HospitalInspections.org

Based on observation, interview, record review and policy review, the facility failed to:
- Prevent the development of a Stage II (partial thickness skin loss usually presenting as a blister or opening in the top layer of skin) pressure sore, failed to have the skin care team assess this pressure sore, and failed to adequately treat the pressure sore for one (Patient #28) of three patients reviewed with pressure sores.
- Adequately address complaints of pain for one (Patient #47) of one patient reviewed with complaints of pain.
- Ensure that staff followed physician's orders for three patients (#1, #15 and #28) of 25 patients reviewed for physician's orders for wound care.
- Follow facility policy for Fall Risk patients when implementing appropriate interventions for twelve patients (#7, #8, #9, #10, #11, #12, #13, #23, #24, #73, #74 and #75) out of 22 fall risk patients reviewed.
These failed practices had the potential to lead to possible harm and/or injury and affect all of the patients at the facility. The facility census was 424.

Findings included:

1. Review of the facility's policy titled, "Patient Care-Skin Impairment Potential Standard of Care for Adolescent/Adult Clinical Guidelines," approved 04/25/17, showed:
- Prevention is key.
- Each patient should have preventative interventions in place for a skin risk score (Braden-a tool utilized to assess the risk for development of pressure sores) of 18 or less.
- Maintain sacral (tailbone) offloading (pressure relief).
- The skin care team will see all new pressure sores.
- Treatment interventions should be based on weak areas identified on the Braden tool.

Review of the facility's education titled, "Dressing Selection at It's Finest," dated July 2016, showed:
- Stage II pressure sores should be cleansed, hydrated and protected or covered.
- If a wound is too wet, you need an absorbent dressing.
- If a wound is too dry, you need a moisture donating dressing.

Review of Patient #28's admission nursing assessment, dated 10/13/18, showed:
- He was admitted on that date with post-surgical wounds on his right lower leg.
- He was continent of both bowel and bladder, required minimal assistance to reposition in bed, and was rarely moist.
- His Braden score was "19," or a high risk for breakdown, and showed his skin was rarely moist.
- The patient's sacrum was intact upon admission.

Review of additional Braden scores showed the patient scored "17-20," with his skin rarely moist six out of eight assessments.

Review of laboratory values dated 10/13/18, showed the patient's total protein and albumin (protein levels whereby low levels can be indicative of poor wound healing ability) levels were low at 6.0 (normal = 6.6-8.7) and 2.7 (normal = 3.5-5.2).

Review of the nursing assessment dated 10/14/18, showed the patient had developed a Stage II pressure injury (sore) on the sacrum/gluteal cleft, measuring 4.0 centimeters (cm, unit of measure) by 1.5 cm. Staff failed to prevent the development of a Stage II pressure sore.

Review of a nutritional assessment dated 10/14/18, showed a Registered Dietitian (RD) was consulted regarding the patient's Stage II pressure sore. The RD noted the patient needed intake of higher protein foods to assist in wound healing.

Observation and concurrent interviews on 10/16/18 at 1:05 PM, showed:
- Patient #28 sat upright in his bed at an approximate 30 degree head of bed elevation (increased pressure on the sacrum). Staff failed to maintain offloading of sacrum.
- There was no evidence of excessive moisture on, or around the patient.
- Staff BBBB, Registered Nurse (RN) stated that the area in the patient's gluteal cleft (crack between the buttocks, at the upper sacral area) was "open." Staff II, Care Team Associate (Staff BBBB's superior) said the skin care team had looked at a picture of the patient's sore and felt it was not a pressure sore, but moisture related.
- The open area was approximately one-inch long and about 1/8-inch wide with red surrounding tissue.
- The open area was cleansed, and a barrier cream applied. No dressing or cover was placed over the barrier cream. Staff failed to cover the wound as stated in the education material.
- The patient asked staff what he could do to help this open area heal and they told him, "nothing," that it was caused by moisture and the barrier would wick it away (barriers keep moisture from entering the wound, they do not wick away moisture).

During an interview on 10/18/18 at 9:34 AM, Staff QQ, Lead Wound and Ostomy RN, stated the following:
- The skin care team was automatically triggered if the patient was identified as having a pressure sore, if staff requested, or called.
- A score of "18" or above on the Braden was high risk; a score of "13-17" was moderate risk; and below "13" was low risk.
- Staff QQ remembered seeing a picture of Patient #28's gluteal cleft wound and thought it was moisture related because it was linear in shape.
- Staff QQ was not sure if the skin care team had actually seen Patient #28.
The skin care team failed to assess Patient #28's pressure sore as directed in the facility policy.

Review of Staff BBBB's documentation dated 10/16/18 at 1:13 PM, related to the Stage II pressure sore, showed, "Patient charted as having stage 2 pressure ulcer. Wound not present. Patient currently has moisture associated breakdown on gluteal cleft. Wound cleansed with soap, blue top lotion applied, then (skin protective solution)."

Review of all physician's orders showed staff failed to obtain a specific order for treatment of the Stage II pressure sore.

