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Based on review and interviews, it was determined that the hospital failed to allow one (#3) of ten (#1-#10) clinical records to participate in planning for admission to the hospital, plan to obtain an alternating pressure bed to prevent bed ulcers and failed to adequately turn Patient #3 which resulted in an Unstageable Hospital Acquired Pressure Ulcer.

The findings included:

Patient #3's (Clinical record #3) was admitted to Emergency Room on 11/7/12, from the EMS with a complaint of right shoulder pain after an unwitnessed ground floor fall. Patient #3 was oriented to the President, but not the year. The radiology report, dated 11/7/12, stated, under impression, "Comminuted fracture (A fracture with several breaks in the bone.) surgical neck of the humerus (the largest bone of the upper arm)". The plan was to place in a swing and to follow up with Orthopedics.

The Complaint allegation stated that the Complainant requested an urinalysis for Patient #3. During interview, Staff #12 stated that she/he consulted with Staff #6 who stated that no urinalysis was warranted at that time, on 11/7/12, prior to discharge from the Emergency Room. Staff #12 had no recollection of informing the Complaint of the decision by Staff #6. Staff #6 failed to allow the Complainant to participate with the planning of care for Patient #3. The failure of Staff #6 to convey the outcome to the Complainant and allowing a discussion with Staff #6 resulted in the return of Patient #3 to the ER with a diagnosis of a Urinary Tract infection.

Patient #3 was admitted to the hospital on 11/08/12. A staff member indicated in a skilled note dated 11/12/12, at 10:12 AM, "Will evaluate need for speciality bed." Patient #3 failed to obtain the speciality bed until 11/15/12, at 21:06 (9:06 PM). The policy under Specialty Beds stated, "Standard hospital bed has no features that prevent or treat pressure ulcers." Staff member #14 stated during interview, that it should take about four hours to obtain a speciality bed. This interview occurred on 01/16/13, at 11:15 AM. The unit staff failed to allow the Complainant to participate in obtaining a speciality bed for Patient #3, until three days had passed.

Based on review of quality indicators, staff interviews, and complaint review, the facility staff failed to have a complete evaluation of each patient that was effected by processes of care. Review of the data base of adverse events related to hospital acquired pressure sores was found to be incomplete for one patient. (Patient #3)

The findings include:

On 1/15/2013 9:30 a.m. at entrance conference, a list of adverse events related to the complaint issues was requested. In the list of adverse events, the patients that had hospital acquired pressure sores was not complete. Patient #1 was not listed, and thus review of the patient care data for potential reasons for lack of care processes and preventative care was delayed.

Review of complaint materials and the medical record for Patient #1 documented a hospital acquired pressure sore that delayed his treatment and hospital stay. Patient #1 had a history of diabetes mellitus, a fracture of the right humerus, and coronary artery disease. The patient was bed ridden. Nursing care measures of turning and repositioning, specialized mattress, and the services of the wound care specialist were not quickly acted upon, which caused him to develop a decubitus ulcer in the coccyx area.

On 1/16/13 at 11:40 a.m., the Director of Quality Management was interviewed regarding how the hospital reviews adverse events. She stated these events are forwarded from the various departments through the supervisors/nursing administration to the Risk Manager. The Risk Manager works closely with Quality Management. These events are put onto reports for the Quality Improvement Committee to look for causal factors, trends, and potential lack of quality of care. The Patient Advocate is the first line communication with patients and families. Complaints will go to the manager of the nursing unit and then forwarded to Quality Management and placed into the agenda of the committee if it meets the definition as an adverse event.

The Director of Quality Management went on to say that she does not know how Patient #1 fell through the cracks, why his case was not reviewed, or listed on the adverse events section under Hospital Acquired Pressure Ulcers (HAPU). She acknowledged the patient was overlooked, and when a complaint came in from the Patient Advocate the committee investigated the case thoroughly.

The Director stated the Grievance Committee recently met on this case. She said the committee felt there was a lack of the usual chain of communication. She was also concerned that Patient #1's family request for a special mattress was not acted upon.

Based on reviews and interviews, it was determined that the skilled nurses failed to prevent one (#3) Hospital Acquired Pressure Ulcer, failed to turn every two hours, failed to provide medication to control diarrhea and failed to obtain a speciality bed of ten (#1-#10) clinical records reviewed.

The findings included:

Patient #3's (Clinical record #3) was admitted to Emergency Room on 11/7/12, from the EMS with a complaint of right shoulder pain after an unwitnessed ground floor fall. Patient #3 was oriented to the President, but not the year. The radiology report, dated 11/7/12, stated, under impression, "Comminuted fracture (A fracture with several breaks in the bone.) surgical neck of the humerus (the largest bone of the upper arm)". The plan was to place in a swing and to follow up with Orthopedics. A 24 hours return to the Emergency Room, by EMS resulted in Patient #3 being admitted to the hospital.

