HospitalInspections.org

Based on observation, interview and record review the facility failed to provide organized nursing services that follow the nursing process of identify and respond to patient needs through assessment, care planning and documentation resulting in increased risk of unmet care needs for all patients. Findings include:
--The facility failed to provide monitoring and interventions of regular turning and repositioning for one current patient (#8), with a facility acquired pressure wound and two discharged patients (#1 & #10) with diagnoses of decubitus ulcers that worsened over time. (A-0396)

Based on interview, record review and policy review, the facility failed to implement interventions to prevent prolonged pressure including failure to reposition immobile patients for three (#1, 8 &10) of ten sampled residents reviewed for impaired skin integrity from a total sample of 10 patients resulting in the degradation of skin wounds, the development of a facility acquired pressure sore, and lack of repositioning of immobile patients. Findings include:

Patient #1
On 11/10/15 at 1130, record review revealed that Patient #1 was admitted into the facility on 05/14/15 with an admitting diagnosis of sepsis, as well as end-stage renal disease, pain, hypertension, congestive heart failure, and osteoarthritis among other diagnoses. Patient #1 was not in the facility at the time of the survey.

The patient's initial skin assessment, dated 5/15/15 revealed that the patient was admitted into the facility with three wounds, a sacral wound that measured 5 centimeters (cm) x 1 cm x 0 cm (stage II), a right ischial wound measuring 4 cm x 6 cm x unable to determine (unstageable wound) as the depth of the wound was unknown due to necrotic tissue, and a left ischial wound that measured 1 cm x 1 cm x 0 cm (stage II).

The Braden Scale for predicting pressure sore risk revealed a score of 14 which represented a moderate risk for pressure sore development. A care plan entitled, 'Impaired Skin Integrity' was developed for the patient at the time of admission.

Review of orders for Patient #1 revealed:
Reposition. Start 05/15/15 1800, q 2h (every two hours)...stop after 30 days, renewable.

According to the facility policy entitled, "Prevention and Treatment of Pressure Ulcers and Non-Pressure Related Wounds" dated 05/2015 revealed, "Repositioning at intervals determine per patient's risk level and condition. A minimum of every two hours for those patients determined to be at moderate or high risk."

The Certified Nurse Aide flow sheet was reviewed to determine whether turning and repositioning was provided for Patient #1.
Documentation revealed that repositioning occurred on the following dates and times: On 05/16/15 at 0059 repositioned on left side, 0323, Patient #1 was repositioned on right side, at 0755, Patient #1 was having dialysis (4.5 hours later), at 1003, Patient #1 was repositioned, 1138, Patient #1 was repositioned, at 1339, Patient #1 was repositioned at 1556, Patient #1 was repositioned (2.5 hours later), at 2142, Patient #1 was repositioned (nearly 6 hours later).

On 05/17/15 at 0101 Patient #1 was repositioned to right side, 0550, Patient #1 was repositioned (4 hours 50 minutes later), 0735, Patient #1 was repositioned to supine, at 1030, Patient #1 was repositioned to supine (3 hours later), 1127, Patient #1 was repositioned to left, at 1542, Patient #1 was repositioned to left (4 hours 15 minutes later) , at 1946, Patient #1 was repositioned to supine (4 hours later), 2200, Patient #1 was repositioned to left.

On 05/18/15 at 0422, Patient #1 was repositioned to right, at 0559, Patient #1 refused care, at 1030, Patient #1 was repositioned to right (4 ½ hours later), at 1245, Patient #1 was repositioned to supine, at 2009, Patient #1 was repositioned to right (7 hours 25 minutes later), at 0256, Patient #1 was repositioned to left (7 hours later), at 0831, Patient #1 was repositioned to semi Fowler (5 ½ hours later), and at 1315, Patient #1 was repositioned to right side (4 hours 45 minutes later).

It was unclear why staff did not reposition the patient at least every two hours per the facility policy.

Review of a wound care consultation report dated 05/21/15 revealed, "...patient is alert and oriented x 3. He is extremely weak ...He requires assistance to turn. There is a right ischial and sacral pressure ulcer that are both open and gangrenous, appeared deep, likely involving muscle or deeper tissue layers with significant necrotic eschars that are dry and not separated from surrounding tissues.
Open gangrenous stage IV right ischial pressure ulcer...open gangrenous stage IV sacral pressure ulcer...Immobility..."

