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Based on observation, interview and record review the facility failed to prevent the development of four pressure sores on one patient (Patient #27), failed to stage these pressure sores, failed to timely implement dietary intervention to increase protein levels, failed to measure consistently, and failed to be knowledgeable regarding staging and treatment for this one patient. The facility also failed to use the Braden Scale as designed to accurately assess the risk of skin breakdown for four (Patient ' s #19, #20, #28, #29) of five patients with skin breakdown. The facility identified five patients with pressure sores out of a census of 209.
Findings Included:
1. Review of Patient #27 ' s History and Physical (H & P) dated 11/01/10 showed the patient was admitted on that date with a diagnosis of a stroke. The patient was admitted without any skin openings or pressure sores. The patient had a history of cellulitis in the right lower extremity, and had current wounds in the legs.
Review of the patient ' s Braden scores (less that 18 = risk for developing pressure sores) showed the patient had a score of 15 (at risk) on admission, and then it fluctuated from 15-18 through 11/10/10.
Review of the patient's laboratory results dated 11/01/10 showed a low albumin level of 2.4 mg/dL, which is indicative of poor protein stores, leading to possible poor wound healing ability.
Review of the initial dietary evaluation dated 11/04/10 showed a note that the patient may benefit from a protein snack three times daily. However, staff failed to amend the diet until 11/09/10, at which time Juven (a supplement) was added twice daily related to wounds, or eight days after admission of a high risk patient, or two days after a new pressure sore was identified.
Review of Treatment Site Management notes showed a nurses ' note which said the patient had pressure sores present on admission; however, staff failed to provide further documented evidence of this.
Review of wound documentation in the record showed the following:
a) A pressure sore on the left lower buttock (#1) was identified on 11/03/10, measuring 1.0 centimeters (cm) by 0.2 cm, with surrounding skin fragile. Staff failed to stage this pressure sore.
b) A pressure sore on the left lower buttock (#2) was identified on 11/03/10, measuring 1.5 cm by 0.5 cm. Staff failed to stage this pressure sore.
c) A pressure sore on the right upper buttock (#1) was identified on 11/03/10, which was red, measuring 1.5 cm by 1.5 cm by 0.1 cm. Staff failed to stage this pressure sore.
d) A pressure sore on the right upper buttock (#2) was identified on 11/03/10, which was red, 0,5 cm by 0.5 cm by 0.1 cm. Staff failed to stage this pressure sore.
e) A pressure sore on the right upper buttock (#2) was identified on 11/03/10, which was red, 1.5 cm by 1.5 cm by 0.1 cm. Staff failed to stage this pressure sore.
f) On 11/07/10, documentation showed all pressure sores above had yellow slough within them. As of 11/10/10, facility staff had failed to stage all above pressure sores.
Observation and interview on 11/10/10 at 9:55 AM showed the patient had four total pressure sores on the buttocks. Three on the right upper buttock, and one on the lower left buttock. Licensed Practical Nurse (LPN) staff member HH measured two of the upper buttock pressure sores together, instead of separately, revealing an inconsistent measurement of 1.5 cm by 1.0 cm, with two areas of yellow slough within measuring 0.5 cm by 0.5 cm and 0.4 cm by 0.5 cm. The third pressure sore on the right upper buttock measured 0.3 cm by 0.4 cm, and it was all yellow. The pressure sore on the left lower buttock measured 1.4 cm by 0.5 cm. LPN HH could not verbalize, with confidence, what stage these pressure sores were. LPN HH was not aware of the treatment being used for these pressure sores, other than a barrier cream.
Review of treatment administration documentation showed an ointment called Xenaderm was to be applied three times daily to the buttock beginning 11/01/10. Staff failed to apply the ointment once on 11/05/10, and once on 11/06/10. No change in treatment orders was evident, even though the tissue within the pressure sores had deteriorated in appearance.
Review of a facility policy entitled, " Skin: Complicated Wound Management Protocol, " revised 10/09, showed wound staging will be completed by the wound and skin specialist. According to the protocol, any pressure ulcer with slough (yellow tissue) is considered a Stage III (slough may be present but does not obscure the depth of tissue loss).
Review of wound and skin specialist notes from 11/04-11/09/10 showed staff failed to document pressure sore staging.


