HospitalInspections.org

Based on document review and interview it was determined for 1 of 12 (Pt. #1) clinical records reviewed, the hospital failed to ensure there were ongoing assessments of the patient's skin integrity.

Findings include:

1. On 4/17/13 the Hospital's policy titled, "Pressure Ulcer Management" (revised 11/11) was reviewed and stated in part, "Nursing...will assess and manage skin integrity for all patients throughout the hospital stay...skin inspections will be completed on admission and daily...assess pressure ulcers by using wound assessment forms every shift..."

2. On 4/17/13, Pt. #1's medical record was reviewed. Pt. #1 was a 61 year old male admitted on 2/1/13 with a diagnosis of cardiopulmonary arrest. Pt. #1 had a medical history of diabetes and hypertension. Pt. #1's medical record contained the following assessments for skin integrity:

-On 2/1/13 Pt. #1's nursing assessment related to skin integrity, which was completed upon admission, documented that Pt. #1 did not have any skin break down.

- On 2/10/13 at 6:44 am the nursing assessment documented Pt. #1 had a right sacrum skin tear related to the rectal pouch support dressing, and DuoDerm was applied.

-On 2/18/13 at 8:00 am the nursing assessment documented Pt. #1 had a right sacrum skin tear and bilateral feet ulcerations; treatment for wound indicated that DuoDerm was applied to the sacral wound.

- On 2/19/13 at 1:46 PM Pt. #1's wound assessment detailed report completed by the wound care nurse (WCN), documented Pt. #1 had a left 5th metatarsal pressure ulcer staged as suspected deep tissue injury (DTI) open to air; left lateral mid foot pressure ulcer suspected DTI open to air; left median bunion pressure ulcer suspected DTI open to air; sacrum pressure ulcer stage 2 (wound injury includes skin and tissue), applied Aquacel foam, dressing changed every 2 days as needed after normal saline cleanse. All wounds were documented as facility acquired. However, prior to 2/18/13, the medical record lacked documentation of the foot wounds and reassessments. In addition, the record lacked documentation that any wound assessments had been completed on 2/2-2/9 and 2/11-2/17/13.

3. On 4/16/13 during an interview the WCN stated it was not until 2/18/13 that he became aware of Pt. #1's wounds, and he had not been informed of the wounds until that date. The WCN stated he only rounds on the intensive care unit (ICU) on Tuesdays and Thursdays.

4. These findings were confirmed on 4/17/13 at approximately 10:00 AM with the ICU Manager (E #6), during electronic medical record review.

Based on document review and interview, it was determined for 1 of 3 (Pt. #1) medical records review of patients with impaired skin integrity, the Hospital failed to ensure the Plan of Care (POC) was updated or revised to include the patient's changes in skin integrity.


Findings include:

1. On 4/17/13 the Hospital's policy titled, "Standard of Care/Standard of Practice" (revised 3/25/11) was reviewed and documented in part, "Upon initiation of the Plan of Care for specific patients each care plan will be individualized as necessary to specific patient needs ...the registered nurse will...place in the patient's chart...patient care standard [also known as plan of care] is modified to suit the patients individual needs..."

2. On 4/17/13 the Hospital's policy titled, "Pressure Ulcer Management" (revised 11/11) was reviewed and required, "Nursing...will assess and manage skin integrity for all patients throughout the hospital stay...skin inspections will be completed on admission and daily...assess pressure ulcers by using wound assessment forms every shift..."

3. On 4/17/13, Pt. #1's medical record was reviewed. Pt. #1 was a 61 year old male admitted on 2/1/13 with a diagnosis of cardiopulmonary arrest. Pt. #1 had a medical history of diabetes and hypertension. Pt. #1's medical record contained the following assessments for skin integrity:

-On 2/1/13 Pt. #1's nursing assessment related to skin integrity, which was completed upon admission, documented that Pt. #1 did not have any skin break down.

- On 2/10/13 at 6:44 am the nursing assessment documented Pt. #1 was assessed with a right sacrum skin tear related to the rectal pouch support dressing and DuoDerm was applied.

-On 2/18/13 Pt. #1 at 8:00 am the nursing assessment documented Pt. #1 had a right sacrum skin tear and bilateral feet ulcerations; treatment for wound indicated that DuoDerm was applied to the sacral wound.

- On 2/19/13 at 1:46 PM Pt. #1's wound assessment detailed report completed by the WOCN, documented Pt. #1 had a left 5th metatarsal pressure ulcer staged as suspected deep tissue injury (DTI) open to air; left lateral mid foot pressure ulcer suspected DTI open to air; left median bunion pressure ulcer suspected DTI open to air; sacrum pressure ulcer stage 2, applied Aquacel foam, dressing changed every 2 days as needed after normal saline cleanse. All wounds are documented as facility acquired.

4. On 4/17/13 Pt. #1's POC dated 2/1/13 through discharge date 2/19/13 was reviewed, and the POC lacked documentation that it was updated or modified to include interventions and goals for Pt. #1's with changes in skin care needs, related to the documented wounds.

5. These findings were confirmed on 4/17/13 at approximately 10:00 AM with the ICU Manager (E #6), during electronic medical record review.