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Based on interviews and documentation review Hospital #2 failed to ensure that staff followed the policy/procedure related to pressure sore prevention/intervention for one of one patients.

Findings included:

See A-0267 for the Patient ' s medical information.

Hospital #2 ' s Policy/Procedure titled Skin Integrity Standard of Care, effective 5/07, indicated that all patients were evaluated on admission for potential to develop pressure sores. For patients at risk or with actual pressure sores, interventions were implemented, a care plan was developed, and the patient/family was involved in education. Care plans were updated as needed. If a patient was admitted with or developed a pressure sore the nurse was responsible for measuring the pressure sore and documenting the measurements. Pressure sores were classified using the staging system (Stage I, Stage II, Stage III, Stage IV, or unstagable). The nurse evaluated the pressure sore for evidence of infection and documented the appearance of the sore (color and condition of the base, if dead tissue [eschar or slough] was present, if drainage present). Pressure sores that were Stage II or greater were photographed with the patient ' s permission. Assessment was performed daily and findings were documented on the Daily Nursing Assessment Form and weekly by the Wound Care Team. Incident reports were completed for patients who developed a Stage II or greater pressure sore or who were admitted with a pressure sore that worsened.

Review of the medical record documentation indicated the following:

The Interdisciplinary assessment, dated 12/7/09, indicated that the Patient was admitted with red areas on the coccyx/buttocks and both heels. Documentation did not indicate if the areas were Stage I or blanchable and there were no measurements.

Review of Physician Orders, dated 12/8/09, indicated that an air mattress was ordered to be applied to the Patient ' s bed. The order was rewritten on 12/11/09 at which time the mattress was applied to the Patient ' s bed.

Review of Physician Orders, dated 12/8/09, indicated that an order was written for the Patient to be turned from side to side every 2 hours.

Review of Daily Flow Sheets, dated 12/8/09 to 1/6/10, indicated that turning and repositioning was inconsistently documented however; documentation present indicated that the Patient was positioned from side to side and on the back.

Review of the Daily Nursing Documentation (assessment and progress notes) indicated that there was no evidence of re-assessment of the coccyx/buttocks redness until 12/16/09 at which time documentation indicated that the redness was resolving.

Review of the Daily Nursing Documentation indicated that there was no evidence of reassessment of the bilateral heel redness until 12/19/09 at which time it was documented the left heel was red and boggy.

The Daily Nursing Documentation, dated 12/19/09, indicated that the Patient had several small Stage II pressure sores on the buttocks. There were no measurements or description of the areas.

The designated Wound Nurse was interviewed in person on 5/12/10 at 9:35 A.M. The Wound Nurse said the usual practice was if a pressure sore was identified a form was initiated and forwarded to the Wound Nurse who then consulted regarding treatment and monitor progress. The Wound Nurse was unaware of the Patient's pressure sore.

Review of the Daily Nursing Documentation indicated that there was no evidence the Stage II pressure sores were reassessed until 12/22/09 at which time documentation indicated the Patient had blisters both intact and open. There were no measurements of the areas.

Review of the Daily Nursing Documentation, dated 12/23/09 to 12/3/1/09, indicated that although the pressure sore(s) on the coccyx/buttocks were documented there were no measurements and no description of the area(s). Documentation was inconsistent as to whether the pressure sores were Stage II or Stage III. There was no documentation regarding the status of the bilateral heels.

Nurses assigned to the Patient from 12/23/09 to 12/31/09 were interviewed as follows: Nurse #2 was interviewed on 5/7/10 at 2:15 P.M.; Nurse #3 was interviewed on 5/7/10 at 3:10 P.M.; Nurse #4 was interviewed on 5/7/10 at 3:30 P.M.; Nurse #5 was interviewed on 5/12/10 at 1:50 P.M., and Nurse #7 was interviewed on 5/13/10 at 6:30 A.M. The nurses interviewed either did not remember the Patient or did not remember specifics regarding the Patient's skin condition.

The Daily Nursing Documentation and Medical Progress Note, dated 12/31/09, indicated that the buttock/sacral pressure sore was debrided. Although the physician documented the pressure sore was a Stage III the nurse documented the pressure sore was a Stage II. Although there was a description of the wound base there were no measurements.

The nurse assigned to the Patient on 12/31/09 (Nurse #1) was interviewed on 5/7/10 at 1:15 P.M. Nurse #1 said the Patient was noted to have a pressure sore on the coccyx area with slough (yellow nonviable tissue). Nurse #1 reported asking the Hospitalist on duty to look at the pressure sore and debride it.

