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Based upon review of 3 of 6 medical records (#1, #2, #5), policies and procedures, incident/accident reports, and staff interviews, the Registered Nurse (RN) failed to evaluate the nursing care for each patient as evidenced by the RN's failure to conduct skin assessments every 12 hours in accordance with established policy and procedure. This was evidenced by the RN's failure to identify new skin breakdown on patients #1, #2, and #5. Findings:

Interview with S2 RN/Chief Nursing Officer (CNO) on 11/27/13 at 11:00 a.m. revealed the Registered Nurses work 12 hour shifts, and at the beginning of each shift, a skin assessment on each patient was to be conducted. S2 RN/CNO further added when the aide bathed the patient, she would also report to the RN any skin breakdown.

Review of the Policy titled "Assessment/Reassessment Plan" #B20:01:13, Effective 10/91, Revised 9/26/11, revealed in part "...The assessment process will be a continuous, collaborative effort with all of the health care members functioning as a team. Communication among the health care team is an essential element of the assessment process..." and "All members of the health care team who are involved in direct patient care will participate in the collection of assessment/reassessment data."
Procedure: "Assessment Framework: The assessment framework will be structured around two components: initial screening and assessment/reassessment of all patients as appropriate to the clinical discipline scope of practice and the individual patient's condition. The assessment/reassessment process is a continuous one, evolving with the patient's changing condition and response to care."
III. Reassessment: "B. Reassessment is ongoing and may be triggered by key decision points and at any interval(s) specified by the department's ancillary disciplines directly involved in providing patient treatment and/or care." "C. 2. The patient's response to treatment, 3. Significant change in the patient's condition."

1) Review of patient #1's medical record revealed on 11/20/13, the physician ordered Cloderm 0.1% to be applied topically to a rash, identified as "poison ivy", to the patient's bilateral upper extremities. Interview with S8 RN on 12/3/13 at 11:10 a.m. revealed she was assigned the care of patient #1 and when asked about the patient having "poison ivy", she replied she was not aware the patient ever had any type of rash. Further review of patient #1's medical record revealed there failed to be documentation in the nursing notes the patient was assessed as having a rash (poison ivy) to the bilateral upper extremities.

2) Review of patient #2's medical record revealed the patient was admitted to the hospital on 10/23/13 for an infected stage IV sacral ulcer. According to the wound care notes dated 11/11/13, the patient acquired a new wound to the right ear measuring 0.5 centimeters (cm) in length, 0.4 cm in width, and 0.1 cm in depth. Review of the nursing notes revealed there failed to be evidence the Registered Nurse had conducted an assessment of the patient and identified the area of new skin breakdown.

3) Review of patient #5's medical record revealed the patient was admitted to the hospital on 1/2/13 for an infected sacral decubitus ulcer. Review of the wound assessments sheets dated 1/3/13 revealed the patient was assessed as having intact purple/maroon areas related to deep tissue injury on the right and left trochanter and the right lateral foot. The patient also had a stage IV pressure ulcer to the sacrum. Review of the wound assessment sheets dated 1/9/12 revealed a wound was identified on the patient's right knee due to "trauma" and measured 0.8 cm in length, 0.9 cm in width, and 0.2 cm in depth. It was also noted this wound the prior week was 1.0 cm in length, 0.8 cm in width, and 0.1 cm in depth; however, there was no wound assessment sheet regarding the right knee wound for the prior week. Review of the initial nursing assessment dated 1/2/13 and conducted by S9 RN revealed there failed to be documentation a skin assessment was conducted on admission.

Interview with S9 RN Charge Nurse on 12/3/13 at 11:55 a.m. revealed she admitted patient #5 to the hospital and conducted the initial nursing assessment. When asked about the patient's wounds, S9 RN replied she remembered something about the patient's knee being injured during ambulance transport; however, the incident was not documented in the patient's medical record.

Review of the incident/accident reports revealed an incident report was initiated when new wounds were found by the Registered Nurse on 1/14/13.

