HospitalInspections.org

Based on record review and interview the hospital failed to
1. ensure a written response was provided in a reasonable time frame for 4 (R1, R2, R3, R4) out of 87 grievances reviewed for timeframes of written responses.

2. ensure a grievance was thoroughly investigated and all problems with the patient's wound care was identified for 1 (Patient #2) of 3 grievances investigations reviewed (Patient #2, R7, and R8).

Findings:

Review of the hospital's policy for Patient Complaints and Grievance Procedure, policy # PM 0200-0091 revealed in part,"... The Patient Experience Coordinator will support the involved leaders to resolve a grievance in a timely matter. Within 7 business days from the system's receipt of the grievance, the Patient Experience Coordinator will communicate with the patient/patient's representative that the hospital has received the complaint and is investigating the concerns or the Patient Experience Coordinator will communicate a resolution within this timeframe. This communication will be provided in writing. If the grievance is not resolved within 7 business days, all attempts will be made to resolve the grievance within 30 business days..."

Review of the Letter Goal by Patient Safety Data present by S6Pt (Patient)Coordinator and S7 VP (Vice President) of Performance revealed from 5/13 to 9/13 there were 87 grievances filed. R1's grievance was received on 7/16/13 and a 7 day letter was sent on 8/21/13 (26 business days later). R2's grievance was received on 7/8/13 and a 7 day letter was sent on 8/13/13 (26 business days later). R3's grievance was received on 7/9/13 and a 7 day letter was sent on 7/24/13 (11 business days later). R4's grievance was received on 5/30/13 and a 7 day letter was sent on 7/1/13 (21 business days later).

An interview was conducted with S6PtCoordinator on 10/30/13 at 1:30 p.m. S6 reported the 7 days letter being sent late to the individual was a result of the employee taking the grievance, delaying putting the grievance into the system.


2.
Review of the grievance for Patient #2 revealed the complaint was lodged on 8/12/13 and the 7 working day/resolution letter was mailed on 8/21/13. The description of the complaint was listed as, " 1. Husband (to Patient #2) -unhappy with care his wife received here. He stated that a heart shaped pad was placed on his wife and when the nursing home took it off- her skin was red under it. 2. Wanted to know how often she was turned. 3. Upset because at discharge on 8/9/13 the social worker asked him if the patient could sit up and he felt as if the social worker should know these things. 4. He stated that he would be reporting this care to Medicare and to his insurance company. 5. He also wanted me to find out for him the following, "if you pay your entire bill in full-do you get 20% off the bill?" "

Immediate Action Taken: 8/12/13 at 8:30 a.m. took the initial complaint and at this time apologized to the family and provided my contact information...8/13/13 8 a.m. I spoke to Husband of Patient #2 and assured him that after I reviewed that chart that I would address the events with my staff. I was informed that the financial department had contacted him and 20% of his bill would be removed....Patient #2's husband stated his wife's bedsore was worst and Nursing Home "A" may have to have it deep cleaned. Patient #2's husband didn't have any other concerns. Again I apologized and reminded him of my contact information . I contacted the legal department and explained this situation and was advised not to contact Nursing Home "A" at this time. Please consider this complaint resolved..."

An interview was conducted with S11MedUnit Coordinator on 10/30/13 at 9:40 a.m. She stated the husband to Patient #2 came to her office on August 12 and complained about the care his wife received while in the hospital on her last admission. Patient #2's husband stated the nursing home was unhappy with the wound under the heart shaped dressing (Mepilex) on his wife's buttocks. He also asked if his wife was turned every 2 hours while in the hospital. S11MedUnit Coordinator reported she was the person that investigated the complaint. She went on to state she focused on the day of discharge, when the Mepilex dressing was changed on the patient. She reported that the Mepilex was not documented as changed prior to discharge, but there was a charge for a Medpilex dressing at 2:47 p.m. on 8/9/13, which was the time immediately prior to discharge. S11 reported that S20RN forgot to document the dressing change. S11MedUnit Coordinator reported she wasn't aware of the lack of assessment of the sacral pressure ulcer and the physician not being notified. She also stated she was not sure if she looked to see if the patient was turned every 2 hours. She reported she sent out 2 e-mails to her staff about the importance of documentation of dressing changes.

