HospitalInspections.org

Based on document review and interview, the facility failed to provide plan of care information to 1 (#2) of 20 patients(#1-#20) or patient respresentatitve, whose records were reviewed. Patient #2 developed a sacral/coccyx wound. Her family was unable to participate in the development of the plan of care due to not being told the change of patient #2's condition.

This deficient practice had the likelihood to effect all patients in the facility.


Findings included.



On the morning of 11/29/2021 the medical record (MR) for patient #2 (Pt/pt) was reviewed with the assistance of staff #7. During the review it was established that pt #2 had been living independently until 3/28/2021. She was found by her family in the floor of her home and taken to the nearest hospital where she was exhibiting symptoms of a stroke. She arrived via air ambulance to the hospital Emergency Department (ED) for higher level of care on the same day.


3/28/2021, Pt #2 was exhibiting left side facial drooping and right sided weakness. She was admitted to the neuro intensive care unit (N-ICU). She was placed on mechanical ventilation with sedation and a gastric tube placement was verified by X-ray. Pt #2 had become immediately dependent for position changes and initiation of basic hygiene needs.

During the review of the MR it was determined that on 4/10/2021 a Registered Nurse, staff #9 documented "open area buttocks". The RN note did not include evidence the family was notified of this change in condition.

3/30/2021, the following day, wound care nurse #38 documented "On assessment the patient has breakdown to her sacrum/coccyx/buttocks. It is unclear if this is due to friction/shear/or possible pressure. Recommend applying venelex ointment to the area covering with a foam dressing. Wound care will return in one week if the patient is still present".

The Wound Care RN did not document the family was notified of the above change in condition.

A review of the physician notes also failed to identify documentation that a physician had notified the family the skin breakdown and change in skin condition.

A review of the discharge planning note failed to identify documentation the family had been notified of skin break down and change in condition. Skin breakdown that remains at discharge would complicate patient discharge to her previous home location.

The above missing documentation was confirmed by RN #7 who was assisting in the MR review.

The family of Pt #2 reported they were never made aware of the skin break down during the hospital stay.


A request was made for evidence of the process used by the hospital when identifying and treating skin breakdown. A printed decision tree/algorithm was provided and reviewed. The decision tree/algorithm did not include notification of family if skin break down occurred.

This step was missing and confirmed by staff #2.

Based on record review and interview, Registered Nurse failed to provide nursing interventions to prevent skin breakdown. Nursing failed to consistently document repositioning and incontinent bowel frequency related to new diagnosis of stroke and implementation of gastric tube feedings for 1(#2) of 20 patient (#1 through #20) records reviewed.

This deficient practice had the likelihood to effect all patients of the facility.


Findings included.


On the morning of 11/28/2021 the medical record for patient (Pt/pt) #2 was reviewed with the assistance of staff #7. During the review it was determined on 3/28/2021 pt #2 was Air flighted from her local hospital to the higher level of care hospital Emergency Department (ED). She had been found at home by her family. She was exhibiting visible signs of a stroke. Pt #2 had been fully independent previous to this episode.

Pt #2 was diagnosed with a stroke exhibiting left facial drooping and right side weakness, inability to swallow and difficulty breathing. Her condition was stabilized. She was placed on mechanical ventilation and admitted to the neuro Intensive Care Unit (N-ICU).

Gastric feeding tube was placed and verified by X-ray and patient #2 was assessed for dysphasia after admission to the Neuro ICU. Upon admission pt #2 was bed bound and immobile, and without the ability to communicate related to mechanical ventilation and initial sedation.

The Registered Dietician (RD) conducted the admission nutritional assessment on 3/30/2021. The RD report documented, "If EN (enteral nutrition) becomes indicated, recommend initiating feeds of Jevity 1.5 and advancing as tolerated to goal rate at 40 millimeters an hour plus 1 packet of prostat BID (twice daily)" The RD further documented "No BM's (bowel movements) recorded yet, consider addition of a bowel regimen".

Per Abbott, the manufacturer's of Jevity, Jevity 1.5 is a calorically dense, high protein, fiber fortified liquid formula providing complete, balanced nutrition" Also, listed are the top three side effects of initiating Jevity 1.5 "Bowel problems, burning sensation in stomach and diarrhea".

The admission history and physical (APH) included precautions for Seizure, Aspiration and Fall. Skin breakdown precautions were not identified as a risk. Documentation indicated that on 4/31/2021 pt #2 developed liquid stool.

A review of the initial skin assessment, identified on the "anatomical man" identified Intravenous access attempts and sites, angionscan puncture, tattoo site, Foley catheter and dry skin. No skin breakdown was identified to the front or back of pt #2 upon admission.

Pt #2 was initially sedated on the ventilator. She was 100% dependent of the staff RN's for turning, bowel care and general hygiene. A review of the documented turning schedule for pt #2 revealed the turn schedule began at 3/28/2021 at 5:00 PM. The turn schedule indicated pt #2 should have been turned every 2 hours. Omissions in the turn schedule were evidenced by a lack of documentation provided in the Medical Record (MR), and were shown as follows:
Staff were scheduled for 2, 12 hours shifts.

Day #1: 3/28/2021, 6 opportunities for position change were not recorded, 12 hours did not have documentation indicating repositioning for pt #2.

