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Based on document review and interview the facility failed to:


A. follow the facility's own policy and document a complete and accurate skin assessment on 1 of 1 patient (Patient #1) from 5/10/2017 through 5/17/2017. The Wound Care (WC) nurse failed to document her initial skin assessment. The staff RNs failed to document their shift assessment of pt #1's coccyx pressure wound. The RN failed to document pt's pressure wounds that were present upon admission.


Pt #1 was admitted to the hospital from the LTC facility with two (2) small stage II pressures wounds to his buttocks at the coccyx area. Each measuring less than 2 centimeters (CM) in circumference. The hospital staff failed to conduct adequate assessment and intervention to the patient's pressure wounds. When Pt #1's admitted back to the LTC facility from the hospital, Pt#1's wounds were bilateral to the sacral coccyx area. The wounds were unstageable due to a dark gray black discoloration which indicated deep tissue injury and were larger. One wound measured 8.0 by 7.30 CM and the other measured 6.7 by 3 CM in circumference respectively


This deficient practice had the likelihood to effect all patients of the hospital.


Refer to A 0395




B. follow their policy on care planning for one of one patient's (Patient #1) from 5/10/2017 through 5/17/2017.


Pt #1 was admitted to the hospital from the LTC facility with two (2) small stage II pressures wounds to his buttocks at the coccyx area. Each measuring less than 2 centimeters (CM) in circumference. The hospital staff failed to conduct adequate assessment and intervention to the patient's pressure wounds. The nursing care plan failed to address wound assessment, wound observations, measurements, treatment, notification of the physician, and appropriate interventions. When Pt #1's admitted back to the LTC facility from the hospital, Pt#1's wounds were bilateral to the sacral coccyx area. The wounds were unstageable due to a dark gray black discoloration which indicated deep tissue injury and were larger. One wound measured 8.0 by 7.30 CM and the other measured 6.7 by 3 CM in circumference respectively



This deficient practice had the likelihood to affect all patients of the hospital.




Refere to A 0396

Based on record review and interview the facility failed to follow the facility's own policy and document a complete and accurate skin assessment on 1 of 1 patient (Patient #1) from 5/10/2017 through 5/17/2017. The Wound Care (WC) nurse failed to document her initial skin assessment. The staff RNs failed to document their shift assessment of pt #1's coccyx pressure wound. The RN failed to document pt's pressure wounds that were present upon admission.


This deficient practice had the likelihood to affect all patients of the hospital.


Findings included:


On 8/15/2017 in the conference room the medical record for patient (Pt/pt) #1 was reviewed with the assistance of the Quality Director. Pt #1's medical record (MR) documented the 73 year old (y/o) male pt arrived via ambulance from a local long term (LTC) care facility with complaint of altered mental status (AMS).


The Emergency Department (ED) record indicated Pt #1 was seen at 2137 for AMS, Chest x-ray positive for left pleural effusion. Pt #1 was admitted to the acute hospital on 5/11/2017. The History and Physical (H&P) indicated his chief complaint was, "AMS, Patient lethargic and with Alzheimer dementia".



5/11/2017 Nursing malnutrition screen qualified pt #1 at a high risk with a documented score of "4". (2 or higher placed a pt at high risk or malnutrition).


5/11/2017 initial nursing assessment indicated "No history of pressure wounds". Pt #1 was unable to answer questions and had no family present.


5/11/2017 The initial Braden Scale (National standard for prediction of skin breakdown). Scored "13", "Moderate risk". Additional information documented "Blanchable redness noted at coccyx. Allevyn dressing DSG (Sic) applied to area turn Q2 (every 2 hours) to relieve pressure on area".


5/11/2017 at 0830 The first complete nursing skin assessment recorded the following findings.
Pressure ulcer present on arrival: N (no)
Mucus membrane - moist
Skin temperature - warm
Skin moisture - dry
Skin texture - Smooth
Generalized skin color - Normal for ethnicity


The initial nursing skin assessment included additional information, referred in their electronic medical record as "Modifiers". The following modifiers were found in the initial skin assessment.

