HospitalInspections.org

Based on clinical record review, policy and procedure review and staff interview, it was determined of the 10 (#1-#10) clinical records reviewed, eight (#1-#7 and #10) patients had skin impairment. The nursing staff failed to accurately assess the skin impairment, failed to include treatment of the skin impairment on the plan of care, failed to implement treatment as ordered by the physician and failed to provide treatment to acquired pressure ulcers for Patient #1-#6 and #10. The failed practices had the potential to affect all 19 patients on census. The findings were:

A. Patient #1: The admission date was on 07/08/10.
1) Review of the History and Physical dictated on 07/09/10 revealed under
Extremities: "...She has venous stasis and hyperpigmentation changes notable and 1 cm (centimeter) wounds on the lower extremities, some appear slightly necrotic and have eschars. She does have a left vein harvest that is without infection."
2) Review of the physician Provider Daily Progress Notes revealed the wounds on the lower extremities were identified as cellulitis/dermatitis.
3) Review of the Interdisciplinary Admission Team Data Base (nursing assessment) dated 07/08/10 revealed there was no description of the wounds located on the lower extremities.
4) Review of the Wound Documentation Record from 07/08/10 to 08/03/10 revealed the Wound Care Team under classification wrote "arterial vs (versus) pressure ulcer" for the right and left foot. There was no evidence an assessment was completed to determine if the wounds were arterial vs pressure ulcer or that the physician was consulted regarding the type of wounds the patient had so that treatment could be specific for the cause. In addition, there was no evidence the Wound Care Team was aware the physicians had identified the wounds as cellulitis/dermatitis.
5) Review of the Interdisciplinary Plan of Care for Hospitalization and Discharge revealed on 07/08/10 the problem of Potential or Actual Impaired Skin Integrity R/T (related to) decreased mobility, altered nutritional status and decreased tissue perfusion was initiated. The expected outcomes/goals were no new skin breakdown and wound size decreasing. The interventions/approaches were position every two hours and PRN (as necessary), assess skin after each change of position and document any sign of impending breakdown, discuss with MD (doctor) use of pressure distributing surface, and protect patients heels from breakdown by (was left blank). The plan of care did not address that a low air low mattress was ordered on 07/08/10 nor did it address the different types of treatment ordered and how they were to be applied. The failure to identify the causative factors for the impaired skin integrity had the potential for the correct treatment not to be implemented.
6) Interview on 08/26/11 at 0900, the CNO (Chief Nursing Officer) confirmed the clinical record findings for Patient #1.

B. Patient #2: The admission date was 07/27/11.
1) Review of the History and Physical dictated 07/27/11 revealed the patient was transferred from another hospital for continued intravenous antibiotics for infected wounds and wound care via a wound VAC (Vacuum Assisted Closure).
2) Review of the Admission Orders dated 07/27/11 revealed an order wound VAC. There was no indication of the type of foam dressing (white or black), whether the vacuum was continuous or intermittent and what the pressure setting should be. Interview on 08/26/11 at 1036, the CNO stated when the doctor was not specific the default was continuous at 120 mmHg (millimeters of mercury). At this time the policy and procedure was requested. Review of W12(2)-N, Negative Pressure Wound Therapy Using Svedman pump revealed "Use default settings of 120 mmHg and continuous therapy unless otherwise ordered." "Use appropriate SVAMP foam dressing to fit wound by cutting foam to fit wound bed shape." The policy and procedures did not define what appropriate SVAMP foam was. This was not clarified until an order dated 08/02/11 at which time the Wound Care Nurse wrote a verbal order for "1. ITI (wound VAC) to left ischial lateral wound-black foam at 120 mmHg cont (continuous)-change Tues-Thur-Sat. 2. Polymen wick dressing to left and right medial ischial wounds, cover with 4x4 and secure with Medipore-change Tues, Thurs,Sat. 3. Tegasorb absorbent to right posterior thigh and right lateral ischial..."
3) Review of the wound care documentation and photographs from 07/27/11 to 08/09/11 revealed the patient had six different pressures. Two were a Stage II and four were a Stage III. The location numbering of the wounds was inconsistent between each weekly documentation and the photographs at the same time. The failure to be consistent with documentation of the location and characteristics of the wound made it difficult to ascertain whether the pressure ulcers had remained the same, improved or declined in status.
4) Review of the 24 Hour Patient Record & (and) Plan of Care from 07/27/11 to 08/09/11 revealed under "Integumentary-IV (intravenous) Therapy, the goal was to "Maintain skin integrity. Promote wound healing" and under "Standard Prevention Bundle/POC (plan of care) (intact)" revealed basinless bath, turn and reposition every two hours and heel protection-float heels were checked. The plan did not include treatment to all six pressure ulcers. Under the assessment portion of this section, the staff wrote wound VAC-see wound care documentation and that the patient was on a Clinitron bed. There was no documentation of the wound VAC regarding the setting at 120 mmHg, that it was to be continuous or the color of foam to use. Review of the wound care documentation from 07/27/11 to 08/09/11 revealed it did not address the wound VAC settings or the type of foam used as directed by the plan.
5) Interview on 08/26/11 at 1030, the CNO confirmed the clinical record findings for Patient #2.

