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Based on a review of the hospital's skin/wound care protocol/policy, medical record reviews and interviews, the hospital's governing body failed to assure the physician responsible for the care of Patient Identifier (PI) # 1 beginning February 2011, provided skin/wound care according to the hospital's established policies and protocols.

This affected Patient Identifier (PI # 1), one of ten sampled patients.

Findings Include:

A. Review of Policies and Procedures:
"Title: Skin/Wound Protocols
Effective Date: 12/1977
Revised: 5/2008
Policy: Standard wound and skin care protocols will be used initially when treatment of skin and wounds are required. Protocols outside standards will be initiated by (CWOCN) Enterostomal Therapy Nurse or specific MD order.
Purpose: Standard wound and skin protocols will provide a guideline for appropriate treatments to nurses rendering wound care and skin care.
Procedure:
1. See Skin/Wound Protocols.
2. Initiate appropriate treatment and documentation."

"Skin/Wound Care Protocols Stage II:
1. Wound care to _____. (fill in blank)
2. Cleanse with Normal Saline or Dermal wound cleanser and pat dry with gauze.
3. Apply hydrocolloid.
4. May tape edges p.r.n. (as needed)
5. Change every 3-5 days.
6. Initiate Pressure Prevention Protocol orders.
Date, Physician Signature, Nurse's Signature.
Physician's Orders, Revised 5/08. " (Become orders when signed by MD).

"Skin/Wound Care Protocols Stage III and IV (Moderate to heavy drainage):
1. Consult (CWOCN) Enterostomal Therapy Nurse.
2. Wound care to _____. (fill in blank)
3. Cleanse wound with wound cleanser and pat dry with gauze.
4. Apply pack/calcium arginade dressing to wound bed.
5. Cover with gauze.
6. Secure with tape.
7. Change every day.
8. Initiate Pressure Prevention Protocol Orders.
9. Consult Wound Care Center's physician for evaluation.
(Become orders when signed by MD).

"Standard of Care: Skin Care Pressure Prevention Protocol, (PPP), when
Braden Score less than/equal to 18):
Pressure: Bed Rest Total:
1. Pressure reduction support surface.
2. Position off affected area (avoid massage).
3. Turn every two hours, approximate a 30 degree angle elevation.
4. Keep heels raised off bed. Select (pillow to float heels, heel boats at all times)...
Friction/Shear
1. Maintain head of bed at lowest degree of elevation consistent with medical condition....
Moisture:
1. Apply moisture barrier, Aloe Vista, with fecal and urinary
incontinence...
Mobility/Activity:
1. Turn schedule.
2. Range of Motion.
3. Physical Therapy consult."

B. Medical Staff Rules and Regulations:
Revised: May 16, 2011
"...6. Responsible Medical Staff Member. A Member of the Medical Staff shall be responsible for the medical care and treatment of each patient in the Hospital, for the prompt completeness and accuracy of the medical record, for necessary special instructions and..."

C. Medical Record Review:
According to the History and Physicals from the Emergency Department Physician and the Attending Physician, dated 2/22/11, PI # 1 was sent via ambulance from a Dialysis Center to the Emergency Department (ED) on 2/22/11 due to Altered Mental Status, jaundiced skin, increased Prothrombin Time (PT) and increased INR (International Normalized Ratio). PI # 1 has a history of end stage renal disease, hypertension, CVA (cardiovascular accident), right sided weakness, reflux, valve replacement, congestive heart failure and total right hip replacement. PI # 1 was admitted to the hospital on 2/22/11 due to septic encephalopathy.

The Physician's Physical Examination Includes:
General Appearance: Moderately nourished, moderately developed...male lying in bed...lethargic.
Vital Signs: 172/81, 77, 22 and 96 (temperature).
Chest: Course breath sounds.
Extremities: No cyanosis or clubbing.
Spine/Back: No deformity.
Neurological: Patient is not oriented.

The Physician's Impression Includes:
1. Septic Encephalopathy; pneumonia versus penile necrosis.
2. End Stage Renal Disease.
3. Anemia.
4. Hypertension.
5. Pneumonia (left lower lobe).
6. Penile Necrosis...

The "Nursing Physical Assessment and Care Flowsheet," dated 2/23/11 at 0200 includes:
Skin: Pale and jaundiced. A "rash" is present on the patient's buttocks.
Skin Care: Braden Score: 16. "Score of < (less than) 18 indicates at risk for breakdown. Initiate Prevention Protocol."
Skin Assessment:
Site 1: Right Heel. Stage: II. Color: Red.
Site 2: Left Heel. Stage II. Color: Red.
Site 3: Penis. Stage: IV. Color: Black. Odor: Foul. Drainage: Purulent.
Site 4: Bottom: Stage: II. Color: Red.

