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BAYLOR SCOTT AND WHITE MEDICAL CENTER SUNNYVALE
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on interview and record review the hospital failed to ensure 1 of 1 (Patient #1) patients didn't acquire an in-hospital pressure injury.
Findings included:
A review of Patient 1's medical record reflected Patient #1 was admitted to the hospital on 8/24/17 without any pressure injuries. Patient #1 was discharged with an unstageable coccyx wound, and a stage II pressure injury on her buttocks on 9/06/17.
Nursing Notes. Date-8/24/17. Patient #1's initial nursing assessment indicated the patient did not have a "decubitus" ulcer (pressure injury).
Nursing Shift Assessment Head to Toe Notes.
Patient #1"s Braden Scale (An assessment tool commonly used to quantify a patient's degree of risk for developing a pressure ulcer. Each assessment parameter is measured on a scale from high risk of 1 to low risk of 3 or 4. The parameters include sensory perception, moisture, activity, mobility, nutrition, and friction and shear, with a possible total score range of 4 to 23. The lower the total score, the higher the risk for pressure ulcer development. Patients are at risk for developing pressure ulcers if the total score is less than 17).
8/24-26/17. Braden Scale-17.
8/27/17. Braden Scale-13.
8/28-31/17. Braden Scale-14.
9/01-06/17. Braden Scale-15.
Wound Assessment Notes
8/29/17. Wound #1. Coccyx wound. Unable to stage. Length was 3.5. Width was 2.6. Depth was 0.2. Slough was 10% and Eschar was 90%. Wound type was pressure.
Wound #2. Bilateral Buttock's wounds were abrasions. Length was 8.0. Width was 0.6. Depth was 0.1. Granulation 60%. Slough 40%.
9/05/17. Wound #1. Coccyx wound. Unable to stage. Length was 4.0. Width was 6.0. Depth was 0.1. Slough was 100%.
Wound #2. Bilateral Buttocks. Stage II. Width was 8.0. Width was 0.6. Depth was 0.1. Granulation was 20%. Slough was 80%.
During an interview with Personnel #3 and Personnel #4 on 11/01/18 at 1:45 PM they both reviewed Patient #1's medical record and confirmed they took part in the care of Patient #1. However, they didn't remember the patient. After a review of her medical record, they confirmed the patient was admitted without any pressure injuries, but was discharged with pressure injuries on her coccyx and buttocks.
NURSING CARE PLAN
Tag No.: A0396
Based on interview and record review the hospital failed to ensure 1 of 1 (Patient #1) patients had a care plan to address the patient's in-hospital acquired pressure injury.
Findings included:
A review of Patient 1's medical record reflected Patient #1 was admitted to the hospital on 8/24/17 without any pressure injuries. Patient #1 was discharged with an unstageable coccyx wound, and a stage II pressure injury on her buttocks on 9/06/17. There was no documentation of a plan of care for Patient 1's pressure injuries.
Nursing Notes. Date-8/24/17. Patient #1's initial nursing assessment indicated the patient did not have a "decubitus" ulcer (pressure injury).
Nursing Shift Assessment Head to Toe Notes.
Patient #1"s Braden Scale (An assessment tool commonly used to quantify a patient's degree of risk for developing a pressure ulcer. Each assessment parameter is measured on a scale from high risk of 1 to low risk of 3 or 4. The parameters include sensory perception, moisture, activity, mobility, nutrition, and friction and shear, with a possible total score range of 4 to 23. The lower the total score, the higher the risk for pressure ulcer development. Patients are at risk for developing pressure ulcers if the total score is less than 17).
8/24-26/17. Braden Scale-17.
8/27/17. Braden Scale-13.
8/28-31/17. Braden Scale-14.
9/01-06/17. Braden Scale-15.
Wound Assessment Notes
8/29/17. Wound #1. Coccyx wound. Unable to stage. Length was 3.5. Width was 2.6. Depth was 0.2. Slough was 10% and Eschar was 90%. Wound type was pressure.
Wound #2. Bilateral Buttock's wounds were abrasions. Length was 8.0. Width was 0.6. Depth was 0.1. Granulation 60%. Slough 40%.
9/05/17. Wound #1. Coccyx wound. Unable to stage. Length was 4.0. Width was 6.0. Depth was 0.1. Slough was 100%.
Wound #2. Bilateral Buttocks. Stage II. Width was 8.0. Width was 0.6. Depth was 0.1. Granulation was 20%. Slough was 80%.
During an interview with Personnel #2 on 11/01/18 at 2:30 PM she was asked to provide Patient #1's care plan for her pressure injuries. She said there wasn't one..