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Based on review of the medical record and staff interviews, the Hospital failed to ensure that one of one applicable Patients, Patient #1 was closely monitored to prevent the development of multiple pressures ulcers on the right foot. A Controlled Ankle Movement (CAM) walking boot was applied because of a non-displaced fracture on 01/09/12. There was no evidence that the walking boot was removed to assess Patient #1's skin for five days between the dates of 01/09/12 to 01/14/12 by either the orthopedic physician assistants, the nursing staff or the physical therapist after Patient #1 complained of continued right foot pain. Patient #1 developed multiple pressure ulcers as a result of wearing the CAM boot for 5 continuous days.

Findings include:

Background Information:
Review of the Emergency Department (ED) Medical Record dated 01/07/12 indicated that Patient #1 complained of feeling dizzy and fell. Patient #1 was not able to stand secondary to right leg and ankle pain. Patient #1 was admitted to a Telemetry Unit for cardiac monitoring. The ED Attending Physician indicated that Patient #1 had a ankle sprain. However, a Computerized Tomography (CT) of the right ankle indicated Patient #1 had a non-displaced fracture of the right ankle. An ace bandage was applied to the right ankle.

The Director of Quality and Patient Safety accompanied the Surveyor on two days of survey and the Hospital's Risk Manager was interviewed in person on 02/22/12 from 11:20 A.M. to 12:00 P.M. Both said that Patient #1 continued with hemodialysis three times a week while hospitalized. Both said Patient #1 experienced some confusion following each dialysis treatment on return to the inpatient unit. Both said that on 01/09/12, Patient #1 had the CAM boot applied by an outside vendor, the Ortotist. Both said that the Ortotist gave instructions and literature to Patient #1, but the information was not added to Patient #1's plan of care.

Review of the manufacturer's literature provided by the Hospital for the Controlled Ankle Movement (CAM) walking boot indicated the ankle hinge of a CAM walking boot adjusts to allow as much or as little movement as the treating orthopedist, physical therapist or orthotic feels is appropriate to the patients condition. Patients were instructed not to change the settings, but to report any discomfort and ask for professional adjustment. The literature indicated that the patient was to follow instructions, particularly to remove the CAM for sleep and bathing. Patients were instructed to frequently inspect the skin covered by the CAM boot frequently for signs for pressure or irritation.

Review of the Physical Therapy Evaluation dated 01/10/12 indicated that Physical Therapist #1 documented that the right lower ankle was not evaluated because the CAM boot was on.

The Physical Therapist failed to adequately assess Patient #1's right foot because she never removed the CAM boot to assess the foot.

Review of the Nurses Note dated 01/14/12 indicated that Patient #1 had a necrotic area on the right foot.

Review of the Physician Orders dated 01/14/12 indicated that the Hospitalist ordered a consultation with the Wound Nurse.

The Wound Nurse was interviewed on 02/22/12 from 1:25 P.M. to 2:00 P.M. The Wound Nurse said she reviewed the other consultations for Patient #1, but did not conduct an assessment. The Wound Nurse failed to conduct as assessment following an ordered consultation by a physician.

Review of the medical record indicated that the Physician's Assistant, Physical Therapist, Wound Nurse and the nursing staff failed to adequately assess Patient #1 for the complaint of pain in the right foot.

Patient #1 developed multiple pressure ulcers as a result of wearing the CAM boot for 5 continuous days.

Refer to A-0347, A-0353, A-0395 and A-0396.

Based on medical record review, physician and physician assistant interview, the orthopedic services failed to evaluate one of one Patients, Patient #1 who developed pressure ulcers beneath a CAM walking boot. The CAM boot remained on for five days from 01/09/12 to 01/14/12.

Findings include:

Review of the History and Physical ( H & P) Examination dated 01/07/12 indicated that Patient #1 had cardiac disease, rheumatoid arthritis, diabetes mellitus with neuropathy (loss of sensation of the lower extremities) and end stage renal disease requiring hemodialysis. However, the H & P lacked documentation that Patient #1 had a history of peripheral vascular/arterial disease with a fifth digit amputation on the left foot secondary to ischemia.

Review of the Physician's Orders dated 01/08/12 indicated that a Physician's Assistant (PA) ordered that Patient #1 wear a CAM/tall walking boot, apply an ace bandage and to elevate the right foot. There were no orders for the management of Patient #1's CAM boot, which included data for the removal of the boot for circulation check, skin inspection, washing and to remove the boot while sleeping.

Review of the Physician's Orders dated 01/11/12 at 2 P.M. indicated that the Orthopedic Service was called for another consultation. The Hospitalist ordered an orthopedic consultation regarding Patient #1's complaint of severe intractable pain in the right ankle.

Review of Physician's Assistant (PA) #1 Progress Note dated 01/11/12 indicated Patient #1 was seen for the evaluation of right knee pain, which was a new complaint. However, PA #1 indicated that pain in the right ankle was tolerable at the time of the evaluation.

PA #1 was interviewed in person on 02/27/12 from 8:40 A.M. to 8:50 A.M. PA #1 said he evaluated Patient #1 on 01/11/12 at 4 P.M. after dialysis. PA #1 said the orthopedic consultation was for a complaint of right ankle pain. However, Patient #1's complaint was pain in the right knee. PA #1 did not remove the CAM boot, nor did he review the consultation note written by the Hospitalist. PA #1 said the walking boot should be removed when the patient is in bed. PA #1 was not aware that the boot was kept on Patient #1 continuously for 5 days. PA #1 failed to evaluate Patient #1's foot according to the requested consultation.