C. Patient #3:
1) The patient was admitted on 08/10/11 with a diagnosis of right hip infected wound over prosthetic device.
2) Review of the physician's order dated 08/16/11 at 1115 revealed the Wound Care Nurse wrote a verbal order to "Pack open area with 1/4 NuGauze moistened with NS (normal saline)-BID (two times a day)".
3) Review of the wound care documentation dated 08/16/11 reflected the wound was surgical, 2 cm long by 1 cm wide by 2 cm deep with tunneling 2.5 cm at 12 O'clock, had small amount of serosanguineous exudate, the tissue was dark red-blistered and the surrounding tissue was "hardiness/induration".
4) Review of the 24 Hour Patient Record & Plan of Care from 08/16/11 to 08/25/11 revealed under "Integumentary-IV Therapy" the assessment portion reflected the documentation varied to include the patient had an incision to the right hip, to see wound care documentation, right hip dressing intact and the patient was on a specialty bed. Under "Standard Prevention Bundle/POC (intact)" revealed the checkmarks varied to include turn and reposition every 2 hours, "heel protection-up off pillows," basinless bath, incontinence care per protocol and protect prominences (no specifics on this task). The plan did not include the physician's order for treatment beginning on 08/16/11. Review 24 Hour Patient Record & Plan of Care, Medication Administration Record (MAR) and wound documentation from 08/16/11 to 08/25/11 there was no evidence the surgical wound was packed with 1/4 NuGauze moistened with NS-BID.
5) Interview on 08/26/11 at 1245, the CNO confirmed the clinical record findings for Patient #3.

D. Patient #4:
1) The patient was admitted on 07/29/11.
2) Review of the Incoming Patient Report reflected the patient had a Stage III pressure ulcer on admission.
3) Review of the Admission Orders dated 07/29/11 reflected the wound care was Tegaderm occlusive to coccyx wound-change every 3 days and Tegaderm foam to left stump every 3 days. Review of the MAR, 24 Hour Patient Record & Plan of Care and wound documentation from 07/29/11 to 08/02/11 revealed there was no evidence the physician's order was carried out.
4) Review of the physician's order dated 08/02/11 revealed "Stop OpSite to coccyx. Start Hydrocolloid Dressing to coccyx, Change every 3 days, Start Mesalt to L (left) BKA (below knee amputation) daily, Cover with 4x4 and Kerlix. Review of the MAR, 24 Hour Patient Record & Plan of Care and wound documentation from 08/02/11 to 08/09/11 revealed there was no evidence the physician's order was carried out.
5) Review of the physician's order dated 08/09/11 at 1200 revealed "Stop Mesalt to L BKA. Start Tegaderm absorbent. Change prn (as necessary) saturation or every 7 days. Review of the MAR, 24 Hour Patient Record & Plan of Care and wound documentation from 08/09/11 to 08/25/11 revealed there was no evidence the physician's order was carried out.
6) Review of the physician's order dated 08/19/11 at 1130 revealed "Mist Therapy to wound. Dakin's 1/2 strength wet to dry BID." The order for Mist Therapy did not indicate the frequency or which wound (coccyx or the left BKA) was to receive the treatment. The order for the Dakin's 1/2 strength did not include which wound (coccyx or left BKA) was to receive the treatment. Review of the MAR, 24 Hour Patient Record & Plan of Care and wound documentation from 08/19/11 to 08/238/11 revealed there was no evidence the physician's order was carried out. 7) Review of the physician's order on 08/23/11 at 1045 revealed "Order clarification: Misty Therapy daily to coccyx wound. May start at next dressing change; Stop Dakin's packing; Mesalt to coccyx wound daily; Protect periwound skin with a hydrocolloid-change every 7 days and prn rolling; Tegasorb absorbent to stump wounds bilat (bilaterally). Review of the MAR, 24 Hour Patient Record & Plan of Care and wound documentation from 08/23/11 to 08/258/11 revealed there was no evidence the physician's order was carried out.
8) Review of the 24 Hour Record & Plan of Care from 07/29/11 to 08/25/11 revealed the plan did not include the treatments for the coccyx wound or the left BKA.
9) Interview on 08/26/11 at 1400, the CNO confirmed the clinical record findings for Patient #4.

