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Based on wound care observation, staff interview, medical record review, and review of the hospital's policy and procedure "Pressure Ulcer Prevention", 2012 Lippincott, Williams and Wilkens, the hospital failed to ensure nursing care was delivered to ensure all the needs of the patients were met in regard to wound care. (A392) . The cumulative effect of these systemic practices resulted in the hospital's inability to ensure the patients ' nursing needs would be met.

Based on wound care observation, staff interview, medical record review, and review of the hospital's policy, the hospital failed to ensure nursing care was delivered to ensure the needs of three patients were met in regard to the documentation of wound measurements obtained during the provision of wound care as directed by the hospital's policy. This affected two (Patients #1, #9, and #11) of 11 patients reviewed . The patient census was 288.

Findings include:

The medical record review for Patient #1 was completed on 09/26/12. The patient was re-admitted to the hospital from the emergency room, on 09/19/12, after a prior hospitalization, for congestive heart failure from 9/15/12 to 9/18/12.
The admitting diagnosis for the 09/1/9/12, hospitalization was shortness of breath with a final impression of extreme weakness and pain in the patient's legs, congestive heart failure and a systemic inflammatory response syndrome. The assessment included in the history and physical documentation indicated the patient had a cellulitis of the right antecubital area which had been the previous access site for intravenous therapy. The medical record reported "(The patient) states did okay last night (09/18/12), and today she started running fevers and (having) chills temperature 101.4 and feeling so weak all over and (the patient) was not able to get up and around with (the patient's) walker."
The patient arrived to the hospital with a sacral decubitus ulcer and the wound care consultant was notified. The ulcer had been treated at home with the assistance of home health care nurses. The medical record lacked documentation of an assessment of this sacral decubitus on the initial nursing assessment dated as completed on 09/20/12. The wound care consultant assessed the patient on 09/21/12 at 15:46. The comment section of the assessment stated " Wound team-consult ulcer on coccyx-met with patient, presents on speciality bed overlay, turned to left side gently with 2 nurses, area at upper coccyx, removed aquacel ag mepilex dressing, area measures approximately 2 cm by 2.5 cm, stage 3 pressure ulcer, red moist at base, with some white tissue noted at base, some undermining noted between 9:00 o'clock and 3:00 o'clock, dark tissue noted at left corner, suggest cleanse area with normal saline, then apply aquacel ag (a hyper-fiber, micro fiber absorbent dressing ) moistened with mepilex ( external dressing with silicone end for decreased adhesions with patients that have frequent dressing changes), dressing to cover, change daily, reposition, won't see unless consult, talked to patient, nurse, " match MD "( electronic method of verifying order). This daily order was approved by the physician on 09/21/12. The next dressing change was documented by a staff nurse as being completed at 04:30 on 09/24/12.

The medical record revealed a lack of documentation of a daily dressing change, from 09/22/12/ to 09/24/12.

This finding was verified during an interview with Staff D (Registered Nurse Manager) and Staff E (Registered Nurse director) on 09/27/12 at 10:15 AM.

The next documentation in the medical record of a dressing change for this wound was on 09/25/12. The documentation lacked a description and measurements of the wound.

The patient's dressing change was observed on 09/26/12 at 11:00 AM . Staff C (the Assistant Nursing Director), and Staff E (the Unit Nursing Director), were present as well as the two staff nurses, Staff J and Staff K, performing the dressing change. The patient's dressing, which was dated 09/25/12, was removed. The wound was located in the patient's sacral area and was measured at this time by the nurse and was determined to be a stage 3, measuring 3 centimeters by 2.5 centimeter with a 1.5 centimeters in depth with tunneling. The drainage was described as gray in color with a foul order emanating from the ulcer. Below the sacral ulcer was an area, not previously described, (as verified by Staff J and Staff K), just posterior to the original ulcer. This area was red and moist with raised blistered areas. The nurse measured this wound as 3.8 centimeters by 1.5 centimeters. The patient's heels were noted to be red and the left heel had 3 to 4 areas of dark blue-black areas that Staff J described as looked like blood blisters. The nurse then applied skin lotion to the bottom the heels and positioned the patient's legs on pillows for support.

