HospitalInspections.org

Based on observation, interview and record review the facility failed to prevent the development and worsening of a pressure ulcer for 1 out 5 sampled patients (SP) for pressure ulcer review. (SP#7)

The findings included:

Record review of the face sheet revealed that SP#7 was admitted on 10/12/15.
Record review of the history and physical dated 10/12/15 revealed that SP#7 was hospitalized and intubated for septic shock. His diagnosis included but were not limited to Diabetes Mellitus II, hypertension, multi organ failure, acute respiratory distress syndrome (ARDS) and gout.
Record review of the skin assessment for SP#7dated 10/12/15 revealed mucous membrane color dusky, dry and warm. Skin integrity general: intact.
Record review of the respiratory therapy assessment for SP#7dated 10/12/15 skin intact with endotracheal tube holder in place.
Record review of the skin assessment for SP#7dated 10/19/15 revealed skin not intact. Pressure ulcer to lip, suspected deep tissue injury with measurements 2 X 0.5 cm.
Record review of the respiratory assessment dated 10/20/15 revealed skin breakdown to upper lip, endotracheal tube holder.
Record review of the skin assessment for SP#7 dated 10/21/2015 pressure ulcer to left ear suspected deep tissue injury.
Record review of the skin assessment for SP#7 dated 10/23/15 revealed pressure ulcer to lip, suspected deep tissue injury. Pressure ulcer to left ear suspected deep tissue injury. Topical agent ointment.
Record review of the photographic image for SP#7 dated 10/23/15 revealed upper lip unstageable pressure ulcer, hospital acquired wound.
Interview on 11/3/15 at 3:19 pm with the Intensive Care Unit (ICU) Registered Nurse (Staff V) revealed that SP#7 was awake and oriented to name, time and place (times X 3), he was waiting to be extubated today. Staff V confirmed that SP#7developed the pressure ulcer to the lip and left ear in house at the hospital.
Staff V noted that SP#7had an endotracheal tube pressure ulcer to lip. Staff V noted that a pressure ulcer to the lip could happen with chronic intubated patients. Staff V noted that the pressure ulcer to the left ear could have resulted from a pillow for a patient on a ventilator. Staff V noted that the ICU just obtained a contour foam pillow today.
Record review of the skin assessment for SP#7dated 10/26/15 revealed pressure ulcer to left transverse ankle stage 3 pressure ulcer with 100 % pink tissue. Pressure ulcer to right transverse ankle stage 3 pressure ulcer with redness (erythema).
Record review of the respiratory assessment for SP#7 dated 10/27/15 revealed skin breakdown to upper lip, endotracheal tube holder.
Record review of the wound care consult for SP#7 dated 10/28/15 at 9:46 am revealed patient presented with suspected deep tissue injury to left lateral ankle and eschar ("Greek, Eschara - dead matter, tissue that is hard, black or brown and leathery in texture"; Medical Dictionary, 2009) to left ear. Apply aloe vesta to areas as well.
Record review of the skin assessment for SP#7 dated 10/28/15 revealed pressure ulcer to left ear unstageable, black necrotic tissue with measurements 2 X 1 cm.
Record review of the skin assessment for SP#7 dated 10/28/15 at 8:30 pm revealed right transverse ankle with unstageable necrotic tissue pressure ulcer.
Record review of the skin assessment for SP#7 dated 10/31/15 revealed pressure ulcer to left ear unstageable, unchanged.
Record review of the skin assessment for SP#7 dated 11/1/15 revealed pressure ulcer to left ear unstageable.
Record review of the wound care consult for SP#7 dated 11/2/15 revealed unstageable pressure ulcer to upper lip. Mepilex foam dressing daily. Patient remained in Medical Intensive Care Unit (MICU). Apply aloe vesta protective barrier ointment to intact skin.
Record review of the skin assessment for SP#7 dated 11/2/15 revealed unstageable pressure ulcer to lip, necrotic tissue, beige pink color with measurements 2 X 3 cm. Pressure ulcer dressing foam, pressure point medical device.
Interview on 11/3/15 at 5:05 pm with wound care registered nurse (Staff W) revealed she confirmed that SP#7 developed the pressure ulcer to the lip and to the left ear in the hospital. The wound care nurse mentioned that SP#7 was intubated. The wound care nurse noted that the left ear pressure ulcer and the lip pressure ulcer were both unstageable pressure ulcers. The wound care nurse noted that she recommended mepilex foam dressing to lip.
