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CHILDREN'S HOSPITAL OF MICHIGAN
NURSING CARE PLAN
Tag No.: A0396
Based on interview and record review, the facility failed to ensure nursing staff developed a "skin" care plan in a timely manner that addressed the potential for an alteration in skin integrity for 1 (#1) of 4 patients reviewed for care plans from a total of 4 sampled patients, resulting in the increased potential for the development of pressure sores. Findings include:
On 9/20/16 at 1330 a review of the electronic record was conducted with Staff L and the following was revealed.
According to the history and physical (H&P) (dated 3/2/16 at 1329) patient #1 was a 15 year old female, admitted to the facility on 3/2/16.
The patient's Braden Score (tool used for predicting pressure ulcer risk) scored the patient at "15" (at risk). According to the nursing admission assessment dated 3/2/16 at 1756, the patient's skin was intact a. However, she developed pressure sores. Further review of the clinical record revealed there were no care plans initiated to prevent skin breakdown.
On 9/20/16 at 1545 when queried regarding the lack of a "Skin" care plan for patient #1 who was coded at risk for pressure sores Staff L confirmed there was not one. She stated, "if the patient was at risk for skin breakdown the nurse should have initiated a "Skin" care plan."
On 9/21/16 at 1400 a review of the electronic clinical record was conducted with Nursing Director Staff B. She stated "the nurse should have initiated the skin care plan based on the patient's Braden score (15) upon her (#1's) admission."
On 9/21/16 at 1520 a review of the facility's "Pressure Ulcers: Prevention and Care" policy (2 PC 5202), (dated 2/14/2014), documented:
Policy:
"1...A. Braden Scale score of 18 or less or low subscale scores indicates that the patient is at risk for developing a pressure ulcer. Interventions targeting risk areas are implemented to prevent and manage pressure ulcers."
Provisions:
RN Responsibilities:
"...6. Initiate Plan of Care for patients with pressure ulcers, healed pressure ulcers or at risk for pressure ulcer based on Braden Scale Score less than or equal to 18."