HospitalInspections.org

Based on observation, interviews, and review of records, the Governing Body did not monitor nursing and medical services to ensure provision of quality health care for 1 of 4 inpatients (Patient #1) who did not come into the hospital with a pressure ulcer, but developed a Stage III sacral pressure ulcer while in the hospital. The patient's pressure ulcer was not evaluated by the Nurse Practitioner until approximately nine days after notified. The patient continued to reside in the hospital receiving pressure ulcer care that may include debridement.

Cross Reference to Tags A-0385 and A-0395.

Based on observation, interviews, and review of records, the hospital did not have an organized nursing service supervised by a registered nurse in that 1 of 4 inpatients (Patient #1) developed an in-house pressure ulcer that required debridement. Patient #1's 09/28/10 "Stage III" pressure ulcer was not evaluated by the Nurse Practitioner (NP) (Personnel #4) until 10/07/10 and the wound care Physician (Personnel #8) until 10/09/10. Two separate wound consults were ordered on 09/28/10 and 10/01/10. The results of the consults indicated Patient #1's sacral area would need debridement and would take about 2 weeks to soften. Patient #1 did not come into the hospital with a sacral pressure ulcer and continued to reside in the hospital receiving treatment.

Findings Included:

Medical Record Patient #1

Patient #1, age 71, was transferred for rehabilitation to this hospital on 09/10/10 after a cerebrovascular accident that resulted in left sided weakness (Physician Report, Dictated 9/10/10).

The 09/10/10 "Multidisciplinary Team Conference Report" skin integrity evaluation noted "incisions to midline thoracic area" and both thighs. No other skin breakdown was indicated.

The 09/21/10 "Daily Nursing Assessment" reflected the patient had a reddened sacral area.

The 09/28/10 "Weekly Wound Assessment" noted Patient #1's sacral wound measured 5.5 x 4 x 1.5 and was clean, "granulating 100%." The area had moderate exudate, no odor, and was classified as a "Stage III." A message was left with the NP (Personnel #4) to see the wound Physician (Personnel #8) for the "... sacral wound."

A physician order was written on 10/01/10 for a wound care consult for sacral decubitus. A copy was given to wound care and a voice message was left with the NP (Personnel #4).

A physician order written on 10/06/10 reflected, "Cancel discharge until pt [patient] is seen by woundcare NP."

The 10/07/10 "Weekly Wound Assessment" noted the sacral wound measured 11 x 5 x 1.8 with "granulating 30%...yellow slough 70%...odor foul." Edges were rolled with a black, yellow, pink, and red base. Edema was 1+ with large exudate and "sero" drainage.

The NP's (Personnel #4) "Progress Notes" dated 10/07/10 noted "sacral wound - will need surgical debridement ..."

The 10/09/10 Physician's (Personnel #8) "Progress Notes" indicated the sacral area would need debridement and will take about 2 weeks to soften. Patient #1 had a sacral area with "unstageable brown/black eschar" and pressure areas on top of the feet.

During the morning of 10/11/10, the surveyor accompanied the wound care Registered Nurse (Personnel #3) during part of her daily care and assessment rounds. Patient #1 had a dry and intact sacral dressing that was marked 10/11/10. Personnel #3 stated the dressing was changed prior to the surveyor's arrival. The dressing was removed at this time. The edges of the wound appeared to be pink. There was no foul odor or drainage present. Personnel #3 was asked if she thought the wound appeared to have improved and she stated the wound would probably not get any better without debridement.

Cross Refer to Tag A-0395.

Based on review of records, observation, and interviews, the nursing department failed to provide care and ongoing assessments to one of four inpatients (Patient #1) which led to development of a stage III sacral decubitus. On 09/21/10, Patient #1 had a reddened sacral area. On 09/28/10, a week later, the reddened area developed into a Stage III sacral wound that would require debridement. Patient #1 was not assessed by the Nurse Practitioner (NP) (Personnel #4) or Physician (Personnel #8) until 10/07/10, approximately nine days after ordered.