Record review of the skin assessment for SP#7 dated 11/4/15 revealed pressure ulcer to left ear unstageable, necrotic tissue.
Record review of the wound care physician orders for SP#7 dated 11/4/15 revealed hydrogel (duoderm gel), gauze wrap, left ear, fluffed 2 X 2 daily. Hydrogel (duoderm gel) to lip daily.
Record review of the wound care consult for SP#7 dated 11/4/15 revealed follow up with patient as to left ear eschar and eschar to lip. Patient had been extubated as of yesterday. Patient presents with eschar to upper lip. Suggest to cleanse with normal saline and apply duoderm gel to lip with fluffed 2 X 2 and medipore tape daily. For eschar to left ear, cleanse with normal saline and apply duoderm gel to area cover with fluffed 2 X 2 and medipore daily.
Observation on 11/4/15 at approximately 8:45 am revealed that SP#7 in ICU had been extubated, he was breathing on his own. He had 100 % dry eschar, unstageable pressure ulcer to the upper lip. SP#7 had 100 % dry, eschar, unstageable pressure ulcer to the left outer auricle of the ear.
Interview on 11/4/15 at 8:58 am with wound care registered nurse (staff W) confirmed that SP#7 had 100 % eschar, unstageable pressure ulcer and 100 % eschar to left outer auricle of ear. Both wounds had no drainage. Staff W noted that SP#7 was extubated yesterday at 3 pm. Staff W confirmed that the lip pressure ulcer was caused by the endotracheal tube holder device pressing against the lip. Staff W noted that the left ear pressure ulcer was presumably caused by the patient lying on his side : "Patients on a ventilator tend to favor a side." Staff W mentioned that the previous treatment to the left ear pressure ulcer was aloe vista protective ointment three times per day. The lip pressure ulcer treatment was mepilex foam dressing daily.
Interview on 11/4/15 at 10:25 with respiratory therapist (Staff Y) revealed that she was responsible for checking around the endotracheal (ET) tube placement. She confirmed that the SP#7 was intubated for 21 days due to multiple organ failure.
Interview on 11/4/15 at 1:33 pm with the wound care registered nurse (Staff W) revealed for SP#7 that the deep tissue injury to the lip was first documented on 10/19/15 and she confirmed that she was first consulted for the pressure ulcer to lip when the lip pressure ulcer had eschar on 11/2/15. She had recommended that mepilex foam dressing to the lip was used. Staff W noted that SP#7 first developed deep tissue injury to left ear on 10/20/15 at 8 am as per the nursing skin assessment. Staff W confirmed that her first wound care consult to the left ear was on 10/28/15 at 9:46 am.
Record review of the wound care policy and procedure dated 03/31/15 revealed "Purpose to outline management of patients with wounds including pressure ulcers, surgical incisions and traumatic injuries.
Supportive Data, Supplemental information:
Initiate wound, ostomy continence nurse (ET) / wound care trained nurse consult for all stage III, stage IV, deep tissue injury and unstageable pressure ulcers."
There is no time frame on the wound care policy when to initiate a wound care consult.
Record review of the policy and procedure dated 07/23/15 titled "Identification and management of patients who are at risk for skin break down and pressure ulcers.
Supportive Data / supplemental information.
Pressure Redistribution for Head / Ear with Fluidized positioner device (page 5 of 8): To help prevent head and ear pressure ulcers, it used to replace pillow, single patient use only, which is molded under head. Fluidized positioner device may be used to maximize positioning for pressure ulcer redistribution if existing occipital or ear pressure uclers".


Interview on 11/3/15 at 5:05 pm with wound care registered nurse (Staff W) revealed that for a preventive measure for pressure ulcer development of the ear there was a Z flow gel positioner which was like a pillow. This was a preventive measure to help prevent ear break down. Staff W confirmed that SP#7 never had a pressure relieving device for the ear since the medical ICU didn't have this device. Staff W confirmed that the whole hospital was being inserviced about the Z flow gel positioner and the charge nurse will follow up on getting the Z flow positoner for the Medical ICU.