HospitalInspections.org

Based on observation, interview and record review, the facility's registered nurse failed to implement the facility's policy and procedure in conducting a full accurate assessment on patients during admission to the facility in 2 of 10 sampled patients. Patient #s 1 and 2.

Findings:

Review of the facility's current Policy and Procedure on Wound Assessment Prevention Documentation; Policy#2 directed staff as follows:
"All patients admitted to the hospital will be screened within 8 hours for risk of skin breakdown and for alteration in skin integrity by a registered nurse. For Braden score of 18 or less, the Skin Breakdown Prevention Protocol (as described in this policy) will be initiated and incorporated into the plan of care. Each patient's wound will be under the direction of a physician."
"Pressure injuries are noted in the record upon discovery (either upon admission or throughout the stay).
(A) A full assessment is completed within 8 hours of admission (or discovery of a new wound) to include descriptions measurement, photos and physician notification. This will aid in communication with the treatment team prior to staging determination."


Patient #2
On 10/30/2018 at 09:20 a.m. the Facility's Wound Care Nurse and Physical Therapist Assistant were observed in Patient #2's room. Observation revealed the Patient had ace bandages wraps with cling bandages to both legs.

Interview with the Patient at that time revealed, the wraps and ace bandages were applied by her home health nurse approximately one week ago, prior to her admission to the facility.

Interview on 10/30/2018 at 11:05 a.m. with Physical Therapist Assistant revealed, the Patient was admitted to the facility over the weekend with diagnosis of Lymphedema for rehabilitation. The Physical Therapist Assistant said she is the only person trained in the facility to remove and apply the bandage and dressing to the Patient's legs. She said she received the order on 10/29/2018 after returning to work from been off during the weekend and so the patient's dressing to her legs were not changed.
She said she was present in the room to remove the bandages to the Patients legs so that the Wound Care Nurse could assess the Patient's legs.

On 10/30/2018 at 10:10 a.m. the Facility's Physical Therapist Assistant was observed removing the soiled dressings and bandages from the Patient's legs and cleaning the legs.
Observation during the procedure revealed, the Physical Therapist Assistant donned a pair of clean gloves, removed the soiled bandages and dressing from the Patient's legs and discarded it in the garbage. She then walked over to the shelf in the Patient's room and secured clean dressings from the self with her contaminated gloved hands.
She did not remove her contaminated gloves and wash/sanitize her contaminated hands. During the procedure the Physical Therapist Assistant was observed removing her contaminated gloves, then without washing/sanitizing her hands she would secure clean gloves from boxes of gloves stored on a cart in the Patient's room.

Observation of the Patient's legs after removal of the dressings and bandages revealed liquid drainage was observed from the Patient's legs along with a skin tear identified by the Wound Care Nurse and the Physical Therapist Assistant.


Record review revealed, the Patient was admitted to the facility on 10/27/2018. Review of the record revealed no indication that the Patient's legs were assessed by the Registered Nurse during admission to the facility and identification of the skin tear.

Review of the Patient's clinical record revealed a physician's order dated 10/28/2018 for initiation of skin care and wound care protocol.

Patient #1
Review of the Patient's clinical record, revealed he was admitted to the facility on 03/25/2018 at 15:37 p.m. with diagnosis of Cerebrovascular Accident, Hypertension, Seizures and difficulty swallowing.

Initial assessment on the nurse's skin assessment report dated 03/25/2018 indicated the Patient was admitted to the facility with an intact skin. A Braden scale assessment was done on the Patient with a score of 18. This indicated that the Patient was high risk for the development of impairment in skin integrity.

Review of the Patient's clinical record revealed wound care progress notes with the following assessment by the Facility's Wound Care Nurse:
03/30/2018: Wound to coccyx with slough measuring 2 cm x 0.8 cm x 0.1 cm
04/02/2018: Wound to coccyx measuring 7 cm x 2 cm x 0.1 cm.
The Pressure Ulcer Scale for Healing (PUSH) dated 3/30/2018 documented that there was necrotic tissue with slough to the Patient's coccyx.

Review of the Patient's clinical record revealed assessments by the Patient's Primary Nurses with the following documentation:

03/25/2018: 19:00 p.m.: An assessment was completed by the Patient's Primary Nurse. There was no documentation of impairment in the Patient's skin integrity on admission to the facility.
03/30/2018: 9:48 a.m.: "Skin intact no wound present."
3/31/2018: 10:00 a.m. Patient's "skin intact. No wound present."
3/31/2018: 22:06 p.m. "Skin intact No incision or wound present"
04/01/2018 at 9:23 a.m. "skin intact no incision or wound present."
04/01/2018 at 19.14 p.m. "skin intact incision and wound present."


During an interview and record review on 10/30/2018 at 11:50 a.m. with Facility's Wound Care Nurse revealed, there was no documentation in Patient #1's clinical record that the Patient was offered, assisted or given a bath/ shower on 3/28/2018.

She said on 03/30/2018 she did a skin assessment on the Patient which identified a wound to the Patient's coccyx, measuring 2 cm x 0.8 cm x 0.1 c.m. She said the wound increased in size on 04/02/2018 measuring 7 cm x 2.cm x 0.1cm.

She said she obtained an order for wound care of hydrocolloid dressing but after the size of the wound increased, then the dressing of choice prescribed by the Patient's physician was foam.
Interview with the Facility's Wound Care Nurse revealed the Patient was not admitted with a pressure sore.

The record indicated inconsistency with the Patient's skin assessment, in that on 03/30/2018 the Facility's Wound Care Nurse assessed the Patient and identified the presence of a wound on the Patient's coccygeal area, yet subsequent assessments by the Patient's primary nurses documented that the Patient's skin was intact with no wound present.