Findings Included:

Medical Record Patient #1

Patient #1, age 71, was transferred for rehabilitation to this hospital on 09/10/10 after a cerebrovascular accident that resulted in left sided weakness (Physician Report, Dictated 9/10/10). The 09/10/10 "Multidisciplinary Team Conference Report" skin integrity evaluation noted, "incisions to midline thoracic area" and both thighs. No other skin breakdown was indicated.

The 09/21/10 "Daily Nursing Assessment" reflected the patient had a reddened sacral area.

The 09/28/10 "Weekly Wound Assessment," completed by the wound treatment nurse, noted Patient #1's sacral wound measured 5.5 x 4 x 1.5 and was clean, "granulating 100%." The area had moderate exudate, no odor, and was classified as a "Stage III." The physician's order dated 09/28/10 noted that a message was left with the Nurse Practitioner (NP) (Personnel #4) to see the wound physician (Personnel #8) for the "... sacral wound."

A 10/01/10 physician order was written for a wound care consult for sacral decubitus. A copy of the order was given to wound care and a voice message was left with the NP (Personnel #4).

The 10/02/10 sacral wound assessment completed by the wound treatment nurse for Patient #1 noted a "foul" odor, moderate exudate, "sero" drainage, and "edema 0." There were viable edges and a red base.

The 10/06/10 sacral wound assessment completed by the wound treatment nurse noted edges rolled with a yellow, black, pink, and red base. There was a foul odor, large exudate, "sero" drainage, and "edema 1+."

A physician order written on 10/06/10 reflected, "Cancel discharge until pt [patient] is seen by woundcare NP (Previously ordered on 09/28/10 and again on 10/01/10)."

The 10/07/10 "Weekly Wound Assessment," completed by the wound treatment nurse, noted the sacral wound measured 11 x 5 x 1.8 with "granulating 30%...yellow slough 70%...odor foul." Edges were rolled with a black, yellow, pink, and red base. Edema was 1+ with large exudate and "sero" drainage.

The NP's (Personnel #4) "Progress Notes" dated 10/07/10 (Note: First time NP assessed wound since ordered 09//28/10.) noted, "sacral wound - will need surgical debridement..."

The 10/09/10 Physician's (Personnel #8) "Progress Notes" indicated the sacral area would need debridement and would take about 2 weeks to soften. Patient #1 had a sacral area with "unstageable brown/black eschar" and pressure areas on top of the feet.

During the morning of 10/11/10, the surveyor accompanied the wound care Registered Nurse (Personnel #3) during part of her daily care and assessment rounds. Patient #1 had a dry and intact sacral dressing that was marked 10/11/10. Personnel #3 stated the dressing was changed prior to the surveyor's arrival. The dressing was removed at this time. The edges of the wound appeared to be pink. There was no foul odor or drainage present. Personnel #3 was asked if she thought the wound appeared to have improved and she stated the wound would probably not get any better without debridement.

During an interview at approximately 4:00 PM on 10/11/10, the wound care Physician (Personnel #8) was asked when he assessed Patient #1. Personnel #8 said that he assessed Patient #1 on 10/09/10 and discussed debridement of the wound with the patient's son. He did not see Patient #1 prior to 10/09/10. Personnel #8's NP (Personnel #4) assessed Patient #1's wounds prior to his assessment on 10/09/10.

During an interview at approximately 9:00 AM on 10/12/10, the NP (Personnel #4) was asked when she assessed Patient #1's wounds for the first time. Personnel #4 said that she assessed Patient #1's wounds on 10/07/10 for the first time. She said that Patient #1 was seen by the wound care team before 10/07/10.

During an interview at 12:30 PM on 10/12/10, a wound care Registered Nurse (Personnel #3) was asked why the ordered wound care Physician consult was not completed until 10/09/10 when the orders were dated 09/28/10 and 10/01/10. Personnel #3 said that she contacted the Nurse Practitioner (Personnel #4) and the Nurse Practitioner (Personnel #4) saw Patient #1 on 10/07/10. The Physician (Personnel #8) saw Patient #1 on 10/09/10.

