HospitalInspections.org

Based on interview the facility staff failed to assess the effectiveness of measures put into place to measure physicians' orders and they way they are documented.

The findings include:

On 3/4/15 Staff Member #1 and the surveyor reviewed the Quality Assessment program. Staff Member #1 stated in a review in February 2015 of how medications are ordered and discontinued the facility discovered some physicians were not discontinuing an order but revising the order. Staff Member #1 stated they did education with the physicians regarding discontinuing versus revising. The outcome was to discontinue and order and re-order and revise.

Staff Member #1 was asked if the Quality Assessment program had re-evaluated the training the facility had completed with the physicians. Staff Member #1 stated, "No, we have not been monitoring the physicians orders."

Based on interviews and documents reviewed the facility's registered nurse failed to ensure the physician's orders were followed for 2 of 10 patients, Patient #7 and 10. Patient #7 had an order for wound care to evaluate and treat that did not occur for 5 days and Patient #10 had an order for daily dressing changes and the dressing was being changed less frequently.

The findings include:

Patient # 7 was a 50 year old admitted on 2/21/15 per the Pre Admission Screen due to a right below the knee amputation (RBKA). Patient #7's Pre Admission Screen electronically signed by the admitting physician on 2/20/15 documented the following: "has a history of bilateral lower extremity paraplegia and documents Patient #7's Weight: 68 pounds. 30.91 kilograms; Height: 149 inches (12.416 feet). 3.78 meters; BMI: 2.16 kilograms per meters squared. Pressure Ulcers: Pressure ulcer(s) present. Location: left heel and right perineal/groin area Type: Stage 2. 2/16/15 wound care nurse notation: Location: L heel dressing removed and wound is 9x4 cm (centimeters) with 70% pink to sides and yellow coloration to the base. Drainage on dressing is slightly green in color. No odor noted and remaining heel coloration wnl (within normal limits). Leg itself is very dry with flaking skin. start Lac-Hydron to assist with dryness and con't dakins for a few more days due to drainage coloration. Pt (Patient) has a full thickness wound that is 3x2. 3x0.2cm with yellow base. Drainage is clear brown to yellow. Site is at the perineal/groin crease of the R (right) leg. No odor or induration noted. P: Dakins to R peri wound and L (left) heel wound every 12 hours. General Skin: right below the knee amputation site."
The physician's note does not mention any buttock wounds on any wounds on the leg.
The Nurses' Admission Assessment on 2/21/15 documents the following: Wound/Incisions: "Right BKA with staples has redness along the incision. Allveyn dressing in place. Left heel wound is 35 mL(milliliters) by 40 mL and 10 mL deep. Red to sides and yellow at the base. Some yellow drainage, but on "oder". Redressed with dressing. Six wounds in different stages of healing on lower leg. Most are circular and measure 10 mL by 10 mL. All are red with no drainage."
The Nurses' Admission Assessment also documented: "Right buttocks wound near sacrum measures 25 by 10 mL. Is yellow with redness around the edges. An allevyn dressing covers it. Wound on right lower buttock measures 20 by 10 mL and in yellow with no drainage. wound on right upper buttock measures 15 by 8 mL and is yellow with no drainage."
The Nurses' Admission Assessment does not mention any perineal/groin wound
Staff Member #4 stated, "I think the nurse meant cm not mL and there should have been a decimal point between the 3 and the 5 and also between the other numbers."
The attending physician wrote an order on 2/21/15 at 14:32 to have Wound Care Evaluate and treat decubiti.
The Wound Care nurse did not see Patient #7 until 2/27/15 at 15:00. The documentation by the wound care nurse states, "R buttock-unstageable wound that is 2.6.cm xx2.6 cm x undetermined depth. There is 20% loosely adherent slough and 80% adherent slough. Patient is experiencing no pain at the site. There is light drainage that is clear to yellowish. Will try using santyl with drawtex covered with an allevyn change Qday (everyday) or prn. Will continue to follow. L heel-Stage 3 pressure ulcer that is 3 cm x 5 cm x 0.8 cm. 75% beefy granulation tissue, 25 % yellow discoloration/slough. Some serous to yellow drainage noted, no odor. Surrounding tissue intact. Will switch to santyl, drawtex, covered with allevyn tomorrow. Change Qday or prn."
Wound Care Nurse's note does not mention any wounds on the leg or perineal/groin area.
Staff Member #2 provided a copy of a policy with another facility name on the policy titled Enterostomal Therapy. Staff Member #2 stated, "Wound Care (Enterostomal Therapy (ET)) is a contracted service and we follow this policy."

