HospitalInspections.org

Based on 5 of 10 (#1 - #5) clinical records reviewed, interview with facility staff and review of policies, the hospital failed to ensure registered nurses evaluated the skin and wounds of patients.

Findings include:

The hospital' policy entitled: "Wound Prevention, Care and documentation" states;

"On admission, all patients will be screened for risk of skin breakdown and for alteration in skin integrity by a registered nurse, utilizing the Braden Scale. For Braden Scale less than 18, initiate Individualized Pressure Ulcer Prevention Plan of Care. Upon admission, a full body assessment to identify the presence of existing wounds will be completed. All initial assessments of wounds will be measured and documented on the Initial Wound Documentation Flow Sheet. The Wound Documentation Update Flow Sheet will be updated at regular intervals including: weekly, with dressing changes, change in wound condition, and 24 hours prior to discharge."

Patient #1 was admitted on 12/22/11 per record review on 10/08/12 at 2:00 PM. Despite skin assessments which indicated WNL (within normal limits) patient #1 developed "quarter sized dark areas on left heel and right lateral heel" on 01/13/12. Up until that date a pressure risk tool was used daily to assess the patient's risk of developing pressure sores. This tool rates different aspects of the patient's condition; sensory perception, moisture, activity, mobility, nutrition and friction/shear assigning each a four point scale (except friction/shear which is given 3) a higher score indicates a lower risk. These scores indicated low-risk even after pressure sores developed on patient #1. Patient #1's complex medical history put her at risk for skin breakdown yet there were no precautions documented that addressed her particular needs. As outlined in patient #1's care plan initiated on 12/22/12 a goal was to ensure skin will remain intact during hospitalization. Interventions to accomplish this included; individualized prevention based on the Braden scale (see pressure risk tool above), repositioning every 2 hours in bed and every hour in chair, and when pt. in bed, keep heels off bed with pillows. These interventions were the responsibility of nursing staff and were documented by the CNA's (certified nursing assistants). CNA charting indicates that patient #1 would reposition herself and that heels were elevated. Per interview with RN A on 10/9/12 at 3:00 PM, pt. #1 would not remain in the optimum position and would require reminders. According to RN A pt. #1 also had a poor appetite and required encouragement to finish meals. The care plan failed to individualize interventions to address pt. #1's needs for staff reminders for positioning. CNA documentation was done on a shiftly basis and did not address these specific challenges instead only indicating pt. was positioned every 2 hours and heels elevated. These interventions proved inadequate and the skin began to breakdown.

Per record review on 10/08/12 at 2:00 PM pt. #1 was admitted again on 1/30/12, a nursing assessment was done which included the measurement of wounds on pt. #1's two heels, and right buttock. These measurements were not repeated until 02/12/12 despite hospital policy which dictates measuring the wound on a weekly basis. The wounds were not measured again before pt. #1 was discharged yet again to the acute care hospital on 02/28/12. Nursing shift assessments for pt. #1's wounds were not documented on the following dates and shifts; 2/2/12 PM, 2/4/12 Night, 2/5/12 PM & Night, 2/11/12 PM, 2/20/12 PM, 2/23/12 Night, 2/25/12 PM, 2/26/12 PM.

Patient #1 returned to the Rehab hospital on 03/19/12. Despite still suffering from wounds on her heels and buttocks the care plan devised on 03/19/12 indicated; "No focus/problem area identified affecting patient's skin integrity" the one intervention listed was: "perform skin assessment every shift and as needed."

Pt. #2 was admitted on 09/26/12, per record review on 10/09/12 at 11:00 AM . Skin assessments were being done inconsistently on the following dates; 09/26/12, 09/27/12, 10/1/12 thru 10/6/12 skin assessments done on PM shifts indicated reddened areas on the buttocks and inner thighs. These areas of concern were not addressed on either the AM or night shifts of these same dates nor was there documentation of their resolution.

Pt. #3 was admitted on 09/18/12 per record review on 10/09/12 at 11:30 AM , a nursing admission assessment done on 9/18/12 indicated two stage 2 pressure ulcers on pt. #3's left buttock neither which were measured.

Pt. #4 was admitted on 09/19/12 per record review on 10/09/12 at 11:30 AM existing pressure sores on both buttocks were not measured at the time of admission. Measurements of the wounds were not documented for the following two weeks.

Pt. #5 was admitted on 09/24/12 per record review on 10/08/12 at 12:00 PM. On admission pt. #5 had a stage 2 coccyx wound measuring 5 cm. X 1.5 cm. Wound assessment was missing for 10/1/12 AM and PM shifts and for the AM shift on 10/2/12.

These findings were confirmed per interview with Infection control Officer B on 10/08/12 at 2:00PM.