HospitalInspections.org

Based on document review and interview, the nurse supervisor failed to evaluate and ensure that nursing personnel followed established policies and procedures (P&P) for prevention of pressure ulcers for 1 of 2 patients identified at risk on initial assessment.

Findings:

1. Review of hospital P&Ps indicated the following:
A. P&P titled Prevention Treatment Plan for Pressure Ulcers, Reviewed/Revised Date: 03/2015, indicated the following:
i. Upon admission, a skin assessment will be performed to visualize the skin. ALL wounds present on admission will be documented. A pressure ulcer risk assessment will be completed and documented within 24 hours of admission. The Braden scale assessment tool will be utilized for those patients who are greater than 5 years of age. Reassessment will be performed with any change in condition, on patient transfer, or every shift.
ii.. Notify Wound Care Team Leader if patient has a Stage I-IV pressure ulcer, DTI (deep tissue injury), unstaged ulcer, chronic wound or scores on the Braden scale 16 or less. Proper documentation will be noted in the medical record.
B. P&P titled Wound Care Protocols for Pressure Ulcers, Reviewed/Revised: 03/2015 indicated the following:
i. The interventions listed in the policy...should be used along with the following wound guidelines to provide overall care for the patient.
ii. Description and documentation of a pressure ulcer will be upon finding and will include the location size as measured in cm (diameter or length, width, and depth) tissue characteristics, as well as color, odor and type of drainage. The Wound Care Nurse and/or physician will be notified of wound to receive orders for appropriate treatment regimen. Send order for Team Leader consult.

2. Review of medical records indicated the following:
A. Patient P2 was admitted to the BHU (Behavioral Health Unit) on 1/27/17. The Admission Assessment Report Braden score was 15/23 on 1/27/17 at 21:52 hours and the area of the note "Wound Consult Order" was indicated to be N/A (not applicable). The MR lacked documentation of notification to the Wound Care Team Leader for the Braden score less than 16 at admission. Daily Assessment Inquiry documentation of P2's Braden scores of 16 or less prior to Wound Consult order/notification were as follows: 1/28/17 19:30 hours 16/23, 1/30/17 08:00 hours 15/23, 1/30/17 20:00 hours 14/23, 1/31/17 08:00 hours 16/23, 1/31/17 19:28 hours 16/23, 2/2/17 14:00 hours 14/23, 2/2/17 19:27 14/23, 2/3/17 08:00 hours 12/23, 2/3/17 19:42 hours 15/23, 2/4/17 19:36 hours 15/23, 2/5/17 20:00 hours 16/23, 2/6/17 10:04 hours 13/23, 2/6/17 19:21 hours 14/23, 2/7/17 10:00 hours 14/23, 2/7/17 19:38 hours 14/23, 2/8/17 08:00 hours 14/23, 2/9/17 08:48 hours 16/23, 2/9/17 12:20 hours 10/23, 2/9/17 19:27 hours 13/23, 2/10/17 07:53 hours 12/23, 2/10/17 19:31 hours 12/23, 2/11/17 08:00 hours 13/23, 2/11/17 19:34 hours 13/23. The MR indicated that the first order for Wound Consult was on 2/12/17 at 05:33 hours with instructions for Red, open area on coccyx, red areas on bony prominences.

3. On 3/15/17 at 3:00 PM, A6, Quality Manager, verified that patient P2 had acquired pressure ulcers while in the hospital and that staff did not follow protocol by not contacting the Wound team according to policy.

4. On 3/15/17 at 4:30 PM, A5, BHU Nurse Manager, verified that the MR for P2 lacked documentation of notification/order for a Wound Care consult per P&P.

5. Review of policy/procedure #OM 6.3.3, Patient and/or Family Care Involvement, indicated the following;
GUIDELINES:
"14. Patient's and/or family will be informed of any unanticipated outcome of care."
This policy/procedure was last reviewed/revised on 03/2015.

6. Review of hospital documentation of HAPU (hospital acquired pressure ulcer) logs from 1/1/17 to present indicated the hospital had had 4 incidents of HAPU in the month of February 2017, that 3 of the 4 occurred on the BHU and that on 2/13/17 patient P2 was reported with HAPU as follows: Brief Description: Left greater trochanter stage 2 pressure, left 5th metatarsal promimal (sic), left rib stage one. Immediate Corrective Action: CPOE (computerized physician order entry) orders were placed on 1/27/17, wound consult not received until today.

7. Review of patient P2's MR lacked documentation that patient P2's responsible party was notified concerning the patient having a hospital acquired pressure ulcer.