The Hospitalist who debrided the Patient's pressure sore was interviewed in person on 5/12/10 at 9:35 A.M. The Hospitalist said when the pressure sore was debrided it was a Stage III pressure sore and to the best of the Hospitalist's recollection the pressure sore measured approximately 3 inches long, 1 to 1 1/2 inches wide, and 1/2 to 1 inch deep.

Review of the Daily Nursing Documentation, dated 1/1/10 to 1/6/10, indicated that there was no description or measurements of the coccyx/buttocks pressure sore(s) and there was no evidence that the bilateral heels were reassessed.

Review of the medical record indicated that on 1/7/10 the Patient was discharged to home with family members and home health services.

The Complainant was interviewed by telephone on 5/18/10 at 12:55 P.M. The Complainant said when the Patient arrived at home the assigned visiting nurse arrived and examined the Patient. The Complainant said a family member was present for the examination. The Complainant said the nurse and the family member observed that the Patient had 3 pressure sores located between the coccyx and rectum. The Complainant said the visiting nurse cleansed and dressed the sores. The Complainant said on 1/8/10 the Patient developed an increased temperature and was admitted to an acute care Hospital (Hospital #3) where the pressure sores were assessed.

Review of the medical record documentation provided by Hospital #3 indicated that upon admission the Patient had 3 pressure sores that measured as follows: #1). = 6 centimeters (cm) x 2cm x 1.5cm; #2). = 6cm x 2.5cm x 0, and #3). = 3cm x 2cm x 0.5cm.

Based on documentation review Hospital #2 failed to ensure that the care plan was updated for one of one patient.

Findings included:

See A-0395 regarding information related to pressure sore development.

Hospital #2 ' s Policy/Procedure titled Standard of Care indicated that the patient can expect the development and implementation of a nursing care plan that will be evaluated and updated as necessary.

Review of the care plans indicated that Hospital #2 used pre-printed care plans that required the staff to check off applicable areas for goals and interventions and add patient specific information as necessary.

Review of the Patient ' s care plan indicated that a care plan was implemented 12/10/09 to address potential, not actual impairment of skin integrity. Although nursing documentation indicated that on 12/19/09 the Patient was identified as having Stage II pressure sores; the care plan was not updated to address actual pressure sores until 12/31/09.

The medical record documentation indicated that the Patient was placed on a pain management program.

Review of the care plan indicated that the pain/comfort care plan was not implemented.

Based on documentation review Hospital #2 failed to ensure that medical record documentation was completed as required for one of one patients.

Findings included:

The Policy/Procedure titled Use of the Nursing Documentation/Physical Assessment Form and Patient Progress Note indicated that the Nursing Documentation/Physical Assessment Form and Patient Progress Note were to be completed daily.

Review of the Nursing Documentation/Physical Assessment Forms and Patient Progress Notes, dated 12/8/09 to 1/7/10, indicated that the Physical Assessment Form was not completed on 12/20/09, 12/27/09, and 1/7/10 (day of discharge). A Patient Progress Note was not completed on 12/27/09 and 12/30/09.

The Policy/Procedure titled Use of the Daily Flow Sheet/Treatment Record indicated that the documentation was to be completed every shift by nursing and therapy.

Review of the Flow Sheet indicated that it was a preprinted form with spaces to document turning and repositioning (back left and right side) every 2 hours, specialty mattress/bed, and splints.

Review of medical record documentation indicated the following:

1). On 12/8/09 an order was written for turning and repositioning side to side every 2 hours.

Review of the Flow Sheets, dated 12/8/09 to 1/7/10, indicated that turning and repositioning was not consistently documented.

A tour of the Nursing Unit was conducted on 5/7/10. Observation determined that daily nursing documentation was maintained in a chart outside each patient room. During the tour a total of 27 charts were reviewed and revealed that turning and repositioning was inconsistently documented.

2). On 12/11/09 an air mattress was placed on the Patient ' s bed.

Review of the Flow Sheets, dated 12/12/09 to 1/7/10, indicated that use of the air mattress was inconsistently documented.

3). On 12/11/09 splints were applied to the Patient's bilateral lower extremities by rehabilitation therapies.

Review of the Review of the Flow Sheets, dated 12/12/09 to 1/7/10, indicated that application of the splints was inconsistently documented.

Based on documentation review the Hospital (Hospital #2) failed to ensure that an incident report was completed: 1). when the Patient developed a Stage II (loss of partial thickness of the skin such as an abrasion or a blister) pressure sore, and 2). when the Patient was administered Heparin which was contraindicated.

