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NORTH FLORIDA REGIONAL MEDICAL CENTER 6500 NEWBERRY RD GAINESVILLE, FL 32605 June 21, 2018
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to ensure practices were put in place to prevent facility acquired pressure ulcers and failed to prevent the worsening of facility acquired pressure ulcers for 2 of 3 sampled patients, Patients #1 and #3.

Findings:

A clinical record review of Patient #1's record revealed the patient was admitted to the facility on [DATE] without a pressure ulcer. The patient was bedbound. Diagnosis consisted of Chronic Obstructive Pulmonary Disease (COPD), Stroke, Mental status change, poorly controlled diabetes, legally blind, anxiety, atrial fibrillation.

During an interview on 06/21/2018 with the wound care therapist Staff D RN/therapy (Registered Nurse) at 1:59 PM, it was stated Patient #1 was found to have pressure ulcers when she was evaluated by wound care on 12/12/2017. Therapy recommended the patient be on a strict every two hour turn schedule. Therapy makes the recommendation and nursing gets the physician order.

During an interview on 06/21/2018 at 3:50 PM, with Staff F, RN 4 South Nurse Manager it was stated, when the nurse is documenting partial thickness that means a pressure ulcer. A skin assessment is completed once a day. A description of a full thickness wound would be a stage 3 pressure ulcer, a description of a partial thickness wound would be a stage 2 pressure ulcer. Staff F, RN confirmed the pressure wounds for Patient #1 were facility acquired.

A clinical record review for Patient #1 revealed the patient was incontinent of bowel and bladder. The skin was blanchable. The patient had skin excoriation (Excoriated skin is skin that has developed a sore or ulcer from urine exposure) to the posterior coccyx. The initial nursing assessment was completed on 11/27/2017. The skin assessment revealed the patient's skin was warm and dry.

A review of the nursing assessments From 11/28/2017 to 12/10/2017 revealed the following: the patient's skin remained with excoriation to the posterior coccyx. There is no documentation to reveal the patient was turned and repositioned during this time frame to help prevent the development of a facility acquired pressure wound.

On 12/08/2018 a review of the nurse's notes at 2:27 PM revealed Left mid back with opened blisters covered with Mepiplex. Turned and repositioned every 2 hours for comfort and skin integrity (no documented times the patient was actually turned or which position the patient was placed).

On 12/11/2017 the patient's skin remained with excoriation to the posterior coccyx. At 8 PM it was observed the patient had excoriation to lateral back middle. The Patient still had excoriation to her posterior coccyx.

On 12/12/2017 at 2:13 AM the nurse documented the patient was repositioned every 2 hours (no documented times the patient was actually turned or which position the patient was placed). A review of the wound therapy note at 4:10 PM revealed moist fragile slouching skin of sacrum and buttocks. Cleansed and dressed to treatment plan. The patient was to be on a Strict 2 hour turn schedule.

0n 12/13/2017 9:56 AM the patient had excoriation to lateral back middle, and posterior coccyx. Cannot calculate area. At 11:00 PM the nurse documented the patient had superficial coccyx wound with partial thickness.

0n 12/14/2017 9:30 AM the patient had excoriation to lateral back middle, and posterior coccyx. Full thickness wound to coccyx. And at 10:36 PM unable to determine back wound area. Coccyx partial thickness dressing changed.

0n 12/15/2017 the patient had excoriation to lateral back middle, and posterior coccyx. The wound was described as Partial thickness.

0n 12/16/2017 the patient had excoriation to lateral back middle, and posterior coccyx. The coccyx wound was described as Partial thickness.

0n 12/17/2017 the patient had excoriation to lateral back middle, and posterior coccyx. The wound was described as partial thickness.

0n 12/18/2017 at 4:04 PM the patient had excoriation to lateral back middle, and posterior coccyx. The patient had a pressure injury related to posterior coccyx. Deep tissue injury. Unstageable pressure injury.

0n 12/19/2017 8:45 AM the patient had excoriation to lateral back middle, and posterior coccyx. The patient had a pressure injury related to posterior coccyx. Deep tissue injury. Stage 3 pressure ulcer. Serosagnious drainage.

