HospitalInspections.org

Based on review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to follow developed nursing care plan's for one out of 10 medical records (MR1).

Findings include:

A review of facility policy "Subject: Assessment and Prevention of Pressure Ulcers," effective date June 30, 2006, revealed "I. Purpose...To insure accurate assessment and documentation for patients at risk for alteration in skin integrity and/or with pre-existing skin breakdown...II. Procedure...A. Patients admitted without an alteration in skin integrity...The RN,...will:...1. complete the Braden Risk Assessment Scale located on Last Word/24 hour flowsheet...2 add the score column to get the patient's total score. This becomes the patient's "at risk" score and determines the nursing care that should be provided...3. assess risk status every 24 hours for acute care...B. Patient's admitted with skin breakdown or existing pressure ulcer (s)...The RN...will: ...2. document skin alteration data on Last Work /24 hour flowsheet...3. individualize the nursing care needed for the existing pressure ulcer (s) by using the pressure ulcer order sets as available...4. Include additional skin integrity information not captured on the skin assessment in a progress note...Document changes and daily care provided...C. Patient who develops pressure ulcers during hospitalization...The RN...will:...provide care as above..."

1) A review of MR1 revealed an emergency department physician note dated January 3, 2011, which indicated that the patient presented to Albert Einstein Medical Center from a long term care facility related to an increased heart rate, increased respirations and an elevated temperature. A further review of MR1 revealed an emergency department nursing note dated January 3, 2011, that indicated the patient had a left lower back reddened area, left thigh reddened area and a stage one pressure ulcer on left hip.
2) A review of MR1 nursing flowsheet dated January 4, 2011, revealed that the patient had a skin breakdown prevention intervention, that included assessing skin over bony prominences every day.
3) A review of MR1 nursing flowsheet dated January 5, 2011, revealed that the patient's skin breakdown, included the following : site five left flank stage two pressure ulcer, site six left elbow pressure ulcer stage two, site seven left thigh pressure ulcer stage two, site eight right thigh pressure ulcer stage two.

There was no documentation that the facility consistently assessed the patient's pressure ulcers as required by the nursing interventions for skin breakdown and the facility's policy. There was no documentation that the patient's left flank, left elbow, left thigh, and right thigh were assessed on January 6, 2011, and January 12, 2011.

An Interview with EMP3 on January 28, 2011, at approximately 2:00 p.m. confirmed that the patient's stage 2 pressure ulcer's were not assessed for the patient's left flank, left elbow, left thigh, and right thigh on January 6, 2011, and January 12, 2011.

4) A further review of MR1 revealed a nursing flowsheet for January 11, 2011, which revealed the patient had an alteration in skin integrity related to a left wrist blister A further review of MR1 revealed no documentation the patient's left wrist alteration in skin integrity was assessed on January 12, 2011, January 13, 2011, January 14, 2011, and January 15, 2011.

An Interview with EMP3 on January 28, 2011, at approximately 2:00 p.m. confirmed that MR1 revealed no documentation that the patient ' s left wrist alteration in skin integrity was assessed on January 12, 2011, January 13, 2011, January 14, 2011, and January 15, 2011.