HospitalInspections.org

Based on review of hospital policy and procedure, medical records, staff and physician interviews, the hospital's nursing staff failed to supervise and evaluate patient care by failing to implement skin breakdown prevention measures for of 6 of 10 sampled patients (Patients #9, #10, #7, #3, #6 and #2).

The findings include:

Review of the hospital policy, "Prevention of Skin Breakdown", revised 11/2209, revealed, "POLICY: All patients will be assessed for skin breakdown by nursing staff, at time of admission and routinely thereafter. Appropriate preventive interventions will be implemented. RATIONALE: Patients with impaired ability to reposition and/or multiple co-morbidities are at increased risk for skin breakdown. Early identification of patients at risk, and implementation of preventive interventions can decrease these patients' morbidity and mortality and increase comfort and general quality of life. PROCEDURE:.. 2. Preventive interventions: WC (Wound Care) Team to be notified of all patients admitted with a Braden Score of less than 12, Braden Score Policy WC-101. ...A. Mechanical Load/Support Surface/Pressure Relieving Devices. i. Turn, when patient is unable to turn self, every two hours according to facility routine and regardless of type surface or bed. ...Guideline for Prevention and Management of Pressure Ulcers...1. Assess individual risk for developing pressure ulcers. A. Risk assessment is more than determining an individual's numerical score. It involves identifying the risk factors that contributed to the score and minimizing those specific deficits. ...C. ...The Braden Scale has six subscales: physical condition, mental state, activity, mobility, and incontinence. ...Braden scores: The Braden Scale consists of six parameters with potential scores from 6 to 23. ... Mild Risk=15-18, Moderate Risk=13-14, High Risk=10-12, Very high risk=9 or below...".

1. Open record review of Patient #9 revealed a 62 year old admitted 05/20/2011 with acute respiratory failure and advanced Amyotrophic Lateral Sclerosis on a ventilator with a tracheostomy. Record review revealed an initial nursing assessment dated 05/20/2011 at 2146. Review of the initial nursing assessment revealed a Braden Score of 10 (high risk for skin breakdown). Record review revealed Patient #9 was turned/repositioned on 05/21/2011 at 0800, 1032 (32 minutes past 2 hour turning schedule); 1600, 1856 (56 minutes past 2 hour turning schedule); 05/22/2011 at 0800, 1119 (79 minutes past 2 hour turning schedule), 1400, 1659 (59 minutes past 2 hour turning schedule); 05/23/2011 at 0800, 1025 (25 minutes past 2 hour turning schedule); 05/24/2011 at 0621, 0856 (34 minutes past 2 hour turning schedule).

Interview on 05/25/2011 at 0900 with Physician #1 revealed, "It is essential for nurses to turn patients every two hours to decrease pressure which causes cellular breakdown and to increase circulation."

Interview on 05/25/2011 at 1400 with the Wound Care Nurse #1 revealed, "If patients are at high risk for skin breakdown, it's pretty important for nurses to turn them every two hours."

Interview on 05/25/2011 at 1440 with Wound Care Nurse #2 revealed, it is "very important" to turn patients at risk for skin breakdown every two hours. Further interview revealed "You should not go over two hours, the longer the patient stays on one side the increase in pressure. Pressure overtime causes skin breakdown especially over bony prominences." Interview revealed not turning a patient every two hours increases the risk of developing skin breakdown. Interview revealed one of the most important things done by the nursing staff to prevent skin breakdown is proper positioning and adhering to the turning schedule. Interview revealed "Because we have so many patients, that staff can not turn them all at the same time" the staff are allowed to turn the patients 30 minutes before and up to 30 minutes after the scheduled 2 hour time frame. Interview revealed the current hospital policy for prevention of skin breakdown does not indicate a 30 minutes before or 30 minutes after time frame. Interview confirmed the hospital policy requires every 2 hour turning/repositioning.

Interview on 05/25/2011 at 1300 with administrative nursing staff revealed, "We try to turn patients every two hours. We do allow 30 minutes before and after the two hours because of the time it takes to round on all the patients." Interview revealed, "it is standard nursing practice to turn at risk patients every two hours. Our policy does not say we have 30 minutes before or after the 2 hour mark." Interview confirmed Patient #9 was at high risk for skin breakdown and was not turned every two hours on 05/21/2011, 05/22/2011, 05/23/2011 and 05/24/2011. Interview confirmed the nurses did not follow the hospital's policy for prevention of skin breakdown.

