HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the pre-admission assessment for 1 of 4 Patient's reviewed [Patient #1] accurately documented [Patient #1's] needs for a specialty bed. The hospital further failed to ensure the admitting Registered Nurse who evaluated Patient #1's care and/or needs ensured a specialty bed was provided upon admission. [Patient #1] was left on a standard mattress for 22 hours and forty five minutes.

Within six days after admission Patient #1 acquired pressure ulcers to the buttock, sacrum and scrotum. The hospital further failed to ensure appropriate treatment was provided for the pressure ulcer to the scrotum and ensure the wound assessment/reassessment record was completed.

Findings Included:

[Patient #1's] hospital inpatient face sheet reflected, [Patient #1] was admitted on 01/19/11 at 15:45 PM.

The pre-admission screening form dated 01/14/11 (five days prior to actual admission) and timed 4:00 PM reflected, "36 year old male [Patient #1] fell from a deer stand 20 feet...patient experienced weakness and numbness of his bilateral lower extremities, could not walk...facial fractures, T6, T7 facet fracture/dislocation, anterior wedge burst T6 involving body...patient has paraplegia due to spinal fractures for which patient has had surgical stabilization...currently has mouth wired shut and tracheostomy...patient is scheduled to have mouth wiring taken off and patient coming off tracheostomy..." The wound care section of the assessment reflected Patient #1 had no pressure ulcers and the nursing section of the document reflected [Patient #1] was not on a specialty bed.

A one page untitled document provided by the hospital with a receive date of 01/17/11 (two days prior to admission) timed at 12:12 PM reflected, "[Patient #1] place in Rotorest bed... [specialized mattress to assist with reducing pressure while lying]."

The pre-admission screening update dated 01/19/11 timed at 2:30 PM reflected no documentation indicating [Patient #1] required the use of a speciality mattress.

The Interdisciplinary Assessment dated 01/19/11 timed at 17:00 PM, reflected under the section entitled, "Integumentary" no pressure ulcers but redness in the perineal area. The Braden scale reflected, "score of eight which indicated patient is at high risk..." No documentation was found indicating [Patient #1] was on a speciality mattress as a preventative measure to prevent pressure ulcers.

The Wound Assessment/Reassessment dated 01/19/11 timed at 22:00 PM reflected, "redness excoriation to scrotum...unable to stage..."

The 01/19/11 Daily Documentation, Daily Nursing Assessment timed at 1600 reflected, "redness to scrotum." No further documentation was found which indicated treatment was initiated.

The 01/20/11 Daily Documentation, Daily Nursing Assessment timed at 05:00 AM reflected no documentation under the section entitled, "Integument Skin Breakdown." No documentation was found which addressed the redness to [Patient #1's] scrotum.

The physician's orders dated 01/20/11 timed at 07:50 AM reflected, "Patient must be turned every two hours when in bed...this is very important...nystatin powder to perineal area twice daily..."

The physician's orders dated 01/20/11 timed at 10:30 AM reflected, "Dolphin Recover Care Air Mattress...recommended by PT [Physical Therapy]."

The Interdisciplinary Daily Documentation, Daily Nursing Assessment dated 01/24/11 timed at 20:00 PM reflected, "excoriated peri-area..." No nursing documentation was found indicating [Patient #1] had open areas on his buttock and sacrum which required a wound evaluation by PT on 01/25/11 timed at 8:00 AM.

The physician's orders dated 01/25/11 timed at 8:00 AM reflected, "PT [Physical Therapy] recommends wound evaluation and treat..."

The Wound Care Assessment/Reassessment initiated by PT dated 01/25/11 timed at 16:00 PM reflected, "#1 wound right medial buttock, onset new...wound type pressure Stage II 0.5 cm [Centimeters] length by 0.5 cm wide with no depth...granulation 100% light red/pink, scant, sero-sanguineous exudate...cleansed with saline soaked gauze. Pat dry. Covered with small tielle...PT [Physical Therapy] to care for Monday-Wednesday-Friday and nursing to do as needed and when soiled...continue with every two hour turn when in bed...at 16:15 PM #2 wound to sacrum, onset new...wound type pressure Stage II 1.3 cm in length by 0.9 cm wide with no depth, exudate scant and sero-sanguineous...cleansed with saline soaked gauze. Pat dry covered with small tielle. PT to care for Monday, Wednesday, Friday and nursing to as needed and when soiled...#3 wound left medial gluteal, onset new...wound type pressure Stage II 4.0 cm in length by 1.2 cm wide with no depth...scant, sero-sanguineous exudate...cleansed with saline soaked gauze pat dry covered with OpSite. PT to care for Monday, Wednesday, Friday and nursing to do as needed and when soiled..."

The Interdisciplinary Daily Documentation, Daily Nursing Assessment dated 01/27/11 timed at 06:30 AM reflected under the section entitled, "Integument Skin Breakdown, Stage II with teal [sic] dressing on buttock, Stage II, weeping on scrotum..." No treatment orders were found for the open Stage II to the scrotum..." Noted the peri-area was being treated with Nystatin powder [antifungal powder twice daily]. No wound care assessment was completed for the open area to the scrotum.