Review of the Vascular Consultation dated 01/14/12 indicated that after removal of the CAM boot, there were three pressure ulcers noted: a linear 2 x 8 centimeter area of ecchymosis on the lateral aspect of the foot, a slightly discolored stage one (reddened area)pressure ulcer on the dorsum of the foot and a Stage 2 (partial thickness loss which may be intact, open or present as a blister) pressure ulcer at the lateral malleolus with dark eschar and Stage one pressure ulcer on the medial malleolus. The right foot was warm with no palpable pulses. The Vascular Surgeon indicated that the ischemic changes to the right foot were a result of consistent pressure from the compression boot.

Review of the medical record indicated that Patient #1 complained of pain in the right ankle after the application of a CAM walking boot and was not evaluated by the PA's for the condition of Patient #1's skin beneath the CAM boot for five days.

Refer to A-0144 and A-0353.

Based on medical record review and interview with physicians and the physician assistants indicated that the Hospital failed to ensure that the orthopedic supervising physician reviewed the care and co-signed the physician assistant progress notes, as outlined in the By-Laws and Delineation of Privileges for one of one applicable Patients, Patient #1 in January 2012.

Findings include:

Medical record review indicated that there was no documentation that the orthopedic service supervising physician reviewed the PA's treatment plan for Patient #1.

Medical record review indicated that there was no documentation that the PA's contacted the supervising physician for Patient #1's a new complaint of right knee pain. There was no documentation that the PA notified the supervising physician of a new consultation request by the Hospitalist for Patient #1's complaint of intractable right ankle pain on 01/11/12. PA #1 did not remove the CAM boot and evaluate the condition of Patient #1's right foot.

Review of the Progress/Consultation Notes by the PA on 01/11/12, 01/12/12, 01/13/12 and 01/14/12 indicated that there were no co-signatures by the supervising physician within 24 hours as outlined in the Delineation of Privileges for PA's in the Medical Staff By-Laws.

The medical staff failed to adequately coordinate the orthopedic needs and services provided to Patient #1 to prevent the development of pressure ulcers following the application of a CAM boot.

There was no documentation that the supervising physician of the orthopedic service evaluated Patient #1 after the application of the CAM/walking boot.

Based on record review and staff interview, the registered nurse failed to evaluate the care provided to one of one applicable Patients, Patient #1, and implement appropriate nursing measures to prevent the development of pressure ulcers on the right foot following a fracture.

Findings include.

Refer to A-0144 and A-396.

Review of the manufacturer's literature provided by the Hospital for the Controlled Ankle Movement (CAM) walking boot indicated the ankle hinge of a CAM walking boot adjusts to allow as much or as little movement as the treating orthopedist, physical therapist or orthotist feels is appropriate to the patients condition. Patients were instructed not to change the settings, but to report any discomfort and ask for professional adjustment. The literature indicated that the patient was to follow the professional instructions, especially for removal of the CAM for sleep and bathing. Patients were instructed to inspect the skin covered by the CAM boot frequently for signs for pressure or irritation.

Review of the Nursing Interventions and Assessments between the dates of 01/09/12 to 01/13/12 did not include any documentation that Patient #1 was in an ortotic device/ CAM boot. There was no documentation that Patient #1's right foot was assessed for skin irritation or skin breakdown. There was no documentation in the nursing assessments that Patient #1 had an amputated fifth digit on the left foot. There was no documentation that the CAM walking boot was removed during that time frame to assess Patient #1's skin.

RN #1 was interviewed in person on 02/22/12 from 1 P.M. to 1:20 P.M. RN #2 was interviewed on 02/27/12 from 9:00 A. M to 9:30 A.M. RN #1 said Patient #1 was screaming and complaining of right ankle pain. Both said on 01/13/12, Patient #1's CAM boot was removed from the right foot, but the ace bandage was not removed to properly assess the skin condition of the right foot.

The nursing staff failed to adequately assess Patient #1 for the complaint of pain in the right foot. The nursing staff failed to adequately assess Patient #1's skin on the right foot. Instead, both RN #1 and RN #2 said they never removed the ace bandage because the application of the ace bandage looked as though it was professionally applied. Both said that they did not routinely care for orthopedic patients on the telemetry unit and were unfamiliar with the management of a patient who was in a CAM walking boot.

RN #2 said she removed both the CAM boot and ace bandage on 01/14/12 and observed a necrotic area on the right foot. RN #2 said she did not put the CAM boot back on.

The nursing staff failed to develop a nursing care plan and obtain orders for the management of a CAM/walking boot.

Based on medical record review and staff interview, the nursing staff failed to develop, implement and revise an individualized plan of care for one of one applicable Patients, Patient #1, that developed multiple pressure ulcers beneath a CAM/walking boot in January 2012.

Findings include:

Refer to A-0144 and A-0395.

Review of the Hospital's Policy for Diabetic Foot Care indicated that the purpose of the policy was to provide basic guidelines for the proper care of the diabetic. The Policy indicated patients with diabetes were at a higher risk for foot problems. Diabetic patients may experience sensitivity to heat, cold and may have numbness or increased pain in their feet. These changes can lead to an increased rate of neuropathy, slow healing of cuts, foot ulcers and infection.

Review of the Nursing Plan of Care indicated that Patient #1 had significant mobility limitations, sensory deficits, lack of knowledge of environmental hazards and safety precautions.

The nursing staff failed to develop, implement and revise an appropriate plan of care for Patient #1 who sustained a fracture and required the application of a CAM/walking boot. As a result, Patient #1 developed multiple pressure ulcers on the right foot.