2. Open record review of Patient #10 revealed a 63 year old admitted 04/26/2011 with acute respiratory failure, ventilator dependent with a tracheostomy performed on 04/28/2011. Record review revealed an initial nursing assessment dated 04/26/2011 at 2141. Review of the initial nursing assessment revealed a Braden Score of 7 (very high risk for skin breakdown). Further review of the initial nursing assessment revealed documentation of a pressure ulcer on the right buttock. Record review of sampled days of turning/reposition of Patient #10 revealed Patient #10 was turned on 04/28/2011 at 0340, 0617 (37 minutes past 2 hour turning schedule), at 1342, 1615 (33 minutes past 2 hour turning schedule); 04/29/2011 at 0337, 0608 (31 minutes past 2 hour turning schedule), 04/29/2011 at 0947, 1236 (49 minutes past 2 hour turning schedule), at 1751, 2027 (36 minutes past 2 hour turning schedule); 04/30/2011 at 1734, 2021 (47 minutes past 2 hour turning schedule); 05/01/2011 at 0817, 1100 (43 minutes past 2 hour turning schedule); 05/02/2011 at 2348, 05/03/2011 at 0219 (31 minutes past 2 hour turning schedule); 05/05/2011 at 1134, 1414 (40 minutes past 2 hour turning schedule); 05/07/2011 at 1111, 1448 (97 minutes past 2 hour turning schedule).

Interview on 05/25/2011 at 0900 with Physician #1 revealed, "It is essential for nurses to turn patients every two hours to decrease pressure which causes cellular breakdown and to increase circulation."

Interview on 05/25/2011 at 1400 with Wound Care Nurse #1 revealed, "If patients are at high risk for skin breakdown, it's pretty important for nurses to turn them every two hours."

Interview on 05/25/2011 at 1440 with Wound Care Nurse #2 revealed, it is "very important" to turn patients at risk for skin breakdown every two hours. Further interview revealed "You should not go over two hours, the longer the patient stays on one side the increase in pressure. Pressure overtime causes skin breakdown especially over bony prominences." Interview revealed not turning a patient every two hours increases the risk of developing skin breakdown. Interview revealed one of the most important things done by the nursing staff to prevent skin breakdown is proper positioning and adhering to the turning schedule. Interview revealed "Because we have so many patients, that staff can not turn them all at the same time" the staff are allowed to turn the patients 30 minutes before and up to 30 minutes after the scheduled 2 hour time frame. Interview revealed the current hospital policy for prevention of skin breakdown does not indicate a 30 minutes before or 30 minutes after time frame. Interview confirmed the hospital policy requires every 2 hour turning/repositioning.

Interview on 05/25/2011 at 1300 with administrative nursing staff revealed, "We try to turn patients every two hours. We do allow 30 minutes before and after the two hours because of the time it takes to round on all the patients." Interview revealed, "it is standard nursing practice to turn at risk patients every two hours Our policy does not say we have 30 minutes before or after the 2 hour mark." Interview confirmed Patient #10 was at high risk for skin breakdown and was not turned every two hours on 04/28/2011, 04/29/2011, 04/30/2011, 05/01/2011, 05/03/2011, 05/05/2011 and 05/07/2011. Interview confirmed the nurses did not follow the hospital's policy for prevention of skin breakdown.

3. Closed medical record review of Patient #7 revealed a 66 year old admitted on 02/09/2011 with a tracheostomy tube and a diagnosis of respiratory failure. Medical record review revealed the patient had a history of "multiple medical illnesses" including peripheral vascular disease, anemia, and renal insufficiency. Medical record review revealed the patient's Braden scores was "11" on 02/09/2011 (high risk for skin breakdown). Medical record review revealed "Patient care plan Pt (patient) care Dx (Diagnosis) Actual impaired skin integrity metabolic and endocrine alteration," dated 02/10/2011 at 0046. Medical record review revealed no documentation the patient was turned/repositioned every 2 hours after admission on 02/09/2011. Medical record review revealed the patient's Braden score was "14" (moderate risk for skin breakdown) on 02/10/2011 and the patient was turned at 0821, 1051, and 2245 on 02/10/2011 (not every 2 hours). Medical record review revealed the patient's Braden score on 02/11/2011 was "15" (mild risk for skin breakdown). Further review revealed no documentation the patient was turned every 2 hours on 02/11/2011. Medical record review revealed the patient was discharged to another facility on 02/12/2011 at 1400.

Interview with administrative nursing staff confirmed there was no available documentation the patient was turned every two hours after admission on 02/09/2011 through 0000 on 02/12/2011. Interview confirmed the patient was at risk for skin breakdown and should have been turned every two hours. Interview revealed nursing did not enter a nursing order for the patient to be turned every 2 hours until 02/11/2011 at 2304. Interview revealed this was a nurse's oversight and the responsible nurse was no longer employed at the facility.

