HospitalInspections.org

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Based on record review, policy review, and staff interview, the facility failed to ensure that there was a mechanism in place to meet the patient's need for obtaining a Wound Care Consultation when the Wound Care Nurse Consultant was not available in one (1) of five (5) records reviewed (Patient #7).

Findings:

Review of the Medical Record for Patient #17 revealed that the patient presented to the Emergency Department on 11/24/14 from a group home with a chief complaint of Altered Mental Status. Patient #17 had a history of Mental Disability, Asthma, Obesity, Hypertension, and Bipolar Affective Disorder. While hospitalized, the patient developed Respiratory Failure, which required mechanical respiratory ventilation, and eventual Percutaneous Endoscopic Gastric (PEG) tube placement on 01/14/15 and tracheostomy insertion on 01/20/15.

During the initial ED presentation and admission on 11/24/14, Patient #17 was noted to have no skin breakdown or Pressure Ulcers. On 12/05/14, the patient was noted to have a right-hand skin tear, identified as Wound #1, on the Daily Nursing Flow Sheets. On 12/23/14 at 10:47AM, Patient #17 was noted to have a "Stage II pressure ulcer on the right buttock".

On 01/01/15 at 11:00AM the patient was documented to have Wound #1 (right hand skin tear) with Pressure Ulcer #1 (Right buttocks Stage II 2 x 3cm); Pressure Ulcer #2 (Left upper buttocks Stage II); Pressure Ulcer #3 (Left buttocks Stage II) and Pressure Ulcer #4 (Shearing injury to left inner thigh).

A "Wound Care Nurse Consultation" was ordered on 01/01/15 at 4:20PM. The reason for the consult was described as, "Pressure Ulcer; Location: Upper Buttocks". Additional information stated, "patient has upper right and left buttock pressure injury, appears as Stage II. Also has friction rub/shearing injury on left inner thigh ... House (group home) staff is requesting and extremely concerned. Patient has been bed bound for six weeks while hospitalized."

On 01/06/15 the Wound Care Consult was not yet completed, and the patient's Physician requested a Wound Center Consult for thigh and sacral wounds, which was performed on 01/06/15 at 2:30PM by the Wound Care Center Surgeon.

Interviews with Staff Members #1 and #2 on 04/17/15 at 10:55AM, revealed that the Wound Care Nurse did not evaluate/consult with this patient until 01/27/15 at 5:46AM. When asked why the delay in evaluation, Staff Member #1 stated that she was on vacation and did not return until that time. She explained that when Nurses enter an Order for a Wound Care Consult electronically, they are encouraged, although not required by Policy, to also place a phone call to the Wound Care Nurse. Staff Member #1 added, had they done this, they would have received her voicemail informing them she is away and is not available for consults.

Staff Member #1 stated that although the Wound Center Surgeons also receive consult requests, they do not receive them electronically, and those consults are usually verbally requested by a Physician to a Physician. She stated that the Skin Care Champions available on each Unit serve as a resource to the Nursing Staff but cannot provide consult-type services in her absence. Staff Member #1 stated there really isn't a defined process to cover the Wound Care Consults in her absence.

The tool titled "Pressure Ulcer Documentation in the EMR (Electronic Medical Record)" requires that the Nurse electronically order a "Wound Care Nurse Consultation" for Pressure Ulcers Stage III or greater but does not require the Nursing Staff to call the Wound Care Nurse Consultant and does not include a procedure to ensure the Consult Order was received or performed.
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Based on record review and interview, the facility failed to ensure that the Nurses consistently and accurately documented the description of the patients' Pressure Ulcers during the patients' hospital stay in two (2) of six (6) records reviewed (Patients #17 and #27).

Findings:

Medical Record review revealed that Patient #27 was admitted on 04/06/15 with Altered Mental Status and a history of Left-Sided Pneumonia, Myocardial Infarction, Hypertension and Below the Knee Amputations Bilaterally. The patient was documented to have a Sacral Pressure Ulcer upon admission.

A review of the Electronic Medical Record "Patient Flow Sheets" Section that provides documentation of the wound size, stage, and area on the patient, revealed that there was inconsistent documentation as follows:

Record review revealed that the patient was admitted on 04/06/15 and that there is no evidence of any initial measurements of the Sacral Ulcer upon admission.

There is no evidence of documentation of the wound on Wednesday 04/08/15.