1. Skin location modifier - Mild
Skin location Body site - Coccyx
Skin problem - Erythema


2. Skin location modifier - Bilateral
Skin location body site - scattered
Skin problem - bruises and scrapes


3. Skin location modifier - left, upper
Skin location body site - face
Skin problem - bruise


On 8/15/2017, afternoon interview with the LTC's Assistant Director of Nursing services presented documentation that on 5/10/2017, pt #1 was discharged from the LTC facility to the hospital with two (2) small stage II pressures wounds to his buttocks at the coccyx area. Each measuring less than 2 centimeters (CM) in circumference. On the evening of pt #1's return to the LTC facility pt#1's wounds were bilateral to the sacral coccyx area. The wounds were unstageable due to a dark gray black discoloration which indicated deep tissue injury and were larger. One wound measured 8.0 by 7.30 CM and the other measured 6.7 by 3 CM in circumference respectively.


On 8/15/2017 in the conference room the Chief Nursing Officer (CNO) requested the presence of the Wound Care (WC) Nurse, to answer questions regarding wound assessment and subsequent wound care orders. The WC nurse explained a Braden scale of 12-13 would automatically generate a wound care consult. The WC nurse confirmed she had completed pt #1's WC consult. The WC nurse was asked if she had completed a skin assessment on pt #1, since his admission Braden scale score was 13. She indicated yes. When asked where the documentation could be found to support her assessment, she replied, "If there wasn't anything to see, I didn't document anything". The WC nurse confirmed she had not documented her observations of pt #1 skin.


On 8/15/2017 in the conference room, further review of the MR for pt #1 was reviewed with the Chief Nursing Officer and the Wound Care Nurse. Documentation from the Registered Dietician was identified on 5/12/2017 at 1342. The Registered Dietician's (RD) Consult was as follows: "Pt asleep when I entered room; RD note from last visit reported pt is demented and did not answer questions. RN (Registered Nurse) states pt ate very well his am--I observed tray 100% intake. Skin: Coccyx pressure ulcer -- NO WCA just Low Braden Scale. "Wt today 177#. Lab WBC (white blood cells) 8.4, BUN 32 high, Albumin 2.4 low. Diagnosis Sepsis, Moderate risk of malnutrition".


The CNO was asked "what did WCA stand for"? She replied "I don't know", and turned to the wound care nurse and asked what does "No WCA" stand for. The wound care nurse did not reply. When asked if "WCA" stood for "Wound Care Assessment" she again, did not reply. The RD's documentation implied a Braden score had been given pt #1 in the absence of s skin wound assessment.


The nursing care plan was initiated on 5/11/2017 at 144 and based on pt #1's nursing skin assessment. One of the problems identified for pt #1 was, "skin". The desired outcome for pt #1's "skin" was, "maintain intact skin". However documentation from the LTC faclity indicated pt #1's skin was not in tact when he arrived at the hospital. Intervention were documented as "Perform hourly rounds, Turn every 2 hours as needed (PRN), Assess skin, minimize friction and shear, keep skin dry, use pressure reduction support surfaces, elevate heels off mattress surface, use pillow foam wedges for positioning".


On 5/11/17 1856 to 1937, the nursing shift assessment recorded, "Skin wounds reviewed "Y" (yes). The nursing documentation included no further evidence of a nursing assessment. There was no wound assessment documented by the nurse.


On 5/12/2017 the nursing skin assessment for both shifts are found below.

Integumentary symptoms: Dryness, flaking, bruising, redness.

Mucus membrane - pink

skin temperature - warm

Skin moisture - dry

skin turgor - loose

skin texture - rough, flaking

generalized skin color - Normal for ethnicity

skin location modifier - Mid

skin location body site - Coccyx

skin problem - Redness dressing in place

skin location modifier - bilateral

skin location body site - scattered

skin problem - bruise

skin location modifier - left, upper

skin location body site - face

skin problem - bruise

Additional Integumentary information - scattered bruising, bilateral upper extremities with multiple small scabs, larger scab on left hand, bruising, fragile skin.


