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Based on a review of policy and procedure, interviews, and review of patient #1's record, nursing failed to turn patient #1 every two hours per the standard of care, failed to provide consistent oversight of patient #1's changing skin condition, and failed to inform a physician of patient #1's changing skin care needs.

Patient #1 is a 21-year-old female who presented via ambulance to the emergency department (ED) on 9/19/2009. Patient #1 was in respiratory distress with a significant amount of shortness of breath and confusion. Patient #1 has a history of cerebral palsy (CP), spasticity and seizure disorder. She has an extensive surgical history including Harrington rods placed in her spine, a left hip replacement, and femur fracture repair x 2 on the left side. Patient #1 has a PEG tube placement, hip tendon releases, hamstring releases, adductor releases x 2, bunionectomies, and fusion of her toes.

Patient #1 presented with multiple flexion contractures of both arms and legs, with numerous surgical scars from her procedures. Additionally, patient #1 has a history of pneumonia. Patient #1 is non-verbal and has an allergy to penicillin with a rash reaction. Home medications were valium 10 mg daily, motrin 200 mg as needed, Benadryl 50 mg at bedtime, and pepcid liquid 0.5 mg daily. All medications are given via PEG tube. Patient #1 lives at home with her mother.

Vitals on admission include a blood pressure of 100/60, pulse of 120, respirations of 21 and temperature 99.1. Labs revealed a glucose of 144, BUN of 19, creatinine of 0.4 and normal electrolytes. Her white blood count was 16.8, hemoglobin12.9, and urinalysis was positive for blood with 0-4 white blood cells. A chest x-ray showed no obvious infiltrate. Patient #1 was admitted with diagnoses of Shortness of Breath and Acute Respiratory Failure.

Patient #1 had a complex course of treatment over three months. Hospital staff had difficulty maintaining her airway. Patient #1 was placed on a ventilator, and then given a tracheotomy. Multiple trach collars were tried due to patient #1 hyper-extending her neck at times with subsequent collapse of the airway.

Patient #1 had multiple surgeries due to feeding tube placements/revision, peritonitis, and the development of multiple antibiotic-resistant organisms in sputum, wound and urine cultures.

Patient #1's nutrition was compromised in part due to, high residuals from an existing gastrostomy feeding tube (G-tube), and subsequent placement of a Jejunostomy tube (J-tube) requiring NPO (nothing by mouth) status for up to 5 days. Subsequently, the J-tube leaked, and she developed of peritonitis, ileus and required a subsequent revision of the J-tube. The Dietician followed patient #1 closely and was able to assist in normalizing her pre-albumin by 11/4/2009. However, through all, patient #1 did lose 17 pounds and was approximately 40 lbs on discharge of 12/3/2009.


Patient #1's initial skin assessment revealed no skin lesions. A Norton Scale for Risk of Decubitus (where a score less than 12 is high risk) was completed. Patient #1 scored an 11 on the scale. Nursing initiated a Skin integrity intervention to patient #1's care plan which included interventions such as a soft air mattress, turning every 2 hours and a 30 degree elevation to the head of the bed. A documented goal of 9/28 states "Remain wound free." This goal remained unchanged for the remainder of patient #1's discharge on 12/3/2010 despite the progression of a sacral decubitus to stage IV.

Beginning 9/21, nursing noted a reddened sacrum. RN turning documentation reveals variances from the standard of care for every 2-hour turning as follows with correlating skin assessments.