Review of the email dated August 15, 2013 from S11MedUnitCoordinator to her nursing staff revealed in part, "....Whenever we have a patient transferred to us from another unit a full body assessment should be completed and documented appropriately. We should not depend on prior skin assessments. For example: Some documentation stated that a Mepilex was being used and others did not. Upon reviewing the chart with the staff it was also discovered that the Mepilex was changed just prior to patient being transferred out to another facility but I was unable to find documentation stating this. All interventions should be documented appropriately."

Review of the email dated August 20, 2012 to from S11MedUnit Coordinator to her nursing staff revealed in part, "... Mepilex dressing should be changed every 5 days and prn (as needed) when soiled. If this dressing is changed this should be appropriately documented on the Assessment Tab in the Docs flowsheet. If you transfer a patient out with Mepilex-this type of information should be given in report (where and when applied)...."

Based on record review and interview the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient by:
1. Failing to ensure pressure ulcers were completely and accurately assessed and documented for 1 patient (Patient #2) out of 4 patients ( Patient #1, Patient #2, Patient #4, Patient #6) reviewed with pressure ulcers out of a sample of 7 patients.
2. Failing to notify the physician of a patient's newly developed pressure ulcer for 1 (Patient #2) out of 3 (Patient #1, Patient #2, Patient #6) patients with newly developed pressure ulcers reviewed out of a sample of 7.

Findings:



1. Incorrect and incomplete assessment of a Pressure Ulcer
Review of the hospital's policy for Wound Care Management, Policy # PS-POL-)140-0900 revealed in part, "...The Registered Nurse(RN) initiates appropriate wound prevention measures B. Stage Wounds. Six Stages of Pressure Ulcers:
1. Deep Tissue Injury- Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage I: Intact skin with non- blanchable redness of a localized area usually over bony prominence. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, black, brown) in the wound bed. F. The RN should consult with the physician and/or WOCN/CWCN (wound care specialist in the hospital) to assure safe, quality nursing measures that facilitate appropriate skin and wound management... A WOCN/CWCN is a recognized as an expert in skin care and wound management and may perform additional activities beyond those taught in basic nursing education programs. The WOCN/CWCN assumes the role of the wound care nursing specialist in a variety of health care settings to include the staging of wounds and wound care management that includes appropriate selections of preventive and therapeutic devices, wound care products, and the frequency of intervention when so directed by an authorized prescriber."

Review of the Hospital's policy on Braden Protocol revealed in part, "...The Braden Protocol shall be used for standardized prevention and skin care guideline based on the Braden Scale Score...2. Initiate the appropriate Prevention Protocols as listed above as determined by the score assigned to the patient. Braden Score 0-12...
5. Maintain adequate hydration and nutrition: report possible issue to the physician as indicated...
7. Consider WOC (Wound Specialist) consult for evaluation and treatment recommendations.
8. If Braden Score is 14 or less, apply preventive border sacral dressing. Change every 5 days as needed.
9. Consider Clinical Nutrition Consult
**For skin injury: document on Skin/Wound Assessment Flowsheet and consider WOC(Wound Care Specialist) consult..."

Review of the Hospital's policy for Skin Assessment and Wound Management, Policy # PS-PROC-0060-0400 revealed in part,"...1. Patients will be assessed upon admit and every 24 hours for the risk of skin breakdown and actual breakdown using the Braden Scale as a risk assessment tool...2. Those patients suffering from the results of pressure sores shall have their treatments options directed by the Braden Scale Protocol and their nursing care documented on the Skin Assessment and Wound Management Flowsheet each shift...Use of the Skin Injury/Wound Assessment Flow Sheet:
1. Date and time each entry.
2. Number each injury/wound on the diagram provided.
3. For each site indicated, follow across and complete each box as directed.
4. Pressure ulcers are to be staged as defined on the flow sheet.
5. Sign each entry with first initial, last name and credentials.
6. Consider WOC (wound care specialist) consult as needed..."

Review of Patient #2's medical record revealed Patient # 2 was an 81 year old white female admitted to the hospital on 7/25/13 from a local nursing home (Nursing Home A) with the diagnoses of Cerebrovascular Accident, Atrial fibrillation, Ulcer of the heels and toes, Congestive Heart Failure, Acute Renal Failure and the patient had a DNR (Do Not Resuscitate) status. On 7/27/13 at 0700 ( 7a.m.) the patient's Braden Score was assessed as a 12.

