HospitalInspections.org

Based on findings from document review and interview, lapses in generally accepted standards of nursing care were identified in the implementation of nursing care plans and interventions related to skin care.

See findings under Tag # 0395 and 0396

Based on document review and medical record review, the nursing staff did not provide ongoing and consistent assessment of Patient #1's skin care needs.

Findings include:

Review of policy # CSC#0019 Effective date April 2014 and titled, Plan of Care policy revealed the plan of care is initiated at the time of admission and should be ongoing.

Review of policy # CSC032 and titled Catholic Health Nurse Standards of Care for Medical Surgical/Critical Care Units with effective date 4/29/14 revealed the patient should have an ongoing head to toe assessment every 4 hours. Nursing interventions should include utilization of Skin Care Nursing Guidelines per the Braden scale and Wound Care policy. Patient ' s skin should be assessed and Braden scale completed daily. Patients are to be turned and positioned with back and heel care every 2 hours and/or as indicated for patients with a Braden scale of less than 18 and at the discretion of the registered nurse. Any signs and symptoms should be reported to the nurse/provider.

Review of Policy # CSC 0050 titled Skin Assessment and Wound Prevention Guidelines dated 2/21/14 revealed the Braden Scale will be completed within the first 8 hours of admission and daily in acute care settings. Patients who score 18 or less are to have preventive interventions based on the Braden Score, " skin bundles " and prescriber orders implemented in the plan of care.

On interview Staff #18, RN on 1/8/15 stated that when skin breakdown is noted, the wound is measured and the physician is notified. Skin assessments are done every shift and measured once a week. Patients with skin breakdown are turned and positioned at least every two hours. Patients can be referred to the skin care specialist.

Review of the nursing admission assessment dated 3/27/14 for Patient #1 revealed a Braden score of 11 or 12. A nursing care plan for skin care was not initiated until 4/11/14 when the patient began to experience skin breakdown consisting of a 2 by 2 blistered area on the back and a right and left buttock Stage II decubitus. Allevyn dressing was ordered on 4/11/14 with initial documentation of the use of the Allevyn on 4/14/14 at 8:00pm.

Review of nursing care plan revealed the use of interventions to protect and pad bony prominences, along with elevating heels off the bed or use of heel protectors was not added to the patient's plan of care until 5/6/14. Turning and repositioning of the patient was not added to the plan of care until 6/12/14.

Review of nursing documentation from 6/27/14 through 7/1/14 revealed documentation of turning and positioning ranging from 2-5 times per day. On 6/30/14 patient position was documented as "back" at 6:00pm and 8:00pm with no further documentation of position change until 7/1/14 at 6:00pm.

Review of nursing documentation on 11/5/14 indicates sacral skin breakdown was present. On 11/6/14 the wound care nurse documented that breakdown was present to the right chin/neck, left great toe (suspect deep tissue injury), right heel, right buttock (Stage IV), right leg (Stage III), sacrum (Stage IV) and right chest.

Based on document review, medical record review and interview, the facility did not implement a complete plan of care for 8 of 8 patients who had skin breakdown or who were identified as patients at risk for skin breakdown (Patient #1, 11, 12, 14, 18, 21, 22 and 23). In addition, nursing care plans could not be accessed for 2 of 23 records reviewed (Patient #2 and 9)

Findings include:

Review of policy # CSC#0019 Effective date April 2014 and titled, Plan of Care policy revealed the following:
A.) The Registered Nurse shall develop and integrate the Plan of Care.
C.)The Plan of Care takes into consideration the total physiologic ...cognitive...medical needs of the patient.
D.) Intervention state a clear concise, plan of actions for all staff to follow and should reflect current standards of practice.
G.) The Plan of Care is initiated at the time of admission. Assessment and evaluation of problems, outcomes and planned care must be completed within 24 hours of admission and should be ongoing.

Review of Policy # CSC 0050 titled Skin Assessment and Wound Prevention Guidelines dated 2/21/14 revealed the Braden Scale will be completed within the first 8 hours of admission and daily in acute care settings. Patient who score 18 or less are to have preventive interventions based on the Braden Score, " skin bundles " and prescriber orders implemented in the plan of care.

On interview Staff #18, RN on 1/8/15 stated that when skin breakdown is noted, the wound is measured and the physician is notified. Skin assessments are done every shift and measured once a week. Patients with skin breakdown are turned and positioned at least every two hours. Patients can be referred to the skin care specialist.

Review of the nursing admission assessment dated 3/27/14 for Patient #1 revealed a Braden score of 11 or 12. A nursing care plan for skin breakdown was not intiated until 4/11/14 when the patient began to experience skin breakdown.

Review of nursing documentation dated 10/4/14 for Patient #1 revealed a wound vac to the right and left buttocks was in place. However, this intervention was not included in the care plan.

Review of the nursing care plan for Patient # 11 who had undergone a hip arthroplasty revealed decreased mobility and potential for skin breakdown were not addressed despite a physician order for bedrest with decubiti precautions.

Review of the nursing care plan for Patient #12 who was admitted with weakness, anemia and Stage 1 decubiti on both buttocks revealed no evidence of a skin care plan. On discharge the patient's decubiti had progressed to Stage II.

Review of the nursing care plan for Patient #14 who developed a Stage II decubitus on buttocks while hospitalized revealed no evidence of a skin care plan.

Review of the nursing admission assessment for Patient #18 identified a dark purple wound on the back. The nursing care plan for skin care was not updated to include the use of an Allevyn dressing and an air mattress that was ordered by the wound care nurse on 10/1/14.

Review of the nursing admission assessment for Patient #21 revealed the patient had fallen prior to admission with multiple skin abrasions and bruises noted. The nursing care plan for skin care did not address a left scapular (shoulder) wound that was present on admission.

Review of the nursing admission assessment for Patient #22 the patient's skin was intact on admission. Three days following admission the patient developed a Stage II decubitus on the buttocks. Review of the nursing care plan revealed no evidence of a skin care plan.

Review of the nursing admission assessment for Patient #23 indicated the patient had fallen prior to admission with multiple skin abrasions and wounds noted. Review of the nursing care plan revealed no evidence of a skin care plan.

Interview with Staff #24 (Lead Application Programmer) on 1/9/15 revealed no evidence of a nursing care plan in the electronic medical record for Patient #2 who was admitted 9/9/14 and Patient # 9 who was admitted on 12/24/14.

Based on medical record review and interview, the medical record did not maintain a complete medical record for 1 of 1 patient (Patient #1).

Findings include:

Review of a certified copy of the patient's electronic medical record on 1/8/15 revealed the record did not include physician orders, consults or complete lab work.

Review of the Patient Discharge Instructions in the medical record dated 11/6/14 revealed wound care instructions were on a " special sheet " in an envelope. Interview with Staff #12 (Significant Event Manager) on 1/12/15 revealed the facility is not able to locate the document.