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AURORA MEMORIAL HOSPITAL BURLINGTON 252 MCHENRY ST BURLINGTON, WI 53105 Aug. 13, 2019
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record review and interview, facility staff failed to perform appropriate preventive interventions for 6 of 10 patients at risk for impaired skin integrity (Patients #1, 2, 5, 6, 9, and 10) in a total sample of 10.

Findings include:

Facility staff failed to implement protective interventions and prevent skin breakdown for patients at risk. See tag A 395.

These deficient practices have the potential to affect all patients at risk for impaired skin integrity admitted to the facility.
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 follow their policy to assess, implement, appropriate interventions for 6 of 10 (Patients # 1, 2, 5, 6, 9 and 10) and follow the established care plan to prevent the deterioration of current pressure ulcers for 2 of 10 patients (Patient #1 and #10) during hospitalization in a total of 10 patients.

Findings include:

Review of policy titled, Skin Integrity Alteration-Potential-Actual, dated 3/21/2019 revealed, "5.8 Interventions for Patients at Risk for Pressure Injuries; b. Repositioning (e.g. redistribute pressure every 2 hours and PRN (as needed)."

Review of policy titled, Nursing Documentation, dated 10/25/2018 revealed, "4.2 Nursing caregivers are responsible for following the polices for documentation in the medical records and for adhering to applicable procedures. 4.3 Nursing caregivers are responsible for the timely documentation of all aspects of nursing care provided to the patient, regardless of venue. 4.6 Inpatient nurses will complete required admission assessments within the time frames established in nursing assessment and reassessment inpatient...and document the findings in the medical record."

Interview of Registered Nurse Medical/Surgical C on 8/13/2019 at 10:22 AM stated, "If patients have Braden score of less that 18 they are considered at high risk for pressure injuries. We will use Stage IV mattress, patients are up in chairs for meals, if able, boots are used for off loading pressure to the heels, chair cushions, and we will reposition the patients every 2 hours. We document only the changes when completing an assessment. A dietary consult is triggered by Braden score or wound documentation. If a patient develops a new pressure injury we apply barrier cream, we measure the area and assess daily. The wound care nurses are consulted and we apply mepilex dressings."

Patient #1

Review of Patient #1's closed medical record on 8/13/2019 at 1:08 PM revealed Patient #1 was admitted on [DATE] at 4:23 PM for lower abdominal pain. The document titled, "Hospitalist Admission History and Physical," dated and timed 5/22/2019 at 3:56 PM, revealed #1 had a history of the following comorbidities: hypertension (high blood pressure), Diabetes, Low back pain, Arthritis, Chronic Obstructive Pulmonary Disease and Peripheral edema.

On 5/22/2019 at 5:06 PM, the nursing admission documentation in "Daily Cares Safety" revealed, Mobility...Level of Assistance...Maximal Assist."

At 7:26 PM, the nursing admission documentation in "Physical Assessment" revealed, "Integumentary...Pressure Injury Coccyx...wound exudate none...wound bed red... Topical agent application cream."

The Braden risk assessment on 5/22/2019 revealed Patient #1 was at risk for skin breakdown with an assessment score of 14 at 5:00 PM.

On 5/22/2019, Patient #1's care plan titled, "Multidisciplinary Problems (Active)" revealed, "Problem: Activity Intolerance...Intervention: Turn q (every) 2 hours..."

Skin Integrity Alteration...Problem: Pressure Injury, Actual...Intervention: # Assess, measure, and stage pressure injury q (every) 7 days or if status is deteriorating..."

