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.

Based on an onsite survey of 1/29/14 inclusive of policy and procedure, interviews, and 10 patient records, it is revealed that nursing failed to identify patient #1's inability to effectively reposition himself, resulting in a deep tissue injury of the left heel.

Patient #1 is a middle-aged male who presented to the emergency department (ED) due to abdominal pain and vomiting, and white blood cell level of 31,100. Patient #1's history is significant in part for strokes with residual left-sided weakness, hypertension, renal insufficiency with weekly peritoneal dialysis, and diabetes mellitus.
Patient #1 was assessed by nursing on the day of entry to care with no skin wounds. Additionally, nursing assessed patient #1 as having " generalized weakness in all extremities." However, nursing flow documentation revealed that patient #1 had "active range of motion " with regards to positioning. Muscle strength grading reveals that patient #1 ' s lower extremities had "active movement against gravity and resistance."
A physician noted in part, "Skin is warm and dry. No bruising and no rash noted. He is not diaphoretic." Five days following admission, an MD wrote, " Pt told me the left side is much weaker then the right. No movement of left leg. Left arm can move but no strength."

Seven days following ED presentation, a sacral tear was noted, and on the eighth day, a deep tissue injury of the heel was noted. A consult to the wound nurse was ordered as well as orders to " turn patient, and elevate heels. " The following day, the Infectious Disease physician wrote, " left arm and leg have minimal movement. Cannot be raised off the bed. Right side is weak also, but not as severe as the left. "

Once identified, the hospital rapidly took steps to treat patient #1's skin. Both the skin tear and left heel were in states of healing at discharge. However, nursing failed to intervene based on the patient history of residual left-sided weakness and the initial nursing assessment of generalized weakness. Consequently, patient #1 proved to have insufficient active range of motion to reposition himself effectively to prevent the deep tissue injury of the left heel.