HospitalInspections.org

Based on medical record review, observation, policy review and staff interview, the facility failed to ensure 1 of 3 sampled patients (Patient 1) with skin breakdown had the care plan updated to address the patient's additional care needs for skin breakdown. The full sample size was 15. The facility census was 234 total for both campuses (acute care facility and psychiatric care facility) on the day of entrance.

Findings are:

Review of the medical record for Patient 1 found on the demographic page that the patient had been admitted on 1/18/13 to the acute care campus. Patient 1 was still an inpatient at the time the patient was selected for the sample on 2/12/13. Review of the medical record documentation revealed Patient 1 had been admitted with bilateral lower extremity deep venous thrombosis (blood clots in both lower extremities) and pulmonary embolus (blood clots had traveled from the lower extremities to the lungs impairing patient ability to breathe and oxygenate the blood). Review of nursing documentation of the facility's Registered Nurse's (RN) assessments revealed the patient had been admitted with a reddened area on the coccyx. The medical record had documentation of daily Braden Scores (a means of determining risk for skin breakdown). The daily scores recorded in the medical record identified Patient 1 as a high risk. The Braden Score on the date of review (2/12/13) revealed a score of 13. According to the facility's Braden Score policy dated 5/11, any score below 18 places the patient at a high risk for skin breakdown. Review of the documentation of the daily scores showed Patient 1 had been at high risk throughout his 26-day hospital stay. The documentation by the facility wound care nurse that was following this patient revealed the area on the coccyx had progressed to a Stage II despite ongoing treatment because the patient was severely compromised. The facility's wound care nurse began following the patient on 1/21/13. Review of the notes by the wound care nurse revealed the area on the coccyx on 1/28/13 showed "deep tissue injury to buttocks." 1/29/13 documentation noted the patient was moved to a Clinitron Bed (a bed that eliminates pressure to the body by means of circulating air). The use of other interventions were found to be documented in the nursing cares provided. Review of the care plan for Patient 1 on 2/12/13 failed to find any mention of the skin breakdown or the interventions that were being provided to the patient.

Observation of care provided to Patient 1 was completed on 2/12/13 at 11:45 AM. The RN providing the skin care to the patient positioned the patient to allow for observation and care to the wound area. The patient had a Stage II open area at the top of the coccyx. There was a smear of fecal material that was cleaned from the area. The wound is an irregular shape noted on the left top side of the buttocks crease. The RN used Alavesta Foam to wipe the area clean very gently. The patient was positioned on the Clinitron bed with the head of the bed elevated to 30 degrees to facilitate patient breathing.

Review of the facility policies and procedures found a policy titled "Nursing Care Plan" with an effective date of 10/12 (revision of policy dated 5/07). The policy directs the following:
"A. All patients will have a nursing plan of care.
B. The RN is responsible for the initiation of the patient's plan of care and it may be updated by an LPN- Certified /Licensed Practical Nurse (C/LPN); the plan of care is reviewed daily and updated as patient care requires.
C. The plan of care process begins on admission as well as planning for discharge to meet the patient's needs and is reviewed by multidisciplinary care planning team on a concurrent basis.
D. The plan of care is based on the assessment of the patient, their needs and/or goals and developing appropriate nursing interventions in response to the needs identified.
E. The plan of care is to be kept current by ongoing assessments of the patient's needs and the patient's response to the interventions, and updating or revising the plan of care in response to assessments."

Review of the facility policy titled "Skin Assessment-Pressure Ulcer, Braden Scale, and Wound" with an effective date of 5/11 (revision of policy dated 5/09) found it directed under the statement identified as "E. Update the plan of care to reflect risk of skin breakdown."

An interview with RN-A on 2/12/13 at 11:00 AM during review of the medical record for Patient 1 confirmed the plan of care for Patient 1 did not contain anything related to the patient's skin breakdown. RN-A stated that it should be in the care plan, and "I'll put it in today." Patient 1 had been hospitalized for 26 days, had been admitted with skin breakdown, and failed to have the problem identified and interventions included in the patient's plan of care.