HospitalInspections.org

Based on medical record review, it was determined Hospital Nursing Staff failed to document information regarding Patient #1's sacral pressure ulcer in accordance with Hospital policies, procedures and/or guidelines.

Findings included:

Medical record documentation indicated Patient #1 was transferred to the Hospital from Hospital #3 for ongoing complex medical management and rehabilitation following a prolonged hospitalization for advanced multiple myeloma complicated by multiple infections including pulmonary infection caused by Aspergillus, sepsis, acute renal failure, septic shock, ischemic colitis requiring a total colectomy and ileostomy, spinal cord compression resulting in paraplegia and abdominal, thoracic and upper extremity muscle weakness, and respiratory failure necessitating a tracheostomy.

Hospital #3 documentation indicated that at the time of transfer, Patient #1 had multiple 6 centimeter (cm) X 3 cm irregular-shaped stage II pressure ulcers on his buttocks with a 4 cm X 2 cm dark maroon area in center that were being treated with hydrocolloid dressings.

The Hospital's policies, procedures and/or guidelines related to pressure ulcers require the nursing staff to assess and measure all pressure ulcers (including deep tissue injuries and unstageable ulcers) on admission, weekly, and when significant changes are noted. The measurements are to be in centimeters and are to include length, width, depth, stage (if stageable) and information related to odor, tunneling and undermining. The policies/procedures also require each Nursing Unit to conduct weekly Skin Rounds. The Skin Rounds are overseen by the Unit's Skin Assessment/Care Resource Nurse and the Skin Assessment/Care Resource Nurse is responsible for keeping an updated Wound Rounds List and ensuring that skin care issues including measurements are documented.

Documentation on Patient #1's Admission Nursing Assessment (incorrectly) indicated Patient #1 was at moderate risk for developing pressure ulcers (he was actually at high risk) and had 2 pressure ulcers; 1 on his coccyx that appeared ecchymotic and measured 3.5 cms X 8 cms and 1 on his left hip that was a blister and measured 2.5 cms X 1.5 cms.

Patient #1's bed was equipped with a Sizewise Alternation Therapy Mattress and Admission Physician Orders included an order for a daily multivitamin with minerals and orders for his buttock wound to be cleansed with normal saline (NS), protected with 3M skin barrier, and dressed with a hydrocolloid dressing (Tegaderm).

Documentation indicated Patient #1's coccyx wound was examined by Oncologist #1 on January 16. The documentation did not include a description of the wound. Oncologist #1 ordered oral Vitamin C and a Wound Care Nurse consultation for January 18.

The Nursing Unit #1 Wound Rounds List dated January 18 indicated Patient #1 had a Stage II coccygeal pressure ulcer.

Nursing documentation completed on January 19 indicated Patient #1 had a large area of coccygeal skin breakdown of multiple Stages, but mostly Stage II, and a possible deep tissue injury. Nursing documentation completed on January 20 indicated the coccygeal pressure ulcer had a necrotic area and was not measurable. The documentation also indicated the Wound Care Consultation was outstanding (had not yet been completed).

Documentation indicated the Patient was started on Juven twice/day on January 21.

Nursing documentation completed on January 25 indicated Patient #1's coccygeal pressure ulcer measured 9 cms X 8 cms and was covered with black eschar. Documentation also indicated the pressure ulcer was evaluated by Attending Physician #1 and twice/day Santyl (an enzymatic debriding ointment) applications followed by a wet-to-dry NS dressings were ordered.

The Nursing Unit #1 Wound Rounds List dated January 25 indicated Patient #1 had a Stage II pressure ulcer on his coccyx.

Documentation completed by the Plastic Surgery PA on January 25 indicated Patient #1 was sitting in a chair and refused examination of his sacrum. The PA recommended continuation of the Santyl/wet-to-dry NS dressings and indicated she would re-evaluate Patient #1 the following week and possibly debride the pressure ulcer.

Documentation indicated the Plastic Surgery PA re-evaluated Patient #1 on February 1, found a 9 cm X 10.5 cm X 2 cm (deep) sacral pressure ulcer completely covered with boggy eschar, but without erythema, and sharply debrided the ulcer (resulting in a Stage IV pressure ulcer). The PA recommended (and ordered) discontinuation of the Santyl/NS dressings and implementation of wet-to-dry 1/4-strength Dakin's solution dressings 3 times/day.

The Nursing Unit #1 Wound Rounds List dated February 1 indicated Patient #1 had a Stage II pressure ulcer on his coccyx.

Patient #1 was transferred to Nursing Unit #2 on February 4. The Nursing Unit #2 Wound Rounds List dated February 7 did not include information related to Patient #1

Documentation indicated the Plastic Surgery PA re-evaluated Patient #1's sacral pressure ulcer on February 15, found necrotic tissue and exposed bone, but no erythema, and performed additional debriding. The PA recommended continuation of the Dakin's solution dressings.

Nursing Unit #2 Wound Rounds List dated February 16 and 21 indicated Patient #1 had a necrotic ulcer on his sacrum.

Nursing documentation completed on February 22 indicated Patient #1's sacral pressure ulcer measured 11 cms X 10 cms X 2 cms and there was tunneling at the 12 and 3 o'clock positions.

Documentation indicated Patient #1 developed signs and symptoms of sepsis on February 23 and was transferred to Hospital #3. Documentation obtained from Hospital #3 indicated Patient #1 was evaluated by the Plastic Surgery Service on February 24 and found to have a 10 cm X 10 cm sacral ulcer with visible bone tissue, undermining, tunneling, a triangular area of necrotic tissue, and a thick fibrinous exudate.