The nursing documentation did not include an assessment of pt #1's actual wound(s).

On 8/15/2017, in the conference room the CNO was asked wouldn't she expect a nurse to document what they assessed regarding the area of pt #1's "Bottom". Her reply was, "well, I would think so".



On 5/13/2017 the nursing skin Assessment for both shifts was identified below.

Integumentary symptoms-Dryness, flaking, bruising, redness.

Mucus membrane-Pink

skin temperature-Warm

Skin moister-Dry

skin turgor-Loose, Smooth, Thin

skin texture-Flaking

generalized skin color-Pale

skin location modifier-Mid

skin location body site-Coccyx

skin problem- Pressure Area

skin location modifier-Bilateral

skin location body site-Scattered

skin problem-Bruise

skin location modifier-Left, Upper

skin location body site-Face

skin problem-Bruise

Additional Integumentary information: Scattered bruising, bilateral upper extremities with multiple small scabs, larger scab on left hand, bruising to L (Left) brow from fall prior to admission



On 5/14/2017 the nursing skin Assessment was identified below.

Integumentary symptoms-Dryness, flaking, bruising, redness.

Mucus membrane-Pink

skin temperature-Warm

Skin moister-Dry

skin turgor-Loose, Smooth, Thin

skin texture-Flaking

generalized skin color-Pale

skin location modifier-Mid

skin location body site-Coccyx

skin problem- Pressure Area

skin location modifier-Bilateral

skin location body site-Scattered

skin problem-Bruise

skin location modifier-Left, Upper

skin location body site-Face

skin problem-Bruise

Additional Integumentary information: Scattered bruising, bilateral upper extremities with multiple small scabs, larger scab on left hand, bruising to L (Left) brow from fall prior to admission.




5/15/2017, the nursing skin Assessment for both shifts were identified below.

Integumentary symptoms-Dryness, flaking, bruising, redness.

Mucus membrane-Pink

skin temperature-Warm

Skin moister-Dry

skin turgor-Loose, Smooth, Thin

skin texture-Flaking

generalized skin color-Pale

skin location modifier-Mid

skin location body site-Coccyx

skin problem- Pressure Area

skin location modifier-Bilateral

skin location body site-Scattered

skin problem-Bruise

skin location modifier-Left, Upper

skin location body site-Face

skin problem-Bruise

Additional Integumentary information: Scattered bruising, bilateral upper extremities with multiple small scabs, larger scab on left hand, bruising to L (Left) brow from fall prior to admission.



5/15/2017, 2150, Integumentary Assessment:

Integumentary symptoms-Dryness, flaking, bruising, redness.

Mucus membrane-Pink

skin temperature-Warm

Skin moister-Dry

skin turgor-Tight, Smooth, thin

skin texture-Flaking

generalized skin color-Pale

skin location modifier-Mid

skin location body site-Coccyx

skin problem- Pressure Area

skin location modifier-Bilateral

skin location body site-Scattered

skin problem-Bruise

skin location modifier-Left, Upper

skin location body site-Face

skin problem-Bruise


On 5/16/2017, the nursing skin Assessment for both shifts was identified below.

Integumentary symptoms-Dryness, flaking, bruising, redness.

Mucus membrane-Pink

skin temperature-Warm

Skin moister-Dry

skin turgor-Tight, Smooth, thin

skin texture-Flaking

generalized skin color-Pale

skin location modifier-Mid

skin location body site-Coccyx

skin problem- Pressure Area

skin location modifier-Bilateral

skin location body site-Scattered

skin problem-Bruise

skin location modifier-Left, Upper

skin location body site-Face

skin problem-Bruise



5/17/2017, 1032 "Goal status: Maintain skin intact- N (no) progressing. Turn Q2, manage moisture, float heels, Allevyn dressing to sacrum". The change in Pt #1's care plan indicated he had not been able to maintian in tact skin. No skin wound assessment was documented. The skin assessment is as follows.

Integumentary Assessment:

Integumentary symptoms-Dryness, flaking, bruising, redness.

