HospitalInspections.org

Based on interview and document review the facility failed to ensure a wound care assessment was completed per hospital policy and failed to ensure the plan of care was updated for patients with and at risk for altered skin integrity for nine (#1,#3,#4,#11,#13,#14,#15,#16,and #17) of 13 patient records reviewed for altered skin integrity/wound care, resulting in the potential to neglect all patients with compromised skin integrity regarding the care of the skin or wounds.


Findings include:
---the facility failed to ensure a wound care assessment was completed per hospital policy for patients with and at risk for altered skin integrity (See A-395)
---the facility failed to ensure the plan of care was updated for patients with and at risk for altered skin integrity (See A-396)

Based on interview and document review the facility failed to ensure a wound care assessment was completed per hospital policy for patients with and at risk for altered skin integrity for nine (#1,#3,#4,#11,#13,#14,#15,#16,and #17) of 13 patient records reviewed for altered skin integrity/wound care, resulting in the potential to neglect all patients with compromised skin integrity regarding the care of the skin or wounds. Findings include:

On 8/25/2017 during observational tour of the Intensive care unit (ICU) patient #4's wife was interviewed at approximately 1145 related to the care of her husband who was incapable of being interviewed because of an extensive cerebral vascular accident (CVA-stroke). She reported her husband had a decubitus ulcer on his coccyx (tailbone area). She reported that the wound has been cared for but did not know if a wound care nurse had been in to evaluate the wound. After completing the interview the medical record was reviewed at the nursing station at approximately 1200. The wound care orders were written by the physician on 8/27/2017 at 2336 that included an order for the wound to be assessed by the wound care team. The wound was assessed on admission 8/27/2017 by the ICU Registered Nurse (RN.) No note could be found documenting assessment of the wound by the wound care team or recommendations for care, cleansing, or frequency of dressing changes. Staff G was asked to assist in the location of the documentation, she stated "I can't find the assessment by the wound care Nurse, that is who does the assessment."

On 8/29/2017 at 1054, review of Patient #11's medical record revealed he was an 81 year old male admitted on 8/22/2017 with a diagnosis of encephalopathy with altered level of consciousness. Upon admission patient #11 was assessed for risk of developing pressure sore using the Braden Scale. Patient #11 scored a 12 out of a possible 23 indicating the patient was at High Risk for developing pressure sores. There was no evidence in the medical record the patient had received a skin/wound care assessment by the wound care team and/or recommendation for care.

On 8/30/2017 at 0846, review of Patient #13's medical record revealed she was a 58 year old female admitted on 8/22/2017 with a diagnosis of septic shock, acute kidney injury, and metabolic encephalopathy. Upon admission, Patient #13 was assessed for risk of developing pressure sores using the Braden Scale. Patient #13 scored an 11 out of a possible 23 indicating that the patient was at high risk for developing pressure sores. There was no evidence in the medical record that the patient had received a skin/wound care assessment by the wound care team and/or recommendation for care.

On 8/26/2017 at 0900 the policy titled "Patient Care Services" dated revised on July 2014 was reviewed. On page 6 of 6 an algorithm outlines the expected steps to be taken related to the care of skin with altered integrity. The algorithm is broken into stages I, II, III, IV, and V. Each level has "Wound care team referral" as a step in the care to be ordered. The algorithm begins with statement "all patients with a Braden scale of 18 or less will be seen by the wound care team for care orders."

On 8/26/2017 at 1135 staff S Hospitalist was interviewed. He stated "All patients that are admitted with a decubitus are seen for consult with the wound care team."

On 8/26/2017 at 0900 during an interview with staff A the Chief Medical Officer he stated "Our inpatient wound care nurse resigned on July 7, 2017." He went on to explain that there has been no one in that role since. During the interview he was asked if the wound care nurse was an advanced practice nurse with privileges to write orders. He stated "No, it is just a regular nurse that makes recommendations to the physicians, who are then supposed to write the orders." He was asked who has been ordering care in the absence of the wound care nurse. He explained that the Physicians are responsible to write all of their own patients orders. He was also asked if all physicians and staff had been made aware of the vacancy of an in patient wound care nurse and that no assessments or recommendations could be done, he stated 'No, not a formal announcement."



