HospitalInspections.org

Based on record review and staff interview it was determined the facility failed to update the nursing care plan for Patient #5's developing pressure sores. The sample size was 12 patients. The census at the time of survey was 35.

Findings included:

Review of Patient # 5's clinical record was completed 3/03/10. The patient was admitted to the hospital on 08/12/09 for ventilator weaning. A Braden scale (a skin assessment tool to determine a patient's risk for developing pressure sores) result of eleven at the time of admission determined the patient to be at high risk for developing pressure sores. Interventions started as per the nursing care plan included repositioning the patient every two hours and "floating" the patient's heels so as to keep pressure off. Also on admission the patient was placed on a low air loss mattress for the prevention of pressure sores.
On 08/18/09 the clinical record revealed nursing documentation of a right heel intact blister and a stage II coccyx wound. Photographs were taken as per policy as well as measurements and descriptions of the wounds. On 08/24/09 the right heel was documented as 6.0 centimeters long by 10.0 centimeters wide and a depth of less than 0.1 centimeter. Also on 08/24/09 the coccyx wound was determined to be unstageable and 9.6 centimeters long by 10.4 centimeters wide with a depth of less than 0.1 centimeter. A physician order dated 08/24/09 revealed the patient was to be "turned side to side only, may be on back when up in chair only " and "apply soft Profo boots to bilateral feet." The nursing documentation did not indicate what position the patient was in (beit the right or left side) anytime during the patient's 64 day stay. The nursing documentation revealed the patient was in "boots" prior to the physician order to do so and then inconsistently after the physician ordered them. The documentation in the patient's clinical record did not reveal a change in the nursing care plan at the time of discovery of these wounds nor at the time of the physician orders of 08/24/09. On 09/19/09, a month after the discovery of the wounds the patient was placed on an advanced dynamic flotation system (a specialized mattress the facility describes as used for the patient with limited mobility and prone to skin breakdown.)

These findings were verified with the director of quality and the director of clinical services during interview on 03/03/10 at 9:30 AM.

This substantiates complaint #OH00052591.