No turning or repositioning was documented in "Daily Cares/Safety" or "Daily Cares/Safety CNA (certified nursing assistant)" for Patient #1 from 5/22/2019 at Midnight until 5 hours later, on 5/23/2019 at 5:00 AM. Repositioning documented through 10:37 AM and then not until 2:00 PM and then next reposition is at 8:00 PM. On 5/24/2019 at 10:45 AM repositioning was documented, the next reposition occurred at 11:32 PM, and then on 5/25/2019 at 8:45 AM. Documentation noted for repositioning on 5/25/2019 at 6:00 PM and then not again until 10:40 PM. On 5/27/2019, there was no documentation of repositioning between the times of 2:45 PM and 10:19 PM and between 5/27/2019 at 10:19 PM and 5/28/2019 at 2:25 AM.

History and Physical for Patient #1 written on 5/22/2019 at 3:56 PM revealed, no mention of pressure ulcers, only under past medical history- pressure ulcer of coccygeal region stage 3.

assessment dated [DATE] at 7:26 PM through 5/26/2019 at 7:05 PM included the following documentation: wound coccyx- pressure injury- bony prominence, Stage 3, present on admission, wound bed is red, cream applied, no dressing.

assessment dated [DATE] at 7:44 PM included the following documentation: wound coccyx- pressure injury- bony prominence, Stage 3, present on admission, Foam silicone dressing with borders clean, dry, and intact. Wound buttocks-right-traumatic-non pressure wound, Foam silicone dressing with borders clean, dry, and intact.

assessment dated [DATE] at 12:13 PM included the following documentation: wound coccyx- pressure injury- bony prominence, Stage 3, present on admission, Wound care team consult date 5/28/19 DTPI (deep tissue pressure injury) dressing changed on 5/28/2019, wound exudate- small sanguineous, wound bed- maroon Epithelialized granulated, Peri-wound condition- [DIAGNOSES REDACTED], mild [DIAGNOSES REDACTED], blanchable. Calazime cream. No dressing, 21 cm x 14 cm.

Patient #1 was discharged from the facility on 5/28/2019 an inpatient wound care consult noted dated 5/28/2019 revealed, "(Patient) has had problems with sacral/buttock pressure injuries in the past. States that prior to admission, did not have any wounds on buttocks... Wound exam: Bilateral Multiple buttocks pressure injuries, wound is intact with ecchymotic lesions let buttock/left hip area with stage II pressure injury. Right buttock skin tear near superior gluteal fold, there are areas of blanchable [DIAGNOSES REDACTED] in the periwound. No signs of cellulitis or infection."

Patient #10

Review on 8/13/2019 at 4:15 PM of Patient #10's closed medical record revealed Patient #10 was admitted on [DATE] at 1:27 PM for sepsis (infection), cellulitis (infection of the skin), and a chronic, unstageable heel ulcer. The document titled, "H&P (History and Physical)" dated and timed 6/18/2019 at 1:15 PM, revealed #10 had a history of the following comorbidities: hypertension (high blood pressure), diabetes, coronary artery disease, low back pain, Parkinson's disease, cerebral infarction (stroke), recurrent cellulitis of of lower leg, and stage 3 chronic kidney disease. "HPI (history of present illness)" revealed, "...[#10] has a chronic right heel ulceration that [he/she] sustained while using [his/her] right foot to push [him/herself] around in a wheelchair. [#10]'s been followed by wound care for this...Skin surrounding the right heel ulcer was reddened and warm and the wound itself was quite foul-smelling..."

On 6/18/2019 at 4:00 PM, the nursing admission documentation in "Daily Cares/Safety" revealed, "Mobility...Level of Assistance...Maximal Assist."

At 2:42 PM, the nursing admission documentation in "Physical Assessment" revealed, "Integumentary...Skin Integrity WDL (within defined limits) Except...Wound...Wound Heel Right Interior Pressure Injury...Wound Assessment Properties...Location: Heel Laterality: Right Modifier: Interior Primary Wound Type: Pressure inj (injury) Initial Pressure Injury Stage: Unstageable/necrotic tissue Date first assessed: 04/08/19 Time First Assessed: 1600 (4:00 PM)...Wound Heel Right Pressure Injury...Location: Heel Laterality: Right Primary Wound Type: Pressure inj (injury) Initial Pressure Injury Stage: Stage 4 Present on Hospital Admission: Y (yes)."

