HospitalInspections.org

Based on document review and interview the facility failed to ensure nursing staff developed a care plan that addressed problems, interventions and goals to promote the healing of pressure sores for 1 (#1) of 10 patients reviewed for care plans from a total of 10 sampled patients, resulting in the potential for worsening of pressure sores. Findings include:

On 7/26/16 at 1340, a review of the closed medical record for patient #1 was conducted with E-care Staff (K).

According to the admission face sheet patient #1 was a 64 year old female admitted to the facility on 6/3/16 with a diagnoses of pneumonia, hyponatremia and acute kidney injury.

A review of a physician's admit/progress note dated 6/3/2016 at 0259 documented the following:

Subjective:
Patient presented to the Emergency department (ED) with a previous medical history (PMHx) of cerebral vascular accident (CVA), with residual contractures, status post (s/p)percutaneous endoscopic gastrostomy tube (PEG), decub ulcer (stage 2-3), hypertension, and anxiety/depression.

Assessment/plan "...decub ulcer: stage 2-3 (partial-full thickness skin loss with subcutaneous fatty tissue exposure), supportive management, consider wound care nurse consult, no active bleeding or discharge..."

A review of the nursing admission assessment for patient #1, dated 6/3/16 at 0407 documented the patient was admitted to the facility with a stage 3 pressure sore on the patient's coccyx, and a deep tissue injury (DTI) was documented on the patient's right lateral foot. There were no measurements or further wound characteristics documented on the nursing admission assessment or in the clinical record for either wound upon admission until 6/14/16 (11 days after the patient's admission).

A Braden Scale for Predicting Pressure Sore Risk scored the patient at "9" (high risk) for skin breakdown on admission.

A review of the patient's care plan section of the electronic record dated 6/3/16 at 0406 documented a "Universal Plan of Care". However, there were no care plans for the patient's pressure sore or deep tissue injury skin care needs to guide or direct the nursing staff with the patients care.

There were no physician's orders regarding patient #1's wound care needs documented in the clinical record until 6/13/16 (wound care consult ordered).

Additionally, there were no wound care treatment records in the clinical record that documented nursing staff had administered wound care for the patient's stage 3 pressure sore or right lateral foot wound until 6/14/16 when documented by the Wound Care Nurse.

On 7/26/16 at 1430, Staff K explained she did not see a "Skin" care plan for the patient's altered skin integrity. Staff K stated, "We do a 'Universal Plan of Care" on admission. I've looked there's not one here. There should be one for the patient's wounds."

On 7/26/16 at 1530 further record review revealed the following:
A review of a wound care consults documented:

On 6/14/16 at 1221:
Wound care consulted for the buttock/skin.

Patient with an unstageable injury/ulcer to the coccyx that measures 2.5 centimeters (cm) x 1.5 cm x 1.0 cm, with undermining at 6-12 o'clock that measures 3.5 cm, wound base with a yellow/gray slough tissue present. Periwound skin with areas of maceration and peeling skin present.
Recommend to coccyx ulcer medihoney for autolytic debridement of necrotic tissue. Recommend 3M no sting to direct periwound skin to protect.

Patient with moisture dermatitis to the bilateral buttocks and perineal skin. Skin is macerated with areas of partial thickness wounds noted. Recommend to barrier cream to protect skin and promote healing.

Follow skin bundle.
Patient on a pressure redistribution mattress
RN notified of above.
Will continue to follow as needed.
Please reconsult for wound deterioration and as needed.


On 6/21/16 at 1144:
Wound care following for the buttock/skin.

Patient with an unstageable injury/ulcer (full thickness tissue loss with the base covered by slough in the wound bed) to the coccyx that measures 3.5 cm x 1.5 cm x 1.0 cm, with undermining from 6-12 o'clock that measures 4.0 cm wound base with a yellow slough present to approximately 30 % (percent) of visible wound base and remaining tissue red. Periwound skin with areas of maceration and peeling skin present.

Recommend to coccyx ulcer medihoney for autolytic debridement. Recommend 3M no sting to direct periwound skin to protect.

Patient with moisture dermatitis to the bilateral buttocks and perineal skin and the lower bilateral thighs. Skin is macerated with areas of partial thickness wounds noted. Linear partial thickness wounds noted to the left lower buttock/thigh area. Recommend barrier cream to protect skin and promote healing. (worsening of skin integrity)

Follow skin bundle.
Patient on a pressure redistribution mattress.
RN at bedside during assessment and aware of above.
Will continue to follow as needed.
Please reconsult for wound deterioration and as needed.

Further review of the clinical record revealed that there was no skin care plan developed by the nursing staff after the wound care consults.

On 7/27/16 at 0840 a review of the facility's "Pressure Ulcer Prevention, Management and Treatment" policy (dated (10/2014 documented:
Policy
"...D: Following assessment a plan of care to prevent/treat pressure ulcers is established and initiated in a timely manner...".

Additionally, a review of the facility's (undated) "Skin Bundle" policy documented:
S: Support surface selection
K: Keep turning at least every 2 hours and prn (as needed)
Keep heels offloaded, Keep patient moving (ambulating as ordered)
Keep pressure causing devices off of skin (i.e., tubes, cast edges, trach phlanges, etc).
I: Incontinence Management-Apply barrier cream after every episode of incontinence.
N: Nutrition Management-Encourage protein and fluid intake unless contraindicated; screen for nutritional risk to consult dietitian, if indicated.

However, there was no evidence in the clinical record that documented the patient's support surface had be reviewed until 6/22/16 following the worsening of the patient's skin integrity when an air mattress was ordered.

On 7/27/16 at approximately 1020 during an interview and record Wound Care Staff Nurse (G) explained she should have written a "Skin" care plan following her consult on 6/14/16. She stated, "I looked there is no care plan."

On 7/27/16 at approximately 1040 during an interview the Vice President of Nursing Staff (P) explained the admitting nurse should have documented the "Skin" care plan. Staff P further explained all nursing staff were responsible for following the patient's care plan.

On 7/27/16 at 1436 an attempt to reach Staff Nurse (O) via telephone was unsuccessful. A voice mail message was left requesting a return phone call to the surveyor.

On 7/27/16 at 1534 during a phone interview Staff O explained she worked the 0700-1900 shift at the facility and she recalled admitting patient #1 on 6/3/16 and performing the assessment. She explained the patient was Ax0x0 (disoriented) not able to speak. She (patient #1) would cry with repositioning.

When asked why she did not document the wound measurements and characteristics of the patient's stage 3 pressure ulcer and right lateral foot DTI Staff O stated, "I remember the wound (coccyx) was small probably 1 inch by 1 inch but it was very deep. There was no necrosis (dead tissue). The wound I cleaned the wound and put on a foam dressing. I don't recall if I measured it."

When asked to describe the extent of the DTI to the patient's right lateral foot wound, Staff O stated, "I don't recall. She (patient #1) was very stiff and contracted during my initial assessment. Towards the end she was more relaxed less contracted. I probably would have elevated her foot to decrease any further pressure on the area."

When asked why she did not get orders for wound care or develop a care plan for the patient's stage 3 pressure ulcer or the patients DTI to the right lateral foot Staff O stated, " I should have if it's not in the chart. I did not."