HospitalInspections.org

Based on interview and record review, the facility failed to ensure staff consistently implemented their policy and procedure/protocol for preventing and treating changes in skin integrity for one patient (#2) of 5 patients reviewed for skin integrity resulting in increased potential for alterations in skin integrity for patient #2.
Findings include:

Review of documents revealed that the first wound care consult was dated 01/04/22. Wound care documentation (by Staff K Certified Wound Care Registered Nurse (RN)) on 01/05/2022 at 12:15 documented as follows, Wound type; cellulitis/vascular wound on the left calf, wound length documented as "no open tissue is noted", Wound bed tissue note, documented; 'There is no open tissue but there is a large area of pink scar tissue with dry, flaky scabby tissue noted scattered within". Status of wound; "not granulating. The skin of the patient's left lower extremity (LLE) is very thick and dry. Apply (brand name) lotion to dry flaky scar tissue daily for moisturization. If tissue opens- apply xeroform to area of open tissue, cover & wrap with kerlix to secure. Change daily/PRN (as needed), Elevate bilateral lower extremity (BLE) whenever possible to minimize edema (swelling). Please reconsult if wound deteriorates. Treatment plan ordered; dietician consulted, inflatable overlay".
The document went on to describe the following "Wound Assessment #2, Pressure Redistribution Note" as documented by Staff K, "Patient reports that his buttocks is intact & that he has no other wounds to be assessed at this time. Turn/reposition Q2 hours (every two hours) for pressure redistribution. Bilateral heels are intact, float bilateral heels at all times while in bed". During an interview with Staff K, conducted on 05/18/22 between 1000 and 1020 it was confirmed that the initial skin assessment conducted on 01/05/22 by Staff K (certified wound care nurse) did not include any photographs, no four eyes skin assessment (two staff members evaluate and confirm the skin assessment) nor did Staff K evaluate or visualize Pt #2's skin in its entirety. Furthermore, Staff K took the word Pt #2 79-year-old acutely and chronically ill at high risk for skin break down.

The record showed that the second wound consult was completed by Staff K on 01/18/22 and read as follows; "Pt is on a 2c (2c is referring to the neuro ICU 2 central where all beds are specialty) air bed for advanced pressure relief. Inflatable overlay to be used when Pt #2 transfers out of 2C"... "Room RN reports that patient's buttocks remain intact and without issue. Pt is receiving bedside HD (hemodialysis) is unable to be turned at the time of Staff K's assessment.".
During the interview with Staff K, conducted on 05/18/22 between 1000 and 1020 it was confirmed that Staff K did not visualize or evaluate Pt #2's skin in its entirety. Upon being queried regarding why Staff K did not visualize Pt #2's skin or return at a time when the evaluation could have been completed, Staff K stated, "he was on a ventilator, and having hemodialysis. The nurse told me there were no problems. I did not return after hemodialysis to evaluate. I feel like I did everything I should have". Staff K failed to return at a more appropriate time to evaluate Pt #2 thoroughly.

Review of the document titled "daily focused assessment" dated 01/23/22 timed 0800 under heading "skin, Braden score of 11/23 requiring interventions be implemented per protocol as follows: if the score is 18 or less, wound care consult, turn every two hours, heels off the mattress with pillows/heel boots".

The wound care documents revealed the third wound care consultation took place, and orders were signed by Staff K dated 01/24/22, timed 1230. The document titled "Wound Care Treatment Orders for Nursing Staff" stated under #2. Location: Bilateral Buttocks and Gluteal Cleft, Etiology: AD, clean with barrier wipes, "apply xeroform to areas to scattered areas of scattered open tissue daily and PRN, cover with large foam dressing. Apply barrier cream to remaining uncovered tissue BID (twice a day)/PRN". There was no evidence of staging or measurements of the "scattered open tissue" or documented condition of the surrounding area, by Staff K. The following was documented on the same order form "Other treatment orders: (handwritten) *Strict Q2 hour turn schedule *, Elevate BLE whenever possible to help minimize edema.". Orders chosen per check box are the following: Re-consult wound care team if tissue deteriorates. Dietitians consult if not following, turn reposition patient every two hours, pre-inflated chair cushion - offloading heel protection boots - Float heels while in bed, low air loss mattress with pulsation.

The fourth wound care consult was dated 01/30/22, no follow up wound care evaluation was found between 01/30/22 and the discharge date 02/18/22 after the request on 01/30/22, in fact the last wound care note discovered and confirmed by both Director of quality Staff D and Ambulatory Wound Care Director Staff L. was the evaluation completed by Staff K on 01/24/22 at 1230.

Nursing flow sheets were reviewed and revealed the following dates and times were greater than the "turn every two hour order/protocol";
01/29/22; 0400-0800 = 2hours 45 minutes,
2300-(01/30/22) 0200 = 3hours 8 minutes,
01/30/22- 01/31/22; 2000- 0000 = 4 hours,
02/03/22; 0400-0800=4hours, 02/04/22; 0400-0800 = 4 hours,
02/04/22; 1600-2030 = 4 hours,
02/05/22; 0220-0800 = 5 hours 40 minutes,
02/06/22; 0400-0800 = 4 hours,
02/07/22; 0400-0800 = 4 hours, 02/07/22; 1200-1600 = 4 hours,
02/08/22; 0600-2000 = 14 hours,
02/09/22; 0400-0941 = 5 hours 41 minutes, 1525-1858 = 3 hours 30 minutes
02/10/22; 0000-0258 = 2 hours 58 minutes,
02/11/22; 2008-0051 = 4 hours 43minutes
02/12/22; 0349-0630 = 3 hours 19 minutes.
02/13/22 = 4 hours 43 minutes
Seventeen separate times between the dates 01/29/22 and 02/12/22 were observed to have recorded time periods of greater than two hours between turning/repositioning Pt #2. The records were randomly selected, the greatest period with no documented turn was fourteen hours on 02/08/22. The previous findings were confirmed with both the Director of Quality, Staff D and Wound Care Director Staff L, both agreed standards of care and the facility protocols were not followed.