HospitalInspections.org

Based on interview and documentation review the facility failed to


A. provide nursing care that identified risks for and provided nursing interventions to prevent the development of pressure wounds for 1 of 11 patients (patient #1) reviewed.

Refer to A 0395


B. provide a plan of care that included the prevention and treatment of pressure related wounds that developed for 1 of 11 patients (patient #1).

Refer to A 0396

Based on record review and interview, nursing failed to provide nursing care that identified risks for and provided nursing interventions to prevent the development of pressure wounds for 1 of 11 patients (patient #1) reviewed.

This deficient practice had the likelihood to effect all patients (pt) of the hospital.


Findings included.



On 2/6/2018 in the board room staff #5 assisted in the electronic review of the pt #1's medical record (MR). The hospital's MR revealed patient #1 was admitted at 11/29/2017 at 6:30 P.M.

Pt #1 was a 76 year old male patient who resided in a long term care facility. His multiple co-morbidities were congestive heart failure, acute on chronic kidney disease stage III, Venus insufficiency, diabetes, chronic systolic congestive heart failure, hypotension anasarca (generalized edema secondary to kidney disease, anemia, low protein or heart failure), diabetic neuropathy, protein calorie malnutrition, non healing wounds, acute blood loss and quadriplegia. Pt #1 was aphasic and could not make his needs known.


Interview with staff #5 indicated the facilities policy allowed the nursing staff 24 hours to document the initial patient skin assessment.

Review of the facilities policy "Wound and Skin Care Nursing Assessment and Management, 1.0, A Registered Nurse (RN) should perform a skin assessment and utilize the Braden Scale on all adult patients upon admission. Reassessment should be completed a minimum of every 24 hours or more frequently as the patient's condition changes and document on the physical assessment/reassessment interventions."

Interview of 2/6/2018 with the Chief Nursing Officer (CNO), confirmed the above policy was the only skin assessment policy in use.


Review of the initial Registered Dietician's (RD) evaluation dated 11/30/2018 at 13:46, reflected non healing wounds. The RD evaluation included documentation that "Pt #1 is at risk of skin break down due to his very low albumin, being a quadriplegic, and having chronic kidney disease".

The initial skin skin assessment identified a previously healed sacral wound. No other skin abnormalities were identified or documented. The Braden scale score (identifies potential skin risk breakdown) was "8". Very high risk.

Review of the facilities policy "Wound and Skin Care Nursing Assessment and Management, 2.0 Risk assessment scores 18 or less require the implementation of additional nursing interventions. These interventions should be documented on the physical assessment/Reassessment intervention."


A review of the nursing assessment was dated 11/30/2017 at 08:00 A.M., 13.5 hours after his admission. The skin assessments were identified below:

11/30/2017 at 8:00 A.M. Skin: "Color appropriate for race, warm and dry, turgor normal for age, smooth NON-WOUND skin issues NO".

11/30/2017 at 8:00 P.M. Skin: color pale, hot, dry, normal for age, NON-WOUND skin issues YES. Left hip irritation/redness, stage I, drainage none. Treatment topical cream.
WOUND, right ear, pressure stage I, localized burning.

The Left hip and Right ear are documented repeatedly without alteration to the description by the nurse until the day of discharge.

12/1/2017 at 8:00 A.M. A third area of pressure is identified and documented. Left heel, pressure stage I, topical skin cream in use.



Nursing documentation did not deviate from the original entry in description and treatment until 12/3/2017.

12/3/2017 at 12:50 P.M. "Wound/Pressure ulcer location, Sacrum/coccyx red, clean granulating (indicated skin breakdown had occurred and healing was in progress) length 4.00 centimeters (cm), width 0.50 cm stage II, irrigant solution, soap and water, dressing changed." Nursing documentation indicated pt #1 had "Huge, profuse diarrhea likely related to gastric tube feedings. Barrier cream was applied."


From "Johns Hopkins University Hospital, Wound and Pressure Ulcer Management:
Manage Incontinence
" Timely cleansing
" Apply barrier ointment to intact skin
" If skin is red or denuded use a paste
" Use appropriate incontinence disposables
" Apply fecal incontinence pouch if needed

By definition a cream is an emulsification of oil and water. It will wipe off or melt off the skin quickly. Creams are recommended for intact skin.

