HospitalInspections.org

Based on record review and staff interview it was determined the facility failed to ensure nursing care plans were developed and interventions implemented for the treatment of pressure sores. The facility also failed to monitor the status of pressure sores to evaluate for possible care plan revisions. This was found for three (3) of ten (10) sampled patients (Patients #1, #6 and #8).

The findings include:

Review of the facility policy titled, "Routine Skin Care and Pressure Ulcer Management", last revised 09/20/16 revealed pressure sores were to be measured with each dressing change.

Review of the facility policy titled, "Nursing Care Plan", last revised June 2011, revealed care plans were to be completed within eight (8) hours of admission.

1. Review of the medical record revealed the facility admitted Resident #1 on 07/21/17 and discharged him/her on 09/12/17. The admission nursing assessment noted the presence of three (3) 0.1 centimeter open areas to the patient's sacrum.

Review of Patient #1's care plan dated 07/21/17 revealed documented generic interventions such as "skin assessment", "nutrition promotion", skin injury prevention-positioning" and "education, skin care"; however, there were no interventions to address ongoing wound assessments.

Review of subsequent Nursing Notes revealed documented daily dressing changes to this area; however, there was no documented evidence the wounds were assessed to identify the size or condition of the wounds.

On 09/05/17 an assessment by the Wound Care Department described the area as being 4 centimeters long, 4.5 centimeters wide and 0.5 centimeters deep with a 20% eschar base. Recommendations from the wound care service included the use of a low air loss surface and surgical debridement.

Review of an Operative Note, dated 09/07/17, revealed surgical debridement occurred. However, further medical record review revealed there was no documented evidence a low air loss mattress was implemented per the Wound Care Department.

2. Review of the medical record revealed the facility admitted Patient #8 on 09/29/17. The admission nursing assessment noted a Stage II pressure sore to the sacrum measuring 2.4 centimeters wide by 1.4 centimeters long. A nursing note on 10/04/17 noted the dimensions of the wound had not changed. However, there were no subsequent measurements of this pressure sore.

3. Review of the medical record revealed the facility admitted Patient #6 on 11/23/17 with pressure sores to both feet.

Further record review revealed Patient #6 did not have a care plan completed even though it was five (5) days past the admission date.

Interview with the Nursing Director on 11/29/17 at 9:55 AM revealed he expected the nursing staff to document wound measurements at least weekly. He stated he did not know why wound care measurements were not documented for Patients #1 and #8 or why a low air surface mattress was not obtained for Patient #1. The Nursing Director further stated care plans were supposed to be completed by the nurse who admitted the patient. He revealed the care plan for Patient #6 had not been completed due to an oversight.