36887

During an interview on 8/28/2017 at 1140, Patient #3 was queried as to the large gauze dressing on his right foot. He stated he was in the hospital for an infection of his right great toe. When queried about his care while in the hospital, he stated, "The nurses and assistants are great but there seems to be a huge lack of communication with different levels of service. It's very frustrating." Patient #3 was asked to elaborate on this statement to which he replied that he had been told multiple times he would "see someone from wound care which never happened." Patient #3 was further queried as to if his dressing had been changed and how often it was changed to which he stated it had been changed "at least once a day."

Review of Patient #3's electronic medical record with Staff AE on 8/29/2017 at 0922 revealed the patient had surgery on 8/2/2017 for a graft and fusion of his right great toe and was admitted to the hospital 8/26/2017 for possible osteomylitis. Physician orders dated 8/26/2017-8/28/2017 reveal no referral to wound care and there are no orders present for wound care or dressing changes from 8/26/2017-8/28/2017. These findings were confirmed by Staff AE on 8/29/2017 at 0930. Staff AE stated, "They should've had a doctor's order. This was a surgical wound."

Staff H was queried on 8/29/2017 at 1039 as to if wound care should have been consulted for a post surgical infection to which she replied, "The wound care nurse does not come in on the weekends...No one covers for them...The nurses should be paging the physicians on the weekends when the wound care nurse is not available."


27713

On 8/29/17 at 12:00 through 17:00, Patient #1's clinical record was reviewed with Staff AE, the Director of Patient Experience, and Staff G, the Director of Patient Care Services. Patient #1 was a 62 year old female who had multiple readmissions to the facility in 2017. Patient #1's was admitted to the facility on 4/26/17 through 4/28/17 for hip replacement surgery done on 4/26/17, and was subsequently readmitted to the facility multiple times for declining health status related to infection of the left hip surgical incision. A Braden Scale Skin Assessment dated 4/28/17 at 16:00 documented a score of 18/23. During a readmission from 5/11/17 at 10:04 through 5/17/17, a Braden Scale Skin Assessment dated 5/11/17 at 21:56 documented that the patient's Braden score was 16/23. On Patient #1's third admission from 5/19/17 at 22:49 through 5/24/17, an Admission Nursing Assessment, dated 5/20/17 at 01:00 noted that the Nursing Admission Braden Score was 16/23. During Patient #1's fourth admission to the facility, on 6/6/17 at 16:07 through 6/15/17, an Admission Nursing Assessment, dated 6/6/17 at 08:22 documented that Patient #1 was at increased risk for developing pressure scores with a Braden Score of 15/23. During Patient #1's sixth admission to the facility, 7/27/17 at 15:47 through 8/3/17, a Nursing Admission skin assessment on 7/27/17 at 16:47 documented a skin tear on the right upper extremity and a Stage II (superficial skin loss) pressure sore on the left posterior thigh, were present on admission. Admission Braden Scale score was 12/23. Documentation for a Wound Care Services Consultation was noted, but was not done. During Patient #1's seventh admission to the facility from 8/8/17 at 20:11 through 8/11/17, an Admission Nursing Skin Assessment dated 8/8/17 at 20:11 documented that Patient #1 was admitted with a left thigh wound (infected surgical wound), multiple Stage II pressure sores on the left thigh, a skin tear on the right arm, and bilateral Stage I (non-blanching redness with intact skin) pressure sores on her heels. No Wound Care Nurse Consultation was done for Patient #1 during any of her admissions. There were no written orders for dressing changes and wound cleansing of Patient #1's pressure sores or skin tear.

