HospitalInspections.org

Based on medical record review, interviews and review of policy and procedure, nursing staff failed to measure, photograph and thoroughly assess and document Patient Identifier (PI) # 1's sacral pressure ulcer on admission, weekly and at discharge. Wound treatment was not consistently performed and/or documented. Although a pressure ulcer was present on admission and PI # 1 was noncompliant at times, staff's failure to consistently assess the wound and document treatment made it difficult to implement interventions that minimized the progression of the wound. Interventions were not initiated per hospital policy and procedure within 24 hours of admission.

This affected one of ten sampled patients.

Findings include:

Hospitals:

Hospital # 1: Rehabilitation Hospital
Hospital # 2: Acute Care Hospital


I. Medical Record Review (Hospital # 1):

1. Prescreening Admission Form Dated 1/26/17:

Wound Description: "Sacrum: X"

2. History and Physical Dated 1/28/17 - Hospital # 1:

Admit Date to Hospital # 1: 1/27/16

Chief Complaint: Lower extremity weakness.

HPI (History of Present Illness): Patient (PI # 1) presented to Hospital # 1 (Rehabilitation Hospital)with history of Cystic Fibrosis, Hypertension, End Stage Renal Disease and CIDP (Chronic Inflammatory Demyelinating Polyneuropathy): a rare neurological disorder. Affects how fast the nerve signals are transmitted and leads to loss of nerve fibers. This causes weakness, paralysis and/or impairment in motor function, especially of the arms and legs. Sensory disturbance may also be present (rarediseases.org).

PI # 1 presented to Hospital # 2 (Acute Care Hospital) on 1/6/17 after a recent course of PLEX (Plasmapheresis: a process by which some of the patient's blood is removed and the blood cells returned without the liquid plasma portion of the blood. It may work by removing harmful antibodies contained in the plasma, gbs-cidp.org) when PI # 1 noticed an acute onset of lower extremities weakness and bilateral lower extremity swelling.

Physical Examination:
Integumentary (Skin): "sacral decub." (Sacrum: A triangular bone made up of five fused vertebrae and forming the posterior section of the pelvis, thefreedictionary.com).

3. Nursing Notes:

1/27/17 at 8:18 PM: A RN (Registered Nurse) described PI # 1's wound to the coccyx (tailbone) as covered with foam (type of dressing). No drainage, no odor and no pain. There was no description of the wound bed, no description of the surrounding tissue, no measurements and no photographs of the wound were taken. There was no documentation to substantiate the dressing was removed for an evaluation by the RN during the admission nursing assessment.

1/28/17: An RN described the wound as "coccyx laceration (a wound produced by the tearing of soft body tissue, google.com). "Ecchymotic, (nonraised skin discoloration caused by the escape of blood into the tissues from ruptured blood vessels, medicinenet.com). Necrotic, (dead tissue; usually results from an inadequate local blood supply. medscape.com). Eschar." (dead tissue found in a full-thickness wound. Acts as a natural barrier to infection by keeping bacteria from entering the wound. If the eschar becomes unstable (wet, draining, boggy, edematous, red) it should be debrided according to the facility protocol, woundsource.com).

Dressing change: 4 x 4 (bandage) dry. "Ointment." No drainage or odor.

1/29/17: The sacral wound was photographed and measured by a staff RN: Length: 3 cm. (centimeters) x Width 4.5 cm.

1/30/17 at 1:06 PM: PI # 1 refused to allow the wound care nurse to evaluate her wounds. Spoke with nursing to "perform a simple dressing change for today."

1/31/17 at 9:00 AM by Wound Care Nurse: "...unstageable wound to...sacrum. Eschar noted. Wound measures 2.8 x 3.8...Will begin Santyl." (ointment that cleans wounds to clear the way for healthy tissue, www.santyl.com).

2/4/17 at 5:06 AM: First documentation of "foul odor," bright red skin surrounding the sacral wound and macerating (softening and breaking down of skin resulting from prolonged exposure to moisture, en.wikipedia.org).

2/7/17 at 5:49 PM: Odor "minimal" per staff RN.

PI # 1 refused evaluation of wound by Wound Care Nurse at 4:36 PM.

