HospitalInspections.org

Based on observation, record review and interview the registered nurse failed to ensure the evaluation of care on an ongoing basis in accordance with accepted standards of nursing practice by failing to ensure patients were accurately assessed for impaired skin integrity for 2 of 3 patients identified with impaired skin integrity in a total sample of 8 patients (#4 and #7). Findings:

1. Review of the hospital's policy and procedure #2.01 titled "Admission of Patient, Initial Assessment and Reassessment" revealed all patients would have a head to toe assessment each 8 or 12 hour shift.

Further review of policy #2.59 titled "Routine Care: Skin" reflected skin assessment would be performed and documented every shift and "should include areas of concern regarding skin integrity."

2. Review of the medical record for Patient #7 revealed the patient was admitted to the Intensive Care Unit (ICU) on 1/20/12 at 2100. Review of the Admission Assessment dated 1/20/12 at 2118 (9:18 p.m.) reflected the patient had no history of pressure ulcer, and the patient's skin integrity was intact. Review of an Admission Assessment dated 1/20/12 at 2100 (9:00 p.m.) completed by S7, RN reflected the patient had a left hip pressure ulcer. There was no description, stage or further assessment documented concerning the pressure ulcer to the left hip site.

Continued review of shift assessments dated 1/21/12 to 1/26/12, completed every 4 hours by RNs, reflected patient #7 had a left hip pressure ulcer. There was no documentation to reflect the description, or stage of the left hip pressure ulcer.

Review of the Wound Care Note completed by S8, RN, Wound Care Nurse on 1/24/12 at 1330 (1:30 p.m.) revealed patient #7 had a stage III pressure ulcer to the sacrum which measured 3.2 centimeter (cm) x 3 cm. There was no documentation to reflect the patient had a left hip pressure ulcer.

Observation on 1/26/12 at approximately 10:30 a.m., of patient #7's skin integrity, revealed the patient had a stage III sacrum pressure ulcer. Further observation at that time in the presence of 2 RNs revealed the patient did not have a left hip pressure ulcer. Observation of the patient's skin revealed the skin was intact and clear.

Interview with S9, RN during the above time revealed the patient only had a stage III pressure ulcer to the sacrum area and the patient's left hip area was clear. S9, RN stated she did not remember the patient having a left hip pressure ulcer during this present admission to ICU. During and interview with S10, RN, who assisted S8 with patient's care, she stated she assisted S9, RN to turn patient #7 earlier, and she confirmed the patient did not have any alteration in skin integrity to the left hip.

Review of the Physical Assessment documentation completed by S9, RN on 1/26/12 at 8:00 a.m. reflected a pressure ulcer to the sacrum , a scab to the right hip, and the left hip problem was discontinued.

3. Review of the medical record for patient #4 reflected the patient was admitted to the hospital on 11/05/2011. Further review of the record reflected the patient was transferred to ICU on 11/16/11. Review of Nursing Assessments revealed documentation on 11/25/11 at 3:00 p.m. to reflect that Patient #4 was observed to have a skin tear to the left upper thigh. There was no documentation to reflect measurements of the skin tear nor was there documentation to reflect the exact location of the skin tear.
There was no documentation to reflect the patient had a pressure ulcer during his admission in ICU.

Review of the Wound Care Note completed by S8, RN Wound Care Nurse, dated 11/28/11 at 1640 (4:40 p.m.) reflected patient #4 had a stage II pressure ulcer to the left buttock which measured 5 cm [length] x 5.5 cm [width]; a stage II pressure ulcer to the right posterior thigh which measured 6 cm [length] x 1 cm [width], and excoriation to the scrotum and bilateral posterior thighs.

Further review of the record reflected Patient #4 was transferred from ICU to another unit on 11/30/11. Review of documentation completed by S11, Licensed Practical Nurse (LPN) on 11/30/11 at 8:00 a.m. revealed the patient had a left buttocks pressure ulcer and a right thigh pressure ulcer. Documentation also reflected the patient had a skin tear to the left thigh.

Further review of the Nursing shift assessment completed by S12, RN, on 12/1/11 at 8:00 a. m. reflected patient #4 had a left buttocks pressure ulcer and skin problems noted to the left and right thighs.

There was no documentation in the ICU shift assessment notes to reflect the patient had pressure ulcer development prior to leaving ICU on 11/30/11. There was also no consistent documentation to reflect an accurate and/or consistent description of patient #4's skin integrity.

Interview with S13, RN, Chief Nursing Officer, on 1/25/12 at approximately 4:30 p.m. confirmed there was no documentation by the ICU nurses to reflect an accurate description of the patient's skin integrity during his stay in ICU from 11/16/11 to 11/30/11.

Based on record review and interview the hospital failed to ensure all patient medical record entries were complete by by failing to follow their hospital's policy regarding transcribing orders for 3 of 8 patients records in a total sample of 8 (#4, 5 and 6). Findings:

Review of the hospital's policy and procedure #2.08A, revised 9/11, and titled "Transcribing of Written Orders Including Medication ..." revealed a policy to assure that physician orders would be transcribed in a prompt, safe, and effective manner Further review of the policy reflected the Unit Secretary or Nurse would transcribe physician's orders from the Physician Order form to the order entry form, medication sheet, test requisitions and/or kardex as necessary.

Continued review of the policy reflected the licensed nurse would then check the transcription against the original order for verification and sign his/her name, time, and date as approved, on the physician's order sheet........

Patient #4
Review of the medical record for patient #4 revealed the following physician's orders documented with no identifying information concerning the licensed nurse who transcribed and verified the order as approved by the nurse:
a. physician's order dated 11/5/11 at 2200 (10:00 p.m.).
b. physician's order dated 11/5/11 at 2145 (9:45 p.m).
c. physician's order dated 11/6/11 at 4:00 p.m.
d. physician's order dated 11/7/11 at 1847 (6:47 p.m.).
e. order dated 11/9/11 at 1954 (7:54 p.m.).
f. physician's order dated 11/16/11 at 1120 (11:20 a.m.).
g. physician's order dated 11/17/11 at 7:50 a.m.
h. physician's order dated 11/17/11 (no time)
i. physician's order dated 11/27/11 at 2121 (9:21 p.m.).
j. physician's order dated 12/21/11 at 0930 (9:30 a.m.).

Patient #5
Review of the medical record for patient #5 revealed the patient was admitted to the hospital on 1/19/12. Review of the medical record for the patient revealed the following physician's orders documented with no identifying information concerning the licensed nurse who transcribed and verified the order as approved by the nurse:
a. physician order dated 1/23/12 (no time).
b. physician order dated 1/20/12 (no time).

Patient #6
Review of the medical record for patient #6 revealed the patient was admitted to the hospital on 1/23/12. Review of the medical record for the patient revealed the following physician's orders documented with no identifying information concerning the licensed nurse who transcribed and verified the order as approved by the nurse:
a. physician order dated 1/24/12 (no time).
b. physician order dated 1/24/12 at 1655 (4:55 p.m.)