HospitalInspections.org

Based on document review and interview, the facility failed to ensure that nursing staff evaluated 1 (#10) of 14 patients timely for skin and extremities status/condition after routine care was provided, resulting in the potential for poor outcomes. Findings include:

On 6/1/16 interviews with Nursing Staff C, E and J at approximately 1000 to 1130, revealed that patient with contractures would be assessed under the "musculoskeletal system" of the nursing shift assessment and pressures sores would be documented under assessment "Skin/Wounds". On 6/1/16 at approximately 1600, medical record review revealed that patient #10 was a 72 year old male admitted to the facility on 11/10/15 with a urinary tract infection, sepsis (multi-drug resistant organism), and renal failure. The patient's Nursing "Admission Assessment Report" dated 11/11/15 at 1228, revealed "Skin Assessment - Dry, Signs/Symptoms - Bruises, Braden Score 12/23 (high risk) and "Musculoskeletal Assessment was Bilateral Movement - Equal, Signs/Symptoms - None". The patient had a Foley Catheter and was bedfast.

On 6/1/16 at approximately 1600, continued review of computerized daily nursing assessments titled "Daily Focus Assessment Report" from admission on 11/10/15 to 11/23/15 for patient #10 revealed no contractures documented until 11/23/15 at 0031 (just before discharge). Skin assessment were documented as "Dry and normal" until 11/14/15, but the Wound Care Nurse was not notified until 11/15/16. It was noted that the patient was not provided an air mattress/bed per facility policy titled "Clinical Practice Guide: specialty Beds, dated 2008" documented, "The patient with a score (Braden) of 18 or less is determined to be at risk for breakdown and should be placed on a group 1 surface. If the patient has skin deterioration on a group 1 surface, the patient should be advanced to a group 2 surface." This had not been done until after the 11/16/15 consultation with the Wound Care Nurse.

Interview with the Wound Care Manger, on 6/1/16 at approximately 1145, revealed that the Wound Care Department/Nurse should be notified of patient's with sores/ulcers right away. On 6/1/16 at approximately 1330, review of the facility policy titled "Clinical Practice Guide: Wound Care Referral", dated 2005, documented, "1. Nursing assess the patient and determines the need for wound care referral. 2. Nursing calls the office voicemail and leaves the patient name, room number and area of the body in need of evaluation."

On 6/1/16 at approximately 1430, review of Skin/Tissue events dated 11/17/15 revealed that the Wound Care Nurse was consulted regarding ulcers and on 11/16/15 she observed "multiple sores all over the bilateral legs; buttock and heel breakdown. Upon assessment patient was noted to have a large deep tissue injury on the left ischium, left foot lateral aspect, right foot, medial aspect great toe, wound below the great toe and right medial heel."

Interview with Nurse I with medical record documentation, on 6/2/16 at approximately 1020, she stated, "I can't remember the exact patient..." Interview with Nurse K with medical record documentation, on 6/2/16 at approximately 1040, she stated, "It's been so long... I can't recall..."

Based on document review and interview the facility failed to ensure nursing staff maintained an updated plan of care (POC) for 1 (#10) of 6 patients with skin/wound concerns, out of a total sample of 14, resulting in the potential for ineffective care. Findings include:

Review of patient #10's medical record on 6/1/16 at approximately 1600 revealed that patient #10 was a 72 year old male admitted to the facility on 11/10/15 with a urinary tract infection, sepsis (multi-drug resistant organism), and renal failure. The computerized daily nursing assessments titled "Daily Focus Assessment Report" from admission on 11/10/15 to 11/14/15 for patient #10 revealed "Skin - Dry, Skin Color - Normal, Sign/Symptoms - None, Braden Scale for Predicting Pressure Sore Risk - Total Score 12/23 on 11/11/15 and 17/23 on 11/12/15." On 6/2/16 at approximately 1600, review of the facility Clinical Practice Guideline: Specialty Beds, dated 2008" documented, "The patient with a score of 18 or less is determined to be at risk for breakdown and should be placed on a group 1 surface. If the patient has skin deterioration on a group 1 surface, the patient should be advanced to a group 2 surface." This had not been done until after the 11/16/15 consultation with the Wound Care Nurse.

On 6/1/16 at approximately 1600, review of the patient #10's "Patient Care Plan Report" dated 11/10/15 through 11/23/15 (discharge), revealed a Skin Plan of Care was not documented in the medical record. Assessments and treatment orders were noted. On 6/2/16 at approximately 1200, review of the facility "Nursing Documentation Guidelines, revised 11/13" documented, "Nursing Care Plan: 1. Within 8 hours of admission the RN will initiate a primary care plan and individual plan/problems, according to the patient's diagnosis and assessment. 2. Nursing care plans are to be evaluated every shift..."