HospitalInspections.org

Based on the review of Medical records (MR), facility policy and procedures, observation and interview the facility staff failed to:

1. Document wound measurements

2. Document specific wound care provided

3. Document wound assessments to include appearance of the wound/ wound bed, exudates, drainage, odor signs and symptoms of infection

4. Have orders for wound care provided

5. Ensure nutritional assessment for the patients were completed.


This had the potential to affect all patients served by this facility.

This did affect MR # 1, # 2 and # 4, 3 of 4 records reviewed.

Findings include:

Policy and Procedure:

Management of Pressure Ulcers # 9202

Policy: "... shall ensure that all patients admitted to this hospital receive a complete head to toe assessment, at which time a thorough examination of the skin will be done.

Any pressure ulcer present at the time of admission will be identified...

Procedure:
Management of Pressure Ulcers:
Nursing staff will take initial pictures if necessary and as needed, identify, date and mount for medical treatment of the patient.
Complete the Skin Assessment Tool at the time the abnormal skin condition is identified. Record the date and time of initial and subsequent treatment, per physician's orders.
Call physician to report condition of pressure ulcer and for treatment orders...
Nursing personnel may initiate the following skin care guidelines when a patient is admitted to the hospital as an in-patient or placed in observation and a ulcer, wound or skin issue is present and there are no further orders received by the physician...
Upon initiation of any of the skin care guidelines, a physician's order should be placed on the chart...

Nursing Staff will:

Assess, reassess and document ulcer's characteristics.
Observe for infection...
Follow physician's orders for treatment of the pressure ulcer, including cleansing and dressing...
With each dressing change or at least weekly, the pressure ulcer wound will be assessed and documentation...:
Date, Location of ulcer and staging, Size (perpendicular measurement of the greatest extent of length and width of the ulceration, depth of the pressure ulcer wound...
Presence of exudates:
Type: purulent/serous, color, odor, amount, pain and wound bed... color and type of tissue/character, including evidence of healing (granulation tissue) or necrosis (slough or eschar)...
Notify the physician if the pressure ulcer/wound is not healing.

Documentation:
Document interventions used to prevent the development of pressure ulcers. Pressure ulcer flowsheet documentation:
Date and time of initial and subsequent treatments.
Dressing changes. Size of the pressure ulcer (length, width and depth)...
Note any change in the condition or size of the ulcer and any elevation of skin temperature in the medical record."

Medical Record findings:

1. MR # 1 was admitted to the facility 9/19/14 with diagnoses of Multiple Trauma, Neglect and Dementia.

On admission 9/19/14 at 5:45 PM the skilled nurse assessment form for Hospital Wound and Pressure Ulcer had documented, " Left hip skin tear/abrasion 10 cm (centimeter) x 4 cm, serosanguineous exudate, painful and erythema. Right hip skin tear 3 cm x 2 cm, pain and erythema. Right cheek bone abrasion 1 cm x 1 cm. Left cheek bone 1/2 cm x 1/2 cm. Bilateral bruising noted to perineal area. Bilateral bruising to bilateral lower extremity area and brusing to upper chest/collar bone area. Treatment to wounds, Bactroban applied."

On 9/19/14 at 3:40 PM the physician ordered, " Bactroban to open skin wounds daily-Bid (twice a day) as needed after routine wound care."

The Patient Progress Notes documented by the LPN (Licensed Practical Nurse) 9/20/14 at 9:25 AM, wound care performed, Telfa dressing applied post cleansing. There was no documentation which wound was dressed, what was used to cleanse the wound and no order to cleanse the wound.

The Patient Progress Notes documented by the LPN 9/21/14 at 8:05 AM, " Dressing changed to the left hip area...reinforced dressing, ointment applied Bactroban, serosanguineous drainage, moderate..."

This was the first documentation of moderate drainage and the nurse failed to document what type of dressing was utilized. There was no documentation the physician was notified concerning the moderate amount of serosanguineous drainage.

The Unisex Body form dated 9/22/14 documented 7 wound care sites. The original assessment on admission only had 4 wounds. The 2 new wound sites were documented as Right Groin area, a small wound from a fall and back/left shoulder, a fluid filled space.

The Patient Progress Notes documented by the LPN 9/22/14 at 9:00 AM, "Cleaned wound with 4 x 4 sterile gauze and Normal Saline(NS). Bactroban applied to all wounds. Telfa Island dressing applied to wound to the left hip... serosanguineous drainage noted. Moderate amount of drainage..."

The Patient Progress Notes documented by the LPN 9/22/14 at 2:49 PM, " Cleaned wound to the left inner thigh with NS and applied Bactroban. Moderate serous drainage noted, no foul odor noted, ABD (abdominal) pad applied..."

There was no order to use Normal Saline to clean the wounds and the physician was not notified of the drainage.

In an interview 9/24/14 at 11:30 AM with Employee Identifier (EI) # 1, Nurse Manager confirmed the documentation was not complete. There was no order to clean the wound and the physician was not notified of the drainage.