The Braden risk assessment revealed Patient #10 was at risk for skin breakdown with an assessment score of 12 on 6/18/2019 at 4:00 PM and 11 on 6/20/2019 at 8:00 AM.

On 6/18/2019 at 4:37 PM, Patient #10's care plan titled, "Multidisciplinary Problems (Active)" revealed "Template: Skin Integrity Alteration...Problem: Pressure Injury, Risk for...Intervention: # Turn/reposition patient q (every) 2 hours..."

No turning or repositioning was documented in "Daily Cares/Safety" or "Daily Cares/Safety CNA (certified nursing assistant)" for Patient #10 from 6/18/2019 at 8:00 PM until 3 hours later at 11:00 PM. The next documented repositioning was nearly 11 hours later, on 6/19/2019 at 9:51 AM.

No turning or repositioning was documented in "Daily Cares/Safety" or "Daily Cares/Safety CNA" for Patient #10 from 6/19/2019 at 9:51 AM until over 11 hours later at 9:00 PM.

No turning or repositioning was documented in "Daily Cares/Safety" or "Daily Cares/Safety CNA" for Patient #10 from 6/19/2019 at 11:50 PM until 14 hours and 10 minutes later, on 6/20/2019 at 2:00 PM. The next documented repositioning was 5 hours and 5 minutes later, at 9:05 PM.

No turning or repositioning was documented in "Daily Cares/Safety" or "Daily Cares/Safety CNA" for Patient #10 from 6/20/2019 at 11:45 PM until over 12 hours later, on 6/21/2019 at 12:00 PM. The next documented repositioning was 3.5 hours later, at 3:30 PM, and again over 7 hours later, at 10:42 PM.

On 6/21/2019 at 3:00 PM, "Physical Assessment" revealed the presence of an additional pressure injury. "Integumentary...Skin Integrity WDL (within defined limits) Except...Pressure Injury; Wound...Wound Coccyx Blister...Wound Assessment Properties...Location: Coccyx Primary Wound Type: Blister Pressure Injury Etiology: Bony Prominence Date first assessed: 06/21/2019 Time First Assessed: 1500 (3:00 PM) Present on Hospital Admission: N (no) Resolution Date: 08/03/2019 Resolution Time: 1158 (11:58 AM)...Pressure Injury Stage...blister/stage 1."

At 4:49 PM, "Progress Notes" revealed, "[Physician], patient, and spouse aware of blister on coccyx. Will continue to monitor."

No turning or repositioning was documented in "Daily Cares/Safety" or "Daily Cares/Safety CNA" for Patient #10 from 6/21/2019 at 10:42 PM until nearly 4 hours later on 6/22/2019 at 2:14 AM. The next documented repositioning was over 5 hours later, at 7:51 AM, again over 7 hours later at 3:00 PM, and again 8.5 hours later at 11:34 PM.

No turning or repositioning was documented in "Daily Cares/Safety" or "Daily Cares/Safety CNA" for Patient #10 from 6/22/2019 at 11:34 PM until nearly 8 hours later on 6/23/2019 at 7:35 AM. The next documented repositioning was nearly 6.5 hours later, at 2:00 PM.

No turning or repositioning was documented in "Daily Cares/Safety" or "Daily Cares/Safety CNA" for Patient #10 from 6/23/2019 at 4:48 PM until nearly 4 hours later at 8:47 PM. The next documented repositioning was over 5 hours later, on 6/24/2019 at 1:58 AM.

No turning or repositioning was documented in "Daily Cares/Safety" or "Daily Cares/Safety CNA" for Patient #10 from 6/24/2019 at 3:11 AM until over 5 hours later at 8:36 AM. The next documented repositioning was over 6 hours later, at 2:44 PM. The next documented repositioning was nearly 18 hours later, on 6/25/2019 at 8:30 AM.

