HospitalInspections.org

Based on observation, interviews and record review the hospital failed to ensure RN's (Registered Nurses) evaluated nursing care furnished to 1 of 1 patient (Patient #8). (Patient #8) developed a Stage II Pressure Ulcer to the Left Ischium identified at the time of survey.

Findings Included:

The Nursing Flowsheet dated 01/03/14 timed at 14:20 PM, reflected, "Skin integrity...intact, no abnormalities..."

The Adult Admission Assessment dated 01/03/14 timed at 14:38 PM, reflected, "Incontinent of bowel and bladder...gait, transfer weak...intermittent confused, limited mobility...no stage II pressure....drooping right side of face..."

The nursing flowsheet dated 01/08/14 timed at 23:00 PM, reflected, "Skin integrity not intact...coccyx erythema, redness, bruising..." It was noted no documentation was found which indicated (Patient #8) had a pressure ulcer to the left ischium.

The nursing flowsheet dated 01/09/14 timed at 15:35 PM, reflected, "Skin not intact...coccyx erythema, redness..." It was noted no documentation was found which indicated (Patient #8) had a pressure ulcer to the left ischium.

On 01/09/14 at 04:05 PM, the surveyor conducted skin rounds with Personnel #2. (Patient #8's) skin was assessed by Personnel #6 with the assistance of Personnel #7. Personnel #6 was asked prior to the assessment if (Patient #8) had any pressure ulcers. Personnel #6 said none that she [Personnel #6] was aware of. (Patient #8) was positioned on the left side facing the door. (Patient #8 was incontinent of feces). Personnel #7 provided incontinent care. Personnel #7 was observed applying barrier cream to (Patient #8's) buttocks when the surveyor pointed out a reddened area located on (Patient #8's) left ischium. A wound was observed to the left ischium located inside a skin fold. Personnel #7 reported she did not know (Patient #8) had a wound in the left ischium. Personnel #6 was asked by the surveyor what the wound type was. Personnel #6 said she did not know it looked like an abrasion. The surveyor requested Personnel #4 assess the wound site. Personnel #4 assessed the site and identified the wound as a house acquired Stage II Pressure Ulcer.

The 01/09/14 nursing flowsheet dated 01/09/14 timed at 18:00 PM, reflected, "Wound dressing adhesive, foam...cleaned with normal saline...wound pressure ulcer Stage II to right ischium...wound length 2 cm (centimeters)...width...1.1 cm...surrounding skin...shear/friction ...erythema..."

The nursing progress note dated 01/14/14 timed at 22:08 PM, reflected, "I incorrectly documented the location of the wound as right ischium, but the location of the Stage II pressure ulcer is actually located on the lt (left) ischium..."

On 01/14/14 at 02:25 PM, Personnel #7 telephoned the surveyor. Personnel #7 stated on the morning of 01/09/14 she provided incontinent care for (Patient #8). Personnel #7 stated she was unaware (Patient #8) had a pressure ulcer and none of the hospital staff reported (Patient #8) had a pressure ulcer.

The Wound Assessment, Prevention and Documentation policy with a review date of 05/16/12 reflected, "Stage II...partial thickness skin loss...daily documentation of skin and wound inspection will include...skin condition...daily documentation will be recorded on the daily nursing assessment...regardless of time or place of origin, all wounds are to be photographed...weekly and within 24 hours of discharge...any other alterations in skin integrity...all pressure ulcers stage II or above...