HospitalInspections.org

Based on review of the facility's policy, medical records (MR), and interviews it was determined the facility failed to ensure:

1. The staff accurately documented wound type, location, size, stage, exudate, and treatment provided with each dressing change.

2. Physician orders were followed for wound care.

3. The facility Pressure Ulcer Prevention and Treatment Practice Guidelines were followed for at risk patients.

This affected 4 of 4 medical records (MR) reviewed with wounds and did affect Patient Identifier (PI) # 5, PI # 2, PI # 3, PI # 1, and had the potential to negatively affect all patients served by this facility.

Findings Include:

Policy: Patient Care Procedures
Subject: Pressure Ulcer Prevention and Treatment Practice Guidelines
Date Revised: 02/2018

Policy: It is the policy that Pressure Ulcer Prevention Guidelines will be initiated for all non-surgical wounds. This includes pressure ulcers (Stages I, II, III, IV, and Unable to Stage), skin tears and abrasions...

III. Procedure:

B. The Body Audit (Skin Assessment) Form will be placed behind the Admission tab in the Medical Record.

1. On admission, for all adult patients, a Skin Integrity/Wound Assessment will be completed by two nursing personnel one of which will be a Registered Nurse. The computerized Braden Scale will be completed at this time also.
2. ...If patient has more than one wound, nurse will fill out on the Body Audit Skin Assessment for each wound...

E. Prevention Guidelines for "At-Risk" patients...

...4. Assess skin daily and document findings...
...6. Pressure Redistribution Mattress...
...9. Provide education to patient and/or home caregivers
10. Document all interventions and outcomes.

F. Patient Positioning Guidelines...

...5. Turn patient at least every two hours while in bed...
6. Float heels off contact surfaces such as a recliner or mattress.
...8. Do not elevate head of bed more than 30 degrees except when medically necessary or at mealtimes...
...11. Document all interventions and outcomes

V. Stage II Pressure Ulcers

Partial thickness skin loss...
D. Patient Positioning
Do not position patient on pressure ulcer.

E. Approved Pressure Ulcer Reduction Devices

1. Pressure redistribution mattress.
If the pressure ulcer fails to improve with appropriate positioning on this surface, a specialty bed may be indicated.

F. Documentation:
1. Initial documentation should include the following. These should also be documented daily or with each dressing change.
a. Location
b. Size
c. Stage initially, every 2 days and at discharge
d. Exudate
e. Necrotic tissue
f. Odor
g. Treatment used
h. Pain

VIII. Pressure Ulcers Unable to Stage
Wounds which are mostly covered with necrotic tissue (eschar/slough) cannot be accurately staged and should be managed the same as a Stage IV area...
A. Wound Cleaning - Normal Saline or other approved wound cleanser.
B. Debridement - If necrotic tissue is present, make physician aware.
C. Treatment -
1. Protect surrounding skin with skin sealant (Sureprep protective wipe) or barrier ointment (e. g. Vaseline).
2. Apply saline moistened gauze in a wet to moist fashion and change each shift.

IX. Deep Tissue Injury
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage or underlying soft tissue from pressure and/or sheer...

C. Patient positioning - Do not position patient on pressure ulcer...
E. Documentation

1. Initial documentation should include the following. These should also be documented daily or with each dressing change.
a. Location
b. Size
c. Exudate
d. Necrotic tissue
e. Odor
f. Treatment used
g. Pain

2. Deep Tissue Injury present on admission must be documented within 24 hours along with description by the physician...
Location
Measurement length-width-depth in centimeters
Amount and character of drainage
Presence or absence of odor
Pressure reduction surface, if needed

Deep Tissue Injury Protocol
A. Skin Care
...Use barrier ointments on skin exposed to urine, stool, or moisture. Reapply after cleansing.
E. Patient Positioning
...Turn every 2 hours while in bed
Do not position patient on pressure ulcer


1. Patient Identifier (PI) # 5 was admitted to the hospital on 8/7/19 with diagnoses including Sepsis due to Urinary Tract Infection, Hypokalemia, Paraplegia, Urethral calculus, Chronic suprapubic catheter, Decubitus ulcer.

Review of the Admission Assessment dated 8/7/19 at 8:27 PM revealed documentation the patient was immobile, bedrest, with Pressure Ulcer to left hip. Wound Vac (vacuum assisted closure device) was in use. Wound draining bloody drainage, small amount...wound vac was not removed. Patient reports that family can bring supplies (wound vac) to hospital on 8/8/19. There was no documentation of the wound or wound assessment at the time of Admission Assessment.

