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HOLSTON VALLEY MEDICAL CENTER 130 WEST RAVINE ROAD KINGSPORT, TN 37662 Sept. 5, 2018
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, review of a facility protocol, facility documentation, medical record review, and interview, the facility failed to follow a physician's order for a timely consult and failed to follow a facility pressure ulcer protocol for 1 patient (#1) of 3 patients reviewed for pressure ulcers.

The findings included:

Review of facility policy "Wound & [and] Skin Care" dated 9/2014 revealed "...provide a wound management program to minimize the development of facility acquired pressure ulcers and to provide guidelines to treat alterations in skin integrity in a timely manner...one consulted the CWOCN [certified wound ostomy continence nurse]...will evaluate the treatment plan and revise as necessary..."

Review of a facility protocol "Addendum A (Pressure Ulcer Management Protocol)," not dated, revealed a facility decision tree for management of patients with pressure ulcers. Further review revealed "...does patient have a pressure ulcer or deep tissue injury..." Continued review revealed if the answer was yes the facility was to "...place patient on pressure relief support [pressure reducing mattress]..."

Medical record review revealed Patient #1 was admitted to the facility on [DATE] with a diagnosis of [DIAGNOSES REDACTED]

Medical record review of an Admission Assessment date 11/17/17 at 7:08 PM revealed the patient had abrasions and bruising to his buttocks with no open areas.

Medical record review of a nurse's note dated 11/24/17 at 7:01 AM revealed "...redness to buttocks...barrier cream ointment applied...Braden score 11 [increased risk for pressure ulcer development]..."

Medical record review of a physician's order dated 11/27/17 at 7:01 AM revealed "...consult to wound care..."

Medical record review revealed a Wound Care Consult was ordered on [DATE] at 7:01 AM. Further review revealed the wound care consult was not completed until 12/5/17 (9 days after the consult was ordered).

Medical record review of a Wound Care Consult dated 12/5/17, not timed, revealed "...he [Patient #1] has a 9 cm L [centimeter length] x [by] 15 cm W [wide] eschar [dead tissue] covered ulcer over his sacrum...there is a small 2 cm partial thickness ulcer over his right gluteal fold [buttocks] and another the same size over the left gluteal fold...impression: pressure ulcer nosocomial. Stage 2 [partial thickness skin loss] of the right and left gluteal fold...unstageable to sacrum..." Continued review revealed the patient was not placed on a specialty pressure reducing mattress until 12/13/17 (20 days later).

Interview with the Wound Care Nurse, on 8/30/18 at 3:25 PM, in the conference room, revealed "...the consult was ordered on [DATE]...the nurses do not stage the wounds, wound care does that. The patient had developed some redness and drainage along the cleft of the buttocks...I assessed the wound on 12/5/17 and found the wound to be unstageable with [DIAGNOSES REDACTED] [redness] on the sacrum and he had two stage 2 [pressure ulcers] on the gluteal folds. At that time I was the only wound care nurse and I was on vacation that week. We did not have another nurse who did [wound care] assessments so I saw the patient when I came back the week after...the patient was unable to move himself, he was on the ventilator...was a diabetic. He was being followed by Nutrition and was receiving tube feedings...he was placed on a specialty bed on 12/13/17 to assist in the keeping the patient off the wound..." Further interview confirmed the wound care consult was not performed until 9 days after the wound care consult was ordered.

Interview with the Intensive Care Unit (ICU) Clinical Leader on 8/31/18 at 1:05 PM, in the conference room, revealed the nursing staff identified the skin breakdown on 11/27/17 and a wound care consult was requested. Further interview confirmed "...the wound care nurse was on vacation...wound care does not work on the weekends...wound care did not see the patient until 12/5/17.

In summary, the facility failed to ensure a physician's order for a wound care consult for Patient #1 was completed timely and failed to follow a facility decision tree for timely placement of pressure relief support for Patient #1.