HospitalInspections.org

Based on medical record review and review of hospital policy and procedure, it was determined the nursing failed to assess and document the alteration of and treatment of impaired skin integrity to the heels of Patient Identifier (PI) # 1, a patient identified to be at risk to develop skin breakdown with diagnoses and co-morbidities.

The physician also failed to document an evaluation of PI # 1's heels and provide orders for treatment.

This deficient practice affected one of five sampled patients and had the potential to affect all patients admitted with impaired skin integrity and/or patients identified as being at risk to develop skin impairment.

Findings Include:

Medical Record Review:

According to the History and Physical PI # 1 was admitted to the hospital on 6/28/2013 with diagnoses to include Left Septic Knee Revision, Status Post Left Total Knee Arthroplasty with Complete Synovectomy, Coronary Artery Disease and Adult-onset Diabetes with Peripheral Neuropathy.

Functional Status: The patient follows simple and complex commands. No verbal communication or auditory comprehension problems. The patient is partial weight bearing: 50 %. Bed mobility, transfer and ambulation requires maximum assistance.


Medical Consultation: 6/29/13

...Past Medical History:
1. Coronary Artery Disease.
2. Type 2 Diabetes.
3. DVT (Deep Vein Thrombosis).
4. Hypertension...

Past Surgical History:
1. Left TKA (Total Knee Arthroscopy).
...4. Amputation of a toe on the right foot.

Physical Examination:
General: ...Alert and in no acute distress.
Extremities: No clubbing, cyanosis or pitting edema. Surgical site intact.

Post Admission Physical Evaluation: (signed by physician 7/2/13)

...Factors Affecting Plan of Care:
1. Could be exacerbation of infection with wound involvement.
2. Diabetes complications with hypoglycemia...


Interdisciplinary Assessment 6/28/13 at 6:20 PM:

Neurologic: Alert.

Orientation:Consistent to person, place, time and situation.

Cardiovascular: Edema: Bilateral Lower Extremities.

Integumentary:
Bruising is indicated on the body diagram to the right clavicle /shoulder area and right and left upper arms. A skin tear is documented on the left arm. A surgical incision with staples is noted to the left knee. Amputation documented with an arrow pointing to PI # 1's right small toe.

A circle is drawn around both heels on a diagram of the bottom of the feet. "Proderm (a non-prescription aerosol which stimulates the capillary beds to help prevent the deterioration of stage I ulcers into deeper stages) applied."

Other Skin Alterations:

Venous Insufficiency: Bil (bilateral) brown color ankle to mid calf.

Skin Breakdown: There was no documentation regarding suspected DTI (Deep Tissue Injury - intact skin or blood filled blister due to damage of underlying soft tissue. Depth unknown). There was no documentation of measurements or color description of impaired area to heels on admission.

Braden Scale Score: 16 (This indicates patient is at high risk to develop a pressure ulcer).

Patient Transfer/Maneuvering Assessment: Weakness or debility.


A review of Physicians' Orders dated 6/28/13 through 7/11/213 reveals no documentation of physician order(s) related to the care of PI # 1's impaired skin on heel(s).

A review of the Daily Nursing Assessments (6/28/13 through 7/11/13) reveals:
- No documentation regarding physician notification of the alteration in skin integrity to PI # 1's heel(s) on admission or at anytime during hospitalization

- Inconsistent documentation regarding wound location (one or both heels), floating of heel(s) to help prevent further skin breakdown and use of Promed and / or Granulex to heel(s).

Wound Assessment / Re-Assessment 6/30/13:
(The first and only photographs):
Wound Location: Right heel dated 6/30/13 at 12:25 PM (almost 48 hours after admission).
Wound Type: Pressure.
Suspected Deep Tissue Injury.
Wound Size: 5 centimeters (cm) x 4 cm.
Current Treatment: Granulex and float heels.

Facility Policy:

Wound Assessment, Prevention and Documentation Policy ID: QCE-002
Effective Date: 8/20/10
Last Review Date: 5/16/12
Purpose:
1. To improve patients' skin integrity though timely and consistent clinical practices for assessment and prevention of wounds.

2. To ensure standard documentation related to the assessment of skin and wounds.

Definitions: The term "wound" is used generically to include all types of alterations in skin integrity...

The three general categories of wounds mentioned in this policy are:
1. Pressure ulcers (also referred to as skin breakdown)
2. Procedure related wounds (e.g. surgical incisions...)
3. Other alterations in skin integrity.

Policy: All patients admitted to Hospital # 1 will be screened for risk of skin breakdown and alteration in skin integrity...For a Braden Scale of 18 or less, the Skin Breakdown Prevention Protocols will be initiated...Each patient's wound care will be under the direction of a physician.

1. Assessment
An RN (Registered Nurse) will inspect each patient's integument system daily, weekly and as often as indicated.

a. The Braden Scale is used to assess all patients for risk of skin breakdown...

b. Pressure Ulcers are noted in the record upon discovery.

i. A full assessment is completed within 24 hours of admission (or discovery) to include staging, measurements, photos and physician notification.

ii. Pressure ulcers will be staged, measured, and photographed...

iii. Within two days of discharge a final complete assessment is conducted,
including descriptions, staging, measuring, and photography as appropriate.

c. Skin tears, procedure - related wounds, traumatic wounds or lower extremity wounds (arterial, venous or neuropathic) are not staged. These types of alterations in skin integrity should be described, measured and photographed...

2. Description Methodology
a. There are three categories used to described wounds:
1) pressure ulcers
2) procedure - related and
3) other alterations in skin.

...Photographs and measurements should be used...to more accurately describe a wound in any category....

vi. Suspected Deep Tissue Injury: Depth Unknown. Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue... The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment...

3. Documentation
A history and physical is needed to determine type / cause of wound...

a. Documentation of Assessment: The clinician will describe the wound precisely...

iii. Measurements: ...other wounds as applicable will include the following documentation: Size - Length, Width and Depth should be recorded in centimeters on admission or discovery, weekly and at discharge...

vii. Condition of surrounding skin: Assess at least four cm. extending from wound edge for discoloration, swelling/edema. skin tears or maceration (softening and breaking down of skin resulting from prolonged exposure to moisture). Palpate for induration (firm) or fluctuance (spongy, soft)...
c. Daily documentation will be recorded by the RN...
d. Weekly and Discharge documentation will include:
i. Re-assessment includes:
a. skin inspections...
b. documentation of current treatment.
c. changes in treatment since the last update.
d. improvement in the patient's skin condition since the last update.
ii. The Plan of Care documents the current risk for skin breakdown through the use of the Braden Scale and a status update, including progress towards goals.
4. Wound Photography
a. Regardless of time or place of origin, all wounds are to be photographed within 24 hours of discovery, weekly and within 24 hours of discharge....
5. Physician Collaboration
The physician assumes leadership over clinical interventions and wound care treatment...

By failing to follow their own Wound Assessment Policy to consistently measure, describe, photograph, float heels, apply Promed / Granulex and provide "physician leadership" over wound care, the hospital was unable to determine the status of the wound to PI # 1's heel(s) on admission, measure response to interventions and have a definitive status of the wound(s) at discharge.