Day #2: 3/29/2021, 6 opportunities for position change were not recorded, 12 hours did not have documentation indicating repositioning for pt #2.

Day #5: 4/1/2021, 8 opportunities for position change were not recorded, 12 hours did not have documentation indicating repositioning or hygiene needs were met for pt #2.

Day #6: 4/2/2021, 6 opportunities for position change were not recorded, 12 hours did not have documentation indicating repositioning or hygiene needs were met for pt #2.

Day #7: 4/3/2021, 5 opportunities for position change were not recorded, 10 hours did not have documentation indicating repositioning or hygiene needs were met for pt #2.

Day #9: 4/5/2021, 6 opportunities for position change were not recorded, 12 hours did not have documentation indicating repositioning or hygiene needs were met for pt #2.

Day #11: 4/7/2021, 1 opportunity for repositioning was not documented. Documentation indicated pt #2 remained in the same position without hygiene needs being met, for 4 consecutive hours.

Day #13: 4/9/2021, 6 opportunities for position change were not recorded, 12 hours did not have documentation indicating repositioning and hygiene needs were met for pt #2.

Day #14: 4/10/2021 The RN documented "Open area to buttocks". No further description was documented. A wound care consult was generated.

Day #15: 4/11/2021 Review of nurses notes indicated a wound care nurse evaluated pt #2. The wound care RN documented, " Every 2 hours position changes were documented.
On assessment the patient has breakdown to her sacrum/coccyx/buttock. It is unclear if this is due to friction/shear or possible pressure. Recommend applying Venelex ointment to the area and covering with a foam dressing. Wound care will return in one week if the patient is still present".

Day#17: 4/13/2021, 11 opportunities for position changes were not recorded, Documentation indicated pt #2 was in the same position for 22 hours without repositioning or hygiene needs met.

Day #18: 4/14/2021, 1 opportunity for position change was not recorded. Documentation indicated pt #2 remained in the same position 4 hours.

Day #19: 4/15/2021, 1 opportunity for position change was not recorded. Documentation indicated pt #2 remained in the same position 4 hours.

On 4/15/2021 pt #2 was discharged to Long Term Acute Care services without documentation of a description or picture of the wound.

A review of the medical record dated 4/15/2021 at 5:09 PM, the initial skin assessment for pt #2 read, "wound to sacrum/buttock measuring 9 centimeters x 3 centimeters x 0. Slough and pale pink Tissue".

The national standard for wound grading indicates slough or eschar may not be graded as a the depth cannot be determines. See reference below.

(Reference CMS.gov, ..."wounds are unstagable including slough and eschar, deep tissue
pressure ulcers).

Pt #2 had no skin breakdown upon admission to the acute hospital. She was discharged with a 9 cm x 3 cm x 0 wound located on her sacrum/coccyx/buttock area.

Based on document review and interview, nursing failed to follow its policy for care planning/assessment/reassessment for 1 of 20 patient (#2 of #1 through #20).

This failed practice had the likelihood to effect all patients of the facility.

Findings included


On 11/29/2021 policy 39237.2 Assessment and Reassessment was reviewed, and can be read in part below:

"Applicability:
Each patient admitted to the hospital should have a physical assessment by a registered nurse (RN). A plan of care should be initiated according to findings within 12 hours of admission. Reassessments are completed at least once during each shift and with changes in patient condition.

Procedure:
1.
h) Upon completion of the initial assessment,the RN should develop a nursing care plan focused on the problems and issues identified. A plan of care should be initiated according to findings within about 12 hours of admission. Care plan is based on needs identified by the patient's admitting diagnosis, assessment/reassessment and diagnostic test results....Care plans are reviewed and updated every shift or more frequently as indicated.

2.
c) Nursing reassessment of a patient should reflect at a minimum, change in patient conditions and/ or diagnosis and response to interventions. More frequent reassessments should be completed as appropriate for the patient population and/or individual patient need.
f) Care plan is based on needs identified by the patient's admitting diagnosis, assessment/reassessment and diagnostic test results. Care plans shoul be reviewed and updated every sift or more frequently as indicated."


A review of pt #2's initial care plan identified the following: Care Plan, Problem: Skin integrity, identified 3/28/2021. The desired outcome was listed as, "Patient will have no skin breakdown during skin breakdown" (SIC). 3/28/2021 was the date of admission. There were no interventions recommended to avoid or prevent skin breakdown. The next Care plan entry was dated 4/15/2021 the day before discharge. "Not Met' was the resolution for the Care plan problem.

Patient #2 was admitted 3/28/2021 and discharge 4/16/2021. This date range provides 20 days or 40 opportunities for a Registered Nurse to update the patient care plan. Pt #2 developed skin breakdown on 4/10/2021. The care plan had not been updated to reflect the extent of skin breakdown. The single photograph taken by the wound nurse on 4/11/2021 shows full thickness skin loss. From the photograph the wound could not be staged because the wound contained a gray/white covering over one portion of the wound.

A photograph was not taken at discharge and no description of the wound was found in the nurses note.

The care plan did not reflect the altered skin integrity for pt #2. There were no interventions provided, and no update entered during 20 days of admission.