Mucus membrane-Pink

skin temperature-Warm

Skin moister-Dry

skin turgor-Tight, Smooth, thin

skin texture-Flaking

generalized skin color-Pale

skin location modifier-Mid

skin location body site-Coccyx

skin problem- Pressure Area

skin location modifier-Bilateral

skin location body site-Scattered

skin problem-Bruise

skin location modifier-Left, Upper

skin location body site-Face

skin problem-Bruise


Pt #1 was in the acute hospital for 6 days. In 6 days the nursing staff never documented a wound assessment on pt #1. Pt #1's care plan was never altered.


On 8/15/2017 in the conference room, the facility policies for assessment were reviewed.

Policy NA-PP-302, "To provide a baseline and ongoing head to toe nursing assessment of the patient in order to gather necessary data for planning, implementing and evaluating nursing care".
Policy: "Each patient's physical and psychological/social status is assessed. Educational needs are determined based on the assessment/reassessment. The multidisciplinary Plan of Care/Process Plans will be initiated within the first 24 hours of admission and /or patients expected to stay longer than 24 hours. The patient's progress will be evaluated as necessary and the plan of care will be revised as indicated. The scope and intensity of any further assessment are determined by the patient's diagnosis, care setting, patient's desire for care and the patients response to previous care.
The Responsibility for assessment: "The RN (Registered Nurse) is responsible for the assessment/reassessment function that is to determine the plan of care to meet a patient's initial needs as well as his/her needs as the change in response to care".


Policy, NA-PP-12, "To provide guidelines for wound care and documentation".

Policy: "Patients admitted to the hospital with wounds resulting from surgery, pressure, diabetes, peripheral vascular disease, trauma or patients who acquire wounds while in the hospital is (sic) followed by the physician, nurses and in some cases the dietician.

Procedure:

1. Documentation of the patient's wound should include but not (sic) limited to:
Location and type of wound
Appearance of the wound including measurements
Odor
Presence of sutures, staples if any
Location, type and number of drains if any.
Amount and characteristics of drainage
Treatment provided
Supplies used.


2. Primary care physician provides treatment orders for the wound and /or consults for ancillary therapies such as Enterostomal Therapy Department or physical medicine for those requiring whirlpools.

3. Anyone (Physician, nurse, family member) may request Enterostomal Therapy Department to assess the patient at any time during the course of the patient's hospitalization.


4. The RN should assess the wound at least every 24 hours unless contraindicated by the type of wound and dressing type. Examples: skin grafts or skin donor sites. Documentation of the wound(s) assessment, treatment is done with each dressing change or every shift if the wound is open to air.


5. In addition, the measurements of wounds is done weekly by the Enterostomal Therapy Department or the RN until the patient is discharged. The documentation can be found on the PCP or the wound Progress form.


6. Instructions for wound care should be given to the patient/family during the course of the hospital stay and upon discharge for continued care. Documentation of education for wound care should be entered on the Multidisciplinary Education Record and the Patient /Family Discharge Instructions."



On 8/15/2017 in the conference room, the wound care nurse was again interviewed. It was brought to the attention of the wound care nurse that throughout pt #1's hospital course, "Allyven to coccyx" was documented by the shift nurse. When the wound care nurse was asked, why the shift nurses were documenting "Allyven to coccyx", if there was no wound, she replied, "it was probably done as a preventative". The wound care nurse was asked if applying a dressing to a patient required a physician's order, she replied, "No, it is a nursing intervention". When asked if she had a protocol or policy permitting this "nursing intervention" of wound dressings without physician notification, she replied, "No, we just have access to the things we need and decide what to use".

The above conversation and interview was witnessed by the Chief Nursing Officer, Director of Quality and Risk Manager.

Based on document review and interview the facility failed to follow their policy on care planning for one of one patient's (Patient #1) from 5/10/2017 through 5/17/2017.


This deficient practice had the likelihood to effect all patients of the hospital.