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2. Observation on 11/09/2010 at 1:30 PM showed Patient #19 in bed and receiving dressing changes by Staff F, RN, Wound Nurse, on both lower extremities for Unna's boot (a special gauze [usually 4 inches wide and 10 yards long] bandage, which can be used for the treatment of venous stasis ulcers and other venous insufficiencies of the leg). The patient's walker was sitting beside the bed which indicated that the patient needed support to ambulate (walk). The Patient's right greater toe was black and crusty looking but the nurse did not apply a treatment to this area.

The Braden Scale is a research-based universally accepted tool used to determine a patient's level of risk for development of pressure ulcers. The Braden Scale is a summated rating scale made up of six subscales scored from 1-3 or 4, for total scores that range from 6-23. A lower Braden Scale Score indicates a lower level of functioning and, therefore, a higher level of risk for pressure ulcer development. A score of 19 or higher, for instance, would indicate that the patient is at low risk, with no need for treatment at this time. The assessment can also be used to evaluate the course of a particular treatment. The Braden Scale scoring states the following criteria: (15-16 = low risk, 13-14 = moderate risk, 12 or less = high risk).

Observation of Patient #19 showed a Patient in need of assistance to walk indicating impaired mobility/activity and lower extremities that are heavily wrapped in bandages to treat venous stasis (Poor circulation in the veins (venous insufficiency) can cause stasis dermatitis and craters (ulcers) in the skin) or impaired sensory perception (inability to feel pain) and more susceptable to injury or the ability to know the skin is damaged.

Record review of Patient #19's medical record showed a Braden Scale score of 18 at 7:00 AM and 19 at 3:00 PM for different shifts on the same day of 11/08/2010. Documentation on the risk intervention portion for the score of 18 stated "improved pitting" (refers to a persistent indentation when pressure is applied to swollen skin). This Patient was assessed by nursing to be at low risk and should have been assessed to be at high risk for further skin breakdown.
Further review of Patient #19's medical record showed no documentation in the chart by Staff #F, RN, Wound Nurse for this patient in regard to the Unna's boot treatment. The Patient's black greater toe on the right foot had no documentation in the record at time of review, no referral to the physician and no treatment plan.

Record review of the SKIN INTEGRITY PROTOCOL dated 07/08/2010, states, in part:
- 3. Assess patients with special needs every twelve hours:
b. Peripheral vascular disease and diabetic patients: Assess feet (including skin between toes), heels and skin folds for signs of redness or skin breakdown.

REPORTABLE CONDITIONS:
34. Notify physician of:
a. Changes in foot assessment for the diabetic patient or the patient with PVD [Peripheral vascular disease (PVD), commonly referred to as peripheral arterial disease]
c. Changes in skin appearance including: 1) Development of skin breakdown stage 1-4.

3. Observation on 11/09/2010 at 2:00 PM showed Patient #20 in bed with a right leg above the knee amputation and a contractured left leg that had an open pressure sore on the heel indicating this Patient had significant mobility/activity impairment. The patient had scooted down in the bed and was assisted by two staff to pull him up into place on the pillow, further indicating the Patient's mobility impairment. Staff W, RN, cleansed the pressure sore as directed by the physician's order and placed an inflated treatment boot on the foot to keep pressure off of the heel and to prevent further damage.

Record review of Patient #20's medical chart showed a Braden score of 18 for the date of 11/08/2010 at 3:00 PM and a Braden score of 14 on the date of 11/09/2010 at 7:00 AM reflecting significant inconsistency in Braden Scoring for this Patient and failure to score the Patient as a high risk for skin breakdown.

4. Record review of Patient #28's medical record on 11/09/2010 showed the patient had been identified as having a pressure ulcer. The Braden Scale score on 11/08/2010 at 7:00 AM was 16; at 3:00 PM on 11/08/2010 the Braden Scale score was 18; no score was documented on 11/09/2010 at 7:00 AM but at 3:00 PM the Braden Scale score was 19. The nursing assessments for the Braden Scale were inconsistent and failed to score the Patient at high risk for skin breakdown.

