HospitalInspections.org

Based on policy reviews, administration
interviews and medical record reviews,
the hospital failed to implement basic
patient's skin care interventions
observed in 1 of 6 medical
records, as noted in P2's record.

Failure to implement the hospital's
comprehensive skin care prevention
program does not assure that patient's
basic needs will be met or incidence
of patient's pressure ulcers will be reduced.

Findings:

1. On 03/16/2010, I reviewed a policy titled,
"Skin Integrity." The policy was approved
on 05/2008 by administration. Review of the
policy documentation identified on page 1 of 3,
noted in point #2 that nursing service was to
used the Braden Assessment Tool to assess
patient's for the risk of skin breakdown.
The Braden Assessment Tool instructed nursing
to do the following:
1) If patient's total skin score is less then 18,
nurses were to institute preventive measures
that addressed skin care areas at risk.
2) The specific nursing interventions to be
instituted included the following:
a) Change patient's position every 2 hours
or as defined in the patient's individual
plan of care. b) Use pillows or foam
wedges apply to patient's bony prominences
(i.e. elbows, knees, heels, sacrum etc.)
to avoid direct pressure contact.
3) Other multidisciplinary team members
should be consulted when appropriate.

2. On 03/17/2010, I reviewed the patient's
medical record (P2). The documentation
determined the patient was an 87 year old
who had fallen at the casino and fractured
his/her left hip. The patient was admitted
on 02/18/2010 from the Emergency
Department to the medical and surgery
unit. Review of the patient's admission
documentation on the care plan determined
that nursing assess the patient's Braden
score and it measured 18. The nursing
documentation on the care plan also
determined the patient had a left hip
replacement on 02/18/2010. The review
of nursing documentation determined
that nursing failed to check off any specific
skin care interventions (i.e. turning the patient
every 2 hours). The nursing intervention of
turning a patient every 2 hours is a basic
nursing intervention that is used to
prevent ulcers.



3. During an interview on 03/17/2010 with the
the Inpatient Services Administrator.
The administrator confirmed that nursing staff
did not check of any skin interventions for the
patient. S/he reported nursing should have
check off nursing intervention related to turning
the patient every 2 hours or more often.
Review of nursing documentation also
determined the patient was confused and
was refusing to be turned because of hip pain.
The nursing staff failed to follow the skin care
policy to reduce potential pressure ulcers
to an 87 year old new post-op surgery patient.

Based on review of medical records,
policy reviews, administration interviews and
staff interviews, the hospital failed to contact
the specific multidisciplinary team member
to assess patient's pressure ulcers. This was
observed in 1 of 6 medical records,
noted in P1's record.

Failure to obtain the Wound Care RN in a timely
manner to assess patient's skin issues does not
assure that nursing is supporting the hospital
pressure ulcer prevention program and
fails to met patient safety goals.



Findings:

1. On 03/16/2010, I reviewed a policy titled,
"Pressure Ulcer Assessment and Care".
The policy was approved on 05/2008 by
administration. The policy described that
RNs would perform a skin assessment
when patients were admitted. The assessment
would include a full body inspection. The RNs
would use the Braden Risk Assessment Tool to
identify patients that were at risk for skin
breakdown. The Braden Risk Assessment Tool
would assist RNs in implementing prevention
strategies for all patients that were at risk for
pressure ulcers. This policy continued to
document the patient's skin would be
assessed within: 1) 2 hours of admission,
2) On every shift, 3) Upon transfer to
a different level of care, 4) As warranted
by change in patient condition, and
5) Upon discharge of the patient.
The policy continued to reveal in the
"Reporting" section, noted on page 4 of 4
that all pressure ulcers found on admission:
A. Will be reported to the charge nurse
and house supervisor.
B. Nurses will generate an incident report
and send it to the Quality Improvement
Committee for review.

2. I reviewed another skin care policy titled,
"Skin Integrity". The policy was approved
on by administration on 05/2008. The policy
read: If patient's Braden Skin assessment
score equal 18 or less, nursing was to
institute preventive measures to address the
specific area of risk.

3. On 03/16/2010, I reviewed P1's medical
record. The review determined the 65 year
old patient was admitted on 11/23/2009 for a
stomach fistula repair. Review of patient's history
and physical documented the patient had multiple
sclerosis, was a quadriplegia and was
"dependent on a trach for 5 plus years."
Review of nursing entry documented on the
patient's admission note dated 11/23/2009
determined that patient's skin integrity was
assessed. The nursing initial skin entry
documented the patient had blanched pink
areas on right and left buttocks and the Braden
Skin assessment score measured 18.
The patient had a peg tube in his/her
stomach for tube feedings. The review
determined the patient's blood pressures were
dropping (BP 81/52). Nursing made an entry
the physician was contacted and patient was
transfer from the Medical Unit to the
Critical Care Unit.