A skin care consultant's note was documented at 16:46 on 09/26/12. The consultant's note stated: " Follow up consult for small new open area close to the previous sacral wound, The wound appears as superficial, popped blister area with red, moist tissue. The unit has placed a piece of Aquacel AG dressing across the small area that is 2 centimeters by 0.25 centimeters. A mepilex dressing is covering all of the Aqua AG dressing, I assessed (the patient's) heels for skin issues, The right heel has non blanchable deep pink skin which is intact. (The patient's) right heel is light pink and does blanche. Ordered protective barrier for the heels and (the patient) remains on an air mattress. I encouraged (the patient) to try to increase her protein intake."


Review of the hospital's policy, "Pressure Ulcer Prevention ", 2012 Lippincott Williams and Wilkens " In the section noted as "Assessing and Cleaning the Wound" the following was stated "inspect the wound. Note the anatomic location, color, amount of drainage and necrotic debris, if present. Measure the wound size according to the facility's policy."

During an interview, at 10:18 AM on 09/28/12, with Staff L (a skin nurse consultant), Staff E (Nursing Director) and Staff H (Vice President of Patient Care) it was stated the hospital's expectation would be a wound measurement would be documented at each dressing change.


The medical record review for Patient #9 was completed on 09/27/12. The 73 year old patient was admitted from the emergency room to the hospital on 08/23/12 at 10:36 AM. The admitting diagnoses included a fall from bicycle with a right cephalohmeatoma, Paget's Disease, mild cardiomegaly and a contusion of the right hip. During the tour of the unit at 3:45 PM on 09/25/12, Staff M (the Registered Nurse manager on the Surgical Intensive Care Unit) described the patient as having skin breakdown. The medical record indicated the patient had a nursing request, dated 09/09/12, for a skin consult to review a decubitus ulcer, stage 3 on the coccyx . There was no prior documentation in the medical record review to indicate when this area had developed. The skin nurse consultant note, dated 09/10/12, reported: "skin care consult " decubitus on coccyx stage 3 ". Met with patient who is on a ventilator with an intravenous infusion. Heavy assist times two, nurses to left side. Removed mepilex to reveal a stage 2 pressure ulcer on patient coccyx and possible DIT (deep tissue injury). Xenaderm (a Vaseline based ointment) was ordered by the physician on 09/09/12, suggest continue apply the layer to area 2 times every day and as needed.. " The consultant's note lacked documentation of measurements of the wound.

Review of the remaining wound dressing changes documentation in Patient #9's medical record for the dates of 09/08/12, 09/09/12, 09/10/12, 09/11/12, 09/12/12 09/13/12, 09/14/12 and 09/15/12 revealed the documentation lacked measurements of the patient's pressure ulcer wounds.
The next wound consultation was dated 09/13/12 by the wound team. This consultation note stated "patient has an evolving deep tissue injury in (the) sacral area. Irregular shape (approximately 10 centimeters by 5 centimeters) and has already blistered and started to seep some. The tissue is red, moist and open, (The patient) is on an air mattress and Vasolex ointment (a Vaseline based ointment) . (The patient) is receiving tube feedings with increased protein. Having loose bowel movements. I did order a pressure reduction cushion for the straight chair that he sits up his room. "

A wound care documentation was noted in Patient #9's medical record on 09/21/12. It stated : "wound care verbal request for assist with wound care of sacral pressure ulcer. Sacral ulcer was cleaned with foam cleanser, then layer of Xenaderm was applied then covered with mepiflex dressing Patient was repositioned for comfort and emotional support. " The report lacked documentation of any measurement of the pressure ulcer.


Review of the medical record for Patient #11 was conducted on 09/27/12. Patient #11 was admitted on 05/25/12, with a primary diagnosis of sepsis (systemic infection). Patient #11 was a 73 years old who had several other health problems including diabetes, obesity, and had end stage renal disease needing dialysis. Review of the medical record revealed a skin integrity assessment completed on admission (05/25/12) documented as "within defined limits".
The medical record revealed the first documentation of a stage 2 decubitus ulcer was on 06/07/12, and a "wound team-consult sacral decub ulcer -met with patient". The same note, dated 06/07/12, revealed the stage 2 pressure ulcer on the right and left coccyx (upper buttocks area) measured approximately 5cm by 5cm by .1cm on the right, and approximately 8cm by 4cm by .1cm red and open on the left.

A discharge summary, dated 06/11/12, revealed, "(the patient) did develop a stage II pressure sacral decubitus ulcer, and wound care will need to be continued at LifeCare".

These findings were confirmed with Staff G on the morning and afternoon of 09/27/12 during the medical record review, and confirmed with Staff H and Staff I on 09/27/12 at 4:30 PM and on 09/28/12 at 9:20 AM.