HospitalInspections.org

Based on interview and record review, the hospital failed to ensure that the nursing care plan for patient #1, developed upon admission to the hospital, was aggressive enough to prevent additional skin breakdown. The patient's medical record was reviewed on site on December 29, 2010 and again on January 13, 2011. Findings are:

-Patient #1 was admitted from home on January 16, 2010. The patient came in from home with a pressure sore. Nursing staff completed a skin assessment at 1730 on the date of admission noting a stage 1 pressure sore to the sacrum and a stage 2 open wound to the right thigh.

-The patient was scored using the Braden scale, and one of the preventative treatments selected by nursing was "protect bony prominences (i.e. elbow pads, heel pads, elevate extremities). But the nursing care plan that staff developed in Meditech, indicated one intervention to maintain skin integrity: "turn and position every two hours". There were no additional interventions developed to mitigate further skin breakdown.

-The patient was reassessed on January 17, 2010 and noted to have the same areas of skin breakdown that she was admitted with. Her Braden scale score declined indicating that the patient was now bedfast and at additional risk for skin breakdown. The nursing care plan in Meditech was not revised to include any additional measures to address the decline in the patient's condition.

-The patient was reassessed again on January 18, 2010 and noted to have a stage 2 pressure sore on the right heel and a stage 1 pressure sore on the left heel. It was at that point that protection (heel protectors and foam ankle rings) was applied to the patient's feet.

-The above findings were confirmed with the charge nurse and the nurse manager of the inpatient unit on which the patient was housed during this admission during an interview on January 13, 2011.