No Physician Orders for wound care are documented in PI # 1's medical record from 2/22/11 through 3/11/11 (date PI # 1 transferred to a specialty unit within the hospital).

D. Interviews:

During an interview with Employee Identifier (EI) # 1 on 8/3/11 at 2:00 PM, the Attending Physician described PI # 1 as septic and "very confused" on admission. The physician said there was no breakdown on PI # 1's buttocks, but he is unable to recall the condition of PI # 1's heels. The physician stated the primary source of infection, PI # 1's penis, was treated with antibiotics. The physician asked the surveyor if there were photographs of PI #1's wounds. The surveyor stated no photographs were found in the medical record, nor were any photographs provided to the surveyor (during the survey).

During an interview on 8/3/11 at 2:15 PM, EI # 4, the Nurse Manager on PI # 1's unit in February/March 2011, stated there is a hospital Protocol (Pressure Prevention Protocol) that a nurse can place in a patient's chart. If the physician chooses and signs the protocol, the protocol becomes an order. EI # 4 said the staff nurse is responsible for measuring and photographing a patient's wounds/ulcers on admission and weekly. The Nurse Manager states she would "usually" call the patient's physician to ascertain if the physician wanted to use the protocol (Pressure Prevention Protocol) or initiate other skin/wound care orders. No Pressure Prevention Protocol was found in PI # 1's medical record.

This standard is written as a result of the investigation of Complaint # AL00024647.

Based on medical record review, review of the hospital's skin/wound care protocol and policies and procedures and interviews, the hospital staff failed to accurately assess/document the condition of the patients' skin, and follow the plans of care for Patient Identifiers (PI) # 1 and PI # 2's related to skin care, wounds and/or pressure ulcers. The staff also failed to measure and photograph PI # 1's pressure ulcers on admission and weekly. This deficient practice affected two of ten sampled patients, PI # 1 and PI # 2.

Findings include:

I. Medical Record Review:
According to the History and Physicals from the Emergency Department Physician and the Attending Physician, dated 2/22/11, PI # 1 was sent via ambulance from a Dialysis Center to the Emergency Department (ED) on 2/22/11, due to Altered Mental Status, jaundiced skin, increased Prothrombin Time (PT) and increased INR (International Normalized Ratio). The Chief Complaint was documented as Altered Mental Status.

PI # 1's History of Present Illness includes a history of end stage renal disease, hypertension, CVA (cardiovascular accident), right sided weakness, reflux, valve replacement, congestive heart failure and total right hip replacement. PI # 1 was admitted to the hospital on 2/22/11 due to septic encephalopathy. PI # 1 was also found to have penile necrosis.

PI # 1's Physical Examination Includes:
Vital Signs: 172/81, 77, 22 and 96 (temperature).
Chest: Course breath sounds.
Extremities: No cyanosis or clubbing.
Spine/Back: No deformity.
Neurological: Patient is not oriented.

The physician's "Impression" includes:
1. Septic Encephalopathy; pneumonia versus penile necrosis.
2. End Stage Renal Disease.
3. Anemia.
4. Hypertension.
5. Pneumonia (left lower lobe).
6. Penile Necrosis...

The "Nursing Physical Assessment and Care
Flowsheet," dated 2/23/11 at 0200 includes:
Neurological: Disoriented to person, place and time. Restless.
Skin: Pale and jaundiced. A "rash" is present on the patient's buttocks.
Skin Care: "Braden Score: 16. "Score of < (less than) 18 indicates at risk for breakdown. Initiate Prevention Protocol."

Skin Assessment:
Site 1: Right Heel. Stage: II. Color: Red.
Site 2: Left Heel. Stage II. Color: Red.
Site 3: Penis. Stage: IV. Color: Black. Odor: Foul. Drainage: Purulent.
Site 4: Bottom: Stage: II. Color: Red.
"Photo (photograph) on admission and q (every) Wednesday. Measurements (on admission) and q Wednesday."

Care Plans:
"Alteration in Skin Integrity," PI # 1's care plan
dated 2/23/11 documents PI # 1's skin is
"intact."
Priority: 2. According to the instructions of the form,this care plan should be selected for a patient with a Braden Score greater than 18.
Goal: Maintain skin integrity.
Interventions: Skin care protocol, Assess skin.