On 8/29/17 at 10:30, Patient #14's clinical record was reviewed with Staff AE and Staff H. Patient #14 was a 66 year old female with diagnoses including left upper extremity pain and left upper extremity deep vein thrombosis. Review of Physician's orders for Patient #14 revealed an order dated 8/28/17 at 12:38 for, "Consult Wound Care Nurse" for "left lower extremity (left leg) Cellulitis". Review of Patient #14's clinical record revealed no documentation that the Wound Care Nurse was consulted. When queried at this time, Staff H stated that the Ostomy Nurse was covering Wound Care Services until a new Wound Care Nurse was hired. On 8/28/17 at 10:50, the Ostomy Nurse, Staff AG was interviewed and stated, "I haven't actually seen any Wound Care Nurse referral patients yet. I've been too busy with the Ostomy clinic and training two new nurses." When queried, Staff H reported that patients were supposed to be seen by the Wound Care Nurse within 24 hours of a referral.

On 8/28/17 at 13:00, Patient #15's clinical record was reviewed with Staff AE. Patient #15 was a 69 year old female who was admitted to the facility on 8/22/17 with diagnoses that included Chronic Venous Stasis with Necrotic Tissue, Left Leg Cellulitis, Morbid Obesity, Chronic Kidney Disease stage III, and Diabetes Mellitus. An order to consult the wound Care Nurse was written on 8/23/17 at 12:35. An Admission Nursing wound assessment, dated 8/23/17 at 00:30 documented that Patient #15 had a left leg ulceration with maggots in the wound and a Braden Scale score of 14/23. There was no documentation to indicate that Patient #15 was seen by the wound care nurse. There were no orders noted on the clinical record for dressing changes or wound cleansing. When queried at this time, Staff AE stated, "The nurses are used to having the wound care nurse write the orders for dressing changes and wound cleansing."

Patient #16 was a 70 year old male admitted to the facility on 8/22/17 with diagnoses including Hyperglycemia, Dehydration, Diabetes Mellitus, Diabetic Peripheral Neuropathy and Non Healing Left Lower Leg wound. An Admission Nursing Braden Scale and Skin Assessment dated 8/23/17 at 00:00 documented that the patient had sores and ulcerations on admission. On 8/23/17 at 08:00, the Nursing Skin assessment documented an "abcess" to the left shin. On 8/28/17 at 10:20, Patient #16 was interviewed during a tour of the facility with the Director of Patient Care Services, Staff H. Patient #16 had a left leg shin superficial wound with pale pink tissue and white curling edges along the length of the shin. The wound was dripping bright red blood from a skin tear in one area of the wound. When queried, Patient #16 reported that the area on his left shin was a "non-healing diabetic ulcer" that he had for 2 years. On 8/28/17 at 10:25, Staff L was observed doing wound care for Patient #16's left leg wound. Staff L cleansed the wound with tap water and a standard (non sterile) washcloth, and then applied two 4 x 4 pads and wrapped the left leg with gauze wrap. When queried, Staff L stated that there was no physician's order or Wound Care Services direction for cleansing or treating Patient #16's diabetic ulcer. Review of Patient #16's clinical record with Staff AE and Staff H on 8/29/17 at 11:30 revealed no documentation of orders to treat or care for Patient #16's diabetic ulcer. On 8/29/17 at 11:50, review of the facility policy/rubric for skin integrity revealed there was no guidance for diabetic ulcers. On 8/29/17 at 11:55, Staff AE and Staff H were interviewed regarding facility policy for treating diabetic ulcers. Staff H stated, "Usually we do a wound care consult. The wound care nurse usually dictates the treatment orders. Our wound care nurse resigned in July. Our nurses were so dependent on the wound care nurse. That's why there are no treatment orders for (Patient #16)."

On 8/30/17 at 10:00, Patient #17's clinical record was reviewed with Staff AE. Patient #17 was a 66 year old female who was admitted to the facility on 8/22/17 with diagnoses which included Urinary Tract Infection (UTI) and End Stage Renal Disease (ESRD). An Admission Braden Scale Skin Assessment dated 8/23/17 at 01:02 documented a score of 15/23 and multiple scabs to bilateral toes and a suspected deep tissue injury to the right heel. Braden Scale scores for Patient #17 ranged as low as 9/23 between 8/23/17 and 8/29/17. "Wound Care Consult" was first noted as a nursing intervention on 8/27/17 at 08:00. There were no written orders for cleansing, dressing or treatment of Patient #17's wounds. There was no documentation to indicate that Patient #17 was seen by the wound care nurse.

