HospitalInspections.org

Based on policy review, record review and interview, the hospital failed to have an organized nursing service which provided ongoing assessments of patients' needs and developed a plan of care in order to ensure they provided the services to meet those needs for 1 of 3 (Patient #1) sampled patients.

The findings included:

Patient #1 presented to the hospital's emergency department (ED) on 3/9/2021 with complaints of multiple falls and left hip and leg tenderness. Patient #1 was admitted into the hospital with a Left Hip Fracture.

Review of the nursing skin assessments revealed inconsistent and incomplete skin assessments. The nurses inconsistently documented the patient's skin was not intact, was intact and/or had bruising. There was no documentation to reflect complete skin assessment findings, description, location or severity of the skin symptoms.

Review of a photograph in the medical record dated 3/13/2021 revealed Patient #1 had large areas of discoloration to the bilateral buttocks that were deep red, maroon and purple in color. The patient was discharged to a rehabilitation hospital on 3/15/2021 and those areas to the patient's buttocks were identified as Deep Tissue Injury.

Review of Patient #1's plan of care revealed there was no documentation of a pressure injury treatment plan for Patient #1.
Refer to A 396.

Based on policy review, record review and interview, the hospital failed to follow its policy and ensure nursing services developed and implemented a nursing care plan using an interdisciplinary team (IDT) approach to provide care and services for the prevention of pressure injuries for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital's "Skin/Assessment & Pressure Injury Prevention" policy dated 1/14/2020 revealed, "... PURPOSE: Assess skin for potential and actual skin breakdown and to initiate treatment per MED Skin/Wound care standing orders. Prevent skin breakdown and improve skin integrity. Policy: Only pressure injuries are staged ...
On Admission Complete the risk assessment (Braden Score) to identify patients at risk for pressure injury as soon as possible but within 8 hours of admission ...
Every Shift...Assigned nurses will assess patients every shift for risk of potential and actual skin breakdown as part of their total body assessment ...
PROCEDURE ... Pressure Relief Mode ... Turn at least every two hours with pillows or wedges propped to the upper ... When the side-lying position is used, avoid positioning directly on the trochanter ... Maintain the head of the bed at or below a thirty (30) degree angle or flat when not contraindicated ... Utilizing lift devices (turning sheets, trapeze, and lifts) to move the patient in the bed rather than dragging the patient ...
Document skin assessment findings and any treatments implemented in the patient's record when the patient is admitted ..."

2. Review of the hospital's "Pressure Injury Treatment, Stage 1 and Deep Tissue Injury" policy dated 12/2019 revealed, "... PURPOSE: Help prevent and treat Stage 1 pressure injuries and Deep Tissue Injury (DTI) ... The primary physician should be notified of the pressure injury when the injury is first discovered. Physician notification should be documented in the patient's record ... Deep Tissue Injury: Persistent non-blanchable deep red, maroon or purple discoloration ... This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or bone-muscle interface ... If necrotic tissue subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI [deep tissue pressure injury] to describe vascular, traumatic, neuropathic, or dermatological conditions. Pressure redistribution measures are the priorities in treatment ..."

3. Review of the hospital's computer program "Braden Assessment" revealed, "Skin Integrity Risk Score ... A score less than 18 will automatically enter a skin breakdown prevention protocol order..."

4. Medical record review revealed Patient #1 presented to the hospital's emergency department [ED] via ambulance on 3/9/2021 and was seen by the ED physician at 9:14 PM. Patient #1 had a fractured left hip and was admitted into the hospital from 3/9/2021 - 3/15/2021.

The ED physician documented the patient presented to the ED after multiple episodes of falls. The patient had lower extremity, left hip and thigh tenderness. An x-ray of the left hip revealed, "... Impression: Acute mildly angulated comminuted left intertrochanteric hip fracture."

Review of the 3/10/2021 skin assessment form revealed at 12:00 AM registered nurse [RN #1] documented the patient had a Braden score of 16 indicating the need to implement the skin breakdown prevention protocol. RN #1 documented that Patient #1 was, "Bedfast", the patient's skin integrity was "Not Intact", and "Friction and Shear" was a potential skin problem. The skin symptoms of "T 38" was documented in the assessment. The key for T 38 revealed at "3/10/2021 00:00 [12:00 AM] ... (Skin Symptoms) Erythema, Itching, Rash, Ulcers/Lesions"
There was no additional documentation of skin assessment findings, description, location or severity of the patient's skin symptoms.

Review of the 3/10/2021 skin assessment form revealed at 8:00 AM RN #2 documented the skin integrity was "Not Intact", and "Friction and Shear" was a potential skin problem.
There was no additional documentation of skin assessment findings, description, location or severity of the patient's skin symptoms.

Review of the 3/10/2021 skin assessment form revealed at 8:00 PM RN #3 documented Patient #1 had a Braden score of 15 indicating the need to implement the skin breakdown prevention protocol. The skin integrity assessment was not completed. A potential skin problem was checked as "Friction and Shear". There was no additional documentation that verified a complete skin assessment had been performed in order to identify the patient's skin integrity.

Review of the 3/11/2021 skin assessment form revealed at 7:44 AM LPN #1 documented Patient #1 had a Braden score of 15 indicating the need to implement the skin breakdown prevention protocol. LPN #1 documented on the skin assessment form that the patient had "Bruising", the patient's skin integrity was "Intact", the patient was "Bedfast", and that "Friction and Shear" was a potential problem.
There was no additional documentation of the location or severity of "Bruising" or additional documentation of an assessment of the patient's skin integrity."

