HospitalInspections.org

Based upon reviews of 2 of 10 medical records (#2, #10), policies/procedures, Incident and Accident Reports (December 2010-March 2011), and staff interviews the hospital failed to ensure all patients received and had on-going assessments by the Registered Nurse (RN) as evidenced by: 1) failure of the RN to follow policies and assess and document on each shift the patient's skin integrity which resulted in the failure to identify new skin breakdown on patient #2's buttocks; and 2) failure of the RN to assess and document on each shift the patient's skin integrity which resulted in the failure to identify a new skin breakdown on patient #10's right lateral ankle. Findings:

Review of patient #2's medical record revealed a form titled "24 Hour Care Record" which was an 8 page document on which the nurses would document, on each shift, the patients' assessments. On page 3 (of 8), the section titled "Integument" was used to record the patients' skin appearance; and the next section was titled "Wound", on which the nurse could document any wounds the patient may have had. Page 4 of 8 had a section titled "Braden Tool", that the nurses utilized to record the patients risk for developing a pressure ulcer.

On admission, 12/06/10, S18 RN documented on the Nursing Initial Assessment that patient #2's Braden Scale total score was 21 (the lower the number, the higher risk for pressure ulcer development, individuals are at risk for developing pressure ulcers if the total score is less than 17).

Review of physician orders, dated 12/06/10, revealed a telephone order by S9 physician for "18. Wound Care: eval (evaluate) and treat". Review of a form titled "Physician Progress Notes" revealed S19 Licensed Practical Nurse (LPN) Wound Care documented: "12/07/10 7:35AM Wound Care Admit Braden Score = (equals) 21, No skin breakdown observed, Will not follow". On 12/07/10 at 8:10AM, S16 RN Wound Care Director documented: "Agree c (with) above assessment".

Continued review of the nursing documentation on the 24 Hour Care Records revealed from 12/07/10 through 12/22/10, patient #2's Braden Score had been documented varying from 18, 19, 20, and 23. On 12/23/10, S20 LPN documented patient #2's Braden Score as 20; on 12/24/10 S14 documented Braden Score at 17; 12/25/10 and 12/26/10 S21 LPN documented Braden Score at 17; on 12/27/10 (patient #2 discharged at 5:00PM) S14 RN documented the Braden Score at 14. Further review of all nursing documentation revealed there failed to be documented evidence of patient #2 having any skin integrity issues even though he was chairfast (did not ambulate often) and was admitted with protein malnutrition (albumin was documented as 2.8--normal albumin 3.2-5).

Review of patient #2's medical record from Hospital B revealed he was admitted on 12/27/10 at 11:00PM. Further review revealed photographs and nursing documentation that patient #2 had a Stage II pressure ulcer on his right buttock on admission.

Review of patient #10's medical record revealed on the initial nursing assessment, dated 12/01/10 at 11:30AM, it was noted that he had Stage III sacral wound and Stage III pressure ulcer on right heel. Patient #10's initial Braden Score was documented as 15 (below 17 patient has risk of developing a pressure ulcer). Continued review revealed: "Care Plan: Alteration in Comfort; Safety R/T (related to) Weakness of BLE (bilateral lower extremities); Alteration in Skin Integrity...R/T Pressure Ulcer Sacrum...Interventions: 1) perform total skin inspection each shift and record results. Utilize pressure reduction measures: float heels off of bed, Turn and reposition Q (every) 2 hours..."

Review of patient #10's "Weekly Team Conferences" revealed updates were documented for 12/10/10; 12/22/10; 12/30/10; 01/07/11; 02/23/11 with "goals met" for the same dates.

Review of form titled "Physician Progress Notes" revealed S19 LPN Wound Care Professional documented "02/15/11 L (length) 1.8cm (centimeters) X (by) W (width) 1.8cm R (right) lateral ankle, Depth: obscured by necrosis (dead tissue) adherent soft black eschar (dead matter/tissue) 75 to 100% of wound covered."

Continued review of patient #10's medical record revealed the nurses who provided care, on each shift, failed to identify and document that patient #10 had developed new skin breakdown.

Review of an Accident/Incident Report, dated 02/15/2011, revealed S19 LPN documented: "2/15/11 10:35AM 2E Medical (2 East Medical Unit) Unstageable pressure ulcer observed on the R (right) lateral ankle. This has not been visualized before, this wound was not present on initial wound care assessment."