5. Record review of Patient #29's medical record on 11/09/2010 showed the patient had been identified as having a pressure ulcer. The Braden Scale score on 11/09/2010 at 11:44 AM was assessed as 17. A score of 17 on the Braden Scale would indicate the patient would be at low risk for a pressure ulcer.

6. Staff F, RN, Wound Nurse stated in the Exit Interview on 10/10/2010 that the facility considers a Braden Scale score of 18 or below to be assessing a Patient for High Risk. Staff F, RN, Wound Nurse is the only wound nurse for the facility and fails to use the research based, universally accepted Braden Scale tool for risk assessment as it was designed for preventive measures.

7. During an interview on 11/10/2010 at 10:00 AM with Staff FF, Supervisor Training it was stated that facility nurses are trained in the Braden Scale scoring during orientation and annually during their skills review. Staff FF stated he/she was not aware that further training in the Braden Scale risk assessment tool needed to be implemented or improved but agreed that the scores were not consistent, varied widely, and did not accurately represent patients with current wounds.

Based on observation, interview and record review the facility failed to administer medications within the required timeframes (30 minutes before or after the scheduled time) for two patients reviewed (Patients #16 and #18). The facility census was 209.

Findings included:

1. Review of a facility policy entitled, "Transcription, Administration and Documentation of Medications," dated 11/23/09, showed medications would be administered in a timely manner, and within the parameters prescribed by the physician.

Review of Patient #16's History and Physical (H & P) dated 11/01/10 showed the patient was admitted on 11/01/10 with diagnoses of an infected elbow and renal disease.

Observation and interview on 11/09/10 at 9:21 AM showed Registered Nurse (RN) staff member I administered Oxacillin (an antibiotic) 2 grams via a piggy back intravenous method to Patient #16. This medication was due to be administered at 8:00 AM. RN I stated that medications were routinely administered from 8:00 to 9:00 AM.

During an interview on 11/09/10 at 9:51 AM, RN staff member G (the unit manager) stated that medications were to be administered thirty minutes before or after the scheduled time. Or, in this case, from 7:30-8:30 AM.

2. Review of Patient #18's H & P dated 11/08/10 showed the patient was admitted on that date with a diagnosis of a left hip pinning.

Review of medications administered to Patient #18 showed staff failed to administer the following medications during the required timeframe:

a) On 11/09, Senokot (laxative) was due at 9:00 AM, but was administered at 8:18 AM, or 12 minutes early.
b) On 11/09, Prilosec (an anti-gas) 40 milligrams (mg) was due at 7:00 AM, but was administered at 3:55 AM, or almost three hours early.
c) On 11/09, an albuterol inhaler was due at 9:00 AM, but was administered at 8:14 AM, or 16 minutes early.
d) On 11/09, Prozac (an anti-depressant) 10 mg was due at 9:00 AM, but was administered at 8:18 AM, or 12 minutes early.


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3. During an interview on 11/10/2010 at 9:26 AM with Staff R, RN, it was stated that he/she has two hours to administer medications to his/her patients. "So, my 9:00 AM meds [medication] can be given anywhere from 8:00 AM to 10:00 AM."

Based on observation, interview and record review the facility failed to label opened solutions with a date opened, time and initials of staff opening per their policy. The facility census was 209.

Findings Included:
1. Review of a facility policy entitled, "Transcription, Administration and Documentation of Medications, dated 11/23/09, showed multi-use vials will not be left in patient rooms.

Observation and interview on 11/08/10 at 3:04 PM, showed a bottle of Citroma, 10 fluid ounces, about one-half empty, in the refrigerator of the medication room on the medical unit. The bottle of Citroma did not have the date opened or initials of who opened it on the label. The unit manager, Registered Nurse (RN) staff member H stated that the policy was to label the solution with date opened, time and initials, then discard after twenty-four hours.

2. Observation on 11/09/10 at 9:48 AM showed a bottle of normal saline, 250 milliliters (mL), about 30 mL's empty, on a bedside table of Patient #16. Staff failed to label the bottle with the date opened and initial per facility policy.