Further review of patient #5's medical record revealed according to the Wound Assessment Sheets dated 1/14/13, the patient acquired the following new wounds: (1) Right anterior leg measuring 2.5 cm in length, 4.2 cm in width, and 0.1 cm in depth. The wound type/etiology was identified as "unknown", the depth of tissue damage identified as "partial thickness", wound bed color "pink, purple/maroon, yellow", normal in color and condition "intact". The wound edge was "open" with "scant" "serous" drainage. (2) A pressure wound to the right medial foot due to deep tissue injury. The wound measured 5.5 cm in length, 3.0 in width, and 0.1 cm in depth. The tissue was identified as red and intact with the wound bed color being "purple/maroon". (3) Left elbow wound measuring 1.2 cm in length, 1.0 cm in width, and 0.1 cm in depth. The wound type/etiology was "pressure; possible shear" Stage II with partial thickness and "open with scant serosangeous drainage". (4) Right medial knee measuring 2.5 cm in length, 1.4 cm in width, and 0.1 cm in depth. The wound type/etiology was identified as "pressure" with the depth of tissue damage as "unstageable" The wound edge was open with a scant amount of serosangeous drainage. (5) Left medial malleolus measuring 2.5 cm in length, 2.5 cm in width, and 0.1 cm in depth. The wound type/etiology was identified as "pressure", "unstageable" depth of tissue damage, and open wound edge with scant amount of serosangeous drainage. (6) Left anterior thigh measuring 0.4 cm in length, 1.0 cm in width, and 0.1 cm in depth. The wound type was identified as "pressure with depth of tissue damage "DTI (Deep Tissue Injury). The wound edge was open with a scant amount of Serosangeous drainage. (7) Left lateral foot/5th MTH with the depth of tissue damage identified as deep tissue injury and red, purple/maroon in color.

Review of the nursing notes revealed there failed to be documented evidence the Registered Nurse conducted skin assessments on patient #5 and identified the new wounds that had developed.

Based upon review of 3 of 6 medical records (#1, #2, #5), observations, and staff interviews, the Registered Nurse failed to keep current the nursing care plan for patients #1, #2, and #5. This was evidenced by: 1) failure to update the plan of care every week for patient #1, 2) failure to follow the plan of care for patient #2 related to assessing the skin every shift, and 3) failure to identify facility acquired wounds in the plan of care for patient #5. Findings:

1) Review of patient #1's medical record revealed the patient was admitted to the hospital on 11/6/13 for an infected sacral decubitus ulcer. According to the physician orders dated 11/20/13, Cloderm 0.1% cream was to be applied daily and as needed to a rash, identified as poison ivy, to the patient's bilateral upper extremities. Interview on 12/3/13 at 11:10 a.m. with S8 RN revealed when asked about the poison ivy rash, the nurse replied she was not aware the patient had any type of rash.

Interveiw with patient #1 on 12/3/13 at 11:30 a.m. revealed when asked about the rash, the patient replied he had gotten the poison ivy on his forearms while outside in his wheel chair.

Review of the plan of care for patient #1, dated 11/6/13, revealed for impaired skin integrity, the patient was to be turned every two hours, the heels were to be elevated off the bed surface, and nursing was to assess the skin every shift. Further review of the nursing plan of care revealed the care plan was to be updated every week; however, there failed to be documentation this update occurred for weeks #2, #3, #4, #5 or #6 or that the patient's rash was identified.

2) Observations of patient #2 on 12/3/13 at 1:30 p.m. revealed the patient was in the bed with her head turned to the right, the upper torso was supine and the lower extremities were turned to the left with a towel located between the legs. On the wall above the patient's bed was a hand written turning schedule which identified from 1:00 p.m. to 3:00 p.m. the patient was to be positioned on the left side.

Review of the medical record for patient #2 revealed the patient was admitted to the hospital on 10/23/13 with the diagnoses of infected stage IV sacral ulcer, Dementia, Deep Vein Thrombosis of the upper extremity, and contractures of the lower extremities (fetal position). Review of the wound assessment sheets revealed on 11/11/13 the patient had a new wound on the right ear.

Review of the plan of care for patient #2 revealed for impaired skin integrity, the goal was for the patient to have no new skin breakdown with interventions listed as: 1) turn every 2 hours, 2) heels elevated off bed surface, and 3) nursing to assess the skin every shift. The plan of care failed to be updated every week for weeks #2, #3, and #4. The nursing staff also failed to follow the plan of care and document a skin assessment was completed every shift even though the patient had developed a new wound to the right ear.