The Enterostomal Therapy Policy states...Request for ET Nurse's screenings and consults will be performed, excluding holiday weekends, within 72 hours of receiving the consult.








34452


Patient #5's medical record was reviewed on March 2, 2015 at 2:30 P.M. with Staff Member #5.

Patient #5 was a 58 year old admitted on January 28, 2015 with a diagnosis of peripheral vascular disease status post left lower extremity by pass graft.

A review of the medical Record for Patient #5 revealed physicians order for daily dressing changes dated January 29, 2015. The documentation in the medical record failed to show dressing changes completed daily for patient #5.

Based on document review and interviews the facility staff failed to ensure the plan of care for 2 of 10 patients, (Patient #2 and #10) reflected accurately the changes in the patient's condition and to document accurately the changes.

The findings include:

Patient #2's medical records were reviewed for admission between December 8, 2014 and January 4, 2015, with Staff Member #5.

Patient #2 was a 80 year old admitted on December 8, 2015 with a diagnosis of Post Cervical Surgery.

The medical record contained the following notes regarding Patient #2:

December 8, 2014
8:36 P.M. Nursing admission assessment: small open area to right buttock 3.5 centimeters (cm) x 1.5 centimeters (cm) non-blanching. Orange top cream applied, covered with allevyn, repositioned off right buttock. Braden score: 16, Level of Risk: At risk, wound present. The following interventions will be instituted: turn patient every 2 hours, assist patient to the bathroom every 2 hours, incontinent protocol, nutritional consult, wound care consult.
Interview with Staff Member # 4 revealed that allevyn is a dressing used prophylactic, changed every three (3) days per manufacturer guidelines, and is not transparent.

The Braden Scale for Predicting Pressure Ulcer Risk, is a tool that was developed in 1987 by Barbara Braden and Nancy Bergstrom. The purpose of the scale is to help health professionals, especially nurses, assess a patient's risk of developing a pressure ulcer.

Assessment using the Braden Scale includes: Sensory perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear.

Scoring with the Braden Scale
Each category is rated on a scale of 1 to 4, excluding the 'friction and shear' category which is rated on a 1-3 scale. This combines for a possible total of 23 points, with a higher score meaning a lower risk of developing a pressure ulcer and vice-versa. A score of 23 means there is no risk for developing a pressure ulcer while the lowest possible score of 6 points represents the severest risk for developing a pressure ulcer. The Braden Scale assessment score scale:

Very High Risk: Total Score 9 or less
High Risk: Total Score 10-12
Moderate Risk: Total Score 13-14
Mild Risk: Total Score 15-18
No Risk: Total Score 19-23

Kozier, Barbara, Glenora Erb, Shirlee Snyder, and Audrey Berman. Fundamentals of Nursing: Concepts, Process, and Practice. 8th ed. Upper Saddle Riveer, NJ: Pearson Education, 2008. 905-907.