Findings included:


On 8/15/2017 in the conference room, the medical record (MR) for pt #1 was reviewed in the presence of the Chief Nursing Officer, Quality Director and Risk manager. The nursing care plan identified pt #1's skin as a problem. The outcome desired for pt #1's skin was, "Pt will maintain intact skin". The interventions were listed as low Braden score, turn Q (Every) 2 hours, float heels, manage moisture". This problem was identified and interventions were initiated on 5/11/2017.


Pt #1 was admitted on 5/10/2017 from a Long Term Care (LTC) facility. On 8/15/2017 in the afternoon, the LTC facility where pt #1 was admitted to the hospital from was visited by this surveyor. The Assistant Director or Nursing (ADON) provided pt #1's medical record which extensively documented the condition of his skin the week prior to his admission to the hospital. Pt #1 had bilateral stage II wounds, to his buttocks at the coccyx. The wounds were less than 2 centimeters (cm) each. The ADON confirmed that both wounds were still present the evening of pt #1's transfer to the hospital. Upon readmission to the LTC facility, Pt #1's stage II wound of less than 2 cm were 7-8 cm respectively and were unstageable due to the dark gray black tissue color which indicated deep tissue injury.


The above MR review and findings were witness and confirmed by the Chief Nursing Officer, Director of Quality and Risk Manager.


On 8/15/2017 in the morning the following policy was reviewed:


Policy NA-PP-302, "To provide a baseline and ongoing head to toe nursing assessment of the patient in order to gather necessary data for planing, implementing and evaluating nursing care".
Policy: "Each patient's physical and psychological/social status is assessed. Educational needs are determined based on the assessment/reassessment. The multidisciplinary Plan of Care/Process Plans will be initiated within the first 24 hours of admission and /or patients expected to stay longer than 24 hours. The patient's progress will be evaluated as necessary and the plan of care will be revised as indicated. The scope and intensity of any further assessment are determined by the patient's diagnosis, care setting, patient's desire for care and the patients response to previous care.
The Responsibility for assessment: "The RN (Registered Nurse) is responsible for the assessment/reassessment function that is to determine the plan of care to meet a patient's initial needs as well as his/her needs as the change in response to care"


The acute nursing staff failed to document a head to toe assessment of pt #1 upon admission. The transferring facility had documented 2 stage II pressure wound to his coccyx. The review of pt #1's MR failed to identify an assessment of pt #1's response to the Plan of Care. There were no changes to the plan of care interventions, even as the documentation for the Plan of care changed from "Patients skin will remain intact-Y (Yes)... to- N (NO).



Policy, NA-PP-12, "To provide guidelines for wound care and documentation".

Policy: "Patients admitted to the hospital with wounds resulting from surgery, pressure, diabetes, peripheral vascular disease, trauma or patients who acquire wounds while in the hospital is (sic) followed by the physician, nurses and in some cases the dietician.

Procedure:

1. Documentation of the patient's wound should include but not (sic) limited to:
Location and type of wound
Appearance of the wound including measurements
Odor
Presence of sutures, staples if any
Location, type and number of drains if any.
Amount and characteristics of drainage
Treatment provided
Supplies used.

2. Primary care physician provides treatment orders for the wound and /or consults for ancillary therapies such as Enterostomal Therapy Department or physical medicine for those requiring whirlpools.

3. Anyone (Physician, nurse, family member) may request Enterostomal Therapy Department to assess the patient at any time during the course of the patient's hospitalization.

4. The RN should assess the wound at least every 24 hours unless contraindicated by the type of wound and dressing type. Examples: skin grafts or skin donor sites. Documentation of the wound(s) assessment, treatment is done with each dressing change or every shift if the wound is open to air.

5. In addition, the measurements of wounds is done weekly by the Enterostomal Therapy Department or the RN until the patient is discharged. The documentation can be found on the PCP or the wound Progress form.

6. Instructions for wound care should be given to the patient/family during the course of the hospital stay and upon discharge for continued care. Documentation of education for wound care should be entered on the Multidisciplinary Education Record and the Patient /Family Discharge Instructions."



There were no additions or changes to pt #1's care plan regarding wound assessment, wound observations, measurements, treatment, notification of the physician, whose care pt #1 was assigned.