HospitalInspections.org

Based on a review of medical records, facility policies and interviews, the facility failed to provide documented evidence that adequate, organized nursing care was provided to 9 of 10 patients [Patients #1-9] with pressure areas, 8 of which were active [Patients #2-9], due to vague or nonexistent patient care policies, non-specific and inadequate documentation of nursing care provided as well as inconsistent documentation of such care. This failure had the potential to affect all patients of the facility at risk for skin impairment.

Findings were:

A review of facility medical records revealed that the nursing Care Plans of active Patients #2-9 used the following two phrases:

? "Assess skin more frequently for pressure damage, as the patient may not be able to report pain ... "
? "Mobility: Turn and reposition every 2hrs or sooner if at risk..."

For example, the medical record of Patient #2 included the two phrases listed above. The Care Plan on 8/24/14 for this patient revealed that turning and repositioning of the patient had occurred every two hours by simply stating "Done" by the phrase "Turn and Reposition every 2 hrs." The entry which stated this task had been completed was entered at 8:30 a.m. for the 7 a.m. to 7 p.m. shift of 8/24/14. This patient had multiple pressure ulcers of varying stages documented in the medical record.

The medical record of Patient #6 included the two phrases listed above. The Care Plan on 8/24/14 for this patient revealed that turning and repositioning of the patient had occurred every two hours by simply stating "Done" by the phrase "Turn and Reposition every 2 hrs." The entry which stated this task had been completed was entered at 7:32 a.m. for the 7 a.m. to 7 p.m. shift of 8/24/14. This patient had been admitted on 8/22/14 with multiple pressure ulcers of varying stages documented. On 8/22/14 at 4:35 p.m. his Braden Risk Assessment Score, a scale used to predict pressure sore risk, was documented as 13.

The medical record of Patient #7 included the following:
1. At 8:00 a.m. on 8/22/14, a Braden Risk Assessment Score of 23 and it was documented the patient "walks frequently."
2. At 20:00 [8:00 p.m.] on 8/22/14, a Braden Risk Assessment Score of 15 and it was documented the patient was "bedfast."
The record of Patient #7 included documentation of a Stage II pressure ulcer on her coccyx.

The medical record of Patient #1, a discharged patient, included multiple Braden Risk Assessment Scores less than 18 throughout her stay. Patient #1 had been transferred to the facility from an acute care setting after undergoing toe amputations. Admission paperwork for Patient #1 on 1/10/14 revealed no documented pressure areas. By her discharge date on 3/13/14, her record included documentation of multiple pressure ulcers of varying stages. Nursing interventions listed in the "Pressure Ulcer Prevention and Management Guidelines" below were frequently not documented in the patient record, thus the facility could provide no documented evidence the interventions had actually been carried out.

In an interview with the Chief Nursing Officer (CNO) on the morning of 8/27/14 in the Hendrick Medical Center small conference room, when asked how it could be documented that the patient had been turned every two hours when the Care Plan documentation was entered at the beginning of a twelve-hour shift or at mid shift, the CNO had no response. When asked for nursing or patient care policies related to skin assessment, pressure ulcer prevention or pressure ulcer care, she stated the facility "had nothing" other than general "guidelines" which "weren't strictly policies."

Facility guidelines entitled, Pressure Ulcer Prevention and Management Guidelines, dated July 2013, stated, in part:
"Multidisciplinary Prevention
1. Identify patients at risk on admission and daily:
? Use Braden Pressure Ulcer Risk Scale
? If a patient scores 18 or less on the Braden Scale, implement these Pressure Ulcer Prevention & Management Guidelines ...
4. Encourage/assist patient with mobility:
? Reposition patient (a minimum of every two hours) using 30? lateral position when on side (Refer to Turning Schedule Section). When possible, do not turn patient onto a body surface that is still reddened from a previous episode of pressure loading...
9. Increase physician awareness to patient's status/needs ...
Skin Assessment ...
? Increase the frequency of inspection if the patient's overall condition deteriorates ...
? Turning schedule ...
? Patients need to be reminded to turn or need to be repositioned at least every 2 hours by nursing personnel ...
[The Braden Pressure Ulcer Risk Scale] is completed daily ...Any patient scoring 18 or less on this scale is considered to be at risk for pressure ulcer development. Interventions in this manual are to then be implemented..."

Facility policy entitled Nursing - Responsibility for Care, index 1.1001, date 8/1/12, stated in part:
"RULES:
1. The Vice-President of Nursing in collaboration with the Directors and Managers of Nursing ensures the delivery of acceptable standards for patient care and nursing performance for all nursing departmental personnel ..."

Based on a review of facility documentation and interviews, the facility failed to provide documented evidence of the proactive participation in the development and implementation of the patient or patient's family, or refusal of such participation, in each patient's plan of care for 10 of 10 patient charts reviewed, including 9 active patients.

Findings were:

A review of the Interdisciplinary Team Worksheets in 10 of 10 patient medical records revealed no area on the forms which documented a patient's involvement or a patient's family involvement in his or her plan of care, or of a refusal of participation. In addition, Patient #1, an inactive patient, had been admitted to the facility on 1/10/14. Her first Interdisciplinary Team Worksheet was dated 2/5/14.

In an interview with the Chief Nursing Officer on the morning of 8/27/14 in the medical center's small conference room, she identified the Interdisciplinary Team Worksheet as the patient plan of care, or treatment plan. In addition, she stated, "I know there won't be any documentation like that on any of the plans of care. We don't have a line for anything like that."

Facility policy entitled Interdisciplinary Care Team Meeting, index 3.1, date 11/16/11, stated in part:
"RULES:
1. A comprehensive plan of care will be completed for all patients.
2. The RN, with the assistance of other members of the patient care team, will initiate and update the plan of care as the patient's needs change.
3. The plan of care will be updated by each member of the team at patient care conferences held on a weekly basis.
4. The interdisciplinary care team will meet with family members and patients who have expressed a desire to participate in the planning of care at the patient care conference or privately as requested by patient and family..."