0n 12/20/2017 10:26 AM the patient had excoriation to lateral back middle, and posterior coccyx. The patient had a pressure injury to posterior coccyx. Deep tissue injury. Stage 3 pressure ulcer. Small amount of bleeding.

A review of the nursing documentation completed during shift assessments from 11/27/2017 to 12/20/2017 showed documentation twice that the patient was turned and repositioned (with no time parameters or position documented). The therapy recommendation was that the patient be on a strict two hour turning schedule.

A review of the nurses noted dated 12/19/2017, revealed the wound was measured on 12/19/17 by the nurse. The nurse noted the coccyx wound increased in size compared to Sunday. The nurse documented the coccyx wound was around 1 inch X 1 inch. But today noted much bigger dark discoloration, and per report from previous shift.

A review of the wound care consult ordered on [DATE]. Revealed the patient had moist fragile sloughing skin of sacrum and buttocks. Strict 2 hour turn schedule. P-500 (specialty bed) placed. Presents with pressure injuries. Injury to right back and sacrum area. The patient would benefit from rehab and dressing selection. Discharge to nursing for daily wound care. Sacrum friction shear. Right back pressure stage 2. Sacrum wound stage 2 was 12 Centimeters (CM) X 8 CM and the back was 2.5 CM X 1.5 CM.

A clinical record review showed there was no standard care plan documented for the prevention of pressure ulcers. The nursing care plans completed by nursing did not address the patient's pressure ulcers.



A clinical record review of patient #3's record revealed the patient was admitted to the facility on [DATE] with a diagnosis of generalized weakness.

A clinical record review of Patient #3's admission assessment dated [DATE] revealed the patient's skin on admission was clean and dry. There was no documentation to show the patient was admitted to the facility with pressure wounds. The clincal record for the period of 01/08/2018 to 01/11/2018 revealed the patient's skin was clean and dry.

A clinical record review of the nurses assessment completed on 01/12/2018 revealed the patient's skin on her buttocks was reddened but blanchable.

A clinical record review of the integrity assessment dated [DATE] revealed the patient has a pink but blanchable cup sized region on sacrum. Her sacrum and coccyx protrude. The patient is being turned every two hours to prevent skin breakdown (no documentation to show the times the patient was turned or what position the patient was turned).

A clinical record review from 01/14/18 to 01/22/18 revealed as documented in the integrity assessment, the patient has pink but blanchable cup sized region on sacrum. Her sacrum and coccyx protrude.

A clinical record review on 01/23/2018 of the wound consult completed by therapy revealed the patient had excoriation to the posterior buttock right. The wound care consult revealed the patient had a Stage 3 sacral decubitus ulcer. Wound #1 sacrum size 4.4 Centimeters (CM) X 4.2 CM. Wound bed pink with small areas of yellow slough in center, RN in room during wound care. Patient will benefit from rehab wound care for dressing selection. Education for pressure relief and wound healing.

A clinical record review On 01/25/2018 at 2:31 PM revealed the patient had excoriation posterior buttock right. The nurse's note at 8:26 AM revealed the nurse was unable to determine document advanced wound measurements. Wound care note for the wound flowsheet revealed wound location sacrum. Serous drainage. Size 4.4 CM X 4.2 CM. A review of the interdisciplinary note revealed the sacral wound has stabilized. At risk for further breakdown related to impaired nutrition and mobility, Will discharge (d/c) to nursing, medication in meditec and supplies at bedside. Nurses assessment revealed the patient has excoriation and a stage 2 pressure ulcer.

A clinical record review of the nursing assessments from 01/29/2018 and 01/30/2018 did not show documentation the patient was turned and repositioned.

A clinical record review of the nursing assessments from 02/01/2018 did not show documentation the patient was turned and repositioned.

A clinical record review on 02/04/2018 at 7:35 AM revealed the patient had a stage 2 pressure ulcer to posterior buttock right. A review of the Interdisciplinary notes at 9:39 AM central portion of sacral wound debrided and cleaned. Rehab note at 9:40 AM stage 3 pressure ulcer with serous drainage. 4.5 X 3.2.