2/9/17 at 1:56 PM - Wound Care Nurse: "Unstageable wound to sacral area - 4.3 x 3.6 cm., redness periwound (around wound). Sensicare applied around wound. Dressing that was removed form sacrum was covered by optifoam. Will speak with nursing to ensure that wound is covered by abdominal pad and not optifoam, and that sensicare (moisture barrier) is placed periwound to protect underlying skin..."

2/12/17: Sacral wound measurement: 9 cm. x 8 cm. by staff RN.

2/15/17: Sacral wound description:
Moderate exudate (fluid and cellular elements that oozes out of blood vessels due to inflammation,
medicinenet.com), purulent type. Brown in color. Foul, strong odor. Maceration - surrounding tissue. Bright red surrounding skin. Localized infection.

2/16/17: Sacral wound description: Moderate amount exudate. Purulent. Brown in color. Foul odor.
Bright red surrounding skin. Surrounding skin - induration (hardening of normally soft tissue, medicinenet.com).

2/16/17 at 7:02 PM: Wound Care Nurse: "...sacral wound is unstageable, and has an odor, slough remain..." Attending physician (name of) notified.

2/17/17: The sacral wound was photographed. Measurement: 4.8 cm. x 3.8 cm. RN documented, "No exudate."

Physician Discharge Summary from Hospital # 1 dated 2/17/17:

PI # 1 has worsening leukocytosis (increased white blood cells; often an indicator of infection). Sacral wound has increasing erythema. Given her leukocytosis and medical complexity, discussed that patient may need evaluation in the acute care hospital. Patient in agreement with the plan.

...Integumentary: sacral decub (decubitus)...

White count on 2/16/17: 23.7 mcL. (normal range: 5,000 and 10,000 white blood cells per microliter of blood (mcL).

...Leukocytosis: Concerning for developing infection. Differential could include a urinary source versus worsening sacral wound. The wound care nurse feels patient is in need of surgical debridement (procedure not done at Rehabilitation Hospital) given unstageable wound and progressive erythema. Have recommended acute care transfer. Patient is making little progress in therapy and patient is concerned for ongoing medical issues...

PI # 1 was discharged to Hospital # 2 (Acute Care Hospital) at 3:00 PM on 2/17/17.


II: Interviews:

During an interview on 3/14/17 at 12:05 PM, the Medical Director at Hospital # 1, Employee Identifier (EI) # 1, looked at a photograph of PI #1's sacral wound dated 1/29/17 via the hospital's electronic medical record. EI # 1 said, "There was no way that was present in 48 hours." Based on the photograph, taken by hospital staff, PI # 1's wound, "Needed surgical debridement with sedation."
(Debridement: to remove all materials that may promote infection and impede healing. This may be done by enzymes, mechanical methods (whirlpool), or sharp debridement (instruments), www.medicinenet.com).

During an interview on 3/14/17 at 10:55 AM, the Certified Rehabilitation Registered Nurse (CRRN)/ EI # 3, functioning as the Wound Care RN at Hospital # 1, stated PI # 1 had an unstageable pressure wound to the sacrum on 1/31/17 when she assessed PI # 1's skin.

During an interview on 3/15/17 at 10:55 AM, a RN (Registered Nurse) Clinical Liaison, EI # 2, responsible for gathering clinical information from the referring hospital, stated she recalled an odor to PI # 1's wound(s) at Hospital # 2 prior to PI # 1's admission to Hospital # 1 (receiving hospital) on 1/27/17. EI # 2 stated Hospital # 2's staff documented PI # 1 had a sacral decubitus ulcer present on admission to Hospital # 2 on 1/6/17.

During an interview on 3/15/17 at 2:45 PM, EI # 4 confirmed she was PI # 1's attending physician. According to EI # 4, PI # 1 was "Dismissive" about the wound. PI # 1 stated she got the wound/pressure ulcer when she fell at home and broke her tailbone. PI # 1 refused to have the wound evaluated on admission. "I can't get it checked now," was PI # 1's response to the physician's (EI # 4) request to evaluate the wound on multiple occasions. PI # 1 also refused to allow the wound care nurse (EI # 3) to evaluate the wound on several occasions. When asked if the patient had a pressure ulcer on admission EI # 4 said PI # 1 had a "Pressure related, unstageable wound to the sacrum. Could have a Stage IV ulcer underneath. You just don't know. There was some deep tissue injury periwound." (periwound: In addition to noting the characteristics of the wound itself, clinicians should also examine the periwound - identified as the surrounding skin, comparing this tissue to the skin outside the affected area, as well as comparing the opposite (contralateral) side where possible, woundeducators.com).

