HospitalInspections.org

Based on policy and procedure review, medical record review and personnel interview, the registered nurse failed to supervise and evaluate the care planned for each patient related to lack of and/or inconsistent documentation of wounds; lack of consulting the wound care nurse and lack of filing a Risk Control Incident Report according to policy and procedure for 1 of 5 (N1) closed patient medical records reviewed.

Findings:

1. Policy No.: NSI-ACT_42 titled, "Pressure Ulcer Assessment and Management Protocol", revised/reapproved 11/11, was reviewed on 5/14/13 at 1:00 PM and indicated on pg:

A. 1, under Policy section, "This protocol will provide guidance for assessing and documenting, pressure ulcers, preventing further tissue breakdown and infection; and promoting healing."

B. 4, under:
i. Communicating and Documenting Wound/Pressure Ulcers section, bulleted list, "Document wounds separately...Documentation of pressure ulcers should include...Measurement in centimeters; length, width, depth. Perform measurements upon admission and every seven (7) days during hospital stay."
ii. Obtain Consultations section, bulleted list, "Refer patients with multiple Stage II and/or Stage III or IV pressure ulcers to the Enterostomal Therapy Nurse using the computer consultation system. Notify the patient's physician of the existence of wounds and pressure ulcers on admission."

C. 5, under Communicating and Documenting Wound/Pressure Ulcers section, bulleted list, "Complete a risk control report and forward to Risk Management when...Patients develop pressure ulcers/wounds following admission."

2. Review of closed patient medical records on 5/14/13 at approximately 11:53 AM, indicated patient N1 was a 56-year-old who presented to the ED on 10/24/12 at 05:59 AM for evaluation of mental status change and was admitted as an inpatient for further medical management. Documentation in the medical record included:

A. per Discharge Summary dictated 2/13/13 at 19:16 PM:
a. "pressure ulcer, stage III; peripheral vascular disease, unspecified; pressure ulcer, lower back; and pressure ulcer, heel."
b. "[left] above-knee amputation on 1/10/13."

B. Wounds were not measured on admission or every 7 days and were documented inconsistently in several different areas of the patient's electronic medical record. At times, measurements were left blank. They were documented as:

On admission, no wounds documented and skin not addressed.

Sacrum Wound, stage II, not pre-existing on the:
a. Daily Care Flowsheets dated 10/26/12 at 0800, 3 cm length (L) x 1 cm width (W) x 0 cm depth (D). This same wound was measured as 5 x 4.5 x 0.2 on the Wound Nurse Notes for the same date and time.
b. Wound Nurse Notes dated 10/30/12 at (time blank), 4 x 4 x 0; this was inconsistent with the wound measurement on the Daily Care Flowsheet as indicated in a. above.
c. Nurses' Noted dated:
i. 12/6/12 at 1159, 7 x 5 x 0.2.
ii. 12/20/12 at 1145, 9 x 6 x 0.1; this is 14 days after the measurement from 12/6/12.

Sacrum Unstageable, not pre-existing on the:
a. Daily Care Flowsheets dated:
i. 10/30/12 at 0832, 8.1 x 8.2 x 0.2 and at 0900 at 4 x 4 x 0; inconsistent measurements.
ii. 11/7/12 at 1347, 9 x 7 x ? (none documented); a measurement for depth is required by policy
iii. 12/18/12 at 2100, 9 x 6 x 0.1; this is over a month since the measurement from 11/7/12.
iv. 1/16/13 at 1645, 9 x 8 x 0.2; this is almost one month after the measurement from 12/18/12.
v. 1/29/13 at 0230, 8 x 9 x 0.2; this is 12 days after the measurement from 1/16/12.

