The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ADVENTHEALTH OCALA 1500 SW 1ST AVE OCALA, FL 34474 Aug. 15, 2012
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review the hospital failed to ensure that policies and procedures for pressure ulcer prevention were implemented in a timely manner concerning patients who developed pressure ulcers during admission for 2 (#2 and #6) of 10 patient records reviewed.

Findings:

1.) Review of grievances revealed that on 4/11/12 Patient #2 notified the hospital that she developed a stage 3 pressure ulcer during her admission for hip surgery on 3/23/12. The grievance is listed as " quality of care, potential for injury. " On 6/28/12 the hospital notified the patient that her bill will be adjusted to write off her deductible amount due of $1116.23 which reflected a zero balance on her account.

Record review revealed that on 3/21/12 the patient was admitted to the hospital for hip replacement surgery. On 3/21/12 at 1:40 PM she is admitted to 6 south after surgery.

On 3/21/12 at 1:40 PM the nurse documented her Braden Score (pressure ulcer risk) at 17 (mild risk), skin care protocol per policy. Her skin is documented as dry, intact with normal skin turgor.

On 3/21/12 at 8:20 PM the nurse documented that Patient #2 ' s Braden Score is 17 (mild risk), skin care protocol per policy. Her skin is documented as dry, intact with normal skin turgor. She is also listed as bedfast.

On 3/22/12 at 8 AM the nurse documented that Patient #2 ' s Braden Score is 18 (mild risk), skin care protocol is initiated per policy. Her skin is documented as dry, intact with normal skin turgor. She is also listed as chair fast.

On 3/22/12 at 8:27 PM the nurse documented that Patient #2 ' s Braden Score is 15 (mild risk), skin care protocol per policy. Pressure relief devices are listed as zoneaire bed with heel relief on. Her skin is documented as normal skin turgor. She is also listed as chair fast.

On 3/23/12 at 7:25 AM the nurse documented that Patient #2 ' s Braden Score is 15 (mild risk), continue skin care protocol per policy. Pressure relief devices are listed as zoneaire bed and pillows. Her skin is documented as normal skin turgor. She is also listed as chair fast.

On 3/23/12 at 7:40 PM the nurse documented that Patient #2 ' s Braden Score was 17 (mild risk), initiate skin care protocol per policy. Her coccyx is documented as warm and fragile. Her skin turgor is documented as loose. Pillows are listed as a pressure relief device. Interventions are listed as pressure ulcer order, initiate per policy.

On 3/24/12 at 7:40 PM the nurse documented that Patient #2 ' s Braden Score was 17 (mild risk), initiate skin care protocol per policy. Her coccyx is documented as warm and fragile. Her skin turgor is documented as loose. Pillows are listed as a pressure relief device. Interventions are listed as pressure ulcer order.

On 3/24/12 at 5:45 PM the nurse documented that Patient #2 is discharged to rehabilitation facility by stretcher accompanied by medical transport.

There was no additional information documented concerning the pressure ulcer. There are no measurements in the hospital record concerning the pressure ulcer. Review of the physician ' s discharge history and physical there is no mention of the pressure ulcer. Review of the Certification for Nursing Facility (form 3008) on page 2 under skin condition revealed that Patient #2 has a decubitus located on her coccyx. The area for stage and size are blank.

Review of the Skilled Nursing Facility admission notes revealed that upon admission assessment on 3/24/12 the nurse noted that Patient #2 had a stage 3 pressure ulcer to her coccyx area. The wound measured 8.3 cm length by 6.5 cm width by 0.3 cm depth. There was a moderate amount of serosanguinous drainage. The tissue is described as 10% epithelial, 40% granulation and 50% slough. The margins are described as irregular and the surrounding tissue is described as blanchable.


Interview with the wound care nurses on 8/15/12 at 9:25 AM stated that they were never consulted for Patient #2 ' s skin condition.

