HospitalInspections.org

Based on an onsite survey of 1/29/14 inclusive of policy and procedure, interviews, and 10 patient records, it is revealed that nursing failed to identify patient #1's inability to effectively reposition himself, resulting in a deep tissue injury of the left heel.

Patient #1 is a middle-aged male who presented to the emergency department (ED) due to abdominal pain and vomiting, and white blood cell level of 31,100. Patient #1's history is significant in part for strokes with residual left-sided weakness, hypertension, renal insufficiency with weekly peritoneal dialysis, and diabetes mellitus.
Patient #1 was assessed by nursing on the day of entry to care with no skin wounds. Additionally, nursing assessed patient #1 as having " generalized weakness in all extremities." However, nursing flow documentation revealed that patient #1 had "active range of motion " with regards to positioning. Muscle strength grading reveals that patient #1 ' s lower extremities had "active movement against gravity and resistance."
A physician noted in part, "Skin is warm and dry. No bruising and no rash noted. He is not diaphoretic." Five days following admission, an MD wrote, " Pt told me the left side is much weaker then the right. No movement of left leg. Left arm can move but no strength."

Seven days following ED presentation, a sacral tear was noted, and on the eighth day, a deep tissue injury of the heel was noted. A consult to the wound nurse was ordered as well as orders to " turn patient, and elevate heels. " The following day, the Infectious Disease physician wrote, " left arm and leg have minimal movement. Cannot be raised off the bed. Right side is weak also, but not as severe as the left. "

Once identified, the hospital rapidly took steps to treat patient #1's skin. Both the skin tear and left heel were in states of healing at discharge. However, nursing failed to intervene based on the patient history of residual left-sided weakness and the initial nursing assessment of generalized weakness. Consequently, patient #1 proved to have insufficient active range of motion to reposition himself effectively to prevent the deep tissue injury of the left heel.