HospitalInspections.org

Based on interview and record review the hospital failed to ensure Floor RN's (Registered Nurses) and 1 of 1 Wound Care RN (Personnel #4) re-evaluated and/or re-assessed and provided treatment for 1 of 1 patient (Patient #1) who developed a DTI (Deep Tissue Injury) to the bilateral heels and for a Stage III pressure ulcer to the sacrum. (Patient #1) did not receive wound care treatment from 10/15/12 to 10/17/12. Additionally inconsistent repositioning and off-loading of heels was provided for (Patient #1) from 10/04/12 to 10/17/12.

Findings included:

(Patient #1's) Interdisciplinary nursing admission assessment dated 10/03/12 timed at 21:00 PM reflected, "Skin breakdown...pressure ulcer stage II..." The assessment indicated no additional skin breakdown.

The 10/03/12 physician's orders timed at 21:00 PM reflected, "Cleanse wound, stage II to the coccyx...apply duoderm every three days and as needed..."

The 10/04/12 wound assessment/re-assessment timed at 14:00 PM reflected, "Wound type pressure ulcer, tissue layers full...no tunneling....size 2.5 cm (centimeters) in length by 0.5 mg wide...surrounding skin color...light red/pink..."

The Internal Medicine Consultation dated 10/09/12 reflected, "76 year old male with...history of prostate cancer...admitted to (transferring hospital) with intractable back pain...in the process, patient had developed a sacral decubitus ulcer at the end of the (transferring hospital) stay...patient transferred to (present facility). Patient has developed bilateral heel decubitus ulcers (present facility) which is not stageable...one culture from the coccyx grew MRSA (Methicillin Resistant Staphulococcus Aureus)...sensitive to doxycycline...plan...doxycycline 100 milligrams twice a day for 10 days...continue wound care...off-load heels and turn every two hours..."

The initial Wound Assessment/Reassessment dated 10/09/12 timed at 09:45 AM completed by the wound care nurse reflected, "Pressure ulcer Stage III 4 x 6 x 0.3 centimeters depth undetermined...slough...tan, purulent exudate...light red/pink surrounding skin color...MRSA positive to sacral wound..."

The 10/09/12 initial Wound Assessment Re-assessment dated 10/09/12 timed at 09:45 AM completed by the wound care nurse reflected, "Onset date post-admit...right heel 4 x 3 x 0 depth...wound type DTI (deep tissue injury)...surrounding skin...light red/pink...signs of infection...localized...pain associated with wound...yes with pressure...initial wound care evaluation..." No further wound reassessment and/or any pictures were taken by the wound care nurse prior to (Patient #1) being discharged on 10/17/12.

The 10/09/12 initial Wound Assessment Re-assessment timed at 09:45 AM completed by the wound care nurse reflected, "Onset date post-admit...left heel 4 x 5.5 x 0 depth...wound typ DTI (deep tissue injury)...surrounding skin...light red/pink...signs of infection...localized...pain associated with wound...yes with pressure...initial wound care evaluation..." No further wound reassessment and/or any pictures were taken by the wound care nurse prior to (Patient #1) being discharged on 10/17/12.

The 10/09/12 wound care orders timed at 11:30 AM written by the wound nurse reflected, "LAL (low air loss) mattress, roho cushion to wheel chair, heel protectors while in bed, off-load...turn every two hours...wound cleanser to bilateral DTI (deep tissue injury) heel wounds apply skin prep to peri-wound, cleanse bilateral feet...cover DTI with optiforam...wrap with kerlix...three times a week (Tuesday, Thursday and Saturday)...wound cleanser to sacral stage III wound...apply skin prep to peri-wound, vocer with duoderm three times a week (Tuesday, Thursday and Saturday)...nursing to apply calamazine lotion to excoriation wound to sacrum twice daily..."

The 10/09/12 physician's orders timed at 19:10 PM reflected, "Bilateral off-loading...please turn from side to side every two hours..."

The Interdisciplinary Daily Documentation Daily Nursing Assessment under the section entitled, "Float heels" reflected no documentation for the following dates and times: On 10/04/12 from 08:00 AM to 22:00 PM, 10/05/12 from 00:00 AM to 16:00 PM, 10/06/12 from 00:00 AM to 22:00 PM, 10/07/12 from 00:00 AM to 22:00 PM, 10/08/12 from 00:00 AM to 16:00 PM, 10/10/12 from 08:00 AM to 16:00 PM, 10/11/12 from 08:00 AM to 16:00 PM, 10/12/12 from 08:00 AM to 16:00 PM, 10/14/12 from 08:00 Am to 18:00 PM, 10/15/12 from 08:00 AM to 20:00 PM, and on 10/16/12 from 08:00 AM to 16:00 PM.