Review of the Provider Order Summary from admission date 8/7/19 to discharge date 8/12/19 revealed no documentation of wound care orders.

Review of the Systems Assessment dated 8/9/19 at 8:05 PM revealed the nurse documented "wound vac in place, dressing change done today per Amedysis Home Health."

Further review of the Systems Assessment dated 8/9/19 at 8:05 PM revealed no documentation of wound assessment or wound measurements.

An interview was conducted on 10/9/19 at 3:15 PM with Employee Identifier (EI) # 1, Director of Nurses (DON), who confirmed the above findings.

2. PI # 2 was admitted on 9/18/19 at 7:46 PM with diagnoses including Weakness, Diabetes Mellitus, Bilateral Lower Extremity Cellulitis, and Hypertension.

Review of the admission orders dated 9/18/19 included orders for "Dressing change to both legs with Polysporin ointment BID (twice daily)."

Review of the Swingbed Nursing Admission Assessment dated 9/18/19 at 7:46 PM revealed the following wound assessments:

a) wound # 1, stasis ulcer left leg, Stage II, no documentation of size
b) wound # 2, right leg, Stage II, no documentation of size
c) wound # 3, right lower leg, Stage II, no documentation of size
d) wound # 4, left anterior ankle, Stage I, no documentation of size.

Review of the Nursing Shift Assessment dated 9/19/19 at 10:00 PM revealed wound # 2 was cleaned with Normal Saline, Polysporin ointment applied, and Xeroform Gauze applied.

Review of the Physician orders revealed no order for Xeroform Gauze.

Review of the Nursing Shift Assessment dated 9/22/19 at 7:30 PM revealed the nurse documented the wounds were cleaned with sterile water, antibiotic ointment applied, and covered with Vaseline gauze.

Review of the Physician Orders revealed no order to clean the wounds with sterile water or to cover with Vaseline gauze.

An interview was conducted on 10/09/19 at 1:45 PM with EI # 1, DON, who confirmed the above findings.


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3. PI # 3 was admitted to the facility from hospice for 5 days of respite care on 8/29/19 with diagnoses including Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Hemiplegia Following Subarachnoid Hemorrhage Affecting Left Nondominant Side, and Pressure Ulcer of Sacral Region, Stage 2.

Review of the medical record revealed a hospice physician order dated 8/26/19 which stated, "patient to go to respite care at Pickens County Medical Center effective 8/29/19 and return home 9/3/19......Stage II pressure ulcer to coccyx: Facility nurse to cleanse wound with wound cleanser and gauze, pat dry with gauze, apply skin prep to periwound to prevent maceration. Cover with Optifoam dressing. Skilled Nurse (SN) to change weekly or as needed for saturation or dislodgement. Last changed on 8/22/19."

Review of the admission assessment by the Registered Nurse (RN) dated 8/29/19 at 1:30 PM revealed the patient was dependent/unable to perform self care activity, eating/drinking, bathing, dressing, toileting, walking, or transfer/change positions.

Review of the RN documentation dated 8/29/19 at 11:15 AM revealed, "skin warm and dry, has 1/2 centimeter (cm) x 1/2 cm open area on coccyx. No odor, has duoderm applied by home health before admission.....Patient (Pt) only complaint is pain in butt, Pt is total care. No other skin problems." There was no documentation of an assessment of the wound bed. There was no documentation of use of a pressure redistribution mattress or floating of heels off the bed as per hospital policy for "at risk" patients.

Review of the RN documentation dated 8/29/19 at 8:00 PM revealed, "skin warm and dry, pressure area noted to coccyx 1/2 cm x 1/2 cm with duoderm covering." There was no documentation of an assessment of the wound bed. There was no documentation of use of a pressure redistribution mattress or floating of heels off the bed.

Review of the RN documentation for the 8/30/19 7 AM to 7 PM shift revealed no documentation regarding the wound, use of pressure redistribution mattress, or floating of heels off the bed.

Review of the RN documentation dated 8/30/19 at 9:30 PM revealed, "Repositioned to left with wedge, legs up on pillows." There was no documentation regarding the wound or use of pressure redistribution mattress.

Review of the RN documentation dated 8/31/19 at 7:05 AM revealed, "duoderm intact to coccyx."

Review of the RN documentation dated 8/31/19 at 3:30 PM revealed, "patient care assistant (PCA) reports duoderm off buttocks. Cleaned with soap and water. Duoderm applied. Positioned to left side using wedges to position off buttocks." There was no physician's order to clean with soap and water and apply duoderm. The physician's order to clean with wound cleanser and apply Optifoam dressing was not followed. There was no documentation of the wound bed appearance or measurements. There was no documentation of use of a pressure redistribution mattress or floating of heels off the bed.