On 02/22/11 at 2:45 PM Staff #5 was interviewed. Staff #5 stated [Patient #1] was paralyzed and at high risk for skin breakdown. Staff #5 stated she evaluated [Patient #1's] heels and sacrum on 01/20/11. She stated at the time of the evaluation his skin was intact. Staff #5 stated she saw the report which said Rhotorest mattress. She stated the patient should have been placed on a speciality mattress upon admission. Staff #5 stated [Patient #1] was placed on a speciality mattress on 01/20/11 at 3:30 PM. She stated the patient went almost 24 hours on a standard bed. Staff #5 was asked to review the treatment for nystatin powder [antifungal powder] to [Patient #1's] peri-area. Staff #5 acknowledged a different treatment should have been initiated when [Patient #1's] scrotum developed open areas. Staff #5 stated she was unaware of the open areas.

On 02/23/11 at 11:58 AM Staff #8 was interviewed. Staff #8 was asked to review [Patient #1's] medical record. Staff #8 stated she completed [Patient #1's] admission assessment. She stated she took photos of his skin and placed them in a zip lock bag and gave to the nurse on the next shift. Staff #8 stated she did not complete the wound forms. She stated the nurse on the next shift should have followed up. Staff #8 stated [Patient #1's] scrotal area was red with no open areas. Staff #8 stated she did not get a treatment order but placed barrier cream on the site. Staff #8 did not offer any explanation as to why a speciality mattress was not obtained for [Patient #1].

On 02/23/11 at 12:56 PM Staff #10 was asked to review [Patient #1's] medical record. Staff #10 stated when nursing completed an assessment they should initiate the necessary care needs. Staff #10 stated [Patient #1] should have been ordered a mattress as he was identified as high risk for skin breakdown.

The hospital Wound Assessment, Prevention and Documentation policy with an effective date of 08/20/10 reflected, "All patients admitted to...will be screened within 24 hours for risk of skin breakdown...for a Braden score of 18 or less, the skin breakdown prevention protocols will be initiated and incorporated in the plan of care...upon discovery of the wound, the clinician will describe the wound precisely...assign a number on the body figure...daily documentation will be recorded by the RN on the daily nursing assessment. The type of specialty bed or support surface used to assist with preventing and/or treating skin breakdown will be documented on the daily treatment section.

Based on observation and interview the hospital failed to ensure the nursing staff kept a current nursing care plan for 1 of 4 patient's reviewed [Patient #1] who developed pressure ulcers to the sacrum, buttocks and scrotum.

Findings Included:

[Patient #1's] hospital inpatient face sheet reflected, [Patient #1] was admitted on 01/19/11 at 15:45 PM.

Patient #1's pre-admission screening form dated 01/14/11 timed at 4:00 PM reflected, "36 year old male [Patient #1] fell from a deer stand 20 feet...patient experienced weakness and numbness of his bilateral lower extremities, could not walk...facial fractures, T6, T7 facet fracture/dislocation, anterior wedge burst T6 involving body...patient has paraplegia due to spinal fractures for which patient has had surgical stabilization...currently has mouth wired shut and tracheostomy...patient is scheduled to have mouth wiring taken off and patient coming off tracheostomy..."

The Wound Assessment/Reassessment dated 01/19/11 timed at 22:00 PM reflected, "redness excoriation to scrotum...unable to stage..."

The 01/19/11 Interdisciplinary Daily Documentation, Daily Nursing Assessment timed at 1600 reflected, "redness to scrotum." No further documentation was found which indicated treatment was initiated.

The 01/20/11 Interdisciplinary Daily Documentation, Daily Nursing Assessment timed at 05:00 AM reflected no documentation under the section entitled, "Integument Skin Breakdown." No documentation was found on [Patient #1's] care plan which addressed the redness to [Patient #1's] scrotum.

The Interdisciplinary Daily Documentation, Daily Nursing Assessment dated 01/27/11 timed at 06:30 AM reflected under the section entitled, "Integument Skin Breakdown, Stage II with teal [sic] dressing on buttock, Stage II, weeping on scrotum..."

On 02/23/11 at 3:15 PM Staff #3 was asked to review [Patient #1's] Interdisciplinary plan of care dated 01/20/11, entitled, "Integument System." Staff #3 stated the care plan was not updated to reflect [Patient #1's] pressure ulcers to the sacrum, buttocks and scrotum.

The hospital policy and procedure entitled, "Plan of Care" with a revised/review date of 08/09 reflected, "Each patient admitted will have an IPOC [Interdisciplinary plan of care] developed, which will be based on his/her assessed individual needs, family caregiver needs, physical, cognitive and functional impairments, and co-morbid conditions...each body system or functional area will have identified problems documented, followed by specific interventions identified to meet the needs of the patient...any new problems identified are checked...any new interventions are dated and initialed..."