The "Wound Care" policy NR040 reviewed by the hospital on 11/01/08 noted, "...The Wound Care Nurse/Primary Nurse or Wound Team will consult and communicate with the patient's physician at all times..."

The "Nursing Assessment" policy NR023 revised 10/20/09 noted, "The Registered Nurse...collaborates with physicians...in making decisions regarding each patient's need for nursing care...through...rounding and consultation with physician..."

Based on observation, interviews, and review of records, the nursing care of 1 of 4 inpatients (Patient #1) was not supervised by the Registered Nurse in that Patient #1's 09/28/10 "Stage III" pressure ulcer was not evaluated by the Nurse Practitioner (NP) (Personnel #4) until 10/07/10 and the wound care Physician (Personnel #8) until 10/09/10. Two separate wound consults were ordered on 09/28/10 and 10/01/10.

Findings Included:

Medical Record Patient #1

The 09/21/10 "Daily Nursing Assessment" reflected the patient had a reddened sacral area.

The 09/28/10 "Weekly Wound Assessment" noted Patient #1's sacral wound measured 5.5 x 4 x 1.5 and was clean, "granulating 100%." The area had moderate exudate, no odor, and was classified as a "Stage III. " A message was left with the Nurse Practitioner (Personnel #4) to see the wound physician (Personnel #8) for the "... sacral wound."

A 10/01/10 physician order was written for a wound care consult for sacral decubitus. A copy was given to wound care and a voice message was left with the Nurse Practitioner (Personnel #4).

The 10/02/10 nursing wound assessment of Patient #1's sacral pressure ulcer noted a "foul" odor, moderate exudate, "sero" drainage, and "edema 0." There were viable edges and a red base.

The 10/06/10 nursing wound assessment noted edges rolled with a yellow, black, pink, and red base. There was a foul odor, large exudate, "sero" drainage, and "edema 1+."

A physician order written on 10/06/10 reflected, "Cancel discharge until pt [patient] is seen by woundcare NP."

The 10/07/10 "Weekly Wound Assessment" noted the sacral wound measured 11 x 5 x 1.8 with "granulating 30%...yellow slough 70%...odor foul." Edges were rolled with a black, yellow, pink, and red base. Edema was 1+ with large exudate and "sero" drainage.

The NP's (Personnel #4) "Progress Notes" dated 10/07/10 noted "sacral wound - will need surgical debridement ..."

The 10/09/10 Physician's (Personnel #8) "Progress Notes" indicated the sacral area would need debridement and would take about 2 weeks to soften. Patient #1 had a sacral area with "unstageable brown/black eschar" and pressure areas on top of the feet.

During the morning of 10/11/10, the surveyor accompanied the wound care Registered Nurse (Personnel #3) during part of her daily care and assessment rounds. Patient #1 had a dry and intact sacral dressing that was marked 10/11/10. Personnel #3 stated the dressing was changed prior to the surveyor's arrival. The dressing was removed at this time. The edges of the wound appeared to be pink. There was no foul odor or drainage present. Personnel #3 was asked if she thought the wound appeared to have improved and she stated the wound would probably not get any better without debridement.

During an interview at approximately 4:00 PM on 10/11/10, the wound care Physician (Personnel #8) was asked when he assessed Patient #1. Personnel #8 said that he assessed Patient #1 on 10/09/10 and discussed debridement of the wound with the patient's son. He did not see Patient #1 prior to 10/09/10. Personnel #8's NP (Personnel #4) assessed Patient #1's wounds prior to his assessment on 10/09/10.

During an interview at approximately 9:00 AM on 10/12/10, the NP (Personnel #4) was asked when she assessed Patient #1's wounds for the first time. Personnel #4 said that she assessed Patient #1's wounds on 10/07/10 for the first time. She said that Patient #1 was seen by the wound care team before 10/07/10.