9/19 1315 - 9/20 at 0000 11 hours back
9/21 2000 Nursing assessment notes "Sacrum red"
9/22 2018 Nursing assessment notes "Bony prominences pink"
9/23 0559 - 9/23 at 2000 14 hours back
9/23 0431 Nursing assessment notes "Coccyx reddened - Transfer to PCU"
9/24 0429 - 0800 4 hours back
9/24 2200 - 9/25 at 0800 10 hours back
9/26 0800 - 9/26 at 1400 6 hours back
9/28 0800 through 9/29 Nursing assessments notes "Red area to bony prominence of sacrum"
10/1 1357 - 1830 4.5 hours back - Nursing assessment states "Rotation bed begins 0800"
10/3 2000 - Nursing assessment states "Sacrum with dsg intact - skin pale color"
10/5 0800 - Nursing assessment states "Pale, Rt buttock crease red small open area"
10/7 0800 - Nursing assessment states "Open area to bony prominence of sacrum, allevyn dsg D/I (dry, intact)"
10/11 0800 - Sacral/buttocks open areas x 2 OTA (open to air)

While the hospital had no wound nurse at the time, no other consistent oversight of patient #1's wound and staging is noted. As patient #1's pressure ulcer progressed, the nursing treatment consisted of barrier cream, allevyn dressings (cushioned dressing) and starting 10/1, a rotation mattress while in the ICU. By 10/30, the pressure ulcer had progressed to a stage III, evidenced by necrotic tissue. However, the nursing assessment identifies only a stage II. A nursing assessment of 12/2 at 8 pm states in part, "Sacral dressing clean dry and intact with Allevyn dsg. overtop of Santyl cream. Decub. is quarter-size and stage 4 to the bone." In contrast to the 12/2 stage IV sacral pressure ulcer assessment, are nursing skin assessments of 12/3, the day of discharge. RN assessments on 12/3 document a stage II sacral pressure ulcer. These assessments indicate disparities in RN pressure ulcer assessment skills, and inaccuracies in the actual patient skin status.

Though patient #1 had necrotic tissue (stage III) on 10/30, no nursing note documents that a physician was informed. Further, no physician notes addressing patient #1's pressure ulcer are found until 11/20/2009 (21 days later), when a surgical consult was ordered and completed. The surgical consult revealed in part that patient #1 was not a flap candidate, and that due to patient #1's nutritional condition, and that enzymatic debridement would be used. An order for Santyl was written for debridement. Patient #1 continued on Santyl, and was seen twice more by the surgeon who documented no change of the wound as of his last consult on 12/1/2009. Patient #1 was discharged on 12/3/2009.

On the 12/3/2009 discharge to home, patient #1 became very agitated. Her mother noted some trach sutures were broken and patient #1 was desaturating into the high 70s. EMS were called who suctioned patient #1 for a large mucous plug. She was taken back to the hospital were a chest x-ray and labs were completed. A decision was made to transfer patient #1 to an out-of-state children's hospital. Her admitting diagnoses of 12/3/2009 at that hospital was Stage 4 sacral pressure ulcer, Sacral Osteomyelitis, Abdominal wound dehiscence, Severe nutritional deficiency/underweight. Patient #1 weighed 40 lbs. (a loss of 10 pounds from an August 2009 visit to the children's hospital). In addition, patient #1 was febrile at 38.0.

Patient #1 was found to have a urinary tract infection with pan-resistant Klebsiella and Pseudomonas. Klebsiella and Candida were found in the sacral wound.

A wound care note states in part, "Assessed ___wound with ___ and Dr. __ of infectious disease. Sacral wound culture obtained ....overall condition is poor with stage IV sacral wound, stage I right trochanter wound, healed stage II or III left groin wound and dehisced abdominal wound. Patient appears emaciated with virtually no body fat visible. Clinitron Rite Hite air fluidization bed ordered and delivered to patient ' s room. Will place her once she returns from having G-tube changed to G/J tube." The sacral wound assessment noted a 1.5 cm round/oval wound with a depth of 0.4 cm with tunneling of 1.6 at greatest depth, and "Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures." Patient #1 was successfully treated for her wounds and discharged on 2/3/2010.

Patient #1 had multiple comorbidities. However, she entered into care with no decubitus wounds. Initially, hospital nursing failed to provide every-two-hour-turning per policy and standard of care, then failed to provide consistent oversight of patient #1's changing skin condition, and failed to inform a physician of patient #1's changing skin care needs, contributing to the development of a stage IV decubitus.