Right Heel, deep tissue injury (DTI), not pre-existing on the:
a. Daily Care Flowsheets dated:
i. 11/5/12 at 1034, 11.5 x 5 x 0.
ii. 11/7/12 at 1347, 4 x 3.7 x ? (none documented); a measurement for depth is required by policy. This measurement is very inconsistent with the one in a.i. from 11/5/12.
iii. 12/19/12 at 0000, 5 x 8 x 0; this is over a month since the measurement from 11/7/12.
iv. 1/16/13 at 1645, 7 x 6 x 0.4; this is almost a month since the measurement from 12/19/12.
v. 1/29/13 at 0700, 9 x 5 x 0.2; this is 12 days after the measurement from 1/16/12.
vi. 1/30/13 at 0745, 6 x ? (none documented) x ? (none documented); measurements for width and depth are required by policy.
b. Wound Nurse Notes dated 11/5/12 at 0900, 7.2 x 4.1 x 0.2 and again at 0900, 11.5 x 5 x 0; these two measurements are very inconsistent for the same date and time.
c. Nurses' Notes dated:
i. 12/6/12 at 1159, 10 x 6.5 x ? (none documented); a measurement for depth is required by policy.
ii. 12/25/12 at 1159, 3 x 3 x ? (none documented); a measurement for depth is required by policy and this is 19 days after the measurement on 12/6/12.

Left Heel and Posterior Leg, deep tissue injury (DTI), not pre-existing on the:
a. Daily Care Flowsheets dated:
i. 11/3/12 at 0800, 3.0 x 3.0 x 0.1.
ii. 11/7/12 at 1347, 5.0 x 4.0 x ? (none documented) and again on the same date at the same time 6.8 x 4.5 x ? (none documented); a measurement for depth is required by policy and these two measurements are very inconsistent for the same date and time.
iii. 12/19/12 at 0000, 5.0 x 5.0 x 0.1; this is over a month since the measurement on 11/7/12.
iv. left leg amputated 1/10/13.
b. Wound Nurse Notes dated 11/3/12 at 0800, 18.0 x 7.0 x 0.2; this is a very inconsistent measurement than the one on the Daily Care Flowsheet dated 11/3/12 in a.i. above.
c. Nurses' Notes dated:
i. 12/6/12 at 1159, 17.0 x 7.0 x 0.2; this is over a month since the measurement on 11/3/12.
ii. 12/25/12 at 1217,16.5 x 4.75 x ? (none documented); a measurement for depth is required by policy and this is 19 days after the measurement on 12/6/12.

Left Toes, deep tissue injury (DTI), not pre-existing on the:
a. Daily Care Flowsheets dated:
i. 11/20/12 at 1116, 1.0 x 2.5 x 0.2.
ii. 12/19/12 at 0000, 0.2 x 0.2 x ? (none documented); a measurement for depth is required by policy and this is almost one month since the measurement on 11/20/12.
iii. left leg amputated 1/10/13.
b. Nurses' Notes dated:
i. 12/6/12 at 1159, 1.0 x 1.0 x 2.0.
ii. 12/25/12 at 1217, 1.0 x ? (none documented) x ? (none documented); measurements for width and depth are required by policy and this is 19 days since the measurement on 12/6/12.

3. Risk Control Incident Reports were not filed according to policy and procedure (see Policy No.: NSI-ACT_42 titled, "Pressure Ulcer Assessment and Management Protocol" under Findings, point 1 above, that states, "Complete a risk control report and forward to Risk Management when...Patients develop pressure ulcers/wounds following admission." The two Risk Control Reports were not filed until 11/5/12 and 12/30/12 by nursing staff indicating patient had acquired wounds after admission. However, wound documentation indicated the patient had wounds on 10/26/12 (see above).

4. Personnel P5 was interviewed on 5/14/13 at approximately 12:24 PM and confirmed:
a. the Enterostomal Therapist (wound care nurse) assesses patients when nursing staff puts in a consult, or at physician discrepancy, or when a change in wounds is seen.
b. the consult for this patient was not put in until 10-29-12, which is 3 days after nursing staff documented a wound to the sacrum on 10-26-12. When nursing staff finds a wound and/or documents one, they are supposed to put in a consult for the wound care nurse to assess the patient. This was lacking for this patient and should have been submitted as soon as the wound was documented on 10-26-12.

5. Personnel P1 was interviewed on 5/14/13 at approximately 2:11 PM and confirmed:
a. wounds are measured on admission within 24 hours and then on Wound Wednesdays, so every week. This was lacking for this patient.
b. Risk Control Incident Reports are also usually done within 24 hours of assessing a patient's wounds. This was lacking for this patient.