Review of the RN documentation dated 8/31/19 for the 7 PM to 7 AM shift revealed no documentation regarding the wound, use of pressure redistribution mattress, or floating of heels off the bed.

Review of the RN documentation dated 9/1/19 at 2:25 PM revealed, " cleaned and changed pt. Duoderm coming off. Cleaned area with soap and water. New duoderm applied." There was no documentation of the wound bed appearance or measurements. There was no documentation of use of a pressure redistribution mattress or floating of heels off the bed.

Review of the RN documentation dated 9/1/19 for the 7 PM to 7 AM shift revealed no documentation regarding the wound, use of pressure redistribution mattress, or floating of heels off the bed.

Review of the RN documentation dated 9/2/19 for the 7 AM to 7 PM shift revealed no documentation regarding the wound, use of pressure redistribution mattress, or floating of heels off the bed.

Review of the RN documentation dated 9/2/19 at 8:00 PM revealed, "Dressing coming off of stage II ulcer on coccyx. Area cleaned and duoderm dressing applied.....repositioned to left side." There was no documentation of the wound bed appearance or measurements. There was no documentation of use of a pressure redistribution mattress or floating of heels off the bed.

Review of the RN documentation dated 9/3/19 at 8:00 AM revealed, "Duoderm on coccyx." There was no documentation of the wound bed appearance or measurements. There was no documentation of use of a pressure redistribution mattress or floating of heels off the bed.

Review of the RN documentation dated 9/3/19 at 2:00 PM revealed, "Discharge (D/C) per stretcher to ambulance. All home meds, ativan and insulins returned to family."

The facility failed to follow the physician's order for wound care, and failed to assess the wound bed and document findings including the size of the wound as directed per hospital policy.

Review of the Hourly Rounds Assessment forms in the medical record, where both the RN and PCA (Patient Care Assistant) document patient care, including turning, failed to include documentation PI # 3 was turned every 2 hours as directed per policy and pressure kept off the wound.

An interview was conducted on 10/9/19 at 11:52 AM with EI # 1, who confirmed the above findings.

On 10/10/19 at 9:00 AM, PI # 3's hospice medical record was obtained from the agency.

Review of the hospice Client Coordination Note dated 9/4/19 revealed documentation, "patient's wound to coccyx on the day that patient (pt) went to respite care (8/29/19) measured at 0.7 x 0.7 x 0.0, and today this area is measuring 5.5 x 3.5 x 1.0. Pt also has a new area to his left heel that is a blackened area - 0.5 centimeters (cm), a new skin tear to his right arm and a new skin tear to his left arm. Both of these sites were covered with a tegaderm dressing when pt returned home."


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4. PI # 1 was admitted to the facility on 9/19/19 at 6:56 PM with diagnoses including Hip Fracture with Surgical Repair.

Review of the MR revealed PI # 1 was bedbound, incontinent of urine requiring diapers, was unable to move both left upper and left lower extremity and required assistance with ADLs (activities of daily living).

Review of the physician's admission orders dated 9/19/19 revealed: skin care to sacrum; wound care to R (right) hip; Venelex Ointment 1 application 2 times per day for 1 month, apply to coccyx ulcer sparingly.

Review of the Nursing Shift Assessment documentation revealed the following:

9/19/19 at 10:47 PM: Wound 1 - incision right hip, 24 cm (centimeters), staples intact, draining moderate amount serous drainage, dressing changed, wound cleansed. There was no documentation what the wound was cleansed with nor what dressing was applied.

Wound 2- stasis ulcer coccyx, reddened, stage II, dressing missing. There was no documentation of the size of the wound nor appearance of the wound bed.

9/20/19 at 5:17 PM: Wound 1-incision, draining slight, dry dressing intact. Wound 2-sacral area, purplish red, no breakdown, duoderm intact. There was no physician's order for the duoderm. There was no documentation the Venelex Ointment was applied as ordered.

9/21/19 at 8:25 PM: Wound 2-coccyx, pressure area skin intact, reddened, clean and dry. There was no documentation of the wound size.

9/22/19 at 5:39 PM: Wound 2- sacral, reddish, purple area, no breakdown, covered with a duoderm...changed today. There was no documentation of the wound size. There was no physician's order for the duoderm dressing.

9/23/19 at 10;03 AM: Wound 2-coccyx, reddened, open to air, applying resinol with diaper changes. There was no documentation of the size of the reddened area.

9/24/19 at 12:13 PM: "Coccyx red due to patient lying on back a lot. Encouraged patient to turn and reposition frequently. Air mattress applied today." There was no documentation the patient was turned and repositioned off the coccyx wound.

