HospitalInspections.org

Based on policy and procedure review, medical record review and interview, the hospital failed to keep a current nursing care plan by ongoing assessment of the patient's needs for skin integrity for 3 of 3 (Patient #1, 2 and 3) sampled patients.

The findings included:

1. Review of the hospital's "Wound Assessment Prevention and Documentation" policy revealed, "...PURPOSE...To improve patients' skin integrity through timely and consistent clinical practices for assessment and prevention of wounds...To ensure standard documentation related to the assessment of skin and wounds...To facilitate both accuracy in wound assessment and quality reporting and assist in fulfilling CMS's [Center for Medicare and Medicaid Services] requirement that all inpatient facilities report data related to developing and worsening wounds...Assessment...An RN [Registered Nurse] will inspect each patient's integument daily, weekly and as often as indicated...Pressure injuries are noted in the record upon discovery (either upon admission or throughout the stay)...A full assessment is completed within 8 hours of admission (or discovery of a new wound) to include descriptions, measurements, photos, and physician notification...Documentation of Assessment: The RN will describe the wound precisely...Daily documentation of skin and wound inspection completed by an RN will include any of the following, if present...skin condition...dressing integrity...description of wound drainage, odor, pain, signs of inflammation or infection, if present..."

Review of the hospital's "Wound Team Duties" procedure revealed, "...Main duties while on as Wound Team...Admission assessment...Complete Skin assessment for all new admits...Weekly Follow-up on Pressure ulcers or involved wounds...Must be done by Designated Clinician/wound team member...Audit documentation making sure documentation is complete each shift for all wound patients..."

2. Medical record review for Patient #1 revealed an admission date of 1/11/18 with diagnoses which included Status Post Multiple Falls, Ossification of the Posterior Longitudinal Ligament, Severe Stenosis and Cord Compression at Thoracic [T] 1-2 and T2-3 with Myelomalacia, Status Post T1, T2, T3 and Superior Rim of T4 Laminectomy, Left T3 Transpedicular Decompression, Status Post Bilateral Pedicle Screw Fixation T1 through T4 Nonsegmental with Posterolateral Fusion, Neurogenic Bowel and Neurogenic Bladder.

The "Adult Systems Assessment" dated 1/11/18 from 00:00-23:59 [12:00 AM-11:59 PM] revealed, "...Skin Integrity...Not intact...Incision/Wound(s) Present...Yes..." There was no other documentation of the location or appearance of the patient's incision or wound. There was no admission skin assessment documented by the Wound Care Team.

The Nurse Progress Note dated 1/25/18 at 11:41 AM revealed, "...Called to room by RNT [Rehabilitation Nurse Technician] to assess sacral lesion. Possible DTI [deep tissue injury] present...Performed By/Author...[Wound Care Coordinator]..." The Wound Care Coordinator documented the wound measured 4 centimeters (cm) in length, 3 cm in width and 0.1 cm in depth. There was a moderate amount of tan, serous exudate from the wound. The wound was documented as unstageable with 90 percent of the wound yellow and 10 percent of the wound black.

The daily RN skin assessment documented Patient #1's skin as intact with abnormalities from 1/23/18-1/28/18. There was no daily RN skin assessment documented on 1/22/18 or 1/29/18.

The Patient Discharge Summary dated 2/8/18 revealed, "...[Patient #1] [Hospital #1] course was complicated by stage 4 sacral deep tissue injury...deep tissue injury worsened with eventual tunneling and development of malodorous drainage. On the morning of 2/3 [2018] patient had a fever of 100.5F [Fahrenheit] and she was acute care transferred to [Hospital #2] ED [Emergency Department] on 2/3 for evaluation of possible osteomyelitis..."

During an interview in the conference room on 5/2/18 at 8:30 AM, the Interim Chief Nursing Officer (CNO) stated a RN should document a skin assessment at least one every 24 hours. The Interim CNO confirmed the RNs' documentation of Patient #1's skin as intact with abnormalities was inaccurate from 1/25/18-1/29/18.

3. Medical record review for Patient #2 revealed an admission date of 3/27/18 with diagnoses of Alzheimer's Disease, Coronary Artery Disease, Hypertension, Hyperlipidemia, Hypothyroidism, Prostate Cancer, Recent 16% Total Body Surface Area Burn and Status Post Left Below the Knee Amputation.

The "Adult Systems Assessment" dated 3/28/18 at 2:00 AM revealed, "...Skin Integrity...Intact with abnormalities...Incision/Wound(s) Present...Yes..." There was no other documentation of the location or appearance of the patient's incision or wound. There was no admission skin assessment documented by the Wound Care Team.

The "Incision Wound Group" dated 4/4/18 at 5:47 PM revealed, "...Left Buttock...Pressure Ulcer Stage...Unstageable due to suspected deep tissue injury..." The Wound Care Coordinator documented the wound measured 5 cm in length, 2 cm in width and 0.1 cm in depth. There was a minimal amount of brown, serosanguineous exudate. The wound was documented as unstageable with 50 percent of the wound red and 50 percent of the wound black.

The daily RN skin assessment documented Patient #2's skin as intact with abnormalities from 4/2/18-4/6/18 and 4/8/18-4/9/18. There was no daily RN skin assessment documented from 3/29/18-4/1/18, 4/7/18 or 4/10/18-4/17/18.

During an interview in the conference room on 5/2/18 at 8:30 AM, the Interim CNO confirmed the RNs' documentation of Patient #2's skin as intact with abnormalities was inaccurate from 4/4/18-4/6/18 and 4/8/18-4/9/18.

4. Medical record review for Patient #3 revealed an admission date of 3/31/18 with diagnoses which included Dementia due to Alzheimer's Disease, Status Post Excision and Split-Thickness Skin Graft, 20% Total Body Surface Area Full Thickness Burn Circumferential Lower Left Extremity and Posteromedial Right Lower Extremity, Status Post Left Below the Knee Amputation and Rash to Groin/Buttocks.

The "Adult Systems Assessment" dated 3/31/18 at 5:13 PM revealed, "...Skin Integrity...Not intact...Incision/Wound(s) Present...Yes..." There was no other documentation of the location or appearance of the patient's incision or wound(s) during this assessment.

The "Incision Wound Group" dated 4/2/18 at 2:00 PM revealed, "...sacrum Pressure ulcer...Description...Necrotic tissue...Drainage...Scant, Serosanguineous..." There was no documentation by the Wound Care Team for measurements or staging of the wound.

There was no daily RN skin assessment documented on 4/1/18.

The Physician Discharge Summary dated 4/3/18 revealed, "...DISPOSITION PLAN: Acute transfer to [Hospital #2] ED for DHT [Dobhoff tube] replacement..."

5. During an interview in the conference room on 5/1/18 at 1:01 PM, the Wound Care Coordinator stated he did not assess every patient upon admission. The Wound Care Coordinator stated he only assessed a patient if the Wound Care Team was consulted.

During an interview in the conference room on 5/2/18 at 8:15 AM, the Chief Nursing Officer Consultant stated the Wound Care Team should assess every patient upon admission and document the assessment in the medical record.