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ADVENTHEALTH ORLANDO 601 E ROLLINS ST ORLANDO, FL 32803 April 29, 2015
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on interview, record review and a review of facility documentation, the facility failed to ensure that the nursing care plan for pressure sore treatment as defined by policy was kept current for a patient with pressure sores in one of ten sampled patients. (#1)

Findings:

A review of the medical record of patient #1 was performed. The patient was triaged in the ER (emergency room ) on 11/11/14 at 10:30 AM. The History & Physical, dictated on 11/11/14, read: "He was found by his son this morning lying next to his bed. He was found to have a left mid shaft femur fracture and he does have extensive hardware in both hips and thighs." A physician note of 11/12/14 at 7:04 PM read: "Underwent successful open surgical repair of his fracture today." Nursing skin assessment documentation revealed no discrepancies through 11/14/14.

Skin assessment documentation revealed the presence of a "tender, reddened area" on 11/15/14 on the coccyx. It indicated that skin barrier ointment was applied. There was no indication as to whether it was blanchable or non-blanchable. There was no evidence of physician notification.

Facility policy "Skin Breakdown: Prevention and Guidelines for Care" read: "Stage I Pressure Ulcer Guidelines (Non-Blanchable Reddened Skin): Notify physician of altered skin integrity." There was nothing in this policy which limited the performance of physician notification to wound care nurses and no one else. Since there was no evidence of physician notification of a skin discrepancy at the above stated site until 11/17/14, the policy was not followed.

Skin assessment documentation revealed the presence of a "tender, reddened area" on 11/16/14 on the coccyx. As with the notation from 11/15/14 of the same site, above, a Stage 1 Pressure sore cannot be discounted. There was no evidence of physician notification.

Skin assessment documentation revealed the presence of a Stage II pressure sore on 11/17/14 at 10:39 AM on the coccyx. A physician note of 11/17/14 at 12:08 PM indicated an awareness at this time of pressure sore concerns, two days after the first evidence of a skin discrepancy as noted above. Skin assessment documentation revealed the presence of an open, full thickness wound (12 X 10), described as "deep tissue injury" on the buttocks on 11/17/14 at 3:36 PM.

During an interview of the Risk Manager on 4/29/15 at 10:30 PM, she confirmed the preceding.