Review of the Work List Mini-Flowsheet Data in the medical record revealed on 8/5/13 a sacrum pressure ulcer was discovered on Patient #2 and described as a medial, with deep purple spots, non-blanching area with surrounding area redness with blanching. The pressure ulcer was only assessed on 8/5/13 at 0748 ( 7:48 a.m.). It was identified as a Stage II pressure ulcer and a dressing called Mepilex was placed on the wound. The wound was discovered by S12RN. There was no other assessment of the wound during the hospital stay, the patient was discharged on 8/9/13 to Nursing Home "A".

An interview was conducted with S12RN on 10/30/13 at 9:30 a.m. She reported that she didn't measure the pressure ulcer she found on Patient #2's sacrum on 8/5/13, but she should have measured it and she should not have staged it as a Stage II pressure ulcer, maybe a Stage I because the skin was not broken. When questioned if she notified the physician of the new pressure ulcer she stated she did not, but she should have notified her. She also reported she placed a Mepilex dressing on the wound. S12RN stated the wound should had been assessed every shift and the dressing should be changed when it won't stick to the site anymore and when it is soiled. She was not aware it should be changed every 5 days. She further reported she usually reports pressure ulcers to the wound specialist if the wound is open. S12RN also reported the ulcers on the patient's left foot (that she was admitted to the hospital with) should have been measured and documented also.

An interview was conducted with S20RN on 10/30/13 at 10 a.m. She reported she took care of the patient on 8/8/13 and 8/9/13 (the day of discharge). She reported after reviewing her documentation on the sacrum wound she reported she did not measure the wound either. She also reported on discharge, from what she remembers (this was not documented) the wound had a small open area on discharge to Nursing Home "A", but it wasn't deep. She couldn't recall any other information related to a description of the wound. She went on to report she did change the Mepilex dressing prior to the patient being discharged. S20RN also reported with new onset pressure ulcers she usually refers to the wound specialist because she doesn't feel comfortable staging wounds.

An interview was conducted with S11MedUnitCoordinator on10/30/13 at 9:40 a.m. She reported she reviewed the chart for Patient #2 after she received a grievance from the husband of Patient #2. She confirmed there was no measurements for the sacral pressure ulcer or the foot ulcers the patient had on admission. She also stated she did not think the wound was assessed correctly as a Stage II, probably it was unstageable at the point it was discovered.

An interview was conducted with S11Wound Care Specialist on 10/29/13. After reviewing the description of the sacral wound on Patient #2, she reported she felt like the wound was probably a Deep Tissue Injury and those wound can progress to an unstageable pressure ulcer. She went on to report that she usually looks at the whole picture of the patient when she assesses a wound.

Review of the Wound/Skin Management Documentation Record from Nursing Home "A" on 8/9/13, the date Patient #2 was discharge from the hospital and admitted to Nursing Home "A", revealed the patient had a 4 cm (centimeter) X 5 cm pressure ulcer on her sacrum. The wound was staged as unstageable. According to the key on the Wound/Skin Management Documentation Record; unstageable was with slough and/or eschar. The wound had serosanguinous exudate, the surrounding area was red and the depth of the wound was .2 cm. There was no odor from the wound.

2. Failure to Notify the Physician of a Newly Developed Pressure Ulcer
Review of the hospital policy titled Change in Patient Condition revealed in part, "...Unexpected changes in patient's condition, physical or psychosocial, must be communicated through appropriate channels...1. Notify the physician when the patient experiences an adverse change in condition...2. The staff RN (registered nurse) is responsible for recognizing those changes in a patient's condition that warrant physician notification..."

Review of S8MD's progress notes and discharge summary did not reveal any information on Patient #2's sacral pressure ulcer.

A phone interview was conducted with S8MD on 10/30/13 at 12:30 p.m. She reported she did not recall being notified of the pressure ulcer on Patient #2's sacrum. If she was aware of the pressure ulcer she would have added it to her progress notes and notified the nursing home of the pressure ulcer when the patient was discharged to Nursing Home "A". S8MD further reported she would have referred the patient to the wound care specialist in the hospital.

