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CHRISTUS MOTHER FRANCES HOSPITAL 800 EAST DAWSON TYLER, TX 75701 March 14, 2013
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview the facility failed to insure the nursing staff met the needs of 1 (#1) of 10 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10) patients (Pt). The Registered Nursing staff failed to supervise the bed side care of this [AGE] year old male patient.

On 3/14/2012 in the conference room at 10:30 AM Pt #1 medical record (MR) was reviewed and revealed. Pt #1 was an [AGE] year old male who was evaluated in the Emergency Department (ED) on 10/30/20 at 11:15 PM. Pt #1 was diagnosed with [DIAGNOSES REDACTED]. Admission nursing documentation revealed Pt #1 had no break in skin integrity. MR revealed Pt #1 was discharge home on 11/16/2012. Documentation revealed wound care teaching at discharge.

At 11:30 AM further MR review revealed the hourly documentation for the Patient Care Flowsheets did not consistently document Pt #1 had been turned from side to side to reduce the pressure on his ventral surface (back side).
10/30/2012 there was no documentation Pt #1 had been turned from 2:00 Am -6:00 AM (4 hours), while in the ED. Pt was admitted for inpatient care.
10/31/2012 reflected a one time statement for the shift, "turns with assistance"
10/31/2012 the initial wound care visit reflected "Pt with double AKA. Pt has slowly blanching redness to lower spine. Xenaderm ointment recommended & waffle mattress ordered. Turn pt every 2 hours".
11/1/2012 reflected a one time statement for the shift, "turns independently",
11/2/2012, reflected a one time statement,"turn q (every) 2 hours",
11/3/2012 reflected no documentation from 3:00 PM -6:00 AM (16 hours),
11/3/2012 at 0400 reflected the following physician's order "Cedifficill culture positive X1, Flagyl 250 mg by mouth every 6 hours". Pt #1 had developed bacterial diarrhea.
11/3/2012 reflected nursing skin assessment Pink stage 1 on coccyx.
11/4/2012 reflected no documentation on on the flow sheet from 1:00 PM- 6:00 AM (18 hours)
11/5/2012 reflected a one time statement for the shift, "repositioned",
11/6/2012 reflected a one time statement for the shift, "repositioned with hourly bed changes" Documentation revealed the nursing staff relied on the function of the bed to reposition Pt #1
11/6/12 at 1543 physician's orders reflected the Flagyl dose was increased to 500 mg by mouth Q (every) 8 hours.
11/6/2012 0745 nursing documentation reflected "coccyx red and raw stage 2 pressure ulcer noted at lower spine".
11/7/2012 there was no documentation of a position change from 7:00 Am to 6:00 AM (24 hours)
11/7/12 at 1330 wound care documentation reflected "Pt with no open wounds or breakdown noted. 1 small sore to each AKA healed. Xenaderm to coccyx Braden score 12".
11/8/2012 reflected a one time statement for the shift, "turned Q2 hours, rotating mattress". Again the documentation revealed the nursing staff relied on the mechanism of the bed for position changes for Pt #1. 11/8/2012 wound care photos reveal a 10.5 centimeter bright red area to Pt #1 buttocks.
11/9/2012 reflected a one time statement for the shift, "rotating bed", again the documentation revealed the nursing staff relied on the mechanism of the bed to reposition Pt #1.
11/9/13 at 1805 nursing documentation reflected "Dressing to lower back changed per MD (Medical Doctor) order...Dressing to Coccyx ..pt keeps urinal between his legs for continence".
11/10/13 at 0740 nursing documentation reflected "Dressing to the spine and bilateral stumps changed".
11/11/2012 reflected a one time statement for the shift, "rotating bed". Nursing staff continue to document reliance on the bed for repositioning PT #1. Pt was transferred to ICU
11/12/2012 reflected documentation that read "rotating bed", Nursing staff continue to document their use of the mechanism of the bed to reposition PT #1.
11/12/2012 wound care photos reveal open tissue to bilateral AKA, open tissue with black eschar over small area of the coccyx and right buttock.
11/13/2012 reflected documentation that read "automatic 30 degree turn", staff continue to document dependence on the mechanism of the bed to reposition Pt # 1.
11/14/2012 reflected no documentation from 3:00 PM - 6:00 Am. Pt #1 was transferred from ICU to a high acuity nursing unit.
11/14/12 at 1353 physician's order read 1). clean wounds to Bilateral AKA with Normal Saline, apply medihoney, cover with mepilex daily. 2) continue Xenaderm ointment to coccyx every 6 hours and as needed. 3) order pt Dolphin mattress when room available to transfer.
11/15/2012 reflected no documentation from 7:00 Am until 6:00. Am the next morning.

