HospitalInspections.org

Based on clinical record, policies and procedure review and staff interview it was determined the Registered Nurse failed to supervise and evaluate care related to physician orders and adhering to facility policy for skin care for 1 (#2) of ten patients sampled. This practice does not ensure patient goals are met and may cause a prolonged stay.

Findings include:

Review of the policy "Maintenance of Skin and Actual Alteration in the Skin Integrity Protocol" last revised 5/06 revealed to outline nursing management of patients identified at risk or patients with an alteration in skin integrity/wound and to be initiated by a Registered Nurse. The Protocol is initiated on patients that are at risk of developing or that have actual skin alteration, due to their diagnosis or condition. This protocol is used in conjunction with pressure reduction or specialty bed usage. The policy reveals to notify the Enterostomal Therapy Nurse of pressure ulcers and perianal erosion.

Review of the policy "Immobility Protocol" for patient care services last revised 10/06 revealed Interventions to be initiated appropriate nursing measures: Review of these policies indicated patients that are unable to turn themselves, the staff was to turn the patient every two hours.

Patient # 2 was admitted with a diagnosis of shortness of breath, weakness and respiratory failure. Review of random days from admission on 5/31/11 to 7/30/11, the day of discharge revealed no documentation that the patient was turned every two hours.
Review of the initial nursing assessment revealed the patient's skin was intact. Review of the skin assessment flow sheet initiated on 5/31/11 at 8:30 p.m. revealed the patient's mobility to be bedrest.

The skin assessment flow sheet dated 6/03/11 at 11:30 p.m. revealed the sacrum was reddened. Review of flow sheet dated 6/4/11 at 7:30 a.m. revealed reddened areas on both elbows and the sacral area was reddened. Documentation revealed at 11:30 a.m. a Mepilex dressing was applied to the elbows twice a day. There was no evidence of a physician order for the Mepilex dressing.

Interview with the Risk Manager on 9/2/11 at approximately 8:00 p.m. revealed the wound care nurse could order the Mepilex dressings for a patient. There was no evidence of a facility policy and procedure for the wound nurse to order treatments for the patients.

Review of the the skin assessment flow sheet dated 6/13/11 at 7:30 a.m. revealed the sacral area was red, dark purple and the skin was broken. Review of the wound care nurse assessment dated 6/14/11 at 2:00 p.m. revealed the gluteal cleft with 4 x 1 centimeter (cm) purple tissue suspected deep tissue injury, blisters in the buttocks, all suspected deep tissue injury, and a blood area of approximately 6 x 8 cm. A Mepilex sacral dressing was in place. The documentation noted a plan for silvadene, scabs on the knee, and the elbows were intact with no redness. Review of the physician orders dated 6/14/11 at 6:00 p.m. revealed the silvadene was ordered.

Review of the skin assessment flow sheet dated 6/15//11 revealed no documentation of turning the patient every 2 hours. The patient was not turned on 6/15/11 at 5:00 p.m. On 6/26/11 there was no documentation of being turned at 5:00 a.m., 10:00 a.m., 2:00 p.m., and 6:00 p.m. The patient was not turned on 6/27/11 at 10:00 a.m., 2:00 p.m., and 6:00 p.m. The skin flow sheets dated 6/28/11 revealed the patient was not turned every two hours on 6/27/11 from 11:00 p.m. until 4:00 a.m. on 6/28/11, a time period of 5 hours later. The skin assessment flow sheet revealed no evidence of the patient being turned at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6.00 p.m. or 10:00 p.m. Review of flow sheet dated 6/29/11 revealed the patient was not turned at 1:00 a.m., 5:00 a.m., 7:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. On 6/30/11 the flow sheet revealed no documentation of the patient being turned at 10:00 p.m. On July 1, 2011 the flow sheet showed no evidence the patient was turned every 2 hours. There was no documentation of turning at 2:00 a.m., 6:00 a.m., 10:00 a.m., 2:00 p.m. 4:00 p.m., 6:00 p.m., or 10:00 p.m. On July 2, 2011 there was no documentation of turning at 2:00 a.m., 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. On July 3, 2011 there was no documentation of turning at 10:00 a.m., 2:00 p.m., 4:00 p.m., 6:00 p.m., and 10:00 p.m. On July 4, 2011 there was no documentation of turning at 2:00 a.m., 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. On July 5, 2011 there was no documentation of turning at 2:00 a.m., 6:00 a.m., 10:00 a.m., 2:00 p.m., and 4:00 p.m. The patient was turned at 5:00 p.m. and at 8:00 p.m., 3 hours difference instead of a 2 hours turning schedule. On July 6, 2011 the patient was not turned at 6:00 a.m., 10:00 a.m., 2:00 p.m., or 4:00 p.m. The patient was documented to be turned at 5:00 p.m. and at 8:00 p.m., 3 hours difference instead of a 2 hours turning schedule. The patient was not turned at 10:00 p.m. July 7, 2011 revealed no documentation of turning at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. July 8, 2011 revealed no documentation of turning at 10:00 a.m., 2:00 p.m., 4:00 p.m., 6:00 p.m., 8:00 p.m. and 10:00 p.m. On July 9, 2011 there was no documentation of turning the patient at 10:00 p.m. July 10, 2011 revealed no documentation of turning the patient at 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. On July 11, 2011 there was no documentation of turning at 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. On July 12, 2011 the patient was not turned at 10:00 p.m. On July 13, 2011 there was no documentation of turning the patient at 6:00 p.m. and 10:00 p.m. July 14, 2011 revealed no documentation of turning the patient at 6:00 p.m. and 10:00 p.m. July 15, 2011 revealed no documentation of turning the patient at 2:00 a.m. and 6:00 a.m. On July 16, 2011 there was no documentation of turning at 2:00 a.m., 4:00 a.m., 6:00 a.m., 6:00 p.m. and 10:00 p.m. Review of the Medical/Surgical flow sheet dated July 16,2011 revealed the patient was transferred to a different unit. The flow sheet revealed the patient had a pressure ulcer without evidence of the location. Review of documentation from July 17 to the 19 th revealed no evidence the patient was turned consistently. The patient was transferred to another unit on 7/19/11 at approximately 3:00 p.m. There was no documentation of turning at 5:00 p.m., 7:00 p.m., 8:00 p.m. or 10:00 p.m. The wound was described as a large decubitus with purulent drainage. July 20, 2011 revealed no documentation of turning the patient at 3:00 a.m., 6:00 a.m., 12:00 p.m. or 10:00 p.m. July 21, 2011 revealed no documentation of turning at 2:00 a.m., 4:00 a.m., 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., or 9:00 p.m. On July 22, 2011 there was no documentation of turning the patient at 2:00 a.m., 4:00 a.m., 6:00 a.m., and 6:00 p.m. On July 23, 2011 the patient was not turned at 2:00 a.m., 4:00 a.m., 6:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m. and 6:00 p.m. July 24, 2011 revealed no documentation of turning the patient at 8:00 a.m. July 27, 2011 revealed no documentation of turning the patient at 5:00 a.m. or 7:00 a.m. On July 29, 2011 the patient was not turned at 10:00 a.m., 12:00 p.m., 2:00 p.m., or 6:00 p.m.

The documentation did not show evidence of the patient being turned every two hour per policy for the prevention of skin break down or physician orders for wound care.