By definition a paste is a combination of oil and powder that protects irritated skin and allows for breathability. Is not easily wiped off and will not melt easily onto healthy skin or fabric. It is not recommended for treatment of pressure related wounds at a stage II."

A review of pt #1's MR "safety rounding documentation" reflected pt #1's position while in his bed from 11/19/2017 through 12/02/2017.

11/29/2017 23:35 position Right
11/30/2017 00:30 position Right
11/30/2017 01:19 position Right
11/30/2017 02:30 position Right
11/30/2017 03:30 position Right
11/30 2017 04:30 position Right
11/30/2017 05:30 position Right
11/30/2017 06:14 position Right
11/30/2017 08:30 position Right
11/30/2017 09:30 position Right
11/30/2017 10:30 position Right
11/30/2017 11:30 position Right
11/30/2017 13:30 position Right

Documentation indicated pt #1 endured 14 hours of right side positioning.

11/30/2017 14:30 position LEFT
11/30/2017 15:30 position Left
11/30/2017 17:10 position Right
11/30/2017 18:30 position Left
11/30/2017 21:26 position Left
12/01 2017 00:36 position Right
12/01/2017 16:30 position Left
12/01/2017 18:37 position Back
12/01/2017 20:00 position Back
12/01/2017 21:00 position Left
12/02/2017 00:00 position Left
12/02/2017 01:01 position Back
12/02/2017 04:05 position Right
12/02/2017 06:02 positron Back

The national standard at "Johns Hopkins University Hospital, Wound and Pressure Ulcer Management:
Managing pressure is also necessary and the following is recommended.
" Provide appropriate support surface
" Reposition every two hours in bed
" Off-load heels - use pillows or positioning boot
" Reposition every hour when in chair
" Use pillow between legs for side lying
" Do not position directly on trochanter
" Do not use doughnut-type devices

Friction and shear need to be reduced. Friction is the mechanical force exerted when skin is dragged against a coarse surface while shear is the mechanical force caused by the interplay of gravity and friction. It exerts a force parallel to the skin resulting in angulation and stretching of blood vessels (shown below on right) within the sub-dermal tissues, causing thrombosis and cellular death. This manifests as necrosis and undermining of the deepest layers (Pieper 2007).

To reduce friction and shear, the following is recommended:
" Use draw sheets for repositioning
" Encourage use of trapeze if possible
" Keep head of bed elevated 30 degrees if tolerated
" Elevate foot of bed slightly, if condition permits
" Use pillow or wedge to support hip for 30 degrees side-lying, lateral position
" Utilize lifts and transfer devices"


On 2/6/2018 RN #7, who was identified as the "Wound Nurse" was interviewed. She indicated, if the patient was not in a high acuity unit, such as the Intensive Care Unit, She did not automatically see the patient. The staff RN decided when the patient was seen by her for evaluation and treatment. She further explained a patient would likely have a stage III wound before she would see them. When asked at what point the physician would become involved she replied at that (Stage III) point. When asked how the nurses decided what interventions to provide for a patient with potential for skin breakdown, she replied, "it is nursing judgement." When asked if the nurse would notify the physician for an order for wound care prior to the wound becoming a stage III she replied "No, again it is nursing judgement". Staff #7 was asked who chose the intervention such as barrier cream, verses paste or dressings, she replied, "the (RN) chooses the wound care dressing."

Staff #7 was asked if she believed the physician was notified concerning pt #1's skin break down , she replied "probably not".

The nursing staff failed to meet the need of pt #1. The RN failed to document provision of effective nursing interventions for pt #1's skin. Pt #1 entered the hospital with no skin wound breakdown documented. Upon discharge 4 wounds were documented. The nursing staff failed to notify the physician when changes in condition resulted in skin break down. The nursing staff failed to document care that would prevent the development of pressure related skin breakdown and failed to document appropriate nursing care that would protect pt #1's skin from excoriation and breakdown secondary to diarrhea.

Based on record review and interview the facility failed to provide a plan of care that included the prevention and treatment of pressure related wounds that developed for 1 of 11 patients (patient #1) reviewed.


This deficient practice had the likelihood to effect all patients (pt) of the hospital.


Findings included.