PI # 1's skin was not intact based on the
admission skin assessment dated 2/23/11 that
documents PI # 1 had four pressure ulcers.

"Alteration in Skin Integrity," PI # 1's care plan, dated 2/25/11, documents
PI # 1's skin is "impaired."
Priority: 1.
Goal: Wound(s) healed.
Interventions: Skin care protocol, assess skin, photograph and measure, implement prevention protocol, float heels and consult ET (Wound Care Nurse).

"Nursing Physical Assessment and Care Flowsheet," dated 2/23/11 at 0730 includes:
Skin Care: Braden Score: 15.
Skin Assessment:
Location: Site 1: Penis. Stage: Unstageable. Color: Multi. Odor: Foul. Drainage: Yes. No other wound sites are documented.
There is no wound documentation on the 7:00 PM to 7:00 AM shift.

The Operative Report, dated 2/24/11 includes:
Preoperative Diagnosis: Penile necrosis/gangrene.
Postoperative Diagnosis: Penile necrosis/gangrene.
History of Present Illness: PI # 1 presented to the emergency room with necrosis of the head of the penis and in the distal shaft and is now brought to the operating room for surgical debridement with probable partial penectomy. Findings: Distal penile necrosis. Drains: Foley Catheter.

The Intensive Care Nurse's Notes include:
2/25/11 0750: "...gauze dressing surrounding penis held in place by mesh drawers. Bilateral SCD (sequential depression device) hose worn..."
2/25/11 0900: Wound care nurse in. "Nutrashield (moisture barrier) applied to reddened area of buttocks."

The "Nursing Physical Assessment and Care Flowsheet," dated 2/26/11 at
0700 includes: Skin Assessment: Site 1: Stage II to left buttocks. Site 2: Penile area (no description).

The "Nursing Physical Assessment and Care Flowsheet," dated 2/27/11 at 0730 includes: Skin Assessment: Site 1: Left buttocks, Stage II. Site 2: Penile area.

The "Nursing Physical Assessment and Care Flowsheet," dated 2/28/11 at 0730 includes: No Skin Assessment. Incision: Groin.

The "Nursing Physical Assessment and Care Flowsheet," dated:
- 3/1/11 includes: No skin assessment.
- 3/2/11: Skin Assessment: Stage II. Left buttock. Color: red.
- 3/3/11: Skin Assessment; Stage II. Left buttock. Color: red.
- 3/4/11: Skin Assessment; Stage II. Left buttock. Color: red.
- 3/5/11: "Skin intact without redness, rash or blisters." No skin assessment documented.
- 3/5/11: Nurse's Notes: Stage II wound to buttocks.
- 3/6/11: Skin Assessment: Stage II. Left "butt."
- 3/7/11: No skin assessment.
- 3/8/11: Skin Assessment: "Skin intact."
- 3/9/11: Skin: "Red buttock."
- 3/10/11: Skin: "Red buttock."
- 3/11/11: Skin: "Buttocks red."

No documentation by the Wound Care Nurse was found in PI # 1's medical record from 2/22/11 through 3/11/11 (date PI # 1 transferred to a specialty unit within the hospital).

No Physician Orders for PI # 1's wound care were found in PI # 1's medical record from 2/22/11 through 3/11/11.

II. Interviews:

During an interview with Employee Identifier (EI) # 1 on 8/3/11 at 2:00 PM, the Attending Physician described PI # 1 as septic and "very confused" on admission. The physician said there was no breakdown on PI # 1's buttocks, but he is unable to recall the condition of PI # 1's heels. The physician stated the primary source of infection, PI # 1's penis, was treated with antibiotics. The physician asked the surveyor if there were photographs of PI #1's wounds. The surveyor stated no photographs were found in the medical record, nor were any photographs provided to the surveyor (during the survey).

During an interview with EI # 2 on 8/2/11 at 2:40 PM, PI # 1's admitting nurse (RN) verified PI # 1 was admitted to the hospital with multiple pressure ulcers to include:
"...Right Heel. Stage: II. Color: Red.
Left Heel. Stage II. Color: Red.
Penis. Stage: IV. Color: Black. Odor: Foul. Drainage: Purulent.
Bottom: Stage: II. Color: Red..."

EI # 2 did not recall measuring and/or photographing PI # 1's pressure ulcers. The RN reports she is not aware of the hospital's pressure prevention protocol. According to EI # 2, PI # 1 was confused, moved around a lot and was able to remove his heel protectors.