E. Patient #5:
1) The admission date was 08/05/11.
2) The admission History and Physical reflected "...noted skin breakdown between her legs due to a leaking Foley catheter, which has contributed to a low grade cellulitis.
3) The Admission Orders dated 08/05/11 revealed for wound care "Please clean perineal area daily and treat per wound care".
4) Review of the physician's order dated 08/06/11 revealed "Silvadene cream to excoriation and folds of thighs and peri-area. Gently cleanse with NS prior to application BID."
5) Review of the physician's order dated 08/09/11 at 1410 revealed "Stop Silvadene and Baza cream. Calmoseptine (Risamine) to groin wound skin folds, coccyx, gluteus bilat (bilaterally), thigh BID."
6) Review of the physician's order dated 08/16/11 at 1415 revealed "Cont (continue) Risamine (Calmoseptine) to coccyx, gluteus bilat and posterior thighs BID. Use Nystatin powder in skin folds BID.
7) Review of the 24 Hour Patient Record & Plan of Care and wound documentation from 08/05/11 to 08/25/11 revealed the wounds were not described on admission and the documentation describing the patient's impaired skin integrity was conflicting in that the nursing staff described it as Stage II pressure ulcers or as Other-moisture, the location #2 was described as the left posterior thigh on 08/09/11 and on 08/16/11 the left gluteus, the location #3 on 08/09/11 was on the right posterior thigh while on 08/16/11 it was the left posterior thigh, etc. The failure to accurately distinguish the location and type made it difficult to determine if the wounds remained the same, improved or declined therefore, it had a potential to affect the choice of treatment.
8) Review of the 24 Hour Patient Record & Plan of Care from 08/05/11 to 08/25/11 revealed the plan under "Standard Prevention Bundle/POC (intact)" revealed the items checked varied from shift to shift and day to day. Items checked included basinless bath, incontinence care per protocol, heel protection-float heel and turn and reposition every 2 hours. The treatment of the wounds was not addressed on the plan of care.
9) Interview on 08/26/11 at 1515, the CNO confirmed the clinical record findings for Patient #5.

F. Patient #6:
1) The admission date was 07/28/11.
2) Review of the Admission Orders dated 07/28/11 revealed the order was for a foam dressing to the left hp and coccyx wounds and to change every 3 days; dry gauze to the abdomen wound-change daily.
3) Review of the physician's order dated 08/02/11 at 0930 revealed to place a thin hydrocolloid under pad to the PEG (percutaneous endoscopic gastrostomy) tube and stop foam dressing to left hip.
4) Review of the physician's order dated 08/16/11 at 1350 revealed a foam dressing was to the left gluteus skin tear-change every 7 days; stop foam dressing to coccyx; stop hydrocolloid under pad; stop foam to right thigh.
5) Review of the 24 Hour Patient Record & Plan of Care and wound documentation from 07/28/11 to 08/25/11 revealed there were discrepancies from the written description versus the photograph taken at the same time. For example the written description of the coccyx wound on 07/28/11 identified it as a Stage III pressure ulcer but the picture did not support it was a Stage III; on 08/23/11 the written description of the left Achilles revealed it was unable to be staged, it was 0.2 cm long by 2 cm wide and the wound bed was pink/purple but the photograph showed the skin was intact was pink/red in appearance.
6) Review of the 24 Hour Patient Record & Plan of Care dated 08/13/11 revealed had a skin impairment but there was no description of the skin impairment.
7) Review of the 24 Hour Patient Record & Plan of Care and wound documentation on 08/23/11 revealed the patient acquired pressure ulcers to the right lower leg (Stage II) and left Achilles area (unstageable). There was no evidence treatment was provided to those areas.
8) Review of the 24 Hour Patient Record & Plan of Care dated from 08/13/11 to 08/25/11 revealed under "Standard Prevention Bundle/POC (intact) revealed the items marked varied from shift to shift and day to day. Items checked included basinless bath, turn and reposition every 2 hours, incontinence care protocol and heel protection-either blank or float heels. There was no evidence the treatment of the skin impairment was ddressed.
9) Interview on 08/26/11 at 1737, the CNO confirmed the clinical record findings for Patient #6.

G. Patient #10:
1) The patient was admitted on 08/20/11.
2) Review of the physician's Progress Notes and Provider Daily Progress Notes revealed on admission the patient had amputation to the left foot 2nd toe and had ischemic areas to the right foot.
3) Review of the 24 Hour Patient Record & Plan of Care revealed the left foot 2nd toe amputation and right foot was not assessed by nursing until 08/23/11 at which time an order was written by the Wound Care Nurse to include foam to dark areas on feet bilaterally, secure with Safe Foam or Kerlix, check daily and change prn soiling. There was no care provided from 08/20/11 to 08/23/11.
4) Review of the 24 Hour Patient Record & Plan of Care under "Standard Prevention Bundle/POC (intact)" from 08/20/11 to 08/25/11 revealed the items checked mark varied from shift to shift and day to day to include basinless bath, turn and reposition every 2 hours, incontinence care per protocol and heel protection-either heels up on pillows or float heels. There was no clear evidence of when the dressings were applied to both feet. The interventions did not include the treatment to be provided to ischemic areas of both feet.
5) Interview on 08/26/11 at 1747, the CNO confirmed the clinical record findings for Patient #10.