HospitalInspections.org

Based on interviews, review of policies and procedures, and record review, the facility failed to inform the patient's representatives of the patient's current medical status regarding the development of pressure ulcers to the sacrum and left heel when first identified by nursing staff (documentation by Wound Ostomy Continence Nurse- WOCN 04-09-13 sacrum and 04-16-13 left heel). According to the patient's representative(s) they were informed of the presence of both pressure ulcers on 04-11-13.

This deficient practice effected Patient Identifier Number 1 (PI #1), one of ten sampled patients, as well as having the potential to affect all patients receiving treatment at this hospital.

The findings include:

1. POLICY AND PROCEDURE

The following policy addresses how this Hospital is currently keeping the patient and/or the patient's designated family member(s) informed of the patient's changes in health status and plan of care, such as the identification of a pressure ulcer. Note that this policy does not address the how, when, where this process will be accomplished to include the documentation of which family member was informed of the change in health status (pressure ulcer), when and how the family member was informed to include the changes in the patient's plan of care.

Patient Bill of Rights and Responsibilities
Policy Number: PRN_HW 089
Purpose:
(This Hospital) adopts a Patient's Bill of Rights ...with the expectation that the observance of these rights will contribute to more effective patient care and greater satisfaction for the patient, significant other, his/her physician, and the hospital organization...
Policy:
(This Hospital) staff and doctors want to enhance your health, dignity and wholeness. Because of our mission, we hereby adopt this Bill of Rights and Responsibilities.

You Have the Right to...
5, Be informed about the outcomes of care, treatment and services... including unanticipated outcomes...
18, Participate in the development of your plan of care while in the hospital...

2. MEDICAL RECORD REVIEW

PI #1's record was reviewed revealing that PI #1 presented to (this Hospital) emergency department (ED) on 03-20-13, "EMT's (emergency medical technician) were called (to patient's home after becoming unresponsive) and patient was noted to have no pulse and initiated CPR (cardiopulmonary resuscitation) after patient being down for approximately 15 minutes... and was intubated. Patient continued to have full cardiac arrest and she responded to ACLS (advanced cardiac life support) protocol while in the ED and continued on ventilator support and remained in critical condition... PI #1's diagnoses include: Hypertension with hypertensive cardiovascular disease and systolic congestive heart failure; coronary artery disease status post coronary artery bypass graft with two vessel coronary artery disease (August 2012) with aortic valve replacement; history of cardiac arrhythmias on chronic Coumadin therapy; peripheral arterial disease; type 2 diabetes mellitus; end stage renal disease; multiple arrhythmias with pacemaker placement; recent cerebrovascular accident; hypothyroidism, chronic obstructive pulmonary disease...

PI #1's record was reviewed revealing the following documentation regarding pressure ulcers.

04-09-13 at 9:19 AM by WOCN (wound, ostomy, and continence nurse).
Initial evaluation. The patient is immobile, incontinent, on the ventilator, nutritionally compromised, on tube feeds. She has a pressure ulcer to the bilateral buttocks and sacrum will order a pressure relief mattress.
Bilateral buttocks and sacrum stage 3: 20 cm (centimeters) (length) x 18 cm (width) x 0.4 cm (depth).
Wound comment: This patient has acquired this pressure ulcer during this admission. The staff has a mepiplex in place (indicates that staff were aware of the wound and treating in but not documenting the wound's presence and treatment). It was changed and will continue this while the patient has a rectal tube in place.

04-16-13 by WOCN
Sacral: 24 cm (length) x 20 cm (width) x 0.4 cm (depth).
Left heel: 4 cm (length) x 3 cm (width) x 0.3 cm (depth). Both pressure ulcers unstagable related to the presence of eschar.

04-17-13 at 1:00 PM
3 colored pictures (out of focus, minimum) of the sacral pressure ulcer classified as unstagable related to the presence of eschar. There is also 1 colored picture of the left heel with the presence of eschar.

04-24-13 at 3:29 PM by WOCN
Sacrum unstagable healing at 9 cm (manual removal of eschar also done >20 cm) x 5 cm x 0.5 cm.

04-25-13 at 3:00 PM by WOCN
Sacrum unstagable healing: 85% slough/eschar, 15% granulation, 9 cm x 5 cm x 1 cm.
Left heel unstagable healing: 90% slough/eschar, 10% granulation. 5 cm x 3 cm x 0.3 cm.

04-29-13 14:00 PM
Sacrum unstagable healing: 85% slough/eschar, 15% granulation, 9 cm x 5 cm x 1 cm.

Under "Other Education" is the following documentation:

Other education skin assessment by WOCN on 04-09-13 at 09:18.
Education given to patient (patient is unresponsive, unable to receive education, therefore, who did receive this education, what exactly was discussed, etc...)
Teaching method verbal.

Other education skin assessment by WOCN on 04-16-13 at 09:34.
Education given to patient.
Teaching method verbal.

Other education skin assessment by WOCN on 04-18-13 at 17:54.
Education given to patient.
Teaching method verbal.

No other documentation was found in the PI #1's record which addressed that PI #1's representative(s) were informed of the presence of pressure ulcer formation when first identified prior to 04-09-13.

3. INTERVIEWS

EI #1 (WOCN) was interviewed on 05-01-13 at 13:25 PM stating "Nurses put in a consult for me to see (PI #1). I saw (PI #1) on 04-09-13. When I do a consult I do a head to toe assessment. I assessed the pressure ulcer on (PI #1's) buttock/sacrum Stage 3 with a Mepiplex dressing in place with additional skin barriers (as indicated per pressure prevention protocols...). I went ahead and ordered a pressure relief mattress which is above the level of protocol listed for treatment... I reassessed (PI #1) on 04-16-13 with the left heel pressure ulcer now present... Both the heel and sacrum pressure ulcers were unstagable related to the presence of eschar... I changed the protocol to chemical debridment..."

EI #2 (chief Nursing Officer) was interviewed on 05-01-13 at 2:05 PM stating "We met with the family member(s) on 04-25-13. The family member(s) had concerns that the patient had two areas of skin breakdown and they did not know about it. They (family members) were not told about the two areas of skin breakdown when they first developed. We see this as an area of opportunity... We could not find it documented in the patient record that the family was informed of these areas of skin breakdown when they were first identified by our staff... Every shift updates the family with what is going on with the patient." EI #1 was asked if a plan of correction had been implemented for this problem. EI #1 explained "No we don't (have a plan of correction in place). We are working on it but don't have anything in place because of the recent (04-20-13) implementation of a new hospital wide digital patient charting computer program.


This deficiency was cited as the result of the investigation of complaint number AL00028910.

Susan A. Reed, RN, MSN