HospitalInspections.org

Based on record review, staff interview, and review of facility policy and procedures it was determined the facility failed to have a registered nurse supervised, evaluated and documented the nursing care, interventions and patient response for one (#1) of eight patients sampled. This does not ensure patient goals are met.

Findings include:

Review of the medical record for patient #1 revealed the patient presented to the facility's emergency department on 4/2/2012 with complaints of abdominal pain, nausea, vomiting, and constipation. The patient was admitted for treatment of a small bowel obstruction. On 4/4/2012 the patient underwent a colectomy with colostomy.

Documentation revealed the patient had no alteration in skin with the exception of the surgical incision and colostomy. On 4/5/2012 at 7:40 a.m., post operative day 1, the patient was noted to be alert, neurological function was within defined parameters and the patient was noted to be sitting up in the chair. Review of the nursing documentation revealed the patient remained sitting in the chair until 4/7/2012 at 10:30 a.m. At this time nursing documentation revealed the patient was assisted to bed with the aid of a walker.

On 4/7/2012 at 8:40 p.m. nursing documented the patient's coccyx was red and purple and had a blister. A mediplex dressing was applied. Review of the nursing documentation revealed the patient developed a stage 2 pressure ulcer. It was determined the pressure ulcer was hospital acquired.

Review of the facility's policy, " Skin Breakdown-Prevention/Management ", effective 10/2004 states 7 (a)(ii) upon identification of a Stage II, III or IV pressure ulcer acquired during the patient's hospitalization wound photographs will be utilized. Review of the record revealed lack of documentation of wound care and treatments and revealed no photographs of the identified pressure ulcer.

On 4/8/2012 at 7:40 a.m. nursing documentation revealed the patient's coccyx was red with an intact blister present. The skin was noted to be open to air and no documentation of a mediplex dressing in place or of being removed. On 4/8/2012 at 10:37 a.m. nursing documented the patient had a pressure ulcer to the coccyx, non-open, purple with red outline to outer edge with opened blister to right buttock, measurement of 10 cm X 10 cm (centimeters) was documented. Nursing documented wound care to the coccyx area on 4/8/2012 at 12:00 p.m.

On 4/9/2012 at 11:49 a.m. the pressure ulcer was measured and documented as 12 cm in length with a blister. There was no documentation of the width, no documentation of wound care or dressing application at that time. At 8:05 p.m. nursing documented a mediplex dressing was in place. Review of the nursing documentation revealed lack of documentation of specific wound treatments and adequate wound description.

Review of the facility's policy, " Skin Breakdown-Prevention/Management " , effective 10/2004. The policy states (4) document specific wound treatments. Review of the nursing documentation revealed the facility failed to ensure nursing documented specific wound treatments. Interview with the risk manager on 11/8/2012 at 1:00 p.m. confirmed the above findings.