During an interview at 12:30 PM on 10/12/10, a wound care Registered Nurse (Personnel #3) was asked why the ordered wound care Physician consult was not completed until 10/09/10 when the orders were dated 09/28/10 and 10/01/10. Personnel #3 said that she contacted the Nurse Practitioner (Personnel #4) and the Nurse Practitioner (Personnel #4) saw Patient #1 on 10/07/10. The Physician (Personnel #8) saw Patient #1 on 10/09/10.

The "Wound Care" policy NR040 reviewed by the hospital on 11/01/08 noted, "...The Wound Care Nurse/Primary Nurse or Wound Team will consult and communicate with the patient's physician at all times ..."

The "Nursing Assessment" policy NR023 revised 10/20/09 noted, "The Registered Nurse...collaborates with physicians...in making decisions regarding each patient's need for nursing care...through...rounding and consultation with physician ..."

Based on review of records, observation, and interviews, the nursing department failed to develop a nursing plan for one of four inpatients (Patient #1) which led to development of a stage III sacral decubitus. On 09/21/10, Patient #1 had a reddened sacral area. On 09/28/10, a week later, the reddened area developed into a Stage III sacral wound that would require debridement. Patient #1 was not assessed by the Nurse Practitioner (NP) (Personnel #4) or Physician (Personnel #8) until 10/07/10, approximately nine days after ordered.

Findings Included:

Medical Record Patient #1

Patient #1, age 71, was transferred for rehabilitation to this hospital on 09/10/10 after a cerebrovascular accident that resulted in left sided weakness (Physician Report, Dictated 9/10/10). The 09/10/10 "Multidisciplinary Team Conference Report" skin integrity evaluation noted, "incisions to midline thoracic area" and both thighs. No other skin breakdown was indicated.

The 09/21/10 "Daily Nursing Assessment" reflected the patient had a reddened sacral area.

The 09/28/10 "Weekly Wound Assessment," completed by the wound treatment nurse, noted Patient #1's sacral wound measured 5.5 x 4 x 1.5 and was clean, "granulating 100%." The area had moderate exudate, no odor, and was classified as a "Stage III." The physician's order dated 09/28/10 noted that a message was left with the Nurse Practitioner (NP) (Personnel #4) to see the wound physician (Personnel #8) for the "... sacral wound."

A 10/01/10 physician order was written for a wound care consult for sacral decubitus. A copy of the order was given to wound care and a voice message was left with the NP (Personnel #4).

The 10/02/10 sacral wound assessment completed by the wound treatment nurse for Patient #1 noted a "foul" odor, moderate exudate, "sero" drainage, and "edema 0." There were viable edges and a red base.

The 10/06/10 sacral wound assessment completed by the wound treatment nurse noted edges rolled with a yellow, black, pink, and red base. There was a foul odor, large exudate, "sero" drainage, and "edema 1+."

A physician order written on 10/06/10 reflected, "Cancel discharge until pt [patient] is seen by woundcare NP (Previously ordered on 09/28/10 and again on 10/01/10)."

The 10/07/10 "Weekly Wound Assessment," completed by the wound treatment nurse, noted the sacral wound measured 11 x 5 x 1.8 with "granulating 30%...yellow slough 70%...odor foul." Edges were rolled with a black, yellow, pink, and red base. Edema was 1+ with large exudate and "sero" drainage.

The NP's (Personnel #4) "Progress Notes" dated 10/07/10 (Note: First time NP assessed wound since ordered 09//28/10.) noted, "sacral wound - will need surgical debridement..."

The 10/09/10 Physician's (Personnel #8) "Progress Notes" indicated the sacral area would need debridement and would take about 2 weeks to soften. Patient #1 had a sacral area with "unstageable brown/black eschar" and pressure areas on top of the feet.

During the morning of 10/11/10, the surveyor accompanied the wound care Registered Nurse (Personnel #3) during part of her daily care and assessment rounds. Patient #1 had a dry and intact sacral dressing that was marked 10/11/10. Personnel #3 stated the dressing was changed prior to the surveyor's arrival. The dressing was removed at this time. The edges of the wound appeared to be pink. There was no foul odor or drainage present. Personnel #3 was asked if she thought the wound appeared to have improved and she stated the wound would probably not get any better without debridement.