Based on interview and document review the facility failed to ensure the plan of care was updated for patients with and at risk for altered skin integrity for nine (#1,#3,#4,#11,#13,#14,#15,#16,and #17) of 13 patient records reviewed for altered skin integrity/wound care, resulting in the potential to neglect all patients with compromised skin integrity regarding the care of the skin or wounds. Findings include:

On 8/25/2017 during observational tour of the Intensive care unit (ICU) patient #4's wife was interviewed at approximately 1145 related to the care of her husband who was incapable of being interviewed because of an extensive cerebral vascular accident (CVA-stroke). She reported her husband had a decubitus ulcer on his coccyx (tailbone area). She reported that the wound has been cared for but did not know if a wound care nurse had been in to evaluate the wound. After completing the interview the medical record was reviewed at the nursing station at approximately 1200. The wound care orders were written by the physician on 8/27/2017 at 2336 that included an order for the wound to be assessed by the wound care team. The wound was assessed on admission 8/27/2017 by the ICU Registered Nurse (RN.) No note could be found documenting assessment of the wound by the wound care team or recommendations for care, cleansing, or frequency of dressing changes. Staff G was asked to assist in the location of the documentation, she stated "I can't find the assessment by the wound care Nurse, that is who does the assessment."

On 8/29/2017 at 1054, review of Patient #11's medical record revealed he was an 81 year old male admitted on 8/22/2017 with a diagnosis of encephalopathy with altered level of consciousness. Upon admission patient #11 was assessed for risk of developing pressure sore using the Braden Scale. Patient #11 scored a 12 out of a possible 23 indicating the patient was at High Risk for developing pressure sores. There was no evidence in the medical record the patient had received a skin/wound care assessment by the wound care team and/or recommendation for care.

On 8/30/2017 at 0846, review of Patient #13's medical record revealed she was a 58 year old female admitted on 8/22/2017 with a diagnosis of septic shock, acute kidney injury, and metabolic encephalopathy. Upon admission, Patient #13 was assessed for risk of developing pressure sores using the Braden Scale. Patient #13 scored an 11 out of a possible 23 indicating that the patient was at high risk for developing pressure sores. There was no evidence in the medical record that the patient had received a skin/wound care assessment by the wound care team and/or recommendation for care.

On 8/26/2017 at 0900 the policy titled "Patient Care Services" dated revised on July 2014 was reviewed. On page 6 of 6 an algorithm outlines the expected steps to be taken related to the care of skin with altered integrity. The algorithm is broken into stages I, II, III, IV, and V. Each level has "Wound care team referral" as a step in the care to be ordered. The algorithm begins with statement "all patients with a Braden scale of 18 or less will be seen by the wound care team for care orders."

On 8/26/2017 at 1135 staff S Hospitalist was interviewed. He stated "All patients that are admitted with a decubitus are seen for consult with the wound care team."

On 8/26/2017 at 0900 during an interview with staff A the Chief Medical Officer he stated "Our inpatient wound care nurse resigned on July 7, 2017." He went on to explain that there has been no one in that role since. During the interview he was asked if the wound care nurse was an advanced practice nurse with privileges to write orders. He stated "No, it is just a regular nurse that makes recommendations to the physicians, who are then supposed to write the orders." He was asked who has been ordering care in the absence of the wound care nurse. He explained that the Physicians are responsible to write all of their own patients orders. He was also asked if all physicians and staff had been made aware of the vacancy of an in patient wound care nurse and that no assessments or recommendations could be done, he stated 'No, not a formal announcement."