The Interdisciplinary Daily Documentation Daily Nursing Assessment under the section entitled, "Reposition Right, Left, Back, Front" reflected no documentation for the following dates and times: On 10/04/12 from 06:00 AM to 22:00 PM, 10/05/12 from 00:00 AM to 18:00 PM, 10/07/12 from 00:00 AM to 22:00 PM, 10/08/12 from 00:00 AM to 16:00 PM, 10/10/12 from 06:00 AM to 16:00 PM, 10/11/12 from 08:00 AM to 18:00 PM, 10/12/12 from 08:00 AM to 16:00 PM, 10/13/12 from 08:00 AM to 16:00 PM, 10/14/12 from 08:00 AM to 18:00 PM, 10/15/12 from 08:00 AM to 20:00 PM, 10/16/12 from 00:00 AM to 22:00 PM and on 10/17/12 from 00:00 AM to 08:00 AM.

The Interdisciplinary Daily Documentation Daily Nursing Assessment from 10/15/12 to 10/17/12 reflected no documentation which indicated (Patient #1's) wound to the sacrum and bilateral heels were assessed and/or evaluated. No dressing change documentation was found and/or a weekly update which included pictures and wound measurements.

The physician's orders dated 10/16/12 timed at 15:50 PM reflected, "Discharge to home tomorrow (10/18/12)..."

(Patient #1's) Medical Record from Hospital B reflected the following:

The History and Physical dated 10/18/12 reflected, "76 year old...male who has been admitted for wound care and recent cellulitis...recently sent to (Hosptial A) for strengthening and conditioning...while there, developed coccygeal wounds and was subsequently discharged home...the wound was draining purulent material...he does have a stage III or IV decubitus ulcer of the coccygeal area..."

A consultation evaluation for multiple wounds and infection dated 10/19/12 reflected, "Patient was recently in the hospital at (Hospital A) for rehabilitation...patient was discharged, but the patient had developed bilateral feet wounds and had developed a sacral wound...the patient was evaluated at home and was thought to have infected wounds on the sacrum...and was admitted to the hospital for treatment..."

On 01/16/13 at 02:40 PM Personnel #4 Wound Care RN was interviewed. Personnel #4 stated she reviews the census sheet and checks to see who was newly admitted to the hospital. Personnel #4 stated the floor nurse on admission takes pictures of any wounds and initiates treatment. Personnel #4 said she sees the patient either the day they come in or the next day. Personnel #4 said it depends on the day of the week as she works Monday to Friday 08:00 AM to 05:00 PM. Personnel #4 reviewed (Patient #1's) medical record and stated the admission nursing assessment revealed a stage II pressure ulcer to the sacrum. Personnel #4 stated she first saw (Patient #1's) wound on 10/09/12. Personnel #4 said she took pictures and measurements. Personnel #4 stated she sees wound care patients weekly and takes pictures of the wounds and at that time determines whether changes in treatment were needed. Personnel #4 stated she staged (Patient #1's) wound to the sacrum at a stage III pressure ulcer on 10/09/12 and (Patient #1's) bilateral heels were a deep tissue injury which he had acquired while at the hospital. Personnel #4 stated a low Braden (scored at 15) was initiated for (Patient #1). The surveyor asked Personnel #4 why she did not see (Patient #1) the following week and/or before he was discharged on 10/17/12. Personnel #4 stated she did not know perhaps she was not on duty. Ms. Woodworth stated she would look at her schedule and let the surveyor know.

On 01/16/13 at 04:45 PM Personnel #6 was interviewed. Personnel #6 stated he was unaware the wound nurse had not seen (Patient #1) until 10/09/12 and did not see (Patient #1) the following week and/or before discharge.

On 01/17/13 at approximately 12:00 noon Personnel #4 was interviewed. Personnel #4 informed the surveyor she was on duty 10/03/12, 10/07/12, 10/08/12, 10/09/12, 10/10/12, 10/11/12, 10/14/12, 10/15/12 10/16/12 and 10/17/12. Personnel #4 stated she did not know why she did not reassess and/or take pictures of (Patient #1's) wounds weekly and/or prior to discharge.

The Wound Prevention, Care and Documentation policy with a revised/review date of 01/2012: reflected, "Purpose...to improve patient's skin integrity through timely and consistent clinical practices...all patient's will have integument and wound inspections daily, weekly, and as often as indicated...pressure ulcers will be staged upon discovery, periodically in conjunction with the wound treatment plan, and at discharge...for all procedure-related wounds, assess the wound appearance, approximation, drainage/exudates, and drainage amount...length, width, and depth should be recorded in centimeters on admission, weekly and at discharge...daily documentation of skin and wound inspection will include observations of the skin condition, dressing integrity, evidence of wound drainage, odor, pain, signs of inflammation or infection...weekly documentation will include...skin inspections and assessment of all of the above ...documentation of current treatment, changes in treatment since the last update, improvement in the patient's skin condition since the last update, current risk for skin breakdown...status update to be completed weekly and reflected in the plan of care and detailed wound assessment...all wounds are to be photographed at discovery, weekly, and discharge...prevention and basic treatment...manage patient positioning to minimize risk of skin breakdown...establish regular repositioning schedule...such as every two hours...individualized turning schedules will be determined by the interdisciplinary team considering contraindications and need for more frequent repositioning...document repositioning, to include frequency and position adopted...maintain clean wound healing environment...clean all wounds at each dressing change in compliance with physician order or hospital approved protocol...assess wound for local or systemic signs of infection..."