2.) Observation of the wound care team performing wound care on Patient #6 on 8/15/12 at 10:30 AM. The wound care team stated that this was their first visit with the patient. They stated that the patient was transferred to this unit (medical-surgical unit) last night. The nurse on the unit notified the physician of the patient ' s coccyx wound and a wound consult order was obtained from the physician. The measurements were as follows: 5cm length by 1cm width by 0.12 cm depth.

Record review for Patient #6 revealed that the patient was admitted on [DATE]. She has remained in the hospital since that time. Review of the documentation concerning Patient #6 revealed the following:

Between 7/29/12 at 11:30 PM to 8/4/12 at 12:41 PM the patient ' s skin is described as within normal limits.

On 8/4/12 at 8 PM the coccyx area is described as fragile with [DIAGNOSES REDACTED]. The Braden Score is 17 (mild risk). The pressure relief devices are pillows, zoneaire bed on prevention mode and skin care protocol per policy.

On 8/5/12 at 11:18 AM the skin is documented as within normal limits with skin turgor described as normal. . The Braden Score is 17 (mild risk). The pressure relief devices are pillows, zoneaire bed on prevention mode and skin care protocol per policy.

On 8/5/12 at 8:57 PM the coccyx is described as fragile with [DIAGNOSES REDACTED]. The Braden Score is 18 (mild risk). The pressure relief devices are pillows, zoneaire bed on prevention mode and skin care protocol per policy.

On 8/6/12 at 10:29 AM the patient ' s skin is described as normal. The Braden Score is 11 (high risk).

On 8/6/12 at 8:36 PM the coccyx is described as fragile with [DIAGNOSES REDACTED]. The Braden Score is 18 (mild risk). The pressure relief devices are pillows, zoneaire bed on prevention mode and skin care protocol per policy.

On 8/7/12 at 7:37 AM the coccyx is described as fragile with [DIAGNOSES REDACTED]. The Braden Score is 12 (moderate risk). The pressure relief devices are pillows, zoneaire bed on prevention mode and skin care protocol per policy.

On 8/7/12 at 5:18 PM the coccyx is described as fragile. The skin is broken. Critic aide cream applied to area.

On 8/7/12 at 9:18 PM the coccyx is described as fragile with [DIAGNOSES REDACTED]. The Braden Score is 12 (moderate risk). The pressure relief devices are pillows and a total care bed.

On 8/8/12 at 9:30 AM the coccyx is described as fragile with [DIAGNOSES REDACTED]. The Braden Score is 12 (moderate risk). The pressure relief devices are pillows, zoneaire bed on prevention mode and skin care protocol per policy.

On 8/8/12 at 8 PM the coccyx is described as fragile with [DIAGNOSES REDACTED]. The Braden Score is 12 (moderate risk). The pressure relief devices are pillows, zoneaire bed on prevention mode and skin care protocol per policy.

On 8/9/12 at 9 AM the coccyx is described as fragile with [DIAGNOSES REDACTED]. The Braden Score is 13 (moderate risk). The pressure relief devices are pillows, zoneaire bed on prevention mode and skin care protocol per policy.

No other nurse ' s notes were provided to the surveyor after 8/9/12 at 9 AM.

There were no more indications in the notes that the physician was notified of the patient having an open wound on her coccyx area until 8/14/12. There was no wound measurements (for the area of [DIAGNOSES REDACTED] on her coccyx) noted in the record.



Review of the physician ' s orders for stage I, II, and suspected deep tissue injury revealed that " wounds in difficult to dress areas on buttocks, or skin is denuded and wound is without depth, apply critic aide (skin barrier paste) every 4 hours and after each incontinent episode. Do not completely remove paste between applications, rinse area and re-apply (if also using antifungal cream may apply critic aide on top of antifungal cream). Initiate prevention protocol: 2 hour turn schedule (post and follow), bed in prevention mode, and to heel ulcers apply heel/lift suspension boots. " These orders are pre-printed and are used for the skin care protocol.

Review of the pressure ulcer risk assessment prevention and treatment policy effective and last reviewed on 2/10/12 on page 5 item g states " notify physician of any nosocomial pressure ulcer at first recognition and request a wound consult. "