Case Study – Unstageable Pressure Ulcer Previous medical history Coronary artery disease, atrial fibrillation, and a pre

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Case Study – Unstageable Pressure Ulcer
Previous medical history
Coronary artery disease, atrial fibrillation, and aprevious hip replacement surgery one year ago.
Event description
83 year old female was admitted on 10/1/2008 from anursing home to the Surgery Admission Unit (SAU) for a two vesselCAB. The surgery was successful with no complications. Postsurgery, the patient was admitted to the ICU. For the next severaldays she was hypotensive, which worsened when she was repositioned.On10/7/2008, she was transferred to the Telemetry Unit. On10/8/2008, the nurse caring for the patient noted an open wound onthe patient’s sacrum. The wound was the size of an eraser withpurple coloring around it. The WOC nurse was consulted anddescribed it as an unstageable pressure ulcer RCAdiscussion
The SAU is responsible for completing a full assessmenton admission, and the ICU process is not to repeat that assessment.The SAU did not communicate any issues related to skin integritywhen the patient was transferred to ICU.
When the patient was transferred from the ICU to theTelemetry Unit, the usual report was documented, which included thepatient’s latest vitals, medications, any order changes, andcurrent activity status. Similar information was exchanged atshift-to-shift report. Nurses indicated that in general, skin isnot a consistent focus area in hand-off communication at shiftchange or report. The hand off communication focuses on the issuesthat occurred during their shift rather than providing acomprehensive overview. There is no standardizedhand-off
communication process that prompts staff for all the keypatient elements of care such as skin, fall risk, etc.
The staff is qualified to care for the patient. Regular,yearly education on skin assessment and inspection is provided forthe staff. The unit was very busy, but staffing was believed to beadequate.
The ICU has a rotation bed to assist with turning apatient; however another patient was in that bed. Although thepatient in the rotation bed did not need it for rotation, the unitwas full and they couldn’t switch beds.
ICU nurses stated the patient’s unstable condition madeit difficult to regularly turn the patient as the blood pressurewould drop significantly. As a result, skin assessments weredocumented inconsistently. Staff knew the policy related toassessments, stating that the policy indicated “document skininspection every shift.” However, when asked what documentation wasrequired for situations where the patient could not be turned to doskin assessments, staff were unsure. It was unclear exactly whenthe skin began to break down. At one entry, a nurse noteda
reddened area on the sacrum, but for several shiftsafter that the nurses noted no skin problems.
2. The electronic health record has screens fordocumenting skin assessment and inspection, and there is thecapability to type in comments in that section. Nurses report it isdifficult to see what was previously documented. One must gothrough several steps in order to view what was previouslydocumented, and the system does not provide prompts to assist staffin finding the necessary screens. Electronic documentation is newin the ICU in the past two months and staff is still becomingaccustomed to documenting and reviewing data electronically. Thedietician was called in to assess the patient while in the ICU. Shemade several recommendations, which were carried out as thepatient’s nutritional status was low. The patient’s daughter is anICU nurse at another local hospital and visited the patient daily.She
assisted with caring for the patient and never mentioneda wound developing. She was very concerned about the patient’s painstatus and would stop staff from moving her if the patient moanedor cried out in pain.
1. Review the case study information
Using the information provided, identify root causestatements for this event. For any human factors or deviation fromexpected process, provide the preceding cause(s) as part ofthe root cause finding
2. Review root cause findings
Develop corrective actions and measurementstrategy
3. Do an ADPIE to help with nursing actions for thisproblem.