4. The Critical Care Staff placed the patient on
the ventilator. On 11/24/2009 nursing assessed
patient's skin integrity issues. This was patient's
second day in the hospital. The patient's Braden
Scale Score measured a total of 15. Review of
the patient's care plan developed by the
Critical Care RNs dated 11/25/2009,
determined that nursing did not check off any
skin care interventions. Review of the nursing
entries on there Progress Notes dated
11/25/2009 at 0900, at 1200 noon, at 1430 and
at 1800 determined that only one skin care
intervention was used by nursing.
This intervention was "repositioning the patient
every two hours". The nursing entry made
at 2230 documented the patient was
repositioned to the right side and cream was
applied to reddened buttock areas. Also, nursing
continued to document that heel protectors
were placed on right and left heels. Review of
nursing documentation failed to document that
patient's skin condition at heel areas were normal
and skin was intact.

5. Review of P1's care plan dated 11/26/2009
documented the patient's Braden Skin
assessment measured 11. The nurse
documented that a dietician consult order would
be obtained. This was a skin care strategy noted
on the patient's care plan.

6. On 03/16/2009 I continued to review the
nursing entries documented on the patient's care
plan dated 11/27/2009, 11/28/2009, and
11/29/2009. The review determined the patient's
Braden Score continued to measure 11.
The nursing continued to document that patient's
buttocks was redden and skin care interventions
were checked off on the care plan.
On 11/30/2009, nursing documented that
patient's Braden score measured 13.
On 12/01/2009 nursing made an entry the
Wound Care Management consult was ordered.
Nursing assessed and documenat the patient's
Braden score measured 12 on 12/01/2009.
This order was obtained on the patient's 9th
hospital day after patient's Braden scores
measured less then 18 for 5 days.

7. Review of the Wound Care RN documentation
on 12/01/2009 determined s/he assess the
patient's right and left buttock and documented
the data on patient's Wound Care Log.
The Wound Care RN's entry identify the patient's
left buttock wound was a "deep tissue injury"
and the right buttocks wound consisted of
"devitalized tissue". The review on the log
determined that no stagging was documented
on the Wound Care Log Report. The patient
was on a Kin Air special bed.

8. On 03/16/2010, during an interview with
Rehabilitation Nurse Manager. S/he explained
the patient's decubitus were to be re-assessed
by the Wound Care RN every 7 days after the
initial assessment was made. Only one
assessment was found on the patient's
Wound Care Log and it was dated 12/01/2009.

9. On 03/17/2010, during, an interview with
the Wound Care RN. S/he reported
the patient's initial skin care assessment was
done on 12/01/2009. S/he confirmed that
only one wound care assessment was
documented in the record. S/he continued to
report a second assessment should have
been done within 7 days prior to patient's
discharge on 12/07/2009. This patient was
being discharged back to the nursing home.

10. On 03/17/2010, during an interview with the
Vice President of Patient Care, RN and Inpatient
Service Administrator, RN. They confirmed the
nursing staff failed to be proactive in managing
this patient's skin care issues. Nursing should
have contacted the Wound Care RN earlier
to assess the patient's skin care issues and
follow-up should have occurred.

11. The nursing documented the patient's
Braden Skin scores measured less then 18
on 11/25/2009, 11/26/2009-11/29/2009.
The nursing documentation entries
determined the patient's Braden Skin scores
measured 11. On 12/01/2009 the patient's
Braden Skin score measured a total of 12
which was noted on the patient's 9th hospital day.
The patient's history identified this patient was
at high risk for developing pressure ulcers.
The nursing service failed to follow the written
skin care policies and procedures and failed to
reassess the implement skin interventions.
The nursing staff was reacting to the treatment
of skin care issues verses acting proactively
in preventing patient's skin ulcers.
The Wound Care RN needs to be contacted
when a patient's Braden Skin score measures
changed i.e. from 18 to 11. When patient's
blood pressures drops this causes a decrease
in patient's cardio-vascular and capillary blood
flow that can cause pressure ulcers.
Nursing needs to use critical thinking judgement
skills when assessing patient's Braden Skin scores.