During an interview at approximately 4:00 PM on 10/11/10, the wound care Physician (Personnel #8) was asked when he assessed Patient #1. Personnel #8 said that he assessed Patient #1 on 10/09/10 and discussed debridement of the wound with the patient's son. He did not see Patient #1 prior to 10/09/10. Personnel #8's NP (Personnel #4) assessed Patient #1's wounds prior to his assessment on 10/09/10.

During an interview at approximately 9:00 AM on 10/12/10, the NP (Personnel #4) was asked when she assessed Patient #1's wounds for the first time. Personnel #4 said that she assessed Patient #1's wounds on 10/07/10 for the first time. She said that Patient #1 was seen by the wound care team before 10/07/10.

During an interview at 12:30 PM on 10/12/10, a wound care Registered Nurse (Personnel #3) was asked why the ordered wound care Physician consult was not completed until 10/09/10 when the orders were dated 09/28/10 and 10/01/10. Personnel #3 said that she contacted the Nurse Practitioner (Personnel #4) and the Nurse Practitioner (Personnel #4) saw Patient #1 on 10/07/10. The Physician (Personnel #8) saw Patient #1 on 10/09/10.

The "Wound Care" policy NR040 reviewed by the hospital on 11/01/08 noted, "...The Wound Care Nurse/Primary Nurse or Wound Team will consult and communicate with the patient's physician at all times..."

The "Nursing Assessment" policy NR023 revised 10/20/09 noted, "The Registered Nurse...collaborates with physicians...in making decisions regarding each patient's need for nursing care...through...rounding and consultation with physician..."

Based on interviews, and review of records, the hospital failed to prepare 1 of 1 patient's family (Patient #1) with counseling regarding Patient #1's post-hospital wound care needs from 09/28/10 to the 10/06/10 anticipated discharge to a skilled nursing facility.

Findings included:

Medical Record Patient #1:

The 09/28/10 "Weekly Wound Assessment" noted Patient #1's sacral wound measured 5.5 x 4 x 1.5 and was clean, "granulating 100%." The area had moderate exudate, no odor, and was classified as a "Stage III." The "Multidisciplinary Team Conference Report" dated 09/28/10 noted Patient #1 had a sacral pressure wound that was being treated.

The "Educational Topic List" included no information given to the family regarding "Home Discharge Planning and Education" as of this survey and no "Additional Education and Comments" between 09/20/10 and 10/06/10.

The 10/06/10 sacral wound assessment noted edges rolled with base yellow, black, pink, and red. There was a foul odor, large exudate, "sero" drainage, and "edema 1+." A 10/06/10 physician order was written to discharge Patient #1 to a skilled nursing facility. The 10/06/10 3:15 PM "Social Worker Discharge Planning Note" included that Patient #1's son had concerns regarding "the pt's. foot wound and whether the wound was infected." The Social Worker forwarded Patient #1 son's call to the nurse "to get a clinical update."

A physician order written on 10/06/10 reflected, "Cancel discharge until pt [patient] is seen by woundcare NP."

During an interview the morning of 10/11/10, the Case Manager (Personnel #6) was asked if she addressed Patient #1's wound care with his family. Personnel #6 reviewed her notes and said that her Supervisor sat in on the 09/28/10 Team Conference where the notes indicated that the wound was discussed.

During a telephone interview the morning of 10/11/10, The Director of Case Management (Personnel #9) was asked if she discussed Patient #1's wound care treatment with his family after the 09/28/10 treatment meeting that she attended. Personnel #9 said that she "did not."

The "Multidisciplinary Team Conferences and Rounds" policy CM011 dated 11/01/07 noted, "The Case Management/Social Worker will meet with the patient/caregiver at least bi-weekly to evaluate the progress and goals until the patient is discharged."

The "Discharge Planning" policy CM013 dated 11/1/07 noted, "A plan to address any educational needs is identified and put in place to assure the patient and family/care giver have sufficient knowledge and understanding to achieve a successful transition to the expected discharge location and level of care."