HospitalInspections.org

Based on review of the medical record and staff interviews, the Hospital failed to ensure that one of one applicable Patients, Patient #1, had the tracheostomy tube changed to prevent further skin breakdown. The delay resulted in a Stage III pressure ulcer.

Refer to A-0267, A-0347 and A-01160

Findings include:

1. Review of the Nurses Progress Note dated 12/03/11 at 2 P.M. indicated that Patient #1 developed an anterior, dime sized, open area at the tracheostomy site.

2. Registered Nurse #1 did not document that she contacted Pulmonologist #1 to report the development of a pressure sore.

3. Registered Nurse #1 was interviewed in person on 01/10/12 between 10:30 A.M. to 11:10 A.M. Registered Nurse #1 said that Respiratory Therapist #1 was aware of the open area and the Pulmonologist #1 was informed of the open area. Registered Nurse #1 was responsible for notifying Pulmonologist #1 that Patient #1 had an open area at the tracheostomy site.

4. Registered Nurse #1 said that a consultation was obtained for Patient #1 to be evaluated by the Wound Nurse. However, the Wound Nurse was not available until 12/05/11 and despite Vaseline Gauze applied as a treatment, the area continued to deteriorate.

5. Review of the Wound Nurse Consultation note dated 12/05/11 indicated that Patient #1's open area deteriorated to a Stage III pressure ulcer beneath the tracheostomy flange (an external flap device that secures the tracheostomy tube). A Stage III pressure ulcer is defined as full thickness tissue loss.

6. The Wound Nurse was interviewed in person on 01/10/12 at 2:30 P.M. to 3:00 P.M. The Wound Nurse said that she assessed Patient #1 on 12/05/11 during the afternoon . The Wound Nurse said that the tracheostomy flange had left an indentation in the shape of the flange on Patient #1's neck and the tracheostomy flange was causing pressure. The Wound Nurse said that the tracheostomy flange was large and despite treatment with a sponge to relieve pressure, the tracheostomy still needed to be changed. The Wound Nurse said Respiratory Therapist #1 recommended changing the tracheostomy. However, Patient #1 had to wait another 24 hours until 12/06/11. The Wound Nurse said that the Respiratory Therapists did not like to change tracheostomies after 5 P.M.

7. The nursing staff failed to ensure that Patient #1 was evaluated by the Wound Nurse in a timely manner after observing the open area. The nursing staff, Respiratory Therapist #1 and Pulmonologist #1 failed to coordinate the necessary services to prevent further injury/harm to Patient #1 who had developed a Stage III pressure ulcer at the tracheostomy site.

Based on medical record review, physician and staff interviews, Pulmonologist #1 did not ensure that prompt and immediate treatment was provided to one of one applicable, Patients #1, who required a tracheostomy change based on the development of a Stage III pressure ulcer at the tracheostomy site on 12/04/11.

Findings include:

1. Patient #1 was admitted to the Hospital with respiratory failure. Review of the Discharge Summary indicated that two days prior to arrival on 11/30/11, Patient #'s tracheostomy tube was changed to a # 8 double lumen cannula (DCT).

2. Review of Respiratory Therapist #1 Progress Note dated 12/04/11 at 10:00 A.M. indicated that Patient #1 needed a tracheostomy change secondary to the development to a pressure sore under the tracheostomy flange.

3. Respiratory Therapist #1 was interviewed in person on 01/10/12 between 11:30 A.M. to 12:40 P.M. Respiratory Therapist #1 said that Pulmonologist #1 examined Patient #1 on 12/04/11 at approximately 9:45 A.M. but he did not feel the tracheostomy needed to be changed.

4. Pulmonologist #1 was interviewed by telephone on 01/17/12 between 1:20 P.M. to 1:45 P.M. Pulmonologist #1 said that Patient #1 had a superficial erosion near the tracheostomy stoma. Pulmonologist #1 said that the tracheostomy did not need to be changed. Pulmonologist #1 said that changing tracheostomies on the weekend was discouraged especially if the tracheostomy was stable and functioning.

5. Pulmonologist #1 did not document the condition of Patient #1 superficial skin erosion in the medical record.

6. Review of the Wound Nurse Consultation Note dated 12/05/11 at 4:10 P.M. indicated that Patient #1 had a Stage III pressure ulcer, measuring 2 x 4 x 0.1 centimeters with yellow slough and red tissue in the surrounding area with small scant exudate. The Wound Nurse documented that respiratory therapist will request a tracheostomy change tomorrow 12/06/11.