On 2/6/2018 in the board room staff #5 assisted in the electronic review of the pt #1's medical record (MR). The hospital's MR revealed patient #1 was admitted at 11/29/2017 at 6:30 P.M. Pt #1 was a 76 year old male patient who resided in a long term care facility. His multiple co-morbidities were congestive heart failure, acute on chronic kidney disease stage III, Venus insufficiency, diabetes, chronic systolic congestive heart failure, hypotension anasarca (generalized edema secondary to kidney disease, anemia, low protein or heart failure), diabetic neuropathy, protein calorie malnutrition, non healing wounds, acute blood loss and quadriplegia. Pt #1 was aphasic and could not make his needs known.

A review of the nursing assessment was dated 11/30/2017 at 08:00 A.M., 13.5 hours after his admission. The Braden scale score (identifies potential skin risk breakdown) was "8". Very high risk. Pt #1 entered the hospital with no skin wound breakdown documented.

Interview with staff #5 indicated the facilities policy allowed the nursing staff 24 hours to document the initial patient skin assessment. However, review of the facilities policy "Wound and Skin Care Nursing Assessment and Management, 1.0, A Registered Nurse (RN) should perform a skin assessment and utilize the Braden Scale on all adult patients upon admission. Reassessment should be completed a minimum of every 24 hours or more frequently as the patient's condition changes and document on the physical assessment/reassessment interventions."

The initial skin assessment identified a previously healed sacral wound. Review of the initial Registered Dietician's (RD) evaluation dated 11/30/2018 reflected non-healing wounds. The RD evaluation included documentation that "Pt is at risk of skin break down due to his very low albumin, being a quadriplegic, and having chronic kidney disease".


11/30/2017 at 8:00 A.M. Skin: "Color appropriate for race, warm and dry, turgor normal for age, smooth, NON-WOUND skin issues NO". No other documentation for findings of pt #1's skin was identified at this date and time.

11/30/2017 at 8:00 P.M. "Skin: color pale, hot, dry, normal for age, NON-WOUND skin issues YES. Left hip irritation/redness, stage I, drainage non. Treatment topical cream.
WOUND, right ear, pressure stage I, localized burning." No treatment or intervention followed the description of this wound.

The Left hip and Right ear are documented repeatedly without alteration to the description by the nurse until the day of discharge 12/18/2017, patient #1 expired.

12/1/2017 at 8:00 A.M. A third area of pressure is identified and documented. "Left heel, pressure stage I, topical skin cream in use." No description of treatment of intervention was documented for this wound."

Nursing documentation did not deviate from the original entry in description and treatment until 12/3/2017.

12/3/2017 at 12:50 P.M. "Wound/Pressure ulcer location, Sacrum/coccyx red, clean granulating length 4.00 centimeters (cm), width 0.50 cm stage II, irrigant solution, soap and water, dressing changed." This documentation indicated pt #1's skin at the sacral/coccyx had broken down to the subcutaneous level and was repairing itself. This single entry from the nursing staff indicated the wound was old enough for the body to begin the granulation process.




On 2/6/2018 in the afternoon the policy "Nursing/Patient Care Planning and Providing Care" was reviewed. Found under the Topic Purpose:

"1.0 Planning and providing care, monitoring its results, modifying or completing care, and coordinating follow-up are fundamental activities requiring for the provision of patient care.

2.0 It is the policy of This hospital to develop an individualized Plan of Care for each patient which involves an interdisciplinary, collaborative approach and reflects the patient's needs, severity of disease, condition, impairment or disability.

3.0 The patients progress will be re-evaluated against the care goals and pan of care at least every 24 hours by a Registered Nurse."


During the review of Pt #1's MR the Nursing Care plan was found to have one problem identified. The problem identified was dehydration. This was confirmed by staff #5 who was the navigator for the electronic MR review. This problem had no documentation of re-evaluation during pt #1's stay in the hospital.

The nursing Staff failed to create a functional patient plan of care for pt #1. No care planning problem was identified for pt #1's high risk for skin breakdown based on his very low Braden risk score of "8". No care planning problem was identified for protein calorie malnutrition, No care planning was identified for quadriplegia, no care planning was identified for sensory deprivation related to blindness and aphasia,or any of the other diagnosis pt #1 was admitted with other than dehydration. At the time of pt #1's discharge 4 wounds were documented.


On 2/6/2018 at 9:30 A.M. the Long Term Care Facility was contacted for information on pt #1. Per the history and physical, Pt #1 was blind and a functioning aphasic quadriplegic. He could not see, speak or move once in bed. His hearing was intact and he responded to voices he recognized.