36887

During an interview on 8/28/2017 at 1140, Patient #3 was queried as to the large gauze dressing on his right foot. He stated he was in the hospital for an infection of his right great toe. When queried about his care while in the hospital, he stated, "The nurses and assistants are great but there seems to be a huge lack of communication with different levels of service. It's very frustrating." Patient #3 was asked to elaborate on this statement to which he replied that he had been told multiple times he would "see someone from wound care which never happened." Patient #3 was further queried as to if his dressing had been changed and how often it was changed to which he stated it had been changed "at least once a day."

Review of Patient #3's electronic medical record with Staff AE on 8/29/2017 at 0922 revealed the patient had surgery on 8/2/2017 for a graft and fusion of his right great toe and was admitted to the hospital 8/26/2017 for possible osteomylitis. Physician orders dated 8/26/2017-8/28/2017 reveal no referral to wound care and there are no orders present for wound care or dressing changes from 8/26/2017-8/28/2017. These findings were confirmed by Staff AE on 8/29/2017 at 0930. Staff AE stated, "They should've had a doctor's order. This was a surgical wound."

Staff H was queried on 8/29/2017 at 1039 as to if wound care should have been consulted for a post surgical infection to which she replied, "The wound care nurse does not come in on the weekends...No one covers for them...The nurses should be paging the physicians on the weekends when the wound care nurse is not available."


27713

On 8/29/17 at 12:00 through 17:00, Patient #1's clinical record was reviewed with Staff AE, the Director of Patient Experience, and Staff G, the Director of Patient Care Services. Patient #1 was a 62 year old female who had multiple readmissions to the facility in 2017. Patient #1's was admitted to the facility on 4/26/17 through 4/28/17 for hip replacement surgery done on 4/26/17, and was subsequently readmitted to the facility multiple times for declining health status related to infection of the left hip surgical incision. A Braden Scale Skin Assessment dated 4/28/17 at 16:00 documented a score of 18/23. During a readmission from 5/11/17 at 10:04 through 5/17/17, a Braden Scale Skin Assessment dated 5/11/17 at 21:56 documented that the patient's Braden score was 16/23. On Patient #1's third admission from 5/19/17 at 22:49 through 5/24/17, an Admission Nursing Assessment, dated 5/20/17 at 01:00 noted that the Nursing Admission Braden Score was 16/23. During Patient #1's fourth admission to the facility, on 6/6/17 at 16:07 through 6/15/17, an Admission Nursing Assessment, dated 6/6/17 at 08:22 documented that Patient #1 was at increased risk for developing pressure scores with a Braden Score of 15/23. During Patient #1's sixth admission to the facility, 7/27/17 at 15:47 through 8/3/17, a Nursing Admission skin assessment on 7/27/17 at 16:47 documented a skin tear on the right upper extremity and a Stage II (superficial skin loss) pressure sore on the left posterior thigh, were present on admission. Admission Braden Scale score was 12/23. Documentation for a Wound Care Services Consultation was noted, but was not done. During Patient #1's seventh admission to the facility from 8/8/17 at 20:11 through 8/11/17, an Admission Nursing Skin Assessment dated 8/8/17 at 20:11 documented that Patient #1 was admitted with a left thigh wound (infected surgical wound), multiple Stage II pressure sores on the left thigh, a skin tear on the right arm, and bilateral Stage I (non-blanching redness with intact skin) pressure sores on her heels. No Wound Care Nurse Consultation was done for Patient #1 during any of her admissions. There were no written orders for dressing changes and wound cleansing of Patient #1's pressure sores or skin tear.

On 8/29/17 at 10:30, Patient #14's clinical record was reviewed with Staff AE and Staff H. Patient #14 was a 66 year old female with diagnoses including left upper extremity pain and left upper extremity deep vein thrombosis. Review of Physician's orders for Patient #14 revealed an order dated 8/28/17 at 12:38 for, "Consult Wound Care Nurse" for "left lower extremity (left leg) Cellulitis". Review of Patient #14's clinical record revealed no documentation that the Wound Care Nurse was consulted. When queried at this time, Staff H stated that the Ostomy Nurse was covering Wound Care Services until a new Wound Care Nurse was hired. On 8/28/17 at 10:50, the Ostomy Nurse, Staff AG was interviewed and stated, "I haven't actually seen any Wound Care Nurse referral patients yet. I've been too busy with the Ostomy clinic and training two new nurses." When queried, Staff H reported that patients were supposed to be seen by the Wound Care Nurse within 24 hours of a referral.