December 9, 2014 Nurses notes
1:39 A.M. Braden score 16, Level of Risk: At risk, No wound is present at this time. The following interventions will be instituted: Turn patient every 2 hours, Incontinent protocol.
8:42 A.M. Wound/incision not assess this shift. Braden score 16, Level of Risk: At risk. No wound is present at this time. The following interventions will be instituted: Assist patient to the bathroom every 2 hours, Nutrition consult.
9:00 A.M. Occupational Therapy note: has pressure sore on bottom.
10:28 A.M. Wound/incision not assessed this shift. Braden score: 16, Level of Risk: At risk. A wound is present. The following interventions will be instituted: Nutrition consult, Pressure relief every 30 minutes while in wheelchair." 2:55 P.M. Braden score 21, Level of Risk: No risk, will reassess every shift.

December 10, 2014 Nurses notes
8:15 A.M. Sacral wound cleansed and covered with allevyn dressing. Braden score: 17. Level of Risk: At risk, a wound is present. The following interventions will be instituted: Wound care consult, Pressure relief every 30 minutes while in wheelchair, Nutrition consult.
3:37 P.M. Team conference note: sacral wound. Turning schedule, speciality mattress and speciality wheelchair cushion active.
7:05 P.M. buttock allevyn dressing dry and intact. Braden score: 13. Level of Risk: Moderate risk. No wound present at this time. The following interventions will be instituted: turn patient every 2 hours and Nutrition consult.

December 11, 2014 Nurses notes
7:38 A.M. Braden score: 18. Level of Risk: At risk. A wound is present. The following interventions will be instituted: Nutrition consult, turn patient every 2 hours, pressure relief every 30 minutes while in wheelchair.
7:58 P.M. Braden score: 17. Level of Risk: At risk. No wound is present at this time. The following interventions will be instituted: (none listed).
11:41 P.M. Wound/incision not assessed this shift. Braden score: 17. Level of Risk: At risk. A wound is present. The following interventions will be instituted: incontinent protocol, nutrition consult. wound care consult.

December 12, 2014 Nurses notes
10:17 A.M. Braden score: 16. Level of Risk: At risk. No wound is present at this time. The following interventions will be instituted: pressure relief every 30 minutes while in wheelchair, Nutrition consult.
2:55 P.M. Braden score: 21. Level of Risk: No risk. Will reassess every shift.
Late entry note for December 12, 2014 entered on March 3, 2015 10:54 A. M. by Staff Member #9 - Patient seen during wound rounding with Staff Member #11 and #12. Patient with areas of moisture associated skin damage to buttocks. Areas are resolving. Continue remedy calazime cream and silicon backed form (Allevyn) dressing.
An interview with Staff Member #9 revealed that the wound team does not follow a patient with moisture related skin damage.

December 14, 2014 Nurses notes
6:47 A. M. Sacral redness covered with a clover-leaf allevyn dressing. Braden score: 21. Level of Risk: At risk. No wound present at this time. The following interventions will be instituted: (none listed)

December 16, 2014 Nurses notes
2:05 A.M. Wound/incisions not assessed this shift. Braden score: 15. Level of Risk: At risk. No wound is present at this time. The following interventions will be instituted: pressure relief every 30 minutes while in wheelchair, assist patient to bathroom every 2 hours, incontinent protocol.
8:22 A.M. Buttock has intact allevyn. Braden score: 19. Level of Risk: No risk. Will reassess every shift.
5:39 P.M. Braden score: 17. Level of Risk: At risk. The following interventions will be instituted: turn patient every 2 hours, wound care consult.

December 17, 2014
4:32 P. M. Team conference note electronically signed by Staff Member #8 and #13 - Skin wound status update: Patient has a peg site, sacral wound and neck incision.

December 20, 2014 Nurses notes
11:26 A.M. Bottom slightly red. Wound/incision not assess this shift. Braden score: 19. Level of Risk: No risk. Will reassess every shift.

December 21, 2014 Nurses notes
1:15 A.M. Patient has redness sacral area and small open area allevyn dressing applied. Braden score: 17. Level of Risk: At risk. No wound is present at this time. The following interventions will be instituted: turn patient every 2 hours, Nutrition consult.
11:21 A.M. dressing dry and intact sacrum. Braden score: 20. Level of Risk: No risk. Will reassess every shift.
2:47 P.M. Sacrum is red with a 1 cm skin tear in the center of redness. No drainage noted. Cleaned with NS solution and covered with clover-leaf allevyn dressing. Braden score: 21. Level of Risk: Moderate risk. The following interventions will be instituted: turn patient every 2 hours.

