HospitalInspections.org

Based on record review, policy review and staff interview, it was determined the Registered Nurses failed to ensure appropriate assessment of skin and implementation of pressure ulcer prevention interventions and failed to ensure patient hygiene needs were met for 1 (#1) of 11 sampled patients. This practice does not ensure that patient care goals are met.

Findings include:

The facility's policy "Skin Care, Care of the Patient Requiring", no number, revised 9/07 was reviewed. The policy requires that the entire body is to be assessed for altered skin integrity each shift. The assessment is to be documented each shift. The patient's risk of developing skin breakdown is to be assessed using the Braden Scale daily. The policy also lists the following pressure relief interventions which are to be implemented for patients at risk: turn and reposition every 2 hours, use of pillows between bony prominences and limit chair sitting to 2 hour intervals among others.
Patient #1 was admitted to the facility on 10/16/12 and discharged on 11/7/12. She was readmitted on 11/8/12 and was still a patient in the facility on 11/21/12. Review of the medical record for patient #1 for the 10/16/12 admission was conducted. The physician documented in the History and Physical that the patient was admitted with altered mental status, and non-healing ulcers of both lower extremities. The physician further noted the patient had a urinary tract infection, acute on set of chronic renal failure, hypertension, peripheral vascular disease, coronary artery disease and diabetes. Review of the nursing skin assessments revealed no Braden score was documented on the day of admission. The Braden score on 10/18/12 was documented as 14. Patients with a score of 18 or less are considered to be at risk of developing skin breakdown. There was no Braden score on the day of discharge. There was no assessment of skin integrity on the 7 p.m. - a.m. shift on 10/29/12 or on the 7 a.m. - 7 p.m. shift on 11/7/12.
Review of nursing documentation of repositioning of the patient revealed the following failures to comply with the requirement to reposition the patient every 2 hours.
10/16/12 - documentation at 7:45 p.m. the patient was lying supine. No other documentation on 10/16/12
10/17/12 - documentation at 7:30 p.m. that heels were floated. No other documentation.
10/19/12 - no documentation of repositioning from 2 a.m. until 6 a.m.
10/29/12 - no documentation of repositioning from noon until 4:00 p.m.
10/30/12 - no documentation of repositioning after 7:55 p.m.
10/31/12 - no documentation until 8 a.m. or after 2:00 p.m.
11/1/12 - no documentation until 2 a.m. No documentation from 8 a.m. until noon.
11/6/12 - no documentation from midnight until 4 a.m. No documentation from 10 a.m. until 2:00 p.m. No documentation form 2 p.m. until 5 p.m.

A stage II pressure ulcer was documented to be present on the 7 p.m. - 7 a.m. shift on 11/3/12. There was no assessment of skin integrity on 11/4/12 during the 7 a.m. to 7 p.m. shift. There was no assessment of skin integrity at the time of discharge on 11/7/12. Two nursing educators were interviewed on 11/21/12 at approximately 2:00 p.m. They had reviewed the medical record and substantiated the above findings.

The medical record for patient #1 for the 11/8/12 admission was reviewed. The patient had sustained a fracture of her left tibia. Review of the History and Physical revealed the physician also diagnosed End Stage Renal Disease, non-healing ulcers of both lower extremities and C Diff infection.
Review of nursing documentation of skin assessments revealed the following deficiencies:
11/9/12 - No documentation of Braden assessment
11/17/12 - No assessment of skin integrity and no Braden Assessment
11/18/12 - No assessment of skin integrity.

Review of nursing documentation of repositioning revealed the following failures to repositioning the patient every 2 hours.
11/13/12 - No repositioning from midnight until a.m.
11/16/12 - The patient remained in a sitting in a chair from 8:00 a.m. until noon, with no documentation of position change.
11/19/12 - No repositioning after 6:00 p.m.
11/20/12 - No repositioning until 4:45 a.m.

The Assistant Nurse Manager was present during the record review on 11/20/12 and substantiated the above findings.

The medical record of patient #1 for the 10/16/12 - 11/7/12 admission was reviewed regarding provision of hygiene care. The following problems were identified:
10/16/12 - no documentation of bath or oral care
10/17/12 - no documentation of bath or oral care
10/18/12 - no documentation of bath, Foley care or oral care
10/29/12 - no documentation of any hygiene care
10/31/12 - no documentation of any hygiene care
11/2/12 - no documentation of any hygiene care
11/3/12 - Foley catheter care only
11/5/12 - no documentation of any hygiene care
Two nursing educators reviewed the record and confirmed the findings.