Review of the 3/12/2021 skin assessment form revealed at 1:42 AM LPN #2 documented Patient #1 had a Braden score of 16 indicating the need to implement the skin breakdown prevention protocol and that "Friction and Shear" was a potential problem.
There was no additional documentation of skin assessment findings, description, location or severity of the patient's skin symptoms.

Review of the 3/12/2021 skin assessment revealed at 7:37 AM RN #4 documented Patient #1 had a Braden score of 15 indicating the need to implement the skin breakdown prevention protocol. RN #4 documented the patient had "Bruising", the skin integrity was "Intact", the patient was "Bedfast", and that "Friction and Shear" was a potential problem. There was no additional documentation of the location or severity of "Bruising."

Review of the 3/12/2021 skin assessment form revealed at 7:08 PM LPN #3 documented Patient #1 had a Braden score of 16 indicating the need to implement the skin breakdown prevention protocol. LPN #3 documented the patient was bedfast and that "Friction and Shear" was a potential problem.
There was no additional documentation of skin assessment findings, description, location or severity of the patient's skin symptoms.

Review of the 3/13/2021 skin assessment form revealed at 7:45 AM Nursing Student (NS) #1 documented Patient #1 had a Braden score of 16 indicating the need to implement the skin breakdown prevention protocol. NS #1 documented the patient was bedfast and "Friction and Shear" was a potential problem.
There was no additional documentation of skin assessment findings, description, location or severity of the skin symptoms.

Record review revealed a photograph of the patient's buttocks dated 3/13/2021 at 9:00 AM and signed by RN #5. The photograph revealed a discolored area that involved the patient's entire right buttock, and was deep red, maroon and purple in color. There was also what appeared to be a fluid filled blister on the right buttock area near the anal area. The patient's left buttock had a discolored area that was deep maroon and purple in color that involved approximately a fourth of the buttock area.

Review of the 3/13/2021 skin assessment form revealed at 6:53 PM LPN # 3 documented Patient #1 had a Braden score of 16 indicating the need to implement the skin breakdown prevention protocol. LPN #3 documented the patient's skin integrity was "Not Intact", the patient was "Bedfast", and that "Friction and Shear" was a potential problem.
There was no additional documentation of skin assessment findings, description, location or severity of the skin symptoms.

Review of the 3/14/2021 skin assessment form revealed at 7:10 AM Nursing Student (NS) #1 documented Patient #1 had a Braden score of 16 indicating the need to implement the skin breakdown prevention protocol. NS #1 documented the patient's skin integrity was "Not Intact", the patient was "Bedfast", and that "Friction and Shear" was a potential problem.
There was no additional documentation of skin assessment findings, description, location or severity of the skin symptoms.

Review of the 3/14/2021 skin assessment form revealed at 6:00 PM RN #5 documented Patient #1 had a Braden score of 15 indicating the need to implement the skin breakdown prevention protocol. RN #5 documented the patient's skin integrity as "Skin Symptoms T 37", patient's skin integrity was "Intact", the patient was "Bedfast", and that "Friction and Shear" was a potential problem. The key for T 37 revealed "3/14/2021 18:00 ... Bruising...blister near anus".
There was no additional documentation of skin assessment findings, description, location or severity of the skin symptoms.

Review of the 3/15/2021 skin assessment form revealed at 8:00 AM RN #6 documented Patient #1 had a Braden score of 15 indicating the need to implement the skin breakdown prevention protocol. RN #6 documented "Skin Symptoms None", patient's skin integrity was "Intact", the patient was "Bedfast", and that "Friction and Shear" was a potential problem.
There was no additional documentation of skin assessment findings, description, location or severity of the skin symptoms.

Review of Patient #1's medical record revealed no documentation of a care plan related to the patient's skin integrity.

On 3/15/2021 at 11:40 AM Patient #1 was discharged and transferred to a Rehabilitation Hospital for continued recovery and therapy.

Review of the rehabilitation hospital's admission skin assessment dated 3/15/2021 at 3:12 PM revealed Patient #1 had a fourteen (14) centimeter (cm) x thirteen (13) cm area to the right buttock, and an approximately eight (8) cm long area to the left buttock, and a blister type area near the anus. The discolored areas to the right and left buttocks were deep red and purple in color.

Review of the 3/16/2021 rehabilitation hospital's skin assessment revealed the areas noted in Patient #1's admission skin assessment were "... Unstageable due to deep tissue injury."

5. In an interview on 11/2/2021 at 3:00 PM, the hospital's Quality Outcomes Manager (QOM) stated the skin assessments for Patient #1 revealed bruising to the patient's buttocks. The QOM stated the patient had several falls prior to coming to the hospital's ED and was taking blood thinners that can cause bleeding.

In an interview on 11/3/2021 at 8:45 AM, the hospital's QOM verified there was no documentation of a care plan for pressure injuries in Patient #1's medical record. The QOM stated the hospital's documentation did however reveal that Patient #1 was turned every 2 hours.

In an interview on 11/3/2021 at 10:50 AM, the hospital's QOM verified there was no documentation the physician was notified of the skin condition of Patient #1's buttocks.

In an interview on 11/3/2021 at 11:00 AM, the hospital's QOM verified there were no additional policies related to skin or wounds other than the policies provided.