3) Review of patient #5's medical record revealed the patient was admitted to the hospital on 1/2/13 for an infected sacral decubitus ulcer. Review of the wound assessment sheets dated 1/3/13 revealed the patient was assessed as having intact purple/maroon deep tissue injuries to the right and left trochanter and the right lateral foot. It was also identified the patient had a stage IV pressure ulcer to the sacrum. Review of the wound assessment sheets dated 1/9/12 revealed a wound was identified on the patient's right knee due to "trauma" and measured 0.8 cm in length, 0.9 cm in width, and 0.2 cm in depth. It was also noted this wound the prior week was 1.0 cm in length, 0.8 cm in width, and 0.1 cm in depth; however, there was no wound assessment sheet regarding the right knee wound for the prior week. Review of the initial nursing assessment dated 1/2/13 and conducted by S9 RN revealed there failed to be documentation a skin assessment was conducted on admission.

Further review of patient #5's medical record revealed according to the wound assessment sheets dated 1/14/13, the patient acquired the following six new wounds: (1) Right anterior leg measuring 2.5 cm in length, 4.2 cm in width, and 0.1 cm in depth. The wound type/etiology was identified as "unknown", the depth of tissue damage identified as "partial thickness", wound bed color "pink, purple/maroon, yellow", normal in color and condition "intact". The wound edge was "open" with "scant" "serous" drainage. (2) A pressure wound to the right medial foot due to deep tissue injury. The wound measured 5.5 cm in length, 3.0 in width, and 0.1 cm in depth. The tissue was identified as red and intact with the wound bed color being "purple/maroon". (3) Left elbow wound measuring 1.2 cm in length, 1.0 cm in width, and 0.1 cm in depth. The wound type/etiology was "pressure; possible shear" Stage II with partial thickness and "open with scant serosangeous drainage". (4) Right medial knee measuring 2.5 cm in length, 1.4 cm in width, and 0.1 cm in depth. The wound type/etiology was identified as "pressure" with the depth of tissue damage as "unstageable" The wound edge was open with a scant amount of serosangeous drainage. (5) Left medial malleolus measuring 2.5 cm in length, 2.5 cm in width, and 0.1 cm in depth. The wound type/etiology was identified as "pressure", "unstageable" depth of tissue damage, and open wound edge with scant amount of serosangeous drainage. (6) Left anterior thigh measuring 0.4 cm in length, 1.0 cm in width, and 0.1 cm in depth. The wound type was identified as "pressure with depth of tissue damage "DTI (Deep Tissue Injury). The wound edge was open with a scant amount of Serosangeous drainage.

Review of the plan of care identified as the Interdisciplinary Plan of Care dated 1/2/13 revealed for skin/wounds status, the goal was to reduce the size of the wounds. Interventions included 1) routine skin maintenance, and 2) wound care protocols. There failed to be further documentation related to the care plan and the goals and interventions to be implemented even though patient #5 developed further skin breakdown that was identified on 1/14/13.

Based upon review of 1 of 6 medical records (#1), and patient and staff interviews, the hospital failed to ensure drugs were administered in accordance with physician orders. This was evidenced by the Registered Nurse's failure to document the administration of the topical medication Cloderm 0.1% ordered by the physician to be applied to a rash to patient #1's bilateral upper extremities. Findings:

Review of patient #1's medical record revealed the patient was admitted to the hospital on 11/6/13 for treatment of an infected sacral decubitus ulcer. Review of the physician orders dated 11/20/13 and timed 3:30 p.m. revealed "Wound Care Orders: Apply Cloderm 0.1% to rash BUE (Bilateral Upper Extremities) "poison ivy" daily and PRN (as needed)." Review of the Medication Administration Record revealed Cloderm 0.1% was listed as one of the medications to be administered to patient #1; however, there failed to be documentation the medication was administered from the date of order 11/20/13 through 12/3/13.

Interview with S8 RN (Registered Nurse) on 12/3/13 at 11:10 a.m. revealed when asked about the Cloderm topical medication for patient #1's poison ivy rash, S8 RN replied she did not know the patient had poison ivy.

Interview with patient #1 on 12/3/13 at 11:50 a.m. revealed when asked about the poison ivy, the patient stated "I got poison ivy on my arms from a bush outside. The nurse put some cream on it and it is all gone now."

Interview with S1 Administrator, S2 RN Chief Nursing Officer, and S3 RN Certified Wound Care Nurse, on 12/3/13 at 1:30 p.m. revealed on 11/20/13, patient #1 told the physician he had poison ivy on his arms and requested medication. The physician gave the wound care nurse a verbal order for the Cloderm topical medication and also applied the cream to patient #1's forearms. S3 RN confirmed the administration of the Cloderm topical medication was not documented in patient #1's medical record either on the Medication Administration Record or on the Wound Care Notes.