1. Implement Pressure Prevention Protocol...

Review of the Hospital's Pressure Prevention Protocol revealed:
A. While in bed:
1. Turn every 2 hours...


Policy and Procedure: Braden Scale for Predicting Pressure Sore Risk
Policy Number: NRS 006, Revised 5/21/15:

A. Admission
...2. For a scale of 18 or less, the patient is considered at risk. Implement Pressure Prevention Protocol...


Review of PI # 1's Medical Record:

A review of the Daily Care Safety Flowsheet revealed no documentation regarding turning of PI # 1 every two hours on the following dates and times:

- 5/23/15: 7:31 PM through 7:10 AM;

- 5/24/15: 7:10 AM through 2:13 PM and 7:41 PM through 11:00 PM

5/25/15: 12:24 AM through 4:00 AM, 1:00 PM through 6:00 PM and 10:00 PM through 9:00 AM on 5/26/15

5/26/15: 9:00 AM through 7:00 AM on 5/27/15

5/28/15: 7:25 PM through 2:58 AM on 5/29/15

5/29/15: 9:00 PM through 1:00 AM and 1:08 AM through 8:00 PM

5/31/15: 8:30 AM through 6:30 PM and 11:00 PM though 7:00 PM on 6/1

6/2/15: 7:00 PM through 8:43 AM; 9:30 - 1:45 PM and 8:30 PM - 8:00 AM on 6/3

6/3/15: 8:00 through 2:30 PM and 7:51 PM through 3:59 AM on 6/4

6/4/15: 10:38 through 6:43 PM

6/5/13: 8:20 PM though 8:32 AM.

During an interview on 10/28/15 at 11:20 AM, the Director of Nursing, Employee Identifier (EI) # 1, confirmed the dates and times on the Daily Care Safety Flowsheets for PI # 1 were correct.


Carolyn Andreu, RN