During interviews on 8/2/11 at 2:00 PM and 3:30 PM respectively, the Quality Management Director/EI # 3, stated hospital staff was unable to locate any documentation by the former wound care nurse in PI # 1's medical record or any other source of documentation. There is no Pressure Prevention Protocol in PI # 1's medical record.

During an interview on 8/3/11 at 2:15 PM, EI # 4, the Nurse Manager on PI # 1's unit in February/March 2011, stated there is a hospital Protocol (Pressure Prevention Protocol) that a nurse can place in a patient's chart. If the physician chooses and signs the protocol, the protocol becomes an order. EI # 4 said the staff nurse is responsible for measuring and photographing a patient's wounds/ulcers on admission and weekly. The Nurse Manager states she would "usually" call the patient's physician to ascertain if the physician wanted to use the protocol (Pressure Prevention Protocol) or initiate other skin/wound care orders. No Pressure Prevention Protocol was found in PI # 1's medical record.

III. Policies and Procedures:
"Title: Skin/Wound Protocols
Effective Date: 12/1977
Revised: 5/2008
Policy: Standard wound and skin care protocols will be used initially when treatment of skin and wounds are required. Protocols outside standards will be initiated by (CWOCN) Enterostomal Therapy Nurse or specific MD order.
Purpose: Standard wound and skin protocols will provide a guideline for appropriate treatments to nurses rendering wound care and skin care.
Procedure:
1. See Skin/Wound Protocols.
2. Initiate appropriate treatment and documentation."

"Skin/Wound Care Protocols Stage 11:
1. Wound care to _____. (fill in blank)
2. Cleanse with Normal Saline or Dermal wound cleanser and pat dry with gauze.
3. Apply hydrocolloid.
4. May tape edges p.r.n. (as needed)
5. Change every 3-5 days.
6. Initiate Pressure Prevention Protocol orders.
Date, Physician Signature, Nurse's Signature.
Physician's Orders, Revised 5/08. " (Become orders when signed by MD).

"Skin/Wound Care Protocols Stage III and IV (Moderate to heavy drainage):
1. Consult (CWOCN) Enterostomal Therapy Nurse.
2. Wound care to _____. (fill in blank)
3. Cleanse wound with wound cleanser and pat dry with gauze.
4. Apply pack/calcium arginade dressing to wound bed.
5. Cover with gauze.
6. Secure with tape.
7. Change every day.
8. Initiate Pressure Prevention Protocol Orders.
9. Consult Wound Care Center's physician for evaluation.
(Become orders when signed by MD).

"Standard of Care: Skin Care Pressure Prevention Protocol, (PPP), when
Braden Score less than/equal to 18):
Pressure: Bed Rest Total:
1. Pressure reduction support surface.
2. Position off affected area (avoid massage).
3. Turn every two hours, approximate a 30 degree angle elevation.
4. Keep heels raised off bed. Select (pillow to float heels, heel boats at all times)...
Friction/Shear
1. Maintain head of bed at lowest degree of elevation consistent with medical condition....
Moisture:
1. Apply moisture barrier, Aloe Vista, with fecal and urinary
incontinence...
Mobility/Activity:
1. Turn schedule.
2. Range of Motion.
3. Physical Therapy consult."

Patient Identifier (PI) # 2 was admitted to the hospital on 7/21/11 with diagnoses to include Diabetes and Hypertension. According to the Nursing Physical Assessment, PI # 2 has a Stage IV ulcer to the left foot documented as a "crater exposing muscle/bone." There are no photographs or measurements of the wound. The Braden Score is 13. No other wounds are identified.

According to the Surgical Consultation dated 7/22/11, PI # 2 has a 10 x 10 centimeter (cm.) wound to the left ankle with exposed tendon. There is also an ulceration on the back of the heel, 5 x 5 cm., with exposed bone.

The Nursing Skin Assessment dated:
- 7/23/11 documents, "Barrier cream to buttocks. Stage II. There are no measurements or photographs of the wound.
- 7/24/11 documents, "Redness to buttocks." There is no documentation related to wound staging.
- 7/25/11 and 7/26/11: No documentation regarding wound to buttocks.
- 7/27/11: "Buttox red," Stage I.
- 7/28/11: No documentation regarding wound to buttocks.
- 7/29/11: Stage II: Buttocks.
- 7/30/11: "Stage II to back side. Shift A."
- 7/30/11 2000: "Stage II - IV buttock, barrier ointment applied."
- 7/31/11: "Buttocks excoriated." "Stage II Right and Left Buttocks. Color: Red. There is a photograph of the wound, but no measurements.
8/1/11: No documentation, no measurements regarding wound to buttocks.
8/2/11: "Coccyx." See tx. (treatment) plan.

