HospitalInspections.org

Based on record review and staff interview, it was determined the facility failed to ensure consistent assessment and implementation of appropriate interventions for 4 (#1, #3, #5, #10) of 10 sampled patients. This practice does not ensure patients will achieve goals of the plan of care.


Findings include:

1. Patient #1 was admitted to the facility on 11/9/10 and discharged to a skilled nursing facility on 12/10/10. Review of the initial skin assessment documented on 11/9/11 revealed The following deficiencies in wound assessments were identified:
11/15/10 - 7 am - 7 p.m. shift - no documentation of repositioning every 2 hours and floating heels off mattress
11/16/10 - 7 am - 7 p.m. shift - no documentation of repositioning every 2 hours and floating heels off mattress
11/17/10 - 7 pm - 7 am shift - no assessment of heel wounds that had been identified by wound care nurse on 11/17/10 at noon.
11/19/10 - 7 am - 7 pm shift - no wound assessment
11/19/10 - 7 pm - 7 am shift - no assessment of heel wounds
11/20/10- 7 am - 7 pm shift - no assessment of heel wounds
11/20/10 - 7 pm - 7 am shift - no wound assessment, no documentation of interventions to relieve pressure, except the specialty mattress
11/21/10 - 7 am - 7 pm - no assessment of heel wounds
11/21/10 - 7 pm - 7 am - no wound assessment
11/22/10 - 7 pm - 7 am - no documentation of interventions to relieve pressure
11/23/10 - 7 pm - 7 am - wounds listed, but not assessed
11/24/10 - 7 pm - 7 am - wounds listed, but not assessed
11/26/10 - 7 am - 7 pm - wound listed, but not assessed
11/27/10 - 7 am - 7 pm - wounds listed, but not assessed
11/28/10 - 7 am - 7 pm - wounds listed, but not assessed
11/28/10 - 7 pm - 7 am - no wound assessment
11/29/10 - 7 am - 7 pm - wounds listed, but not assessed
11/29/10 - 7 am - 7 pm - wounds listed, but not assessed
11/30/10 - 7 am - 7 pm, - no assessment of right heel
11/30/10 - 7 pm - 7 pm - no assessment of either heel
12/1/10 - 7 am - 7 pm - no assessment of either heel
12/2/10 - 7 am - 7 pm - wounds listed not assessed
12/6/10 - 7 am - 7 pm - wounds listed, not assessed
12/8/10 - 7 am - 7 pm - nurse documented both heel wounds were open, but did not document appearance of wound
12/8/10 - 7 pm - 7 am - wounds listed , not assessed
12/9/10 - 7 am - 7 pm - wounds listed, not assessed
12/9/10 - 7 pm - 7 am- wounds listed, not assessed
12/10/10 - 7 am - 7 pm - no wound assessment
12/10 10 - 11:56 am - wound care nurse assessment did not include assessment of pressure ulcers of coccyx and bilateral heels.
The patient was discharged on 12/10/10. The condition of the wounds had not been documented since 12/7/10 and were not documented at the time of discharge.

2. Patient # 3 was admitted to the facility on 6/30/11 and discharge on 7/6/11. Wounds of the sacrum and left heel were identified during the initial assessment. The following deficiencies related to skin assessments were noted:
7/2/11 - 7 am - 7 pm - no wound assessment, no documentation of intervention to relieve pressure
7/2/11 - 7 pm- 7 pm - no wound assessment
7/3/11 - 7 pm - 7 am - no wound assessment
7/4/11 - 7 am - 7 pm - no skin assessment, no documentation of intervention to relieve pressure
7/6/11 - Patient discharged at 10:30 a.m. - No assessment of wounds prior to discharge.

3. Patient #5 was admitted to the facility on 7/7/11 with a fractured femur as the result of a ground level fall. He was a patient on the MICU at the time of the investigation. He had been identified as having a hospital acquired pressure ulcer by the Director of Quality Improvement. The initial skin assessment documented on 7/8/11 at 12:38 a.m. indicated hematomas on both arms and both shins. It also indicated the coccyx was reddened. The following deficiencies related to skin assessments were noted:
7/9/11 - 7 am - 7 pm - no assessment of arms, legs and coccyx wounds. There was also no documentation of a Braden score and no documentation on interventions to prevent pressure ulcer development.

4. Patient #10 was admitted to the facility on 6/24/11 with the diagnosis of acute gastrointestinal bleeding. She was also identified as having a hospital acquired pressure ulcer. The initial skin assessment documented on 6/24/11 at 10:50 a.m. noted the patient had a incision on the right foot and no other wounds. The following deficiencies regarding skin and wound assessments were noted:
6/24/11 - 7 pm - 7 am - no wounds or incisions noted
6/25/11 - 7 am-7 pm - no wounds or incisions noted
6/25/11 - 7 pm - 7 am - no wounds or incisions noted
6/26/11 - 7 am - 7 pm - no documentation of Braden score or interventions to relieve pressure
6/26/11 - 7 pm - 7 am - no skin assessment
6/27/11 - 7 am - 7 pm - no wound or incision noted
6/27/11 - 7 pm - 7 am - no documentation regarding incision on right foot. First documentation of a blister on the coccyx
6/28/11 - 7 pm - 7 am - no documentation of incision on right foot. The blister on the coccyx was listed, but not assessed
6/29/11 - 7 am - 7 pm - no wound or incision assessment
6/29/11 - 7 pm - 7 am - coccyx blister now open, the right foot incision again documented
6/30/11 - 7 am - 7 pm - open blister on right heel, new wound
7/2/11 - 7 pm - 7 am - coccyx wound not documented or assessed
7/5/11 - 7 am - 7 pm - coccyx wound not documented or assessed.
7/7/11 - 7 pm - 7 am - wounds listed but not assessed
7/9/11 - 7 am - 7 pm - wounds listed but not assessed
7/10/11 - 7 am - 7 pm - wounds listed but not assessed
7/12/11 - 7 am - 7 pm - no documentation of coccyx wound

Review of the physician orders dated 6//24/11 revealed an order to transfuse 2 units of packed red blood cells. Review of the medical records revealed no evidence that the blood was administered. There was also no documentation that the blood administration had been canceled by the physician.