Findings included:

1). The medical record documentation indicated that on 12/1/09 the Patient was admitted to an acute care hospital (Hospital #1) after experiencing lower extremity weakness, a fall, and subsequent paraplegia. The Patient ' s medical history included repair of an abdominal aortic aneurysm (weakening in the wall of the aortic artery) and pulmonary embolism (blood clot in the lung) with anticoagulant therapy (medication that reduces the risk of blood clot formation; side effects include hemorrhage). Prior to the onset of weakness the Patient lived at home and was independent in activities.

The medical record documentation indicated that diagnostic testing determined the Patient had spinal cord hemorrhaging and a large blood clot. The Patient was diagnosed with a spinal cord infarction second to spinal cord arteriovenous malformation (AVM; an abnormal communication between an artery and vein; can be congenital or result from injury or infection; symptoms include numbness, weakness, balance problems or paralysis; can affect bowel and urination habits; bleeding occurs due to weakened blood vessels; the biggest risk is stoke of the spinal cord; most AVMs go undiagnosed until a bleed occurs). The Patient was not considered a surgical candidate for repair due to the extent of the hemorrhage. On 12/7/10 the Patient was admitted to Hospital #2 for rehabilitation therapies and medical management.

The medical record documentation from Hospital #1 and provided to Hospital #2 indicated that upon discharge the Patient had reddened buttocks. Recommendations included frequent repositioning and a specialty mattress.

Hospital #2 ' s Policy/Procedure titled Skin Integrity Standard of Care, effective 5/07, indicated that all patients were evaluated on admission for potential to develop pressure sores. For patients at risk or with actual pressure sores, interventions were implemented, a care plan was developed, and the patient/family was involved in education. Care plans were updated as needed. If a patient was admitted with or developed a pressure sore the nurse was responsible for measuring the pressure sore and documenting the measurements. Pressure sores were classified using the staging system (Stage I, Stage II, Stage III, Stage IV, or unstagable). The nurse evaluated the pressure sore for evidence of infection and documented the appearance of the sore (color and condition of the base, if dead tissue [eschar or slough] was present, if drainage present). Pressure sores that were Stage II or greater were photographed with the patient ' s permission. Assessment was performed daily and findings were documented on the Daily Nursing Assessment Form and weekly by the Wound Care Team. Incident reports were completed for patients who developed a Stage II or greater pressure sore or who were admitted with a pressure sore that worsened.

Review of medical record documentation indicated that on 12/19/09 the Patient was identified as having several Stage II pressure sores on the buttocks.

Review of the Incident Report Log, dated 11/109 to 4/29/10, indicated that there was no incident report logged for the Patient.

The Unit Manager was interviewed on 5/7/10 at 9:00 A.M. and throughout the survey. The Unit Manager said an incident report was not completed for the Patient.


2). The medical record documentation provided by Hospital #1 to Hospital #2 at the time of the Patient ' s admission included the Transfer Summary, the 12/7/09 Medication Administration Record (MAR), and the Final Progress Note and Instructions from the Physician. The Final Note was 3 pages and included a medication list from the physician and nurse.

Review of the Transfer Summary indicated that the Patient was not a candidate for anticoagulant medications due the diagnosis of spinal cord AVM (see above for definition).

Review of the MAR indicated that the Patient was not receiving anticoagulant medication.

Review of the Medication List indicated that at the bottom of the list of medications Heparin 5000 units every 8 hours was added. Just below the Heparin order was an alert not to take Coumadin due to spinal cord infarction.

Admission Orders at Hospital #2 indicated that medications were listed on the Medication Reconciliation Form and included the order for Heparin. Documentation indicated that each medication order was reviewed with the Attending Physician via the telephone and several were discontinued. Heparin was ordered to be continued.

Review of the MAR, dated 12/7/09 and 12/8/09, indicated that the Patient was administered Heparin twice and was discontinued.

Review of Hospital #2 ' s Policy/Procedure for Incident Reporting indicated that an incident report was completed for every occurrence not consistent with the routine care or operation of the facility such as medication variances (such as the medication that should not have been given because of a contraindication).

Review of the Incident Report Log, dated 11/109 to 4/29/10, indicated that there was no incident report logged for the Patient.

The Attending Physician was interviewed on 5/12/10 at 11:05 A.M. The Attending Physician reported reviewing the medical record, contacting the physician at Hospital #1 for clarification, and discontinuing the Heparin. The Attending Physician said an incident report was not completed because it was not their error the Heparin was ordered and given.