The Attending Physician, EI # 4, reviewed the photograph of PI # 1's sacral wound dated 1/29/17 and stated the wound condition on 1/29/17 would have taken weeks to a month to develop. PI # 1 was admitted to Hospital # 1 on 1/27/17 and the wound could not have deteriorated that much in 48 hours when the photograph was taken as documented on 1/29/17.

On 2/16/17, EI # 4 said she evaluated PI # 1's sacral wound and described the wound as, "Roofed by necrotic (dead) tissue." There was no tunneling or depth.

III. Policy and Procedure:

Title: Wound Assessment, Prevention and Documentation

"Policy: All patients admitted to Hospital # 1 will be screened within 24 hours for risk of skin breakdown and for alteration in skin Intergrity by a registered nurse, utilizing the Interdisciplinary Assessment. For a Braden score of 18 or less, the Skin Breakdown Prevention Protocols (as described in this policy) will be initiated and incorporated into the Plan of Care. Each patient's wound care will be under the direction of a physician.

Definition:
The term "wound" is used generically to include all types of alterations in skin integrity...
The three general categories of wounds mentioned in this policy are:

1. Pressure ulcers (also referred to as skin breakdown).
2. Procedure-related wounds (surgical incisions, tube placement sites).
3. Other alterations in skin integrity.

WAPD - Wound Assessment, Prevention and Documentation.

I. Procedures
I. Assessment: An RN will inspect each patient's integument daily, weekly and as often as needed.
a. The Braden scale is used to assess all patients for risk of skin breakdown. Record findings:
i. At admission on the Interdisciplinary Assessment.
ii. Weekly on the care plan.

b. Pressure ulcers are noted in the record upon discovery.

i. A full assessment is completed within 24 hours of admission (or discovery) to include a
description of the wounds and physician notification.

ii. Pressure ulcers will be staged, measured and photographed...but no less than weekly.

iii. Within 2 days of discharge a final assessment is conducted...

II. Description Methodology

A. Classification of Pressure Ulcers:
...
v. Unstageable: Depth unknown. Full thickness tissue loss in which the depth of the wound cannot be determined because the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

III. Documentation: Upon discovery of the wound, the clinician will describe the wound precisely.

i. Wound label: Assign a number or a letter on the body figure in the Integumentary section...

ii. Exudate (drainage): Amount...Characteristics...

iii. Measurements: Stag II and greater pressure ulcers ...will also include the following:

Size: Length, Width and Depth should be recorded in centimeters on admission, weekly and at discharge...

v. Wound base: State the color and type of tissue located in the wound base...

vii. Wound edges:...

viii. Condition of surrounding skin: Assess at least 4 cm. extending from wound edge for discoloration, swelling, skin tears or maceration. Palpate for induration or fluctuance (spongy, soft).

ix. Signs and symptoms of infection:
a. Local: Increased erythema, edema, purulence, increased temperature, pain and change in color or increase in exudate, uncharacteristic odor.

b. Systemic: Elevated temperature and or white blood cells,decreased blood pressure, increased pulse.

c. Pain: ...can signify an inflammatory condition or infection.

Daily documentation will be recorded by the RN...the type of specialty bed or support surface used to assist with preventing or treating skin breakdown will be documented on the daily treatment section.

Weekly and discharge documentation will include:
- Reassessments include:
a. skin inspections and assessment of all of the above.
b. documentation of current treatment.
c. changes in treatment since the last update.
d. improvement...since the last update.

IV. Wound Photography

a. Regardless of time or place of origin, all wounds as below are to be photographed at discovery, weekly and discharge.

i. All pressure ulcers Stage II or above...

VI. Prevention and Basic Treatment:

a. Determine and provide Appropriate Support Surfaces for Pressure Relief.
..ii. Evaluate need for a specialty bed for all high risk patients...