Interview on 05/25/2011 at 0900 with Physician #1 revealed, "It is essential for nurses to turn patients every two hours to decrease pressure which causes cellular breakdown and to increase circulation."

Interview on 05/25/2011 at 1440 with Wound Care Nurse #2 revealed, it is "very important" to turn patients at risk for skin breakdown every two hours. Further interview revealed "You should not go over two hours, the longer the patient stays on one side the increase in pressure. Pressure overtime causes skin breakdown especially over bony prominences." Interview revealed not turning a patient every two hours increases the risk of developing skin breakdown. Interview revealed one of the most important things done by the nursing staff to prevent skin breakdown is proper positioning and adhering to the turning schedule. Interview revealed "Because we have so many patients, that staff can not turn them all at the same time" the staff are allowed to turn the patients 30 minutes before and up to 30 minutes after the scheduled 2 hour time frame. Interview revealed the current hospital policy for prevention of skin breakdown does not indicate a 30 minutes before or 30 minutes after time frame. Interview confirmed the hospital policy requires every 2 hour turning/repositioning.

Interview on 05/25/2011 at 1300 with administrative nursing staff revealed, "We try to turn patients every two hours. We do allow 30 minutes before and after the two hours because of the time it takes to round on all the patients." Interview revealed, "it is standard nursing practice to turn at risk patients every two hours. Our policy does not say we have 30 minutes before or after the 2 hour mark." Interview confirmed Patient #7 was at high risk for skin breakdown and was not turned every two hours on 02/09/2011 thru 02/12/2011. Interview confirmed the nurses did not follow the hospital's policy for prevention of skin breakdown.


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4. Closed record review of Patient #3 revealed a 45 year old male admitted 11/08/2010 Guillain-Barre Syndrome, severe axonal form with ventilator dependent respiratory failure, with a tracheostomy, pneumonia, and Protein-calorie malnutrition and was discharged to a skilled nursing facility on 03/09/2011 (122 days later). Record review revealed an initial nursing admission assessment dated 11/08/2010 at 1633. Review of the initial nursing admission assessment revealed a Braden Score of 11 (high risk for skin breakdown). Review of new admission assessment documentation performed by the wound care team on 11/09/2011 at 1423 revealed the patient was noted to have a stage I pressure ulcer to the left ischial tuberosity, the left buttock, and the right posterior upper heel upon admission (community acquired). Further review revealed the patient was "placed on a typical repositioning schedule (turn every two hours)." Record review of the following sampled days of turning/repositioning documentation of Patient #3 revealed the patient was turned/repositioned: on 11/09/2010 at 0349 and 0626 (37 minutes past 2 hour turning schedule); 11/09/2010 at 2131 and 0024 on 11/10/2010 (53 minutes past 2 hour turning schedule); 11/12/2010 at 1800 and 2050 (50 minutes past 2 hour turning schedule); 11/14/2010 at 0349 and 0637 (48 minutes past 2 hour turning schedule); 11/23/2010 at 0400 and 0647 (47 minutes past 2 hour turning schedule); 11/29/2010 at 1400 and 1704 (64 minutes past 2 hour turning schedule); 12/28/2010 at 0600 and 0848 (48 minutes past 2 hour turning schedule); 01/27/2011 at 0400 and 0630 (30 minutes past 2 hour turning schedule); 02/05/2011 at 2000 and 2240 (40 minutes past 2 hour turning schedule); and on 03/08/2011 at 2200 and 0039 on 03/09/2011 (39 minutes past 2 hour turning schedule). Record review of weekly wound assessment documentation by a wound care nurse on 11/23/2010 at 1018 revealed an abrasion left buttocks "hospital acquired" further review revealed pressure ulcer right ischial tuberosity "hospital acquired." Review of weekly wound assessment documentation by a wound care nurse on 11/29/2011 at 1410 revealed abrasion sacrum "hospital acquired." Review of weekly wound assessment documentation by a wound care nurse on 11/30/2010 at 0846 revealed pressure ulcer right ear "hospital acquired." Review of weekly wound assessment documentation by a wound care nurse on 12/10/2010 at 0716 revealed pressure ulcer sacrum, Stage II, "hospital acquired." Review of weekly wound assessment documentation by a wound care nurse on 12/13/2010 at 0835 revealed pressure ulcer Left ischial tuberosity "hospital acquired." Review of weekly wound assessment documentation by a wound care nurse on 12/20/2010 at 0950 pressure ulcer sacrum, Stage III (increasingly worse) "hospital acquired." Consequently, record review revealed the patient was admitted to the hospital with three pre-existing community acquired pressure ulcers and during his hospitalization developed multiple hospital acquired pressure ulcers to include a Stage III pressure ulcer to the sacrum.