December 22, 2014 Nurses notes
3:07 P.M. Sacral area red with skin tear on left inner buttock. Cleansed with NS solution and place a clover-leaf allevyn dressing. Braden Scale: 18. Level of Risk: At risk. The following interventions will be instituted: turn patient every 2 hours, assist patient to bathroom every 2 hours.

December 25, 2014 Nurses notes
3:52 P.M. No wounds or incisions. Braden score: 17. Level of Risk: At risk. The following interventions will be instituted: (none listed).

December 26, 2014 Nurses notes
7:17 A. M. Open are to both buttock; upper buttock has an area with thick grayish material covering wound, areas cleansed with NS and covered with allevyn dressing. Braden score: 17. Level of Risk: At risk. A wound is present. The following interventions will be instituted: pressure relief every 30 minutes while in wheelchair. Turn patient every 2 hours. Incontinent protocol. Wound care consult.

December 27, 2014 Nurses notes
3:16 P.M. Pt has new order wound washed with wound cleanser patted dry santyl applied covered with dressing. Sacrum right buttocks has several sites open some with yellow tissue moderate yellow purulent drainage.
4:19 P.M. Braden score: 17. Level of Risk: At risk No wound present at this time. The following interventions will be instituted: (none listed)

December 29, 2014 Nursing notes
7:15 A. M. Open area on sacral some redness noted and yellow tissue noted santyl applied and covered with allevyn. Braden score: 19. Level of Risk: No risk. Will reassess every shift.
10:38 Wound Care note: Wound to sacrum measures 2.5 cm x 3 cm x UTA, wound bed 100% yellow/tan firmly attached necrotic tissue, mostly likely etiology pressure - unstageable, no drainage, no malodor. Periwound skin with blancable erythema with areas of excoriation. Unstageable pressure ulcer with periwound moisture associated skin damage. Continue santyl to assist with debriding wound bed. Add Vashe to cleanse wound to address any surface microorganisms.
Interview with Staff Member # 9 revealed UTA means unable to assess.
8:58 P.M. Wound/incision not assessed this shift. Wound nurse changed dressing. Braden score: 15. Level of Risk: At risk. A wound is present. The following interventions will be instituted: turn patient every 2 hours, incontinent protocol, air mattress, wound care consult.

December 31, 2014 Wound Rounds
4:28 P. M. Wound to sacum measures 2.5 cm x 3 cm x UTA, wound bed 100 yellow/tan firmly attached necrotic tissue, most likely etiology pressure-unstageable, no drainage, no malodor. Periwound skin with blancable erythema with areas of excoriation. Unstageable pressure ulcer with periwound moisture associated skin damage. Continue santyl to assist with debriding wound bed. Add vashe to cleanse wound to address any surface microorganisms.

January 2, 2015 Wound Rounds
6:12 P.M. Sacral wound measures 2.5 cm x 5 cm x uta, wound bed 100% yellow tissue base, softening necrotic tissue. Decrease in erythema to periwound skin with resolving excoriations. Wound with softening necrotic tissue, width has increased, but is due more to patient positioning than true increase in wound size. Wound cleansed with vashe (saturated gauze, placed on wound bed, allowed to dwell for 6 minutes, wiped clean). Santyl applied to wound bed, secured with slightly moist vashe gauze and silicone backed foam.