During an interview on 11/09/10 at 11/50 AM, RN staff member I stated that he/she thought the surgeon changed the patient's elbow dressing this AM, using the bottle of saline to do the treatment. The physician failed to date, time and initial the bottle of saline.

Based on observation and record review the facility failed to use standard precautions while inserting an intravenous (IV) line for one patient (Patient #16). The facility census was 209.

Findings Included:

1. Review of facility policies entitled, "Hand Hygiene," dated 06/17/10, and "IV Therapy: Initiating IV Therapy Procedure," dated 01/28/09, showed the following:

a) Wash hands
b) Apply tourniquet and check for the presence of a pulse.
c) Don gloves.
d) Cleanse insertion site with alcohol wipe.
e) Insert the IV catheter, watch for blood return.
f) Remove the tourniquet.
g) Secure the IV.
h) Wash hands before clean procedures.
i) Wash hands before and after all patient contact.
j) Gloves are used to protect the hands of employees when there is risk of exposure to blood.

Observation on 11/09/10 at 9:48 AM showed Registered Nurse (RN) I entered the room of Patient #16 to insert an IV. RN I placed the IV supply tote in a chair and assisted the patient up in the bed. RN I used his/her bare hands to palpate for an IV site. RN I failed to wash his/her hands prior to putting gloves on. RN I palpated the arm, then cut the fingertip out of the right index finger glove to feel again. RN I failed to change gloves or wash his/her hands prior to starting the IV. RN I stuck Patient #16 (who was on a blood thinner) and blood spilled out the catheter onto the patient's arm, bed and RN I. Blood was dripping down the patient's arm. RN I failed to change gloves prior to cleaning up all the blood and supplies.

Based on observation, interview and record review the facility failed to ensure staff followed the facility policy of hand hygiene for Patients (#12, #17, #20 and #24) when staff did not wash their hands between glove changes or failed to change their gloves when soiled during a procedure. The facility census was 309.

Findings included:

1. Observation on 11/8/10 at 3:30 PM showed Registered Nurse (RN) F enter Patient #12's room and don non sterile gloves. The RN opened the bathroom door and returned to the room and proceeded to clean the top of the tray table with an alcohol wipe and the paper towels. The RN opened the room door and (spoke to someone outside the door) wearing the non sterile gloves. The RN then went to the patient and proceeded to measure the wounds on the right and left buttocks. The RN measured the depth of both wounds using the same sterile Q tip. No glove changes or hand cleansing was done between the non patient tasks and the patient.

During an interview on 11/8/10 at 3:50 PM Registered Nurse B stated the expectation was staff would change gloves and cleanse their hands between non patient tasks and patient tasks and would use a new sterile Q tip to measure the depth of the two separate wounds.

2. Observation on 11/9/10 at 10:00 AM showed Registered Nurse enter Patient #17's room and donned non sterile gloves to remove the dressing from a wound. The RN removed the gloves and donned sterile gloves. No hand cleansing was done between the glove changes.



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3. Observation on 11/09/2010 at 2:10 PM showed Staff Q, RN, go into Patient #20's room to clean wound on Patient's left heel and apply a pressure relieving boot to the foot. Staff Q, RN donned gloves and cleaned the wound with Betadine (antiseptic) and cotton tipped swabs. Staff Q, RN removed gloves and donned another pair of gloves without performing hand hygiene in between glove changes.



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4. Observation on 11/09/10 at 2:20 PM showed Staff BB, RN assisting Patient #24 to stand. Patient #24 attempted to stand and blood ran down the patient's leg. Staff BB had gloves on and cleansed the blood from the patient's legs. Staff BB continued to assist Patient #24 with care and failed to remove the blood soiled gloves, wash hands or use hand hygiene.

During an interview on 11/10/10 at 8:40 AM Staff Z, Manager Post Partum, Labor and Delivery, and Well Baby Unit, said that gloves should be changed after cleaning blood from a patient.

5. Record review of the facility Hand Hygiene policy from Addendum R: Infection Prevention Measures dated 06/17/10 showed, in part, the following information:

1. Handwashing, done properly, is the most effective procedure for preventing the spread of infection. Hands should be washed:
? Before and after the removal of any personal protective apparel
? After all patient contact procedures