Interview on 05/25/2011 at 0900 with Physician #1 revealed, "It is essential for nurses to turn patients every two hours to decrease pressure which causes cellular breakdown and to increase circulation."

Interview on 05/25/2011 at 1400 with Wound Care Nurse #1 revealed, "If patients are at high risk for skin breakdown, it's pretty important for nurses to turn them every two hours."

Interview on 05/25/2011 at 1440 with Wound Care Nurse #2 revealed, it is "very important" to turn patients at risk for skin breakdown every two hours. Further interview revealed "You should not go over two hours, the longer the patient stays on one side the increase in pressure. Pressure overtime causes skin breakdown especially over bony prominences." Interview revealed not turning a patient every two hours increases the risk of developing skin breakdown. Interview revealed one of the most important things done by the nursing staff to prevent skin breakdown is proper positioning and adhering to the turning schedule. Interview revealed "Because we have so many patients, that staff can not turn them all at the same time" the staff are allowed to turn the patients 30 minutes before and up to 30 minutes after the scheduled 2 hour time frame. Interview revealed the current hospital policy for prevention of skin breakdown does not indicate a 30 minutes before or 30 minutes after time frame. Interview confirmed the hospital policy requires every 2 hour turning/repositioning.

Interview on 05/25/2011 at 1300 with administrative nursing staff revealed, "We try to turn patients every two hours. We do allow 30 minutes before and after the two hours because of the time it takes to round on all the patients. Our policy does not say we have 30 minutes before or after the 2 hour mark." Interview revealed, "It is standard nursing practice to turn at risk patients every two hours." Interview confirmed Patient #3 was at high risk for skin breakdown and was not turned every two hours on 11/09/2010; 11/10/2010; 11/12/2010; 11/14/2010; 11/23/2010; 11/29/2010; 12/28/2010; 01/27/2011; 02/05/2011;03/08/2011; and 03/09/2011. Interview confirmed the nurses did not follow the hospital's policy for prevention of skin breakdown.


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5. Closed medical record review of Patient #6 revealed an 83 year old admitted on 10/07/2010 with a diagnosis of "ventilator (breathing machine) dependent respiratory failure." Medical record review revealed the patient had a history of peripheral vascular disease and anemia. Medical record review revealed "Potential impaired skin integrity related to Braden scale prevention: mobility, Braden scale prevention: friction/shear. Patient care plan...Intervention Reposition, Start 10/16/10 16:00, q2h (every 2 hours)..." dated 10/16/2011 at 1515. Record review revealed Patient #6 was turned/repositioned on 10/25/2011 at 0335, 0611 (36 minutes past 2 hour turning schedule); at 1006, 1238 (32 minutes past 2 hour turning schedule); at 1603, 1836 (33 minutes past 2 hour turning schedule); at 1921, 2232 (71 minutes past 2 hour turning schedule). Record review revealed Patient #6 was turned/repositioned on 11/13/2010 at 2137 and 11/14/2010 at 0233 (33 minutes past 2 hour turning schedule); at 0358, 0623 (25 minutes past 2 hour turning schedule); at 0959, 1230 (32 minutes past 2 hour turning schedule); at 2002, 2235 (33 minutes past 2 hour turning schedule).

Interview on 05/25/2011 at 0900 with Physician #1 revealed, "It is essential for nurses to turn patients every two hours to decrease pressure which causes cellular breakdown and to increase circulation."

Interview on 05/25/2011 at 1400 with Wound Care Nurse #1 revealed, "If patients are at high risk for skin breakdown, it's pretty important for nurses to turn them every two hours."

Interview on 05/25/2011 at 1440 with Wound Care Nurse #2 revealed, it is "very important" to turn patients at risk for skin breakdown every two hours. Further interview revealed "You should not go over two hours, the longer the patient stays on one side the increase in pressure. Pressure overtime causes skin breakdown especially over bony prominences." Interview revealed not turning a patient every two hours increases the risk of developing skin breakdown. Interview revealed one of the most important things done by the nursing staff to prevent skin breakdown is proper positioning and adhering to the turning schedule. Interview revealed "Because we have so many patients, that staff can not turn them all at the same time" the staff are allowed to turn the patients 30 minutes before and up to 30 minutes after the scheduled 2 hour time frame. Interview revealed the current hospital policy for prevention of skin breakdown does not indicate a 30 minutes before or 30 minutes after time frame. Interview confirmed the hospital policy requires every 2 hour turning/repositioning.