A hospital admission occurred for Patient #3 on 11/08/12. A staff member indicated in a skilled note dated 11/12/12, at 10:12 AM, "Will evaluate need for speciality bed." Patient #3 failed to obtain the speciality bed until 11/15/12, at 21:06 (9:06 PM). The policy under Specialty Beds stated, "Standard hospital bed has no features that prevent or treat pressure ulcers." Staff member #14 stated during interview, that it should take about four hours to obtain a speciality bed. This interview occurred on 01/16/13, at 11:15 AM. The unit staff failed to allow the Complainant to participate in obtaining a speciality bed for Patient #3, until three days had passed.

A physician's order was written on 11/11/12, to turn Patient #3 every two hours. Skilled Nurses noted documented that Patient on 11/11/12, at 21:00 (9 PM), Patient #3 was turned to the right side. Almost eight hours later, Patient #3 was turned to the left side, on 11/12/12, at 0456 AM . On 11/12/12, at 07:54 AM, the Patient Mobility Team (A contractor assigned to turn patient identified every two hours), without documenting why. Turned to the left side at 11/12/12, at 22:25 (10:25 p.m.) was documented in the skilled nursing notes. The skilled nursed failed to follow the physicians' order to turn Patient #3 every two hours resulting in a Hospital Acquired Pressure Ulcer ( A bedsore.)

Patient #3, on 11/15/12, at 16:55 , in the skilled nursing notes stated, "A deep tissue indication was noted to the left buttock, that has opened and now appears to be an unstageable pressure ulcer, with red-pink unblanchable skin. There are areas of sloughing purplish/black tissue to the edges of this wound also. Patient (#3) also has incontinent dermatitis close to this area along each inner buttock. Wounds were cleansed with and white zinc cream to the Incontinent Dermatitis and a foam dressing. Xenaderm cream to left buttock bid (Twice daily) along with a speciality mattress. The Complaint requested the specialty mattress on 11/12/12, at 10:12 AM, as documented by the skilled nursing notes. Skilled nursing notes documented the transfer to a speciality bed on 11/15/12, at 21:06 (9:06 PM). The urgent priority of not obtaining a speciality bed contributed to acquiring a pressure ulcer.

An Emergency Room visit happened was on 11/7/12, 2012 covered with stool stated Staff #14, during interview on 01/16/13, at 1:05 PM. The Wound Care Nurse noted in her skilled notes dated 11/30/12, at 11:44 AM, "I removed soiled dressing and cleaned patient's (#3) peri-wound skin of stool with skin barrier wipes ... Staff nurse reminded that patient (#3) has Immodium (Anti diarrhea drug) ordered PRN (As needed) and to please give it to him. The healing process will be greatly expedited without the constant stool." The Registered Nurse fails to assess and develop a care to control Patient #3's diarrhea, which contributed to the pressure ulcer's healing process.

Upon Admission Patient #3's initial nursing assessment stated that no pressure ulcers were present. On 11/12/12, a generic notes was added by the Wound Care Team to be on the look out for pressure ulcers because the skilled nurses had assessed the Braden Scale to be at or equal to 14 (A Braden Scale is utilized for prescribing for pressure sore risk). " Per the Skin Integrity Policy: Responsible for implementing the bed policy for Patients with a Braden score of 18 or less." The skilled nurses failed to implement it's policy for Patient #3.

The Wound Nurse noted on 11/23/12, that the sacral/buttocks wound was markedly improved with some tan slough in the middle wound. Seven (length) by 6.5 (width) by zero depth in centimeters were documented as measurements on 11/28 12. This note stated, "It was impossible to get an occlusive seal next to the anus. Santyl needs to rid the wound of the slough, and this will not happen if the patient (#3) is constantly soiling the wound/dressing. " December 4, 2012 wound care note stated that the left buttock pressure ulcer is still covered with slough and unstageable and the pressure ulcer was connected to a lot of incontinent dermatitis. Prior discharge, the on 12/10/12 to a skilled nursing facility, the wound care note stated that the area of slough where the pressure ulcer is located on the left buttocks still contain a thin layer of slough. The skilled nurses failed to assess and prevent a pressure ulcer for Patient #3.

Staff #14 verified during interview that the pressure ulcer on the left buttocks for Patient #3 was a hospital acquired pressure ulcer. This interview occurred in the office on 01/16/13, at 11:45 AM.


Staff #9 verified during interview that Skilled Nursing Services on the unit left opportune to improve. A plan of action was being imitated. This interview occurred on 1/16/13, at 14:00 PM.