It was unclear why one week after admission into the facility, the patient's wound increased in severity from stage II sacral ulcer as the wound care nurse documented on 05/15/15, to a stage IV wound on 05/21/15 per the wound doctor.

Further review of the wound care documentation revealed that on 06/01/15, Patient #1 had the following wound measurements:

Sacral wound that measured 4 cm x 4 cm x 0 cm,
Right ischial wound measured 9 cm x 4.5 cm x unable to determine, and
Left ischial wound that measured 4 cm x 4.5 cm x 0 cm .
On 11/10/15 at 1100, an interview was conducted with wound care nurse (B) who explained that the physician recommended that the patient (#1) have his wounds debrided (removal of non living tissue), but the family refused initially, but later agreed for the debridement. However, there was no documented evidence that verified that the patient's wounds were debrided.

Patient #8
On 11/10/15 at 1630, record review reveled that Patient #8 was admitted into the facility on 10/09/2015 with diagnoses of severe sepsis, Atrial Fibrillation, and hypertension among other diagnoses. Patient #8 was a 68 year old male with a Braden score of 13 (moderate risk of developing a pressure sore) and was ventilator dependent.
Upon admission into the facility, the wound nurse (E) documented on 10/10/15 that Patient #8 was admitted with a venous ulcer on his right lateral leg that measured 4 cm x 3 cm with no depth.
An order was written on 10/10/15 for "hydrophilic wound dressing to right lower leg, lateral, topical cream, 170 gm."
However on 10/28/15 a new wound was identified on the patient's sacrum/perianal rectal area which measured 9 cm x 6 cm.
A new order was written on 10/28/15 for "hydrophilic wound dressing, sacrum, perianal-rectal area, topical cream 170 gm."
According to a wound consultation report dated 11/05/15 "...the patient is on the ventilator. He is unable to sit or turn. He is weak ...incontinent of feces and urine...the patient's right lateral leg has a large gangrenous ulcer ...there is a large perianal area that is erythematous...open tissue secondary to moisture...significant maceration present."
Review of the turning and repositioning activity for Patient #8 revealed that on the day of the survey 11/10/15 as of the time of the record review, documentation revealed that Patient #8 had only been repositioned one time at 1206. On 11/09/15 Patient #8 was repositioned at 0023, 0400 (3 ½ hours later), 1151 (7 hours later), and 1547. There was no other repositioning documentation on 11/09/15 after 1547.
Patient #8 was not repositioned at least every two hours by staff.
An observation was made of Patient #8 on 11/10/15 at 1700. The patient was laying supine on his bed. There were no positioning devices noted on either side of the patient.
An interview was conducted with wound care nurse (B) at 1705 on 11/10/15 who verified that Patient #8 acquired the sacral/perianal wound after he was admitted into the facility. It was unclear how a wound the size of the sacral/perianal wound (9 cm x 6 cm) was not identified before it progressed to that size.
Nurse Manager (D) was queried about the frequency of skin assessments for patients with moderate risk for developing pressure sores. Manager (D) explained that the nurse aides assess the patient's skin during bathing but they do not document changes that they observe.
Patient #10
On 11/10/15 at 1650, review of clinical records for Patient #10 revealed that the patient was admitted into the facility on 07/31/15 and discharged on 10/16/15. Patient #10 was admitted with multiple decubitus ulcers on her left hip, left ischial, right hip, right upper back, left and right posterior thigh, left and right elbows, and left buttocks. The wounds ranged in size from stage 2 through stage four.
An impaired skin integrity care plan was developed for Patient #10 at the time of admission, and she (#10) was on a turn and reposition (T&R) schedule.
Review of the T&R flow sheets revealed that Patient #10 was not turned or repositioned at all on the last three days that she spent at the facility (10/14/15, 10/15/15 or 10/16/15).
Further review of repositioning sheets reveled that on 08/01/15 (day after admission) Patient #10 was repositioned at 0154 on right side, 1550 on left side (14 hours later), 1929 on left side (nearly four hours later), and 2333 on right side.
On the day following, Patient #10 was repositioned at 0154 on right side, 0407 left side, 0553 (right side), 0725 (left side), 1648 (right side) over 9 hours later and 2341, (nearly six hours later).