7. The Wound Nurse was interviewed in person on 01/10/12 at 2:30 P.M. to 3:00 P.M. The Wound Nurse said that she assessed Patient #1 during the afternoon . The Wound Nurse said that the tracheostomy flange left an indentation in the shape of the flange on Patient #1's neck and the tracheostomy flange was causing pressure. The Wound Nurse said that the tracheostomy flange was a large size and despite treatment with a sponge to relieve pressure, the tracheostomy still needed to be changed. The Wound Nurse said Respiratory Therapist #1 recommended changing the tracheostomy on 12/06/11 because the therapists did not like to change tracheostomies in the evening.

8. There was a two day delay from 12/04/11 through 12/06/11 in providing necessary treatment, changing the tracheostomy, to Patient #1 who developed a Stage III pressure ulcer caused by pressure from the tracheotomy flange.

9. The nursing staff and respiratory therapy staff interviewed said that it was Hospital practice that tracheostomies were not routinely changed on the weekends or evenings.

10. The Hospital failed to ensure that Patient #1 was protected from further harm and pain secondary to the pressure and skin breakdown caused by the tracheostomy flange which resulted in a Stage III pressure ulcer because the respiratory therapist and Pulmonologist #1 deferred necessary treatment until 12/06/11.

11. Pulmonologist #1 failed to ensure that Patient #1's tracheostomy was changed in a timely manner following observation of an open area and subsequent documentation by the Wound Care Nurse of pressure caused by the Flange. The lack of changing Patient #1's tracheotostomy resulted in a Stage III pressure ulcer.

Based on medical record review, physician and staff interviews, the medical record lacked documentation by a physician for one of one applicable Patient, Patient #1 who developed a Stage III pressure ulcer beneath the tracheostomy flange on 12/04/11.

Findings include:

1. Review of the medical record indicated there was no documentation by a physician that Patient #1 developed a Stage III pressure ulcer beneath the tracheostomy flange.

Based on medical record review, physician and staff interviews, the Hospital failed to ensure that the respiratory therapists followed procedures to ensure that one of one applicable Patients, Patient #1, had a tracheostomy change in a timely manner. The lack of changing Patient #1's tracheotostomy resulted in a Stage III pressure ulcer.

Findings include:

Refer to A-0144, A-0267 and A-0347.

1. Review of Respiratory Therapist #1 Progress Note dated 12/04/11 at 10:00 A.M. indicated that Patient #1 needed a tracheostomy change secondary to the development to a pressure sore under the tracheostomy flange.

2. Respiratory Therapist #1 was interviewed in person on 01/10/12 between 11:30 A.M. to 12:40 P.M. Respiratory Therapist #1 said Pulmonologist #1 examined Patient #1 on 12/04/11 at approximately 9:45 A.M., but he did not feel the tracheostomy needed to be changed.

3. Review of the Respiratory Therapist Progress Note dated 12/06/11 indicated Patient #1's tracheostomy was changed to a #8 Shiley.

4. The nursing staff and respiratory therapy staff interviewed said that it was Hospital practice that tracheostomies were not routinely changed on the weekends or evenings.

5. The Hospital failed to advocate for safe patient practice for Patient #1 who was in need of a tracheostomy change in a timely manner to prevent further harm.

Based on medical record review, physician and staff interview, the Hospital failed to adequately analyze and implement quality improvement measures for one of one applicable, Patient #1, who developed a Stage III pressure ulcer beneath a tracheostomy flange (an external flap device which secures the tracheostomy tube) on 12/03/11 through 12/06/11.

Findings include:

Refer to A-0347

1. Review of the medical record indicated that Patient #1 developed a pressure ulcer beneath the tracheostomy flange on 12/03/11 through 12/04/11.

2. Review of the medical record indicated that Patient #1 needed a tracheotomy change in order to relieve the pressure caused by the tracheostomy flange. However, Patient #1's tracheostomy change was delayed for two additional days from 12/04/11 through 12/06/11, secondary to the practice within the Hospital to not change tracheostomies after 5 P.M. in the evening and on weekends.

3. There was no documenation of an internal review of this incident by the Hospital.

4. The Hospital failed to ensure that Patient #1 was protected from further harm and pain secondary to the pressure and skin breakdown caused by the tracheostomy flange which resulted in a Stage III pressure ulcer because the respiratory therapist and Pulmonologist #1 deferred necessary treatment until 12/06/11.