No turning or repositioning was documented in "Daily Cares/Safety" or "Daily Cares/Safety CNA" for Patient #10 from 6/25/2019 at 11:04 AM until 3 hours and 3 minutes later at 2:07 PM. No repositioning was documented from 3:18 PM until nearly 6 hours later at 9:00 PM.

Further review of the medical record revealed documentation of staging of #10's heel wounds did not change during the course of the 8 day hospital stay, between 6/18/2019 and 6/26/2019. Patient #10 was followed by wound care and underwent surgical debridement of the wound during the inpatient stay. The assessment and staging of #10's coccyx blister did not change during the remainder of the hospital stay, between 6/21/2019 and 6/26/2019. There was no documentation found that wound care was consulted or treatments ordered for the coccyx blister.

Patient #10 was discharged on [DATE] to a skilled nursing facility with orders for intravenous antibiotics.

Interview with Manager of Clinical Informatics L on 8/13/2019 at 5:00 PM regarding the chart reviews, "there appears to be some missing documentation,"

Interview with Nurse Educator M on 8/13/2019 at 3:45 PM, "We have recognized areas and opportunities for improvements in the hospital acquired conditions and pressure injury prevention and are in the process of creating a resource binder."

Patient #2

Review of Patient #2 open medical record on 8/13/2019 at 2:44 PM revealed Patient #2 was admitted on [DATE] at 10:19 AM for lethargy (state of tiredness, weariness, fatigue) due to septic shock (widespread infection causing organ failure). The document titled, "Hospitalist Admission History and Physical," dated and timed 8/12/2019 at 9:44 AM, revealed #2 had a history of the following comorbidities: Parkinsonism.

On 8/12/2019 at 8:00 PM, the nursing admission documentation in "Daily Cares/Safety" revealed, "Mobility...Level of Assistance...Total Assist." At 10:30 PM, "Mobility...Positioning...Head of bed elevated, turned every two hours; reposition."

The Braden risk assessment on 8/12/2019 revealed Patient #2 was at risk for skin breakdown with an assessment score of 6 at 10:20 AM.

On 8/12/2019, Patient #2's care plan titled, "Multidisciplinary Problems (Active)" revealed, "Problem: Activity Intolerance...Intervention: Turn q (every) 2 hours..."

No turning or repositioning was documented in "Daily Cares/Safety" or "Daily Cares/Safety CNA (certified nursing assistant)" for Patient #2 from 8/12/2019 at 10:30 AM until 4.5 hours later, on 8/12/2019 at 3:00 PM, then there was no documentation again until 7:45 PM. Documentation on 8/12/2019 at 11:00 PM and then none again until 8/13/2019 at 4:00 AM.

Patient #5

Review of Patient #5 closed medical record on 8/13/2019 at 4:55 PM revealed Patient #5 was admitted on [DATE] at 12:45 PM abdominal pain. The document titled, "Hospitalist Admission History and Physical," dated and timed 5/22/2019 at 12:38 PM, revealed #5 had a history of the following comorbidities: Osteoporosis, Hypertension (high blood pressure), Cerebral vascular Accident, and Osteoarthritis.

On 5/22/2019 at 11:51 PM, the nursing admission documentation in "Daily Cares/Safety" revealed, "Mobility...Level of Assistance...Moderate assist." At 10:30 PM, "Mobility...Positioning...Head of bed elevated, reposition."

The Braden risk assessment on 5/23/2019 revealed Patient #5 was at risk for skin breakdown with an assessment score of 18.

On 5/22/2019, Patient #5's care plan titled, "Multidisciplinary Problems (Active)" revealed, "Problem: Impaired Physical Mobility...Intervention: Turn q (every) 2 hours..."