Interview on 05/25/2011 at 1300 with administrative nursing staff revealed, "We try to turn patients every two hours. We do allow 30 minutes before and after the two hours because of the time it takes to round on all the patients. Our policy does not say we have 30 minutes before or after the 2 hour mark." Interview revealed, "It is standard nursing practice to turn at risk patients every two hours." Interview confirmed Patient #6 was at high risk for skin breakdown and was not turned every two hours on 10/25/2011; 11/13/2010; and 11/14/2010. Interview confirmed the nurses did not follow the hospital's policy for prevention of skin breakdown.

6. Closed record review of Patient #2 revealed a 69 year old male admitted 03/29/2010 with respiratory failure, ventilator dependent with a tracheostomy, encephalopathy and debility and was discharged to a skilled nursing facility on 06/21/2010. Record review revealed an initial nursing assessment dated 03/29/2010 at 1750. Review of the initial nursing assessment revealed a Braden Score of 11 (high risk for skin breakdown). Further review of the initial nursing assessment revealed documentation of a right lateral hand wound from a burn prior to admission. Further review of the initial nursing assessment revealed a pressure ulcer on the left buttock and a surgical incision on the right side of the head. Record review of sampled days of turning/reposition of Patient #2 revealed Patient #2 was turned on 03/30/2010 at 0400, 0643 (43 minutes past 2 hour turning schedule), at 1200, 1419 (19 minutes past 2 hour turning schedule), 1651 (32 minutes past 2 hour turning schedule); 03/31/2010 at 1200, 1439 (39 minutes past 2 hour turning schedule), 1702 (23 minutes past 2 hour turning schedule); 04/01/2010 at 0421, 0652 (31 minutes past 2 hour turning schedule), 1130, 1436 (66 minutes past 2 hour turning schedule), 1600, 1850 (50 minutes past 2 hour turning schedule) ; 04/02/2010 at 1627, 1850 (23 minutes past 2 hour turning schedule); 04/03/2010 at 0400, 0657 (57 minutes past 2 hour turning schedule), 1539, 1816 (37 minutes past 2 hour turning schedule); 04/05/2010 at 0734 and 1016 (42 minutes past 2 hour turning schedule). Further record review revealed documentation dated 04/05/2010 at 0955 by the wound care nurse, "Wound care, coccyx extends to bilateral buttocks..."

Further record review revealed Patient #2 had debridement of the sacral wound on 05/04/2010. Interview on 05/25/2011 at 0900 with Physician #1 revealed, "It is essential for nurses to turn patients every two hours to decrease pressure which causes cellular breakdown and to increase circulation."

Interview on 05/25/2011 at 1400 with the Wound Care Nurse #1 revealed, "If patients are at high risk for skin breakdown, it's pretty important for nurses to turn them every two hours."

Interview on 05/25/2011 at 1440 with Wound Care Nurse #2 revealed, it is "very important" to turn patients at risk for skin breakdown every two hours. Further interview revealed "You should not go over two hours, the longer the patient stays on one side the increase in pressure. Pressure overtime causes skin breakdown especially over bony prominences." Interview revealed not turning a patient every two hours increases the risk of developing skin breakdown. Interview revealed one of the most important things done by the nursing staff to prevent skin breakdown is proper positioning and adhering to the turning schedule. Interview revealed "Because we have so many patients, that staff can not turn them all at the same time" the staff are allowed to turn the patients 30 minutes before and up to 30 minutes after the scheduled 2 hour time frame. Interview revealed the current hospital policy for prevention of skin breakdown does not indicate a 30 minutes before or 30 minutes after time frame. Interview confirmed the hospital policy requires every 2 hour turning/repositioning.

Interview on 05/25/2011 at 1300 with administrative nursing staff revealed, "We try to turn patients every two hours. We do allow 30 minutes before and after the two hours because of the time it takes to round on all the patients. Our policy does not say we have 30 minutes before or after the 2 hour mark." Interview revealed, "It is standard nursing practice to turn at risk patients every two hours." Interview confirmed Patient #2 was at high risk for skin breakdown and was not turned every two hours on 03/30/2010, 03/31/2010, 04/01/2010, 04/02/2010, 04/03/2010 and 04/05/2010. Interview confirmed the nurses did not follow the hospital's policy for prevention of skin breakdown.

NC00072394, NC00071013, NC00071097