Patient #10's medical records were reviewed for current admission between February 20, 2015 and March 3, 2015, with Staff Member #5.
Patient #10 was a 62 year old admitted on February 20, 2015 with a diagnosis of Right Total Knee Replacement.
The medical record contained the following notes regarding Patient #10:
Patient #10's medical records were reviewed for current admission between February 20, 2015 and March 3, 2015, with Staff Member #5.
Patient #10 was a 62 year old admitted on February 20, 2015 with a diagnosis of Right Total Knee Replacement.
The medical record contained the following notes regarding Patient #10:
February 20, 2015 Nursing admission assessment
surgical incision right knee with staples intact, 22 centimeter.

February 21, 2015 Nurses notes
2:30 A.M. right knee incision, 0 centimeters with staples.
10:40 A.M. right knee incision with staples.
5:52 P.M. right knee incision 10 centimeters with staples.

February 22, 2015 Nurses notes
4:16 A.M. dressing dry and intact, not assessed.
3:00 P.M. neck incision 22 centimeters staples.

March 3, 2015 Nurse notes
1:52 A.M. right knee incision, 22 centimeters with staples.

Based on interviews and document reviews the facility staff failed to ensure the medical records were accurate for 4 of 10 patients, Patients #2, 3, 7 and 10. Patients #2 and 10 documented a wound that changed locations and for Patients #3 and 10 the number of wounds and location documented by the physician, admitting nurse and wound care nurse do not coincide.

The findings include:

1. Patient #3 was a 50 year old admitted on 2/20/15 with a diagnosis of Transmetatarsal amputation of the left foot. Patient #3's History and Physical (H&P) dated 2/20/15 also noted Patient #3 had a history of a right below the knee amputation in 2013 and a past history of a left femoral bypass on 2/6/15. The H&P notes under Skin "Open wound of left foot stump with sutures and active sanguineous drainage, staples of right medial thigh and leg clean, dry, and intact over incision. 2+left lower extremity edema, 1+ right lower extremity edema, scrotal swelling. Right stump with well-healed incision."
The Nursing Admission Assessment started on 2/20/15 and electronically signed on 3/2/15 noted the following under Wound/Incisions: "left foot toes amputated black eschar noted sutures in place mod (moderate) amount of drainage noted area cleaned and dry dressing applied. Left inner lower leg has 5 incisions which are scabbed over 1st 9 cm (centimeters), 2nd 5 cm, 3rd 6 cm, 4th 9.5 cm / 5th 10.2 cm open to air...old right aka (above the knee amputation) is healed open to air with stump shrinker in place.
Nursing note dated 3/1/15 noted under Wounds/Incisions: "Incision to left inner thigh, Allveyn dressing dry and intact. OTA (open to air). Incision of left shin, no redness/drainage noted. Incision to left foot with sutures intact.
Patient # 7 was a 50 year old admitted on 2/21/15 per the Pre Admission Screen due to a right below the knee amputation (RBKA). Patient #7's Pre Admission Screen electronically signed by the admitting physician on 2/20/15 documented the following: "has a history of bilateral lower extremity paraplegia and documents Patient #7's Weight: 68 pounds. 30.91 kilograms; Height: 149 inches (12.416 feet). 3.78 meters; BMI: 2.16 kilograms per meters squared. Pressure Ulcers: Pressure ulcer(s) present. Location: left heel and right perineal/groin area Type: Stage 2. 2/16/15 wound care nurse notation: Location: L heel dressing removed and wound is 9x4 cm (centimeters) with 70% pink to sides and yellow coloration to the base. Drainage on dressing is slightly green in color. No odor noted and remaining heel coloration wnl (within normal limits). Leg itself is very dry with flaking skin. start Lac-Hydron to assist with dryness and con't dakins for a few more days due to drainage coloration. Pt (Patient) has a full thickness wound that is 3x2. 3x0.2cm with yellow base. Drainage is clear brown to yellow. Site is at the perineal/groin crease of the R (right) leg. No odor or induration noted. P: Dakins to R peri wound and L (left) heel wound every 12 hours. General Skin: right below the knee amputation site."
The Nurses' Admission Assessment on 2/21/15 documents the following: Wound/Incisions: "Right BKA with staples has redness along the incision. Allevyn dressing in place. Left heel wound is 35 mL by 40 mL and 10 mL deep. Red to sides and yellow at the base. Some yellow drainage, but on oder (odor). Redressed with dressing. Six wounds in different stages of healing on lower leg. Most are circular and measure 10 mL by 10 mL. All are red with no drainage."
The Nurses' Admission Assessment also documented: "Right buttocks wound near sacrum measures 25 by 10 mL. Is yellow with redness around the edges. An allevyn dressing covers it. Wound on right lower buttock measures 20 by 10 mL and in yellow with no drainage. wound on right upper buttock measures 15 by 8 mL and is yellow with no drainage."
Staff Member #4 stated, "I think the nurse meant cm not mL and there should have been a decimal point between the 3 and the 5 and also between the other numbers."
ML(milliliter) is a measure of volume. CM (centimeter) or MM (millimeter) is a measure of the length or width.