Even though requested, the facility failed to provide evidence the skin care team assessed Patient #28's new pressure sore.

The facility identified 11 patients with facility-acquired pressure sores from 08/24/18 through 10/14/18, including Patient #28.

2. Review of the facility's policy titled, "Pain Care-Pain Assessment and Interventions Policy," revised 02/09/18, showed the following:
- Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
- Pain will be assessed and managed by measuring pain levels using a standardized tool (a scale where 0 = no pain and 10 = the worst pain).
- Mild pain (1-3) is treated with Acetaminophen (Tylenol, mild pain medication); moderate pain (4-6) is treated with Tylenol #3 or Vicodin (strong pain medications); severe pain (7-10) is treated with morphine, oxycodone, etc (stronger pain medications).
- Staff will implement pharmacological (medications) and non-pharmacological (does not include medications) interventions.
- Ongoing assessment is needed to evaluate the changing nature of the pain and to determine the response to treatment.
- The provider will be notified if the patient remains in pain after a pain relief intervention.

Review of Patient 47's History and Physical (H&P) dated 10/14/18, showed:
- The patient was admitted on that date with thoughts of harming himself and others.
- The patient was a diabetic (can result in poor circulation and poor healing ability).
- The patient had dropped a brick on his right foot causing swelling and severe pain.
- The patient's right great toe had a big blood blister on it that had to be drained.

Record review of an X-ray report dated 10/15/18, showed the patient had a mildly displaced fracture of the fourth toe and associated soft tissue swelling.

Record review of the patient's pain medication regime and pain assessments showed the following:
- The patient complained of pain consistently from admission through 10/17/18, utilizing a scale of one to ten with ten being the worst pain.
- The patient rated his pain at eight to ten at all times.
- The patient had two pain medications ordered, Acetaminophen 650 milligrams (mg, unit of measure) every four hours as needed for mild pain of 1-4, and Naproxen 500 (Aleve-or an anti-inflammatory, pain reliever) daily as needed for mild pain of 1-4.
- The patient received the Acetaminophen nine times, and the Naproxen one time. Three episodes of administration were either not evaluated for pain relief or there was no relief.
- The Naproxen was more helpful than the Acetaminophen.

During interviews on 10/17/18 at 9:38 AM, Staff WW, RN, stated the staff should have encouraged the patient to take the Naproxen rather than the Acetaminophen, and Staff XX, RN Supervisor, stated that the staff could have notified the physician to receive orders for a more appropriate pain control, but had not done so thus far.

Staff failed to comprehensively assess and/or treat Patient #47's pain.

3. Review of Patient #1's admission H&P dated 10/12/18, showed he was admitted on 10/11/18 with bilateral below the knee amputations (BKA). His right stump (area where the amputation occurred) was swollen.

Review of an Orthopaedic (bone specialist) consult dated 10/11/18 showed a recommendation for maintaining a compressive dressing (stump shrinker) on the limb to help with the swelling of the right stump.

Review of an Orthotics and Prosthetics (specialists in artificial limbs) consult dated 10/12/18 at 5:23 PM, showed an order, "Needs stump shrinker."

Observation and concurrent interview on 10/15/18 at 2:10 PM, showed Patient #1 had no stump shrinker/stockings on either stump. Patient #1 stated that his right stump was swollen and he needed a stump stocking.

Review of orders for the patient on 10/15/18 showed, "Stump shrinker for right BKA," four days after admission.

During an interview on 10/15/18 at 2:45 PM, Staff A, Clinical Supervisor, could not explain how staff failed to complete this recommendation and order, until after surveyor inquiry.

Staff failed to follow a recommendation and physician's order.

4. Review of physician orders for Patient #15's wound care and dressing instructions, showed that the right chest (surgical site wound) was to be dressed with a wet to dry dressing (wet gauze put on or in the wound, that is allowed to dry), then covered with a woven gauze, two times per day.

Observation on 10/15/18 at 3:00 PM, on the Oncology Unit, showed that Staff U, RN, removed the old dressing, applied dry gauze to Patient #15's wound and then applied dry gauze to the outside with tape. The dressing change was not performed according to the physician's orders.

During an interview on 10/16/18 at 9:54 AM, Staff MM, Clinical Manager of Oncology, stated that she expected nurses to follow physician orders.

During an interview on 10/18/18 at 9:35 AM, Staff QQ, Team Lead Wound and Ostomy Nurse, stated that staff were to date and initial all dressings and Staff UU should not have placed a dry to dry dressing on the patient.

5. Review of the facility's policy, "Patient Care - Fall Prevention-Policy," dated 02/12/18, showed direction for staff to initiate the following interventions for a patient identified to have a fall risk:
- Place a yellow bracelet on the wrist;
- Apply non-slip socks on the patient; and
- Place a yellow tiger magnet or a full size laminated tiger sign on the door of the patient's room.

