HospitalInspections.org

Based on interview and record review, the facility failed to ensure a nursing care plan in compliance with hospital policy for a patient with documented skin tears and pressure sores for 1 of 10 sampled patients (#1).

Findings:

Patient #1's medical record revealed the patient was seen in the emergency room on 2/21/17 and admitted to the 3 East unit on 2/22/17 at 3:01 AM. The "Wound/Ulcer Evaluation", dated 2/22/17 at 2:30 AM, read, "Tear-left buttocks. Non-open....Open to air." This site and type of wound (tear) was mentioned in other shift notes on subsequent days during the patient's stay, until there was classification of this site as a stage II pressure sore on 2/27/17. On 2/24/17 at 3:35 PM, the "Wound/Ulcer Evaluation" read, "Location: RU (right upper) posterior back. Wound eval: open....transparent dressing." This was the first mention of a wound at this location.

Regarding the steps to take upon discovery of a skin tear, a review of facility policy "Skin and Wound Care Policy" read, "Within 24 hours of discovery and identification of skin tears... the registered nurse will obtain the 'Skin Tear, Abrasion and Perineal Dermatitis Treatment Order' form... and notify the physician. The nurse will....(2) review the treatment outlined in the form that corresponds to the appropriate type of skin alteration with the physician, (3) mark any changes indicated by the physician, and (4) either obtains signature or telephone/read back signature. It is the intent that the physician review and indicate treatment within 24 hours."

A review of the medical record did not reveal any evidence that these steps were followed with respect to the two skin tear entries, and with any of the other subsequent record entries which continued to indicate the presence of a skin tear either on the buttocks or on the upper back. Although the above entry regarding the left buttocks skin tear site revealed an initial approach to keep the site open, and later entries concerning the site indicated the use of a dressing, there was no evidence in the record at any other point in the patient's stay that either of these approaches were instituted as a result of physician contact which lead to an order, as specified in policy. Also, although the above entry and later entries regarding the upper back skin tear revealed an approach to apply a dressing, there was no evidence in the record at any point in the patient's stay that this approach was instituted as a result of physician contact which lead to an order, as specified in policy.

A nurse's note on 2/27/17 at 6:15 AM read, "(The patient) has stage 2 center buttocks...." This was the first and only entry in the record which classified the buttocks wound site as a stage II pressure sore. The next wound entry in the medical record, on 2/27/17 at 8 AM, again classified it as a skin tear. Until 2/27/16 at 6:15 AM, there was no explanation in the medical record regarding this classification from pressure sore on the back to a skin tear. There was no statement which indicated that the preceding 2/27/17 at 6:15 AM entry was in error.

The hospital's "Skin and Wound Care Policy" read, "The physician is notified immediately upon suspicion of a developing pressure ulcer/or confirmation of the presence of a pressure ulcer....The Wound Care Nurse is also notified for recommendations for further interventions and changes to be made to patient treatment plan....Assessment and Documentation of Pressure Ulcers and Wounds....Measurements are to include length X (by) width X depth in centimeters....The condition of the surrounding skin and wound edges....is noted. The color of the wound bed is noted and the percentage described using colors....The presence of exudate....is noted. The findings are documented on the nursing assessment and the physician notified of the findings." There was no evidence in the record that any of these steps were taken upon the documentation of the presence of a pressure sore.

The hospital's "Skin and Wound Care Policy" also read, "Orders need to be obtained for post-hospital care for the treatment of any ulceration that remains open. These orders are to be indicated on discharge instructions for the patient." There were no such instructions in the medical record for the patient's two wound sites. The policy was not followed.

During an interview of the Risk Manager at approximately 5:45 PM on 5/03/17, she confirmed the finding.