34452



2. Patient #2's medical record was reviewed for admission between December 8, 2014 and January 4, 2015 with Staff Member #5.

Patient #2 was a 80 year old admitted on December 8, 2014 with a diagnosis of Post Cervical Surgery.

The medical record contained the following documentation regarding Patient #2:

December 8, 2014
8:36 P.M. Nursing admission assessment: small open area to right buttock 3.5 centimeters (cm) x 1.5 centimeters (cm) non-blanching. Orange top cream applied, covered with allevyn, repositioned off right buttock. Braden score: 16, Level of Risk: At risk, wound present. The following interventions will be instituted: turn patient every 2 hours, assist patient to the bathroom every 2 hours, incontinent protocol, nutritional consult, wound care consult.
Interview with Staff Member # 4 revealed that allevyn is a dressing used prophylactic, changed every three (3) days per manufacturer guidelines, and is not transparent.

The Braden Scale for Predicting Pressure Ulcer Risk, is a tool that was developed in 1987 by Barbara Braden and Nancy Bergstrom. The purpose of the scale is to help health professionals, especially nurses, assess a patient's risk of developing a pressure ulcer.

Assessment using the Braden Scale includes: Sensory perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear.

Scoring with the Braden Scale
Each category is rated on a scale of 1 to 4, excluding the 'friction and shear' category which is rated on a 1-3 scale. This combines for a possible total of 23 points, with a higher score meaning a lower risk of developing a pressure ulcer and vice-versa. A score of 23 means there is no risk for developing a pressure ulcer while the lowest possible score of 6 points represents the severest risk for developing a pressure ulcer. The Braden Scale assessment score scale:

Very High Risk: Total Score 9 or less
High Risk: Total Score 10-12
Moderate Risk: Total Score 13-14
Mild Risk: Total Score 15-18
No Risk: Total Score 19-23

Kozier, Barbara, Glenora Erb, Shirlee Snyder, and Audrey Berman. Fundamentals of Nursing: Concepts, Process, and Practice. 8th ed. Upper Saddle Riveer, NJ: Pearson Education, 2008. 905-907.

December 9, 2014 Nurses notes
1:39 A.M. Braden score 16, Level of Risk: At risk, No wound is present at this time. The following interventions will be instituted: Turn patient every 2 hours, Incontinent protocol.
8:42 A.M. Wound/incision not assess this shift. Braden score 16, Level of Risk: At risk. No wound is present at this time. The following interventions will be instituted: Assist patient to the bathroom every 2 hours, Nutrition consult.
9:00 A.M. Occupational Therapy note: has pressure sore on bottom.
10:28 A.M. Wound/incision not assessed this shift. Braden score: 16, Level of Risk: At risk. A wound is present. The following interventions will be instituted: Nutrition consult, Pressure relief every 30 minutes while in wheelchair.
2:55 P.M. Braden score 21, Level of Risk: No risk, will reassess every shift.