During an observation on 10/15/18 at 2:25 PM, on 7 West Surgical Services, it was noted that a total of six patients (#7, #8, #9, #10, #11, and #12) were placed on Fall Risk precautions, but the appropriate signs/magnet were not located on their doors, and two patients (#7 and #12) did not have yellow fall bracelets in place.

During an observation on 10/15/18 at 2:50 PM, on 7 East Neuro Science, it was noted that Patient #13 was identified as a fall risk, but did not have the appropriate sign/magnet in place on her door.

During an interview on 10/15/18 at 2:20 PM, Staff L, Care Team Associate - Clinical (CTA-C), stated that Patient #7 should have had a yellow fall bracelet in place.

During an interview on 10/15/18 at 1:50 PM, Staff K, RN, 7 West Surgical Services Clinical Supervisor, stated that all fall risk patients should have a sign/magnet on their door, a yellow wrist band, and non-slip socks in place.

Observation on 10/16/18 at 9:25 AM, of patients that had fall risk signs on their doors, and concurrent interview on the Five East/West units, showed:
- Patient #23 had a fall risk sign on his door; however, staff failed to place a yellow wrist band on the patient.
- Patient #73 had a fall risk sign on the door; however, staff failed to place a yellow wrist band on the patient.
- Patient #74 a fall risk sign on the door; however, staff failed to place a yellow wrist band on the patient.
- Patient #75 had a fall risk sign on the door; however, staff failed to place a yellow wrist band on the patient.
- Staff V, RN, stated that staff was supposed to place the yellow fall risk wrist bands on the patients when the fall risk was identified. Staff V stated that administrative nursing staff checked, periodically, for staff compliance with fall risk signage, wrist bands and non-slip socks, but (based on the above observations) they were failing miserably.

Observation on 10/16/18 at 9:43 AM, showed Patient #24 had a fall risk sign on her door; however, staff failed to place a yellow wrist band on the patient.




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Based on observation, interview, and record review the facility failed to develop comprehensive, individualized care plans based on the assessment of patient needs for three patients (#1, #47 and #53) of 15 patient care plans reviewed. This failed practice had the potential to affect all patients admitted to the facility by not meeting individual needs of the patient. The facility census was 424.

Findings included:

1. Review of the facility's policy titled, "Patient Care-Plan of Care-Policy," dated 02/22/18 showed:
- The plan of care (care plan) is based on assessing the patient's care needs and developing appropriate care goals and nursing interventions in response to those needs, with evaluation of the progress towards those goals.
- The care plan will be initiated by Registered Nurses (RN's) completing the admission process within 24 hours of admission.
- The care plan will be reviewed and updated each shift as the needs of the patient change.

During an observation on 10/17/18 at 10:00 AM, on 7 West Surgical Services, it was noted that Patient #53 had all four side rails of his bed raised.

During an interview on 10/17/18 at 10:00 AM, Staff DDD, RN, stated that Patient #53 had all four side rails of the bed raised to aide with his mobility.

Review of Patient #53's medical record showed that he was a 35 year old male that fell from a tree stand which resulted in multiple fractures of his spine, and a left and right lower leg fracture. His care plan was never updated to include mobility, and the use of four side rails for mobility had not been documented or addressed.

Review of Patient #1's admission H&P dated 10/12/18, showed he was admitted on 10/11/18 with bilateral below the knee amputations (BKA). His right stump (area where the amputation occurred) was swollen.

Review of an Orthopaedic (bone specialist) consult dated 10/11/18 showed a recommendation to maintain a compressive dressing (stump shrinker) on the limb to help with the swelling of the right stump.

Review of an Orthotics and Prosthetics consult dated 10/12/18 at 5:23 PM, showed an order, "Needs stump shrinker."

During an interview on 10/15/18 at 2:10 PM, Patient #1 stated that his right stump was swollen and he needed a stump stocking.

Review of orders for the patient on 10/15/18 showed, "Stump shrinker for right BKA."

Review of the patient's care plan dated 10/11/18, showed staff failed to address the patient's stump care or need for a stump shrinker to reduce swelling.

Review of Patient 47's History and Physical (H&P) dated 10/14/18, showed the patient had dropped a brick on his right foot causing swelling and severe pain. The patient's right great toe had a big blood blister on it that had to be drained.

Record review of an X-ray report dated 10/15/18, showed the patient had a mildly displaced fracture of the fourth toe and associated soft tissue swelling.

Record review of the patient's pain medication regime and pain assessments showed the following:
- The patient complained of pain consistently from admission through 10/17/18, utilizing a scale of one to ten with ten being the worst pain.
- The patient rated his pain at eight to ten at all times.
- The patient had two pain medications ordered, Acetaminophen (Tylenol) 650 milligrams (mg, unit of measure) every four hours as needed, and Naproxen 500 (Aleve-or an anti-inflammatory, pain reliever) mg daily as needed.
- The patient received the Acetaminophen nine times, and the Naproxen one time.

Review of the patient's care plan dated 10/14/18 showed staff failed to address the patient's complaints of, and treatment of pain.


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