HospitalInspections.org

Based on interview and record review the facility's nursing staff failed to develop, and keep current the care plan for 1 of 6 sampled patients #1.

Findings include:
Review of SP#1 clinical records revealed that the sample patient #1 was admitted to the hospital with complaint of shortness of breathe . The emergency department nurses notes stated that SP#1's Skin was normal and skin was intact, fragile and thin. The admission notes of SP#1 revealed documentation that the sample patient #1's skin was intact and no skin breakdown /decubitus noted. According to the nurse ' s progress notes and daily flow sheets from 02-23-10 thru 03-01-10 showed that SP#1 was incontinent of urine. The patient ' s skin was assessed daily using the Braden scale assessment tool (score - 12-17) and this determined that the patient was high risk for skin breakdown. The patient was on a specialty bed however , on 02-27-10 (7pm-7am shift), it was noted that the patient had redness to the sacral area and incontinent care was done and a condom catheter was used for that time as recorded. On 02-28-10 (7pm-7am), it was then noted that SP#1 had sacral redness and 2 open sores but no bleeding. On 03-01-10, it was also noted on the discharge AHCA Medserv-3008 form that SP#1 had Stage II decubitus on sacrum.

Further review of SP#1 care plan dated 2/25/10 to 3/1/10 revealed that there was no documentation of interventions or approaches for altered skin integrity . In addition, the need for dietary consult was not done as part of the protocol. SP#1 diet was 2 gram Sodium, low fat diet all throughout the patient ' s stay in the hospital. Further review of records showed no updated plan of care or doctor's orders to address sp#1 sacral redness and 2 open sores.

Interview with the Chief Nurse Officer conducted on 09-23-10 at 1:00 pm confirmed above findings that there was inconsistent documentation of skin care protocol for SP#1, that dietary consult was not done, and that plan of care was not updated. He/she further stated that as a result of this that the facility already is in the process of correcting this concern and that a Quality Assurance Performance Improvement was already initiated in the month of June, 2010. Review of the facility Performance Improvement report conducted on 09-23-10 showed that all efforts are now being done to address this concern regarding prevention of pressure sores. Review of records revealed that education for Pressure Ulcer Prevention and Staging was done among nursing staff. Review of the Skin and Wound Report for the 2nd quarter, 2010 showed improvement in compliance with the staff performance.

Based on interview and record review the facility's nursing staff failed to develop, and keep current the care plan for 1 of 6 sampled patients #1.

Findings include:
Review of SP#1 clinical records revealed that the sample patient #1 was admitted to the hospital with complaint of shortness of breathe . The emergency department nurses notes stated that SP#1's Skin was normal and skin was intact, fragile and thin. The admission notes of SP#1 revealed documentation that the sample patient #1's skin was intact and no skin breakdown /decubitus noted. According to the nurse ' s progress notes and daily flow sheets from 02-23-10 thru 03-01-10 showed that SP#1 was incontinent of urine. The patient ' s skin was assessed daily using the Braden scale assessment tool (score - 12-17) and this determined that the patient was high risk for skin breakdown. The patient was on a specialty bed however , on 02-27-10 (7pm-7am shift), it was noted that the patient had redness to the sacral area and incontinent care was done and a condom catheter was used for that time as recorded. On 02-28-10 (7pm-7am), it was then noted that SP#1 had sacral redness and 2 open sores but no bleeding. On 03-01-10, it was also noted on the discharge AHCA Medserv-3008 form that SP#1 had Stage II decubitus on sacrum.

Further review of SP#1 care plan dated 2/25/10 to 3/1/10 revealed that there was no documentation of interventions or approaches for altered skin integrity . In addition, the need for dietary consult was not done as part of the protocol. SP#1 diet was 2 gram Sodium, low fat diet all throughout the patient ' s stay in the hospital. Further review of records showed no updated plan of care or doctor's orders to address sp#1 sacral redness and 2 open sores.

Interview with the Chief Nurse Officer conducted on 09-23-10 at 1:00 pm confirmed above findings that there was inconsistent documentation of skin care protocol for SP#1, that dietary consult was not done, and that plan of care was not updated. He/she further stated that as a result of this that the facility already is in the process of correcting this concern and that a Quality Assurance Performance Improvement was already initiated in the month of June, 2010. Review of the facility Performance Improvement report conducted on 09-23-10 showed that all efforts are now being done to address this concern regarding prevention of pressure sores. Review of records revealed that education for Pressure Ulcer Prevention and Staging was done among nursing staff. Review of the Skin and Wound Report for the 2nd quarter, 2010 showed improvement in compliance with the staff performance.