On 8/28/17 at 13:00, Patient #15's clinical record was reviewed with Staff AE. Patient #15 was a 69 year old female who was admitted to the facility on 8/22/17 with diagnoses that included Chronic Venous Stasis with Necrotic Tissue, Left Leg Cellulitis, Morbid Obesity, Chronic Kidney Disease stage III, and Diabetes Mellitus. An order to consult the wound Care Nurse was written on 8/23/17 at 12:35. An Admission Nursing wound assessment, dated 8/23/17 at 00:30 documented that Patient #15 had a left leg ulceration with maggots in the wound and a Braden Scale score of 14/23. There was no documentation to indicate that Patient #15 was seen by the wound care nurse. There were no orders noted on the clinical record for dressing changes or wound cleansing. When queried at this time, Staff AE stated, "The nurses are used to having the wound care nurse write the orders for dressing changes and wound cleansing."

Patient #16 was a 70 year old male admitted to the facility on 8/22/17 with diagnoses including Hyperglycemia, Dehydration, Diabetes Mellitus, Diabetic Peripheral Neuropathy and Non Healing Left Lower Leg wound. An Admission Nursing Braden Scale and Skin Assessment dated 8/23/17 at 00:00 documented that the patient had sores and ulcerations on admission. On 8/23/17 at 08:00, the Nursing Skin assessment documented an "abcess" to the left shin. On 8/28/17 at 10:20, Patient #16 was interviewed during a tour of the facility with the Director of Patient Care Services, Staff H. Patient #16 had a left leg shin superficial wound with pale pink tissue and white curling edges along the length of the shin. The wound was dripping bright red blood from a skin tear in one area of the wound. When queried, Patient #16 reported that the area on his left shin was a "non-healing diabetic ulcer" that he had for 2 years. On 8/28/17 at 10:25, Staff L was observed doing wound care for Patient #16's left leg wound. Staff L cleansed the wound with tap water and a standard (non sterile) washcloth, and then applied two 4 x 4 pads and wrapped the left leg with gauze wrap. When queried, Staff L stated that there was no physician's order or Wound Care Services direction for cleansing or treating Patient #16's diabetic ulcer. Review of Patient #16's clinical record with Staff AE and Staff H on 8/29/17 at 11:30 revealed no documentation of orders to treat or care for Patient #16's diabetic ulcer. On 8/29/17 at 11:50, review of the facility policy/rubric for skin integrity revealed there was no guidance for diabetic ulcers. On 8/29/17 at 11:55, Staff AE and Staff H were interviewed regarding facility policy for treating diabetic ulcers. Staff H stated, "Usually we do a wound care consult. The wound care nurse usually dictates the treatment orders. Our wound care nurse resigned in July. Our nurses were so dependent on the wound care nurse. That's why there are no treatment orders for (Patient #16)."

On 8/30/17 at 10:00, Patient #17's clinical record was reviewed with Staff AE. Patient #17 was a 66 year old female who was admitted to the facility on 8/22/17 with diagnoses which included Urinary Tract Infection (UTI) and End Stage Renal Disease (ESRD). An Admission Braden Scale Skin Assessment dated 8/23/17 at 01:02 documented a score of 15/23 and multiple scabs to bilateral toes and a suspected deep tissue injury to the right heel. Braden Scale scores for Patient #17 ranged as low as 9/23 between 8/23/17 and 8/29/17. "Wound Care Consult" was first noted as a nursing intervention on 8/27/17 at 08:00. There were no written orders for cleansing, dressing or treatment of Patient #17's wounds. There was no documentation to indicate that Patient #17 was seen by the wound care nurse.