December 10, 2014 Nurses notes
8:15 A.M. Sacral wound cleansed and covered with allevyn dressing. Braden score: 17. Level of Risk: At risk, a wound is present. The following interventions will be instituted: Wound care consult, Pressure relief every 30 minutes while in wheelchair, Nutrition consult.
3:37 P.M. Team conference note: sacral wound. Turning schedule, speciality mattress and speciality wheelchair cushion active.
7:05 P.M. buttock allevyn dressing dry and intact. Braden score: 13. Level of Risk: Moderate risk. No wound present at this time. The following interventions will be instituted: turn patient every 2 hours and Nutrition consult.

December 11, 2014 Nurses notes
7:38 A.M. Braden score: 18. Level of Risk: At risk. A wound is present. The following interventions will be instituted: Nutrition consult, turn patient every 2 hours, pressure relief every 30 minutes while in wheelchair.
7:58 P.M. Braden score: 17. Level of Risk: At risk. No wound is present at this time. The following interventions will be instituted: (none listed).
11:41 P.M. Wound/incision not assessed this shift. Braden score: 17. Level of Risk: At risk. A wound is present. The following interventions will be instituted: incontinent protocol, nutrition consult. wound care consult.

December 12, 2014 Nurses notes
10:17 A.M. Braden score: 16. Level of Risk: At risk. No wound is present at this time. The following interventions will be instituted: pressure relief every 30 minutes while in wheelchair, Nutrition consult.
2:55 P.M. Braden score: 21. Level of Risk: No risk. Will reassess every shift.
Late entry note for December 12, 2014 entered on March 3, 2015 10:54 A.M. by Staff Member #9 - Patient seen during wound rounding with Staff Member #11 and #12. Patient with areas of moisture associated skin damage to buttocks. Areas are resolving. Continue remedy calazime cream and silicon backed form (Allevyn) dressing.
An interview with Staff Member #9 revealed that the wound team does not follow a patient with moisture related skin damage.

December 14, 2014 Nurses notes
6:47 A.M. Sacral redness covered with a clover-leaf allevyn dressing. Braden score: 21. Level of Risk: At risk. No wound present at this time. The following interventions will be instituted: (none listed)

December 16, 2014 Nurses notes
2:05 A.M. Wound/incisions not assessed this shift. Braden score: 15. Level of Risk: At risk. No wound is present at this time. The following interventions will be instituted: pressure relief every 30 minutes while in wheelchair, assist patient to bathroom every 2 hours, incontinent protocol.
8:22 A.M. Buttock has intact allevyn. Braden score: 19. Level of Risk: No risk. Will reassess every shift.
5:39 P.M. Braden score: 17. Level of Risk: At risk. The following interventions will be instituted: turn patient every 2 hours, wound care consult.

December 17, 2014
4:32 P.M. Team conference note electronically signed by Staff Member #8 and #13 - Skin wound status update: Patient has a peg site, sacral wound and neck incision.

December 20, 2014 Nurses notes
11:26 A.M. Bottom slightly red. Wound/incision not assess this shift. Braden score: 19. Level of Risk: No risk. Will reassess every shift.

December 21, 2014 Nurses notes
1:15 A.M. Patient has redness sacral area and small open area allevyn dressing applied. Braden score: 17. Level of Risk: At risk. No wound is present at this time. The following interventions will be instituted: turn patient every 2 hours, Nutrition consult.
11:21 A.M. dressing dry and intact sacrum. Braden score: 20. Level of Risk: No risk. Will reassess every shift.
2:47 P.M. Sacrum is red with a 1 cm skin tear in the center of redness. No drainage noted. Cleaned with NS solution and covered with clover-leaf allevyn dressing. Braden score: 21. Level of Risk: Moderate risk. The following interventions will be instituted: turn patient every 2 hours.

December 22, 2014 Nurses notes
3:07 P.M. Sacral area red with skin tear on left inner buttock. Cleansed with NS solution and place a clover-leaf allevyn dressing. Braden Scale: 18. Level of Risk: At risk. The following interventions will be instituted: turn patient every 2 hours, assist patient to bathroom every 2 hours.