On 7/27/11, a left above the knee amputation was performed. The pre and post operative diagnosis is left foot osteomyelitis.

According to the Hospitalist Progress note dated 7/31/11, PI # 2's buttocks are "excoriated. PI # 2 has a "Decubitus Stage II" to buttocks -barrier cream..."

During an interview on 8/1/11 at 4:15 PM, the Third Floor Nurse Manager/ EI # 5, stated PI # 2 developed an in-house pressure ulcer. A low air loss mattress was ordered, but is not expected to be implemented until 8/2/11.

During an interview on 8/4/11 at 2:00 PM, PI # 2's family member stated the nursing care has been good. The only difference between hospital care/treatment and treatment of PI # 2 at home is the mattress. At home, PI # 2 has a special mattress. According to the family, PI # 2 did not receive a specialty mattress in the hospital until yesterday (thirteen days after PI # 2, a patient at high risk for additional skin breakdown was admitted).

This standard is written as a result of the investigation of Complaint # AL00024647.

Based on medical record review and interviews, hospital staff failed to maintain a medical record that accurately documented Patient Identifier
(PI) # 1's skin/wounds present on admission and throughout the patient's hospitalization from 2/22/2011through 3/11/2011.

This deficient practice affected PI # 1, one of ten sampled patients.

Findings Include:

I. Medical Record Review:

The "Nursing Physical Assessment and Care Flowsheet," dated 2/23/11 at 0200 includes:
Skin Assessment:
Site 1: Right Heel. Stage: II. Color: Red.
Site 2: Left Heel. Stage II. Color: Red.
Site 3: Penis. Stage: IV. Color: Black. Odor: Foul. Drainage: Purulent.
Site 4: Bottom: Stage: II. Color: Red.

The "Nursing Physical Assessment and Care Flowsheet," dated 2/23/11 at 0730 includes:
Skin Assessment:
Location: Site 1: Penis. Stage: Unstageable. Color: Multi. Odor: Foul. Drainage: Yes. No other wound sites are documented.
There is no wound documentation on the 7:00 PM to 7:00 AM shift.

The "Nursing Physical Assessment and Care Flowsheet," dated:
- 3/1/11 incudes: No skin assessment.
- 3/2/11: Skin Assessment: Stage II. Left buttock. Color: red.
- 3/3/11: Skin Assessment; Stage II. Left buttock. Color: red.
- 3/4/11: Skin Assessment; Stage II. Left buttock. Color: red.
- 3/5/11: "Skin intact without redness, rash or blisters." No skin assessment documented.
- 3/5/11: Nurse's Notes: Stage II wound to buttocks.
- 3/6/11: Skin Assessment: Stage II. Left "butt."
- 3/7/11: No skin assessment.
- 3/8/11: Skin Assessment: "Skin intact."
- 3/9/11: Skin: "Red buttock."
- 3/10/11: Skin: "Red buttock."
- 3/11/11: Skin: "Buttocks red."

No Physician Orders for skin/ wound care were documented in PI # 1's medical record from 2/22/11 through 3/11/11 (date PI # 1 transferred to a specialty unit within the hospital).

II. Interviews:
During interviews on 8/2/11 at 2:00 PM and 3:30 PM respectively, the Quality Management Director/EI # 3, stated hospital staff were unable to locate any documentation by the wound care nurse in PI # 1's medical record or any other source of documentation by the wound care nurse. There is no Prevention Protocol in PI # 1's medical record.

During an interview with EI # 2 on 8/2/11 at 2:40 PM, PI # 1's admitting nurse (RN) verified PI # 1 was admitted to the hospital with multiple pressure ulcers to include:
"...Right Heel. Stage: II. Color: Red.
Left Heel. Stage II. Color: Red.
Penis. Stage: IV. Color: Black. Odor: Foul. Drainage: Purulent.
Bottom: Stage: II. Color: Red..."

During an interview with Employee Identifier (EI) # 1 on 8/3/11 at 2:00 PM, the Attending Physician described PI # 1 as septic and "very confused" on admission. The physician said there was no breakdown on PI # 1's buttocks, but he is unable to recall the condition of PI # 1's heels.

This standard is written as a result of the investigation of Complaint # AL00024647.