HospitalInspections.org

Based on document review and interview the facility failed to insure a RN accurately assessed/supervised the care of 1 of 1 patient reviewed.

On 2/22/2012 at 9:30 AM the medical record for patient (pt) #1 was reviewed and documentation revealed the following:
-Pt #1 was an 83 year old female who was admitted from an acute care hospital after stabilization of injuries suffered in a motor vehicle collision. (MVC)
-Pt #1 diagnosis upon admission the specialty hospital included the following:
-Acute respiratory failure
-Chronic respiratory failure
-Dysphagia
-Protein malnutrition
-Debilitation
-Multiple Fractures (Fx)
-chest wall contusion
-abdominal wall contusion

Further review revealed the following documentation:
-Patient #1 was assessed by an RN upon admission to the specialty hospital on 3/25/2010
-Her call light system was assessed as taught but the patient was not able to return demonstration secondary to bilateral cast on her arms.
-Pt #1 was diagnosed with Methocillin Resistant Staphylococcus Aurus positive sputum 3/31/201-On 4/1/2010 the patient was given a "Pancake" style call system. She was able to demonstrate use of it.
-Methocillin Resistant Staphylococcus Aurus positive in sputum 4/1/2010
-Antibiotics continue as Vancomycin
-She was in a room with a TV monitor and was observed on the monitor waving to the staff with her cast on her arms.(Not in distress)
-The nursing staff documented the Braden scale as 11 (high risk for skin breakdown is 10-12)
-patient #1 was assessed by the RN as occasionally moist and given a #2, while the did have a Foley catheter she was incontinent of bowel. usually 2-3 times per day which could be graded a #1
-patient #1 was assessed by the RN and documented on the Braden scale as probably inadequate nutrition.
-Pt #1 was admitted with protein malnutrition
-Pt #1 had a documented albumin level of 2.6 (normal low is 3.5)
-Pt #1 expired 4/25/2010

Nursing staff documented the following:
-Pt admitted to specialty hospital on 3/25/2012
-Pt initial skin assessment does not document pressure wound to occiput of head
-Pt skin assessment documents skin warm dry without redness from 2/25/2012 through 2/29/2012
-Pt skin assessment documents "sore to back of head beginning 3/30/2012
Pt skin assessment continues to document "sore to back of head" and "skin appearance smooth no redness" "no irritation" until 4/25/2012
-pt assessment records position changed left back and right from 3/25/2012 through 4/25/2012
-Pt medical record, documents no other intervention other than wound care treatment orders

The nursing staff (RN) staff did not properly assess the needs of patient #1, an 83 year old debilitated female patient. Pt #1 was not able to independently reposition herself. She was maintained with a tracheostomy until 4/25/2012 . The nursing staff (RN) did not utilize nursing interventions to treat the pressure wound to the back of her head. The nursing staff did not document an awareness, assessment or treatment of the wound to the back of pt #1's head from 3/25/2012 until 3/30/2012. Five days passed before documentation is found for "sore on back of head"

A review of the medical record from the acute hospital revealed the wound to pt #1 head was identified on 3/11/2010. Pt #1 was admitted to the specialty hospital on 3/25/2010. The initial skin assessment did not document awareness of this preexisting pressure wound to the pt occiput of her head. The documentation records the wound was not identified until 3/30/2012 5 days after admission to the specialty hospital.