HospitalInspections.org

Based on medical record review, interview and review of policy and procedure the hospital failed to correctly document the status of Patient Identifier (PI) # 1's pressure ulcer beginning 4/29/15. As a result of this deficient practice, it is unclear if the pressure ulcer declined or improved at the time of discharge for this patient identified at high risk for pressure ulcer development by hospital staff based on the Braden Scale score. (Scale that identifies patients at risk for developing pressure sores, www.nlm.nih.gov).

Findings include:

(PI) # 1 was discharged from the hospital on 4/14/15 after being admitted for Aspiration Pneumonia. PI # 1 was readmitted 4/27/15 due to a melatonic (dark colored) stool and weakness. The patient's medical history includes severe gastroesophageal reflux, hiatal hernia, mild dementia, paroxysmal atrial fibrillation and advanced lumbar stenosis causing inability to ambulate.

PI # 1 is incontinent of bowel and bladder.

Review of Nursing Flowsheets:

4/27/15: Braden Scale Score - 12.

Integumentary (Skin): 18:13 (Staff Nurse Documentation)
Integrity: "Intact; broken..."

Redness to sacrum and both heels.

There is no documentation if the areas are bleachable or non-bleachable. Nor is there documentation of actual skin breakdown.

4/28/15 at 08:10: (Staff Nurse Documentation)

Integumentary (Skin): 08:10
Integrity: "Intact; broken..."

Redness to sacrum/coccyx and both heels.

No documentation regarding bleachable versus non-bleachable. No documentation of actual skin breakdown.

4/28/15 at 14:45 (Documentation by the Wound Care Nurse):
Type visit: New patient, Pressure Ulcer

Wound Description: "non blanch red"
Wound 1 Location: coccyx/sacrum
Length: 5.0 cm (centimeters)
Width: 5.9 cm.
Depth: 0 cm.
POA (Present on admission): Yes
Stage: Stage 1
Heels clear/floated...Poor po (oral) intake.
Linear darkened area: center 3.0 x 5.0 cm. Will monitor.

4/29/15 at 07:12 (Staff Nurse Documentation)
Skin issue 1 location: Back/buttock.
Reddened area location: sacrum/coccyx
Skin issues 2 location: foot - left and right. No documentation of color.

4/29/15 at 19:31 (Staff Nurse Documentation)
Skin issue 1 location: Back/buttock.
Reddened area location: sacrum/coccyx
Skin issues 2 location: foot - left and right. No documentation of color.

4/30/15 at 07:20 (Staff Nurse Documentation)
Integrity: Broken- see below. No additional documentation noted.

4/30/15 at 19:10 (Staff Nurse Documentation)
Integrity: Broken- see below. No additional documentation
noted.

5/1/15 at 07:48 (Staff Nurse Documentation)
No documentation regarding the condition of PI # 1's feet and/or back, buttocks, sacrum/coccyx

5/1/15 at 19:30 (Staff Nurse Documentation)
Integrity: Broken- see below. No additional documentation
noted.

5/2/15 at 07:42 and 19:46 (Staff Nurse Documentation)
No documentation regarding the condition of PI # 1's feet and/or back, buttocks, sacrum/coccyx

5/3/15 at 07:07 and 19:24 (Staff Nurse Documentation)
No documentation regarding the condition of PI # 1's feet and/or back, buttocks, sacrum/coccyx

5/4/15 at 08:29 (Staff Nurse Documentation)
No documentation regarding the condition of PI # 1's feet and/or back, buttocks, sacrum/coccyx

Policy and Procedure:
Patient Care Practice Guideline: Care of Patient: Skin Care- Assessing and Staging Skin Breakdown, Last Revised: 12/18/12

...A. All patients shall be assessed on admission and daily during hospital stay as follows:
...b. Stage 1: Intact skin with non-bleachable redness of localized area usually over a bony prominence...

Interviews

During an interview on 10/15/15 at 11:14 the Certified Wound Ostomy Continence Nurse / CWOCN, (Employee Identifier / EI # 1) stated she evaluated PI # 1 on 4/28/15. PI # 1's pressure ulcer on the coccyx/sacrum was red, non-bleachable and measured 5.0 cm. x 5.0 cm with a linear darkened area in the center. According to the CWOCN, she would have documented the area was intact as opposed to broken as documented by the staff RN's (Registered Nurses).