The first documented measurement of a wound was on Thursday 04/09/15 at 1:29AM. The wound was described as a Stage II on the Coccyx with a measurement of length 1 centimeter (cm) and width of 0.5cm.

On 04/09/15 at 9:34AM the measurement of the Coccyx Stage II was documented as length, 1cm by width, 1 centimeter.

On 04/11/15 at 9:00AM the Ulcer was documented as a Coccyx Stage I.

On 04/12/15 at 7:25PM the Ulcer was documented as Buttock/Coccyx Stage II.

On 04/15/15 at 9:15PM two (2) Ulcers were documented as Left and Right Buttocks Stage II with only one (1) measurement of length, 2cm and no width measurement.

An interview with Staff #9 on 04/16/15 at 10:30AM revealed that measurements are to be completed every Wednesday and that each wound should have a length and width measurement.

Staff Members #3 and #6 were present upon review of the chart and agreed that there were inconsistencies in documentation of the Skin Pressure Ulcer as noted above.

Medical Record review revealed that Patient #17 presented to the Emergency Department on 11/24/14 with a chief complaint of Altered Mental Status, and a history of Mental Disability, Asthma, Obesity, Hypertension, and Bipolar Affective Disorder.

On 12/23/14 at 10:47AM, Patient #17 was noted to have one (1) "Stage II pressure ulcer on the right buttock" on the Nursing Skin Assessment Flow Sheet with no Pressure Ulcer measurements documented.

On 12/28/14 at 5:17PM Patient #17 had a description for Wound #1 on the Nursing Skin Assessment Flow Sheet of "epithelialization and granulation without eschar or slough underneath Right Leg". Wound #1 had previously been identified as a Right-Hand Skin Tear on 12/28/14 at 1:05AM, and again on 12/29/14 at 1:39AM.

On 12/29/14 at 9:42AM Patient #17 was documented as having, "skin intact" by the Dietitian.

On 12/30/14 at 6:43PM Patient #17 was noted to have, "Skin within defined limits (WDL) without pressure ulcers" on the Nursing Skin Assessment Flow Sheet despite the documented Pressure Ulcer noted on 12/23/14.

On 01/01/15 at 4:50AM the patient was noted to have "Skin WDL" on the Nursing Skin Assessment Flow Sheet. However, at 11:00AM on 01/01/15, the patient was noted to have Wound #1 (Right-hand skin tear) and Pressure Ulcer #1 (Right buttocks Stage II 2x3cm); Pressure Ulcer #2 (Left upper buttocks Stage II); Pressure Ulcer #3 (Left buttocks Stage II) and Pressure Ulcer #4 (Shearing injury to left inner thigh).

On 01/02/15 at 1:27AM Patient #17 was noted as having "Skin WDL and no pressure ulcers" on the Nursing Skin Assessments/Flow Sheets.

During interviews with Staff Members #1 and #2 on 04/17/15 at 10:55AM, the staff members agreed with findings.

The Policy titled "Pressure Ulcer: Prevention, Assessment and Management" dated May 2013, documents the definitions of a Pressure Ulcer and reviews the Classification System. This Policy indicates to "assess and inspect skin daily and as indicated by patient's condition". The Nurse is directed to document the Pressure Ulcer Assessment and monitor them on admission to the health care setting, at minimum weekly, and with any signs of skin/wound deterioration. Under Documentation, the Policy states that "all prevention, assessment and management strategies are to be documented in the patient's Medical Record".

The tool titled "Pressure Ulcer Documentation in the EMR (Electronic Medical Record)", indicated that the following areas must be addressed:

Location/Stage
Dressing Appearance
Length in cm/Width in cm
Wound Depth, etc.

It further advises that there should be a weekly assessment which must include updated measurements and assessment of the appearance of the wound as well as the Stage. The Wound Bundle should be completed with the shift assessment.

The North Shore-LIJ Health System Pressure Ulcer Performance Measurements in the Pressure Ulcer Prevention Tool Kit documents that "Registered Nurses are responsible for assessing patient on admission and each shift. If a patient has pressure ulcer(s), the nurse does a complete wound assessment when a pressure ulcer is first identified, weekly, as condition of pressure ulcer changes, and when a patient with a pressure ulcer is transferred from another unit. The electronic medical record documentation is done on the Patient Profile and the Assessment and Intervention Flow Sheets.