Based on record review and interview the hospital failed to identify and add interventions for the increased risk of pressure ulcers on the patient's plan of care after a pressure ulcer developed on 1 patient (Patient #2) out of 4 patients (Patient #1, Patient #2, Patient #4, and Patient #6 ) reviewed with pressure ulcers out of a sample of 7.
Findings:

Review the hospital's policy for Patient Needs List/ Care plan revealed in part, "... The purpose of the Patent Needs List/Care plan is to provide an interdisciplinary plan of care document which identifies patient's problems and discharge goals, which will determine the patient's plan of care...Nursing will review the Patient Needs List/Care Plan as needed or
a. When a significant change occurs in the patient's condition
b. When a significant change occurs in the patient's diagnosis...."


Review of Patient #2's medical record revealed Patient # 2 was an 81 year old white female admitted to the hospital on 7/25/13 from a local nursing home (Nursing Home A) with the diagnoses of Cerebrovascular Accident, Atrial fibrillation, Ulcer of the heels and toes, Congestive Heart Failure, Acute Renal Failure and the patient had a DNR (Do Not Resuscitate) status.

Review of the Work List Mini-Flowsheet Data in the medical record revealed on 8/5/13 a Sacrum Pressure ulcer was discovered on Patient #2 and described as a medial, deep purple spots, non-blanching area with surrounding area redness with blanching.

Review of the Patient #2's care plan dated 7/25/13 until discharge on 8/9/13 revealed no problem related to pressure ulcers or skin integrity on her plan of care.

An interview was conducted with S19PtSafety on 10/30/13 at 2:40 p.m. She confirmed there was no problem related to pressure ulcers and alteration in the patient's skin integrity on Patient #2's plan of care.

Based on record review and interview the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient by:
1. Failing to ensure pressure ulcers were completely and accurately assessed and documented for 1 patient (Patient #2) out of 4 patients ( Patient #1, Patient #2, Patient #4, Patient #6) reviewed with pressure ulcers out of a sample of 7 patients.
2. Failing to notify the physician of a patient's newly developed pressure ulcer for 1 (Patient #2) out of 3 (Patient #1, Patient #2, Patient #6) patients with newly developed pressure ulcers reviewed out of a sample of 7.

Findings:



1. Incorrect and incomplete assessment of a Pressure Ulcer
Review of the hospital's policy for Wound Care Management, Policy # PS-POL-)140-0900 revealed in part, "...The Registered Nurse(RN) initiates appropriate wound prevention measures B. Stage Wounds. Six Stages of Pressure Ulcers:
1. Deep Tissue Injury- Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage I: Intact skin with non- blanchable redness of a localized area usually over bony prominence. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, black, brown) in the wound bed. F. The RN should consult with the physician and/or WOCN/CWCN (wound care specialist in the hospital) to assure safe, quality nursing measures that facilitate appropriate skin and wound management... A WOCN/CWCN is a recognized as an expert in skin care and wound management and may perform additional activities beyond those taught in basic nursing education programs. The WOCN/CWCN assumes the role of the wound care nursing specialist in a variety of health care settings to include the staging of wounds and wound care management that includes appropriate selections of preventive and therapeutic devices, wound care products, and the frequency of intervention when so directed by an authorized prescriber."

Review of the Hospital's policy on Braden Protocol revealed in part, "...The Braden Protocol shall be used for standardized prevention and skin care guideline based on the Braden Scale Score...2. Initiate the appropriate Prevention Protocols as listed above as determined by the score assigned to the patient. Braden Score 0-12...
5. Maintain adequate hydration and nutrition: report possible issue to the physician as indicated...
7. Consider WOC (Wound Specialist) consult for evaluation and treatment recommendations.
8. If Braden Score is 14 or less, apply preventive border sacral dressing. Change every 5 days as needed.
9. Consider Clinical Nutrition Consult
**For skin injury: document on Skin/Wound Assessment Flowsheet and consider WOC(Wound Care Specialist) consult..."

