HospitalInspections.org

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Based on document review, observation and interview, in one (1) out of five (5) Medical Records reviewed, Nursing Services failed to ensure assessment, prevention, and care of the pressure ulcers.

These failure place all patients at risk for developing new or worsening pressure wounds.

Findings:

On 11/19/15, review of Patient #2's Medical Record, who was admitted on 10/13/15, revealed a Note in the Skin Assessment dated 10/18/15 that documented "positioned off wounds", and two (2) additional Nurses' Notes on 10/25/15 and 10/26/15, that documented "pressure ulcer". No description of the size, type, location of the pressure ulcer were noted in the Record.

On 10/29/15, the Nurse documented a Stage II pressure ulcer to the sacrum and initiated the CPG (Clinical Practice Guidelines) which is the facility's Care Plan. On 11/01/15 another Nurse documented a Stage III to the left buttock, and on the next shift another Nurse documented a Stage II to sacrum. Further review of the Record determined that the patient had developed one (1) wound on the sacrum.

Review of the Medical Record Wound Assessment also revealed that the Nurses documented wound dressings as: "Comfeel" for the 7A-7P shift on 10/29/15 and the 7P-7A shift on 10/29/15, "Hydrocolloid" for the 7A-7P on 10/30/15 and no documentation for the 7P-7A shift on 10/30/15. Nurses also documented "Comfeel" for both shifts on 11/01/15, "Thin Film" for the 7A-7P on 11/02/15, and no documentation of any dressing for 11/03/15.

Review of the facility's Policy titled "Pressure Ulcers: Guidelines for Tracking and Monitoring the Care of Pressure Ulcers", dated 05/21/15, revealed on Page 2:4:a, that "The Wound Champions have Unit based responsibilities which include... " "Insuring that all RN Assessments and documentation are consistent."

The Medical Record lacked evidence of consistent Nursing Assessments, description and location of the wound, and treatment.

This was confirmed with Staff A and H at the time of Record review.

Review of Patient #2's Medical Record also revealed that the patient, who was initially identified in a Skin Assessment as having a pressure ulcer on 10/18/15, and documented as having a Stage III pressure ulcer on 11/01/15, did not receive a Wound Care Consult or Orders by the WOCN (Wound Ostomy Certified Nurse) or a Physician until 11/04/15. The patient was discharged the next day on 11/05/15 with a Stage III pressure ulcer.

During an interview with Staff Members C and F on 11/19/15 between 9:15AM - 10:00AM, both staff members stated that staff are to notify the WOCN or the Physician of any Stage III or greater pressure ulcer.

Review of both facility Skin Policies titled "Pressure Ulcers: Guidelines for Tracking and Monitoring the Care of Pressure Ulcers", dated 05/21/15, and "Pressure Ulcer: Prevention, Assessment, and Management", dated 05/16/13, lacked criteria and/or instructions for who the staff reported to and the type of wounds that are to be reported.

Additional Medical Record review documented that Patient #2 was readmitted on 11/12/15 and had a Stage III wound on the left sacrum. Observation of the sacral wound on 11/19/15 at 11:45AM revealed a Stage III wound with macerated edges that were several millimeters wide and bright white in color.

The dressing which was removed was damp and lacked the Calcium Alginate as ordered by the Wound Care Physician. Nurse B, who was caring for the patient on 11/19/15, advised that she is aware that Night Nurse F from the previous shift did not have the Calcium Alginate on hand and only applied the 4 x 4 dressing.

Nurse B was asked why Calcium Alginate would be used for this type of wound and she replied that it is used to absorb moisture from the wound in order to prevent further breakdown.

Record review revealed that the dressing was signed for by the Night Nurse at 00:42 on 11/19/15. The Physician's Order written on 11/12/15 is for Calcium Alginate and a dry dressing for every other day and as needed.

The WOCN, Staff C, was interviewed on 11/19/15 and advised that the Calcium Alginate was not formulary and came from The Wound Care Center on Campus. She advised that when Calcium Alginate was needed a "runner" would go retrieve the product for the Nurse.

Staff G, Administrator, advised that the facility has access to the Wound Care Center at any time.

Nurse B advised that the patient was given Lactulose and that she had loose stools and the dressing had to be changed more frequently without additional stock of Calcium Alginate on the floor.
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Based on record review, policy review and interview, in four (4) out of five (5) Medical Records reviewed, Nursing Services failed to implement Care Plans for patients with pressure ulcers.

This failure places all patients at risk for not receiving needed interventions and necessary care.

Findings:

On 11/19/15, review of the Medical Record for Patient #2 revealed that the patient was admitted from 10/13/15 - 11/05/15 with intact skin and assessed as "at risk" for skin breakdown with a Braden Scale Score of 10.

During review of the Medical Record with Staff A on 11/19/15 at 1:40PM, the staff member stated that the Braden Scale was part of the Skin Assessment done by the Nurses and a score of less than eighteen (18) required an intervention.

During the review of the Medical Record for Patient #2, no evidence of turning and positioning was noted in the Record. The patient subsequently developed a Stage III pressure ulcer during her stay.

When asked to view the patient's Skin Care Plan, the staff stated that the facility uses "Clinical Practice Guidelines" (CPG) as their Care Plans.

Staff Members A & H confirmed that turning and positioning can only be documented when the CPG is activated in the Electronic Medical Record. When asked to review the patient's CPG for skin care, the staff replied "There is none."

A lack of Skin Care CPGs were also noted in Patient #5's Medical Record with an admission date of 07/25/15, a Braden Scale Score of 11, and who developed bilateral Stage III pressure ulcers to his ears; in Patient #4's Medical Record with an admission date of 10/28/15 who had a Stage IV pressure ulcer upon admission with a Braden scale of 10; and Patient #7's Medical Record with an admission date of 11/12/15 who had a deep tissue injury upon admission with a Braden Scale Score of 12.

These findings were confirmed on 11/20/15 at 10:30AM with Staff H at the time of Record review.

During interview with Staff H, at the time of Medical Record review, when asked when a Nurse should initiate a CPG, the staff replied "anyone who scores less than eighteen (18) on the Braden Scale or is identified with wounds upon admission."

Review of the facility's Policy titled "Pressure Ulcer: Prevention, Assessment, and Management", dated 05/16/13, revealed on Page 2 under "Prevention as applicable #1" that staff should "Implement measures to reduce the risk of developing pressure ulcers for patients at risk and those who have pressure ulcers."

The Medical Records lacked evidence that CPGs were initiated or interventions were put into place, upon admission, to prevent or treat pressure ulcers.

Review of the facility's Policy titled "Knowledge-Based Charting Documentation", dated 07/26/13, revealed under "Procedures and Guidelines" Section I: "Clinical Practice Guidelines are part of the care planning process, and are selected based on the clinical diagnosis and unique needs of the patient" and Section II:7:I "Each patient will have at least one (1) CPG added to the Plan of Care Flow Sheet, which will be individualized, within 24 (twenty-four) hours of admission."

The Policy lacks specific criteria and/or guidelines, including when to add additional problems or concerns to the CPG Care Plan.

These findings were confirmed with Staff F on 11/19/15 between 9:15AM - 10:00AM.