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Based on policy and procedure review, clinical record review, and interviews, it was determined that the facility failed to develop, update, implement, and individualize an interdisciplinary integumentary plan of care for Patient #6. Failure to develop an individualized interdisciplinary integumentary plan of care for Patient #6 did not assure the skin policies, protocol, and orders were followed in order to prevent further skin breakdown. The failed practice affected Patient # 6 during the course of hospitalization and had the potential to affect any current patient in the facility requiring an interdisciplinary individualized integumentary plan of care. See Tag A0396.

Based on policy and procedure review, clinical record review, and interviews, it was determined that the facility failed to develop, update, implement, and individualize an interdisciplinary integumentary plan of care for Patient #6. Failure to develop an individualized interdisciplinary integumentary plan of care for Patient #6 did not assure the skin policies, protocol, and orders were followed in order to prevent further skin breakdown. The failed practice affected Patient # 6 during the course of hospitalization and had the potential to affect any current patient in the facility requiring an interdisciplinary individualized integumentary plan of care.


Findings:

A. Turns:

1) Review of Patient #6's Plan of Care dated 03/31/20, 04/06/20, 04/13.20, 04/16/20, 04/20/20, 04/27/20, and 05/04/20 show the following:

IPOC (Interdisciplinary Plan of Care) -Integumentary

Interventions:

Provide education to patient/care giver on wound care

Encourage adequate nutrition

Encourage adequate hydration

Patient Education Discussed

Education integumentary

2) Review of Physician's orders dated 03/31/20 showed the following order: Skin Care Protocol

(i) Review of Skin Care Protocol showed the facility should make sure the Patient is being turned every two hours.

3) Review of Physician's orders dated 04/17/20 showed the following order: turn every 2 hours and use pillows to offload bony prominences.

4) Review of policy and procedure Titled "Pressure Injury Basic Treatment" showed the following:

a) Educate the patient regarding the importance of self-initiated movement to reduce pressure through weight shifts and reposting.

b) Limit the time a patent spends seated in a chair without pressure relief seating support to brief transitions as to and from the bathroom or shower.

c) If sitting in a chair for long periods of time is necessary for individuals with pressure injures/ulcers on the sacrum/ coccyx or ischia to develop an individualized plan that limits sitting to three times a day (excluding therapy sessions where patients are in motion during the sessions) in periods of 60 minutes or less at any one time. When this cannot be avoided the plan should include techniques to off load the pressure from the involved areas.


5) Review of clinical record on 6/15/20 for Patient #6 showed the following:

a) On 4/2/20, documentation showed the patient was in chair with no position changes noted from 10:00 AM to 1:00 PM.

b) On 4/2/20-4/3/20, documentation showed the patient was in semi-Fowler's position on 4/2/20 at 10:00 PM - 4/3/20 at 7:00 AM with no repositioning documented.

c) On 4/7/20-4/8/20, documentation showed the patient was in semi-Fowler's position from 4:00 PM - 6:30 PM, from 6:30 PM to 10:23 PM and from 10:23 PM to 4/8/20 at 7:09 AM with no repositioning documented.

d) On 4/8/20, documentation showed the patient was in chair with no position changes noted from 10:00 AM to 1:00 PM.

e) On 4/28/20-4/29/20, documentation showed the patient was in semi-Fowler's position on 4/28/20 at 4:00 PM - 4/29/20 at 3:00 AM with no repositioning documented.

f) On 4/29/20, documentation showed the patient was in chair with no position changes noted from 11:15 AM to 2:00 PM.

g) On 4/30/20-5/1/20, documentation showed the patient was in semi-Fowler's position on 4/30/20 from 3:41 PM - 5/1/20 at 7:00 AM with no repositioning documented.

h) On 5/2/20-5/3/20, documentation showed the patient was in semi-Fowler's position on 5/2/20 at 8:00 PM - 5/3/20 at 1:00 PM with no repositioning documented.

i) On 5/5/20, documentation showed the patient was in chair with no position changes noted from 9:00 AM to 1:00 PM and from 3:30 PM - 5:00 PM.

6) The findings in A were confirmed by the Chief Nursing Officer in an interview on 6/25/20.


B. Wound Measurements:

1) Review of policy and procedure titled, "Wound Assessment and Documentation," showed the RN will describe the wound precisely with stage 2 and greater pressure injuries and other wounds including the following documentation: Size: LENGTH, WIDTH, and DEPTH should be recorded in centimeters on admission or discovery and at discharge.

2) Review of clinical records for Patient #6 showed no evidence of wound measurements for sacral pressure ulcer.

3) The findings in B were confirmed by the Chief Nursing Officer in email dated July 2, 2020.


C. Skin Assessment every shift.

1) Review of policy and procedure titled, "Wound Assessment and Documentation," showed an RN will inspect each patient's integument daily and as often as indicated.

2) In an interview with the Chief Nursing Officer on 6/10/20 at 2:40 PM, the facility had an initiative in place for skin assessments to be performed twice a day based on Quality Council Meetings.

3) Quality Council Meeting minutes dated May 9, 2019 stated that documentation of skin assessment every shift was a, "new measure based on case drill down."

4) Review of clinical record for Patient #6 showed no evidence of complete skin assessment on the day shift for 4/4/20, 4/18/20, 4/19/20, 4/24/20, 4/25/20, 4/26/20 or on the night shift for 4/20/20, 4/23/20 and 5/1/20.

5) The findings in C were confirmed by the Chief Nursing Officer in an email interview dated 7/6/20.