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PALMS WEST HOSPITAL 13001 SOUTHERN BLVD LOXAHATCHEE, FL 33470 April 13, 2016
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review, policy review and interview the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, Chapter 464.003(5) for 3 of 10 sampled patients (Patient #2, #3 and #9) as evidenced by failure to accurately assess wounds for Patient #2 and #3 and failure to complete nursing reassessment as specified in the facility policies and procedures for Patient #9.

The findings included:

Facility policy titled "Assessment and Reassessment" last revised 05/2015 documents, "Each patient is assessed by appropriate disciplines beginning at the time the patient enters the hospital service and progressing through discharge. Assessments contain data for analysis and support treatment decisions. All assessments are documented in the patient's medical record.
Reassessments by the Registered Nurse and other disciplines of patient needs and response shall occur at regular intervals as determined by the policy of each discipline or established unit standards.
Medical surgical and telemetry units:
Each patient is reassessed as the patient condition warrants and every 12 hours and the plan of care is reviewed and updated as applicable by a registered nurse. Reassessment includes a biophysical and psychosocial assessment of the patient's current plan of care/problem list. Additionally each patient is reassessed when there is a change in condition or diagnosis, on patient transfer to another level of care. Notify the physician with any change in condition, document in Meditech in physician notification screen."

Facility policy "Skin and Wound care policy" last revised 12/2015 documents "skin will be assessed upon admission and at every shift. Skin alterations will be photographed on discovery, weekly and with any significant change in status. Nursing will document presence of wounds in the wound site field. Notify the physician of any changes in skin integrity and nosocomial skin breakdown and obtain dressing orders."

Clinical record review conducted on 04/12/2016 revealed Patient #3 was admitted to the facility on [DATE] for an elective surgical procedure. The record indicates Patient #3 developed a pressure wound to the buttocks on 02/22/2016.

Dermatology consult dated 02/22/2016 documents, "there is a partial thickness loss of skin involving epidermis and dermis that appears as an open shallow ulcer with a pink wound bed located on the buttocks and mid back. Unless the presentation changes, will consider Stage II decubitus ulcer, will treat topically with Silvadene twice a day."

Review of the nursing shift assessments and nurses' notes dated 02/26/2016, 02/27/2016, 02/28/2016 and 02/29/2016 failed to document wound assessments as per guidelines.

Photographic evidence dated 02/26/2016 documents a change in the wound condition from a stage II to a wound with yellow slough. The photographic wound documentation noted the wound as a stage II pressure ulcer despite of the yellow slough; there are no measurements written by the assessor. Photographic wound documentation dated 02/29/2016 does not include documentation of an assessment of the wound; slough and eschar is visible on the picture. The wound is unstageable. Photographic wound documentation dated 03/02/2016 verified the wound is now unstageable. There is no assessment or measurements documented by the assessor.

The clinical record failed to provide evidence of documented measurements of the wound from 02/23/2016 thru 03/04/2016, when the wound was surgically debrided.

Physician's order dated 02/22/2016 documents Silver Sulfadiazine (Silvadene) apply twice a day. The order does not specify the location the cream is to be applied.
Administration Record documents the prescribed cream was apply to the coccyx wound and it was not administered on 02/25/2016.
Patient #3 had a new treatment order prescribed on 03/05/2016 with Dakin's solution 0.25% topical daily. The record documents the Silvadene cream was applied on 03/06/2016 and 03/08/2016 to the buttocks. The clinical record failed to provide clarification if both treatments were to be implemented simultaneously.

Further review of the administration records indicate the Silvadene cream was applied to the upper arm and generalized areas on 03/10/2016 and 03/14/2016. No indication for the use was documented.

Plastic Surgery consult dated 03/01/2016 documents patient needs pre albumin measured. The record failed to provide evidence a pre albumin level was obtained.

Interview with the Director of Patient Safety on 04/12/2016 at 12:26 PM while navigating the electronic record revealed there is no evidence of a comprehensive wound assessment on the days identified above; there are no measurements of the wound and there is no evidence the physician was notified of the change of wound status on 02/26/2016. The Director confirmed there is no pre albumin record on file.

Interview with the Director of Medical Surgical Services, Director of Intensive Care and Director of Patient Safety on 04/13/ at 9:10 AM revealed the facility does not have a policy for wound assessments; the facility follows Lippincott guidelines and provided a copy. In addition, Director of Medical Surgical Services explained photographic evidence is obtained weekly and placed in the chart for physician review. The photographic documentation is not a wound assessment; the assessment is documented on Meditech as part of the shift assessments.

Lippincott, Wound Assessment procedures document as follows: "A thorough wound assessment should consist of objective criteria and measurements that promotes accurate consistent comparisons to determine the extent of the wound and the effectiveness of wound healing. You should complete a comprehensive wound assessment during every dressing change and compare the results to the previous assessment so you can monitor, communicate, treat and document healing progression or complications. Wound assessment includes wound drainage description, wound color and measurements. Documentation: Record the general appearance of the patient ' s skin and bony prominence; the location, size and appearance of the wound site; whether there are drains or tubes are present; and whether drainage is present. Include the color, type, amount and odor of any drainage. Document the date and time of the assessment."

2) Clinical Record review conducted on 04/12/2016 revealed Patient #2 was admitted to the facility on [DATE]. The record indicates the patient developed a stage II pressure ulcer on 02/12/2016.
Treatment order for Mepilex was initiated on 02/12/2016. Further review of the record failed to provide evidence of a comprehensive wound assessment, including measurements, on the days the Mepilex was changed. Patient #2 was discharged home on 02/23/2016 with the Mepilex dressing in place. The discharge instructions did not address the status of the wound and treatment or follow up care if needed.
Interview with the Director of Patient Safety on 04/12/16 at 11:22 AM who was navigating the electronic record confirmed there is no comprehensive assessment of the stage II ulcer, no documented measurements and discharge instructions did not address the pressure wound.

3) Clinical record review conducted on 04/13/2016 revealed Patient #9 was admitted to the facility on [DATE]. Review of the record failed to provide evidence a nursing reassessment was completed every twelve hours, there is no record of a reassessment for 04/12/2016 night shift.
Interview with the Director of Patient Safety and the Director of the 4th floor on 04/13/2016 at approximately 12:15 PM revealed there is no record of the assessment, they have attempted to contact the nurse but have not heard back, "most likely it was human error."