The Admission Nutritional Screen document includes the following instruction: Check appropriate items and total their scores. Patients considered nutritional risk if the score is over 6 and/or has one or more of the automatic risk indicators. The automatic risk indicators include: Serum Albumin less than 3.5, Stage III or IV Decubitus, Major Burns, Vent Patient, Malnutrition or Tube feed/TPN (total parenteral nutrition).

The Admission Nutritional Screen completed on admission 9/19/14 by the registered nurse failed to document if the patient was at nutritional risk.

The patient was admitted after being found in the home with dementia, multiple trauma and neglect according to the History and Physical examination. The past medical history is pertinent for hypertension, reflux dyspepsia, osteoarthritis, hepatitis C positive and diabetes mellitus type II.

The only information marked on the nutritional assessment was hypertension and over age 65. The nurse failed to document all areas the patient had problems with and identify the numerous wounds the patient sustained prior to admission.

There was no documentation EI # 3, the Dietary Manager had reviewed the Admission Nutritional Screen.

In an interview with EI # 2, the Administrator on 9/24/14 at 11:00 AM, confirmed the above and stated a new dietitian would be present effective October 13, 2014 and the nutritional assessments would be completed accurately and timely.

2. MR # 2 was admitted to the facility 9/18/14 with diagnoses of Anemia, Hypertension, Congestive Heart Failure and Atrial Fibrillation. The patient was discharged 9/23/14.

The Admission Nutritional Screen completed on admission 9/18/14 by the registered nurse failed to document the patient was at nutritional risk even though the score was totaled to 8.

The nurse failed to include the patient's age greater than 65 and a hemoglobin of 5.7 requiring 4 units of blood to transfuse ordered on admission.

The nurse documented on her initial assessment the patient had a poor appetite for greater than 2 weeks.

There was no documentation EI # 3, the Dietary Manager had reviewed the Admission Nutritional Screen.

In an interview with EI # 2, the Administrator on 9/24/14 at 11:00 AM, confirmed the above and stated that a new dietitian would be present effective October 13, 2014 and the nutritional assessments would be completed accurately and timely.

3. MR # 4 was admitted to the facility 9/17/14 with diagnoses of Parkinson's Disease, Alzheimer's Disease, Colon Cancer and Diabetes Mellitus.

The Unisex Body form dated 9/18/14 at 8:00 AM documented location of wound coccyx, see photos on chart. There was no measurements or documentation of the wound appearance or any care provided.

The physician documented wound care orders 9/19/14 at 12:15 PM to use Duoderm to coccyx and change every 3-5 days or as needed and apply moisture barrier cream as needed.

The skilled nurse documented 9/18/14 Hydroguard applied to coccyx.
The moisture barrier cream was not ordered until 9/19/14.

The skilled nurse documented in the assessment 9/18/14 at 7:30 PM, " Skin condition, redness, pressure wound location coccyx 1 cm, several small open areas to buttocks noted, no drainage, see pictures on chart, ABD pad to buttocks."

The skilled nurse documented 9/19/14 at 9:30 AM, " Buttocks area red and Hydroguard cream applied to buttocks."

The Unisex Body form dated 9/19/14 at 8:44 PM documented, " Location of wound coccyx, notes skin is broken and red. Hydroguard is being used..."

The Unisex Body form dated 9/20/14 at 8:58 PM documented, " Location of wound coccyx, notes hydrogel in use turn every 2 hours."

This was the first documentation of a dressing used on the wound as ordered 9/19/14 at 12:15 PM.

The Unisex Body form dated 9/21/14 at 7:12 AM documented, " Location of wound site date first observed 9/20/14: A) coccyx, 1 cm pressure ulcer with sinus tract, no drainage. Site B) left buttock, 1 cm x 1 cm redness no drainage, no tunneling. Site C) right buttock various small red areas serous drainage noted."

This was the first measurement of any wounds and the first time 3 different wounds were identified. There was no documentation the physician was notified of the new wounds or the drainage from wound C.

The Unisex Body form dated 9/22/14 at 7:30 PM documented location of wound right buttock, notes Duoderm dry/intact.

The nurses failed to follow the policy for measuring wounds, identifying wounds, providing wound care as ordered and informing the physician of changes in the wounds and drainage.

In an interview with EI # 1, Nurse Manager 9/24/14 at 11:30 AM the above information was confirmed and that only one wound existed on the coccyx.

The Admission Nutritional Screen completed on admission (9/17/14) and dated 9/19/14 by the registered nurse failed to document a complete assessment. The nurse failed to document the patient had cancer and an Albumin of 2.7 from the admission lab work performed 9/18/14.

The Dietary Manager, EI # 3, reviewed the form 9/23/14, 6 days after admission. There was no documentation the Dietitian was notified of the information collected by EI # 3. When asked 9/24/14 at 9:00 AM, EI # 3 stated that after she completed the forms the copy was put in the kitchen for the Dietitian to review. The Dietitian comes to the facility 2 times a month. When asked if information was ever faxed to the Dietitian she stated, " Not that I know about."

In an interview with EI # 2, the Administrator on 9/24/14 at 11:00 AM, confirmed the above and stated that a new dietitian would be present effective October 13, 2014 and the nutritional assessments would be completed accurately and timely.

Carol Williams, RN