On 3/14/2013 in the conference room at 11:00 Am Wound Care Nurse, staff #4, was interviewed and revealed, Pt #1 was placed on the RT3000 bed while on the cardiac unit. The ICU beds were comparable and both were high quality low air loss beds, however the mechanism of off loading did not replace repositioning the patient at least every 2 hours. Nursing staff were responsible to reposition the patient at least every 2 hours.

The nursing staff failed to document turning Pt #1 from side to side. Failure to off load his ventral surface, while he was debilitated and bed bound, contributed to skin integrity breakdown.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to maintain a current care plan for 1 (#1) of 10 patient (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10).

On 3/14/2013 at 10:00 AM the facilities policy for referral to the wound care program was reviewed. Policy WC-3 revealed the following:
3.1 A referral to the Inpatient Wound Care Nursing Team is generated by the Braden Scale Score of equal to or less than 16.
3.4 The inpatient Wound Care Nursing Team consult will occur within 24-72 hours of receipt of referral.
3.11 Interdisciplinary Care Plan (ICP) Notes will be updated when the patient is seen by a member of the Inpatient Wound Care Nursing Team.

On 3/14/2013 at 10:30 AM in the conference room the medical record (MR) for Patient (Pt) #1 was reviewed and revealed. As identified in the History and Physical (H&P) Pt #1 was an [AGE] year old male who was evaluated in the Emergency Department (ED) on 10/30/2013 at 11:35 PM. Pt #1 was in [DIAGNOSES REDACTED]and was admitted to the acute coronary care (ACC) unit. Pt #1 secondary diagnosis was Myocardial Infarct. Pt #1 was a bilateral above the knee amputee (AKA).

Further MR review revealed Pt #1 had a Braden score of 11 and was seen for a wound care consult on 10/31/2012. Pt #1 was placed on an inflatable air mattress called a Waffle mattress at the time of the consult . Pt #1 had bright pink tissue to the sacral and lower back area. The was no break in skin integrity documented. There was no documentation by the Wound Care Nursing Team that an ICP was initiated.

Further MR review revealed, on 11/1/2012 nursing documentation reflected abrasions on the bilateral AKA stumps. Pt #1 was mobile in bed with an overhead trapeze bar. A nutritional screening was completed on 11/5/2012. The Registered Dietitian recommended increasing Jevity 1.2 liquid supplement via naso gastric tube at a rate of 45 milliliters(ML) and hour, with a bolus of 150 ML of water every 6 hours.

On 11/7/2012 Pt #1 was scheduled for an upper endoscopic gastric examination to rule out an upper gastric bleed. The following day, 11/8/2012, the wound care nurse did a follow-up consultation and upgraded the mattress to an air fluctuation mattress. On 11/9/2012 Pt #1 was diagnosed with [DIAGNOSES REDACTED]. Pt #1 was intubated and transferred to the intensive care unit (ICU).

On 3/14/2012 at 2:00 PM an interview with staff #4 confirmed the bed/mattress quality for patient use in ICU was the same quality bed as Pt #1 had used while on the ACC unit.

Review of Pt #1 lab value, necessary for healing, revealed his Albumin level was recorded as 2.1 on 11/ 2 and on 11/12/2012, after 2 units of blood was given, his Albumin was 3.3. Normal level of Albumin is 3.9-5.0. His total protein recorded on 11/12/2012 remained low at 5.8 (Normal 6.3-8.2)

Review of the MR for Pt #1 revealed between 10/30/2012 through 11/13/2012 skin break down occurred with bright red tissue and black areas visible on his sacrum and lower back. Further review revealed there was no documentation of a care plan problem to maintain skin integrity, initiate treatment or preventative interventions for skin break down.

Pt #1 was discharge home with documentation for wound care treatment on 11/16/2012.