Review of hospital policy #PC. 4.1, 5.1, 5.5, 5.6, 6.3 titled "Wound/Skin Care, Prevention of Breakdown" revealed: "Procedure: A. Assessment 1. Assessment of skin integrity risk is performed as follows using the Braden Scale For Predicting Pressure Sore Risk: a. By the admitting nurse within 4 hours of admission to the facility b. Verified by the Wound Care Professional within 24 hours of receiving Wound Care Program order for consult...2. If Braden Score is determined to be 18 or less, if there is presence of compromised skin integrity, and/or if skin integrity becomes disrupted an any time during the patient's hospitalization, prevention measures as per Braden Risk Prevention Protocol are initiated in the following manner:...5. Manage Friction and Shear a. INSPECT SKIN DAILY especially bony prominences...6. Use support Surface (pressure-relieving surface) a. Support surfaces may include surfaces on bed, wheelchair, or chair and include a wide variety of equipment...C. Planning 1. Floor staff to report significant changes in the patient's condition affecting the risk for pressure ulceration to the Wound Care Professional...D. Monitoring and Evaluation 1. Floor staff to monitor and record skin condition on a daily basis...6. Any significant change in patient's condition related to skin care management gives rise for reassessment..."

Review of hospital policy #PC. 2.1, 2.2, 5.5 titled "Assessment, Wound/Skin/Risk" revealed: "Policy: Skin integrity, risk, and wound assessment will be performed upon patient admission to the facility and routinely thereafter. Procedure: A. ...2. Skin assessment includes: a. Viewing/inspecting bare skin...patient must be undressed and in bed b. Inspection is from head to toes, viewing entire posterior of body initially and continues with anterior head to toes inspection...c. Documentation of skin disruption is recorded on the...assessment...4. Reassessment a. Floor staff to monitor and record skin condition on a daily basis...B. Risk Assessment 1. A risk assessment is performed as follows using the Braden Scale For Predicting Pressure Sore Risk...4. Reassessment ...c. Change in Braden Score necessitates re-evaluation of prevention measures..."

Interview, 04/06/11 at 10:00AM, with S15 CNA (certified nursing assistant) revealed when questioned regarding patient #2's skin and if S15 had noticed any skin breakdown, S15 replied, "not at first, when he (patient #2) first was admitted he did not have any skin breakdown." S15 was questioned how he knew this, and he replied, "I assisted him with his bath and that was part of my job to look at the skin and make sure there were no new areas of skin breakdown." S15 was asked what he would do if he noticed a patient with skin breakdown, he replied, "I tell the nurse." S15 CNA stated patient #2 refused to get in his bed and preferred to sit and sleep in the reclining chair in his room. S15 stated may be a week before patient #2 was discharged he had noticed that his buttocks had early skin breakdown and he reported this to the nurse, unfortunately he could not recall which nurse or what date he made the report.

Interview, on 04/06/11 at 10:30AM, with S3 RN Quality Assurance revealed patient #10's pressure ulcer had been reported and reviewed through the hospital's Quality Assurance committee and was documented as a hospital acquired pressure ulcer. S3 agreed the nurses who were responsible for performing shift by shift assessments of patients' skin integrity failed to assess patient #10 as having a new pressure ulcer and it was not discovered until the re-assessment and documentation made by Wound Care on 02/15/11.

Interview, 04/06/11 at 4:10PM, with S2 DON (Director of Nursing) revealed when questioned in regard to nurses' performance of skin assessments she indicated the nurses performed patient assessments on each of the 2 shifts (7a-7p and 7p-7a). S2 DON was further questioned in regard to patient #2 and the information obtained from an interview with S15 CNA relative to his report to a nurse that patient #2 did have skin breakdown on his buttocks. S2 replied, the nurse should have inspected the patient's skin and documented the assessment. When S2 DON reviewed patient #2's medical record she agreed there lacked documented evidence the nurse had identified patient #2 had skin breakdown on his buttocks. S2 DON confirmed the nurses did not follow the hospital's policies (see above policies) and report a change in patient #2's Braden Score when it was documented as 20 on 12/23/10 and then 17 on 12/24/10. According to the hospital policy (#PC. 4.1, 5.1, 5.5, 5.6, 6.3) the nurse should have notified the Wound Care Professional when patient #2's Braden Score was below 18. S2 DON confirmed there lacked a re-assessment of patient #2's skin integrity.

S2 DON confirmed nurses had not followed hospital policies and procedures and performed on-going assessments on patients to ensure new skin integrity issues were discovered as soon as possible to ensure that the patient/s could have received care for the skin integrity issue/s.