9/25/19 at 9:43 AM: Wound 2-sacral area, reddish purple, no breakdown, covered with duoderm. There was no physician's order for the duoderm.

9/26/19 at 12:54 PM: Wound 2-sacral, reddish purple, no breakdown, covered with duoderm. There was no physician's order for the duoderm.

9/27/19 at 1:22 PM: Wound 2 - no wound assessment documentation.

9/27/19 at 8:20 PM: Wound 2 - no wound assessment documentation.

9/28/19 at 11:00 AM: Wound 2 - no wound assessment documentation.

9/28/19 at 8:00 PM: Wound 2 - no wound assessment documentation.

9/29/19 at 10:30 AM: Wound 2-right knee (wound 2 was identified as sacral/coccyx wound on prior documentation), abrasion, clean/dry, dressing removed, scabbed, healing well.
Wound 3-right lower leg, abrasion, clean/dry, dressing removed, healing well.
Wound 4-sacrum (previously identified as Wound 2), reddened, red/purple area to bony region of tailbone duoderm applied as needed and when soiled. There was no documentation of the size of the reddened area and no order for the duoderm.

9/30/19 at 7:40 PM: Wound 4-sacrum, coccyx, reddened, stage III, duoderm intact, healing nicely. There was no documentation of the wound bed, the size of the wound nor that the physician was notified the area was now a stage III wound.

10/1/19 at 7:35 PM: There was no documentation of wound assessment or care.

10/2/19 at 8:10 AM: Wound 3-coccyx,pressure area (previously identified as Wound 4), wound cleansed, duoderm wadded up, new duoderm applied. There was no documentation of assessment of the wound bed, size of the wound nor what was used to clean the wound. There was no physician's order for the duoderm.

10/3/19 at 8:45 AM: Wound 3-buttocks, pressure area, granulating/red, reddened, partial thickness, slight drainage, stage I (Stage I wound is defined as intact skin), duoderm in place changed 10/2/19. The documentation was conflicting and unclear whether this was a new wound or the coccyx wound previously identified as Wound # 4.

10/4/19 at 2:29 PM: Wound 1-coccyx area, covered with duoderm. Documentation is unclear - wound 1 was previously identified as a right hip surgical incision.

10/5/19 at 3:29 PM: Wound 1-right leg incision, open to air. Wound 2-coccyx area, covered with duoderm. Wound 3-back, covered with duoderm. There was no physician's order for duoderm to be applied to the coccyx and back, nor how often it was to be changed. The wound identification for wound 1 was conflicting and unclear.

10/6/19 at 12:22 PM: Wound 1-right leg incision. Wound 2-red area center backbone (previously identified as coccyx area), skin not broken covered with duoderm. Wound 3-coccyx, slough/yellow, "duoderm placed no drainage area noted whitish tan in color no odor, will have MD look at area in am." There was no documentation of the size of the wound and the assessment documentation was not clear.

Review of the Body Audit dated 10/6/19 at 1:00 PM revealed the coccyx wound measured - length 2 1/2 inches by width 3/4 inches (6.35 cm by 1.9 cm). There was no wound depth documented.

10/7/19 at 11:52 AM: Wound 1-coccyx, stasis ulcer, slough/yellow, slight drainage, stage II, duoderm applied. There was no documentation of the size of the wound, amount of slough in the wound bed, whether there was an odor, no documentation the wound bed was cleansed prior to applying the duoderm. There was no physician's order for the duoderm.

An observation of wound care provided by EI # 2, Registered Nurse, was conducted on 10/9/19 at 9:35 AM. EI # 2 cleansed the area with saline soaked gauze and prepared to apply a duoderm dressing. The surveyor asked EI # 2 if she was going to measure the wound. EI # 2 stated it was measured earlier that morning when the duoderm came off and it was 4 cm by 2 cm.

Observation of the wound revealed an approximately half dollar size wound across the gluteal fold on both buttocks. The wound bed was 100% covered with yellow slough.

EI # 2 obtained a measuring tool, measured the wound bed and stated it was "5 by 3." EI # 2 failed to measure the wound depth.

The facility staff failed to notify the physician of the change in wound status from a deep tissue injury at admission on 9/19/19 to an open pressure ulcer, unstageable due to the wound bed covered with slough on 10/8/19.

Further review of the MR revealed no documentation PI # 1 was turned every 2 hours and kept off the pressure area as directed by the facility policy.

An interview conducted on 10/9/19 at 3:05 PM with EI # 1 confirmed the above findings.