No turning or repositioning was documented in "Daily Cares/Safety" or "Daily Cares/Safety CNA (certified nursing assistant)" for Patient #5 from 5/23/2019 at 8:00 AM until 9 hours later, on 5/23/2019 at 5:00 PM. Repositioned on 5/23/2019 at 11:59 PM and then no documentation of repositioning until 5/24/2019 at 10:36 AM.





Patient #6

Review of Patient #6's open medical record on 8/13/2019 at 1:15 PM revealed Patient #6 was admitted on [DATE] at 6:07 PM for lethargy (state of tiredness, weariness, fatigue). The document titled, "Hospitalist Admission History and Physical," dated and timed 8/12/2019 at 6:26 PM, revealed #6 had a history of the following comorbidities: anemia (low red blood cell count), coronary artery disease, chronic kidney disease, hypertension (high blood pressure), and dementia.

On 8/12/2019 at 7:09 PM, the nursing admission documentation in "Daily Cares/Safety" revealed, "Mobility...Level of Assistance...Total Assist."

At 8:00 PM, the nursing admission documentation in "Physical Assessment" revealed, "Integumentary...Moisture...Excessive Dryness...Skin Integrity WDL (within defined limits) Except...Skin abnormality (abrasions/scratches, insect bites or rashes)."

The Braden risk assessment on 8/12/2019 revealed Patient #6 was at risk for skin breakdown with an assessment score of 14 at 7:13 PM.

On 8/12/2019 at 6:43 PM, Patient #6's care plan titled, "Multidisciplinary Problems (Active)" revealed, "Template: Skin Integrity Alteration...Problem: Pressure Injury, Risk for...Intervention: # Turn/reposition patient q (every) 2 hours..."

No turning or repositioning was documented in "Daily Cares/Safety" or "Daily Cares/Safety CNA (certified nursing assistant)" for Patient #6 from 8/12/2019 at 7:04 PM until 5 hours later, on 8/13/2019 at 12:14 AM.

Patient #9

Review on 8/13/2019 at 2:59 PM of Patient #9's open medical record revealed Patient #9 was admitted on [DATE] at 4:02 PM for dementia and an open wound on the right wrist fracture site. The document titled, "Hospitalist Admission History and Physical," dated and timed 8/9/2019 at 5:23 PM, revealed #9 had a history of the following comorbidities: hypertension (high blood pressure), arthritis, degenerative disc disease, lumbar (lower back), chronic renal (kidney) insufficiency, edema (swelling), incontinence, dementia, wrist fracture.

On 8/9/2019 at 4:56 PM, the nursing admission documentation in "Daily Cares/Safety" revealed, "Mobility...Level of Assistance...Total Assist."

At 5:14 PM, the nursing admission documentation in "Physical Assessment" revealed, "Integumentary...Skin Integrity WDL (within defined limits) Except...Skin abnormality (abrasions/scratches, insect bites or rashes)."

The Braden risk assessment revealed Patient #9 was at risk for skin breakdown with an assessment score of 17 on 8/9/2019 at 7:13 PM and 15 on 8/10/2019 at 8:50 AM.

On 8/9/2019 at 11:58 PM, Patient #9's care plan titled, "Multidisciplinary Problems (Active)" revealed, "Template: Skin Integrity Alteration...Problem: Pressure Injury, Risk for...Intervention: # Turn/reposition patient q (every) 2 hours...Implement interventions to protect/heal skin related to incontinence and/or incontinence-associated dermatitis."

No turning or repositioning was documented in "Daily Cares/Safety" or "Daily Cares/Safety CNA" for Patient #9 from 8/9/19 at 5:33 PM until nearly 25 hours later, on 8/10/2019 at 6:50 PM.

On 8/11/2019, no turning or repositioning was documented in "Daily Cares/Safety" or "Daily Cares/Safety CNA" for Patient #9 from 12:12 AM until nearly 4 hours later at 4:00 AM. The next documented repositioning was nearly 13.5 hours later, at 7:25 PM.