Review of the Hospital's policy for Skin Assessment and Wound Management, Policy # PS-PROC-0060-0400 revealed in part,"...1. Patients will be assessed upon admit and every 24 hours for the risk of skin breakdown and actual breakdown using the Braden Scale as a risk assessment tool...2. Those patients suffering from the results of pressure sores shall have their treatments options directed by the Braden Scale Protocol and their nursing care documented on the Skin Assessment and Wound Management Flowsheet each shift...Use of the Skin Injury/Wound Assessment Flow Sheet:
1. Date and time each entry.
2. Number each injury/wound on the diagram provided.
3. For each site indicated, follow across and complete each box as directed.
4. Pressure ulcers are to be staged as defined on the flow sheet.
5. Sign each entry with first initial, last name and credentials.
6. Consider WOC (wound care specialist) consult as needed..."

Review of Patient #2's medical record revealed Patient # 2 was an 81 year old white female admitted to the hospital on 7/25/13 from a local nursing home (Nursing Home A) with the diagnoses of Cerebrovascular Accident, Atrial fibrillation, Ulcer of the heels and toes, Congestive Heart Failure, Acute Renal Failure and the patient had a DNR (Do Not Resuscitate) status. On 7/27/13 at 0700 ( 7a.m.) the patient's Braden Score was assessed as a 12.

Review of the Work List Mini-Flowsheet Data in the medical record revealed on 8/5/13 a sacrum pressure ulcer was discovered on Patient #2 and described as a medial, with deep purple spots, non-blanching area with surrounding area redness with blanching. The pressure ulcer was only assessed on 8/5/13 at 0748 ( 7:48 a.m.). It was identified as a Stage II pressure ulcer and a dressing called Mepilex was placed on the wound. The wound was discovered by S12RN. There was no other assessment of the wound during the hospital stay, the patient was discharged on 8/9/13 to Nursing Home "A".

An interview was conducted with S12RN on 10/30/13 at 9:30 a.m. She reported that she didn't measure the pressure ulcer she found on Patient #2's sacrum on 8/5/13, but she should have measured it and she should not have staged it as a Stage II pressure ulcer, maybe a Stage I because the skin was not broken. When questioned if she notified the physician of the new pressure ulcer she stated she did not, but she should have notified her. She also reported she placed a Mepilex dressing on the wound. S12RN stated the wound should had been assessed every shift and the dressing should be changed when it won't stick to the site anymore and when it is soiled. She was not aware it should be changed every 5 days. She further reported she usually reports pressure ulcers to the wound specialist if the wound is open. S12RN also reported the ulcers on the patient's left foot (that she was admitted to the hospital with) should have been measured and documented also.

An interview was conducted with S20RN on 10/30/13 at 10 a.m. She reported she took care of the patient on 8/8/13 and 8/9/13 (the day of discharge). She reported after reviewing her documentation on the sacrum wound she reported she did not measure the wound either. She also reported on discharge, from what she remembers (this was not documented) the wound had a small open area on discharge to Nursing Home "A", but it wasn't deep. She couldn't recall any other information related to a description of the wound. She went on to report she did change the Mepilex dressing prior to the patient being discharged. S20RN also reported with new onset pressure ulcers she usually refers to the wound specialist because she doesn't feel comfortable staging wounds.

An interview was conducted with S11MedUnitCoordinator on10/30/13 at 9:40 a.m. She reported she reviewed the chart for Patient #2 after she received a grievance from the husband of Patient #2. She confirmed there was no measurements for the sacral pressure ulcer or the foot ulcers the patient had on admission. She also stated she did not think the wound was assessed correctly as a Stage II, probably it was unstageable at the point it was discovered.

An interview was conducted with S11Wound Care Specialist on 10/29/13. After reviewing the description of the sacral wound on Patient #2, she reported she felt like the wound was probably a Deep Tissue Injury and those wound can progress to an unstageable pressure ulcer. She went on to report that she usually looks at the whole picture of the patient when she assesses a wound.

Review of the Wound/Skin Management Documentation Record from Nursing Home "A" on 8/9/13, the date Patient #2 was discharge from the hospital and admitted to Nursing Home "A", revealed the patient had a 4 cm (centimeter) X 5 cm pressure ulcer on her sacrum. The wound was staged as unstageable. According to the key on the Wound/Skin Management Documentation Record; unstageable was with slough and/or eschar. The wound had serosanguinous exudate, the su