December 25, 2014 Nurses notes
3:52 P.M. No wounds or incisions. Braden score: 17. Level of Risk: At risk. The following interventions will be instituted: (none listed).

December 26, 2014 Nurses notes
7:17 A.M. Open are to both buttock; upper buttock has an area with thick grayish material covering wound, areas cleansed with NS and covered with allevyn dressing. Braden score: 17. Level of Risk: At risk. A wound is present. The following interventions will be instituted: pressure relief every 30 minutes while in wheelchair. Turn patient every 2 hours. Incontinent protocol. Wound care consult.

December 27, 2014 Nurses notes
3:16 P.M. Pt has new order wound washed with wound cleanser patted dry santyl applied covered with dressing. Sacrum right buttocks has several sites open some with yellow tissue moderate yellow purulent drainage.
4:19 P.M. Braden score: 17. Level of Risk: At risk No wound present at this time. The following interventions will be instituted: (none listed)

December 29, 2014 Nursing notes
7:15 A.M. Open area on sacral some redness noted and yellow tissue noted santyl applied and covered with allevyn. Braden score: 19. Level of Risk: No risk. Will reassess every shift.
10:38 Wound Care note: Wound to sacrum measures 2.5 cm x 3 cm x UTA, wound bed 100% yellow/tan firmly attached necrotic tissue, mostly likely etiology pressure - unstageable, no drainage, no malodor. Periwound skin with blancable erythema with areas of excoriation. Unstageable pressure ulcer with periwound moisture associated skin damage. Continue santyl to assist with debriding wound bed. Add Vashe to cleanse wound to address any surface microorganisms.
Interview with Staff Member # 9 revealed UTA means unable to assess.
8:58 P.M. Wound/incision not assessed this shift. Wound nurse changed dressing. Braden score: 15. Level of Risk: At risk. A wound is present. The following interventions will be instituted: turn patient every 2 hours, incontinent protocol, air mattress, wound care consult.

December 31, 2014 Wound Rounds
4:28 P.M. Wound to sacrum measures 2.5 cm x 3 cm x UTA, wound bed 100 yellow/tan firmly attached necrotic tissue, most likely etiology pressure-unstageable, no drainage, no malodor. Periwound skin with blancable erythema with areas of excoriation. Unstageable pressure ulcer with periwound moisture associated skin damage. Continue santyl to assist with debriding wound bed. Add vashe to cleanse wound to address any surface microorganisms.

January 2, 2015 Wound Rounds
6:12 P.M. Sacral wound measures 2.5 cm x 5 cm x uta, wound bed 100% yellow tissue base, softening necrotic tissue. Decrease in erythema to periwound skin with resolving excoriations. Wound with softening necrotic tissue, width has increased, but is due more to patient positioning than true increase in wound size. Wound cleansed with vashe (saturated gauze, placed on wound bed, allowed to dwell for 6 minutes, wiped clean). Santyl applied to wound bed, secured with slightly moist vashe gauze and silicone backed foam.




Patient #10's medical records were reviewed for current admission between February 20, 2015 and March 3, 2015 with Staff Member #5.
Patient #10 was a 62 year old admitted on February 20, 2015 with a diagnosis of Right Total Knee Replacement.
The medical record contained the following notes regarding Patient #10:
February 20, 2015 Nursing admission assessment
surgical incision right knee with staples intact, 22 centimeter.

February 21, 2015 Nurses notes
2:30 A.M. right knee incision, 0 centimeters with staples.
10:40 A.M. right knee incision with staples.
5:52 P.M. right knee incision, 10 centimeters with staples.

February 22, 2015 Nurses notes
4:16 A.M. dressing dry and intact, not assessed.
3:00 P.M. neck incision, 22 centimeters staples.

March 3, 2015 Nurse notes
1:52 A.M. right knee incision, 22 centimeters with staples.