HospitalInspections.org

AS/BL

Complaint survey OH00063215

Based on medical record review and staff interview, the facility failed to provide all pressure sore prevention methods for four of four patient's with pressure sores in a sample of five medical records reviewed. ( Patient #'s 1, 2, 3, and 4) These findings substantiate the complaint.

Please refer to A 395 regarding the facility's failure to provide care and services to treat and prevent the development of pressure ulcers.

Based on medical record review and staff interview the facility failed to ensure all nursing care for patients with pressure sores was provided. This affected four of four patients identified with pressure ulcers and whose medical records were reviewed. Patients #s 1, 2, 3, and 4 developed pressure ulcers while a patient in the hospital.

Findings include:


The medical record for Patient #4 was reviewed on 12/14/11. The patient was admitted to services on 08/23/11 with diagnoses which included respiratory failure, tracheotomy, ventilator dependent, and right below the knee amputation. Review of the Photographic Wound Documentation dated 08/23/11 revealed there was balanceable erythema (redness) present. On 09/07/11 the Photographic Wound Documentation revealed deep tissue injury to the left heel measuring 1.3 centimeters by 1.5 centimeters. On 10/12/11 documentation revealed a pressure ulcer on the left heel measuring 1.5 centimeters (cm) by 1.5 centimeters (cm) on the lateral aspect of the left foot that was untraceable and a second area on the medial side of the left foot that measured 1.2 centimeters (cm) by 0.8 centimeters (cm) that was also untraceable. On 10/20/11 black, escar tissue was documented on three sites on the left heel; posterior heel 0.7 cm by 1 cm, lateral outer left foot 1 cm by 0.7 cm, and lower lateral posterior heel 1.5 cm by 2 cm. Surgical abridgement of the left foot wounds were completed on 12/06/11. A plan of care for the impaired skin integrity had been implemented on 08/23/11 that called for the patient to be turned and repositioned every two hours, a low air mattress was to be applied to the bed, and the patient's left foot and heel to be floated off the bed. Review of the 24 hour Patient Record and Plan of Care revealed inconsistent documentation of turning and repositioning every two hours as per the impaired skin integrity plan of care. Documentation on the Patient Record revealed the following:

On 08/28-7/11: No documentation of turning and repositioning every two hours between 01700 (5:00 PM) and 2000 (8:00 PM), 3 hours.
On 08/31/11: No documentation of turning and repositioning every two hours between 01700 (5:00 PM) and 2200 (8:00 PM), three hours.
On 09/02/11: No documentation of turning and repositioning every two hours between 0700 (7:00 AM) and 0200 (2:00 PM), seven hours.
On 09/05/11: No documentation of turning and repositioning every two hours between 01700 (5:00 PM) and 2200 (8:00 PM), three hours.
On 09/06/11: No documentation of turning and repositioning every two hours between 1200 (12:00 PM) and 1500 (3:00 PM), three hours, and 01700 (5:00 PM) and 2200 (10:00 PM), three hours.
On 12/06/11: No documentation of every two hour turning and repositioning between 2200 (10:00 PM) to 0300 (3:00 AM), five hours.
On 12/07/11: No documentation of every two hour turning and repositioning between 1300 (1:00 PM) to 2000 (8:00 PM), seven hours.
On 12/08/11: No documentation of every two hour turning and repositioning between 1800 (6:00 PM) and 2000 (10:00 PM), four hours.
On 12/09/11: No documentation of turning and positioning between 01700 (5:00 PM) and 2000 (8:00 PM), three hours.
12/10'11: No documentation of every two hour turning and repositioning between 1800 (6:00 PM) and 2000 (10:00 PM), four hours.


07312


Review of the medical record of Patient #1 on 12/13/11 revealed this patient was admitted to the hospital on 10/19/11. The patient's skin was assessed at admission and the patient was found to have intact heels. The physician's order was that the patient be turned every 2 hours and to have heels positioned off the bed. Documentation dated 11/09/11 revealed this patient had an 8 by 8 centimeter blister on one heel.
Review of the nursing documentation for this patient revealed the turn schedule did not show that the patient was turned every two hours on 10/20/11, 10/23/11, 10/25/11, 10/30/11, 10/31/11, 11/02/11 11/03/11, 11/04/11 11/09/11, 11/14/11, 11/15/11, 11/16/11, 11/17/11, 11/18/11,11/19/11, 11/20/11, 11/22/11.
These findings were confirmed by Staff F on 12/14/11 at 3:00 PM.

Review of the medical record of Patient #2 on 12/14/11 revealed this patient was admitted to the hospital on 10/26/11. The patient's skin was assessed at admission and was found to have pressure sores on the left and right outer hips and sacrum. The physician's order was that the patient be turned every 2 hours.
Review of the nursing documentation for this patient revealed the turn schedule did not show that the patient was turned every two hours on 12/03/12/07, 12/08/11, 12/09/11, 12/10/11 and 12/11/11.
These findings were confirmed by Staff C on 12/14/11 at 3:45 PM.

Review of the medical record of Patient #3 on 12/14/11 revealed this patient was admitted to the hospital on 9/28/11. The patient's skin was assessed at admission and was found to have open areas on the right buttock and sacrum. The physician's order was that the patient be turned every 2 hours. The nursing documentation on 10/14/11 revealed the patient developed a new open area on the left lateral heel.
Review of the nursing documentation for this patient revealed the turn schedule did not show that the patient was turned every two hours on 11/28/11, 12/03/11, 12/04/11, 12/09/11, and 12/12/11.
These findings were confirmed by Staff C on 12/14/11 at 3:45 PM.

These findings were verified with Staff F and Staff A on 12/14/11 at 12:00 PM.
Staff F stated on 12/14/11 at 12:00 PM that technicians and nurses document the turning and repositioning of patients on the 24 hour Patient Record and Plan of Care.

This substantiates complaint #OH00063215