HospitalInspections.org

Based on interviews and record review, the facility failed to implement interventions to patients with tracheostomies which potentially resulted in the development of a wound. Specifically, nursing staff failed to prevent further injury once a pressure injury was identified in one of two tracheostomy patients reviewed (Patient #2).

Findings include:

Facility policy:

The Skin Wound Ostomy and Incontinence Adult Patient Care Operational Workflow policy read, it provides direction for the care of wounds, skin, ostomy issues and for the prevention of adult patient skin/tissue breakdown. Health Care Professionals are to initiate appropriate care based on the following operational workflow. Patients that require notification and/or referral to the wound team include: patients determined to be high skin risk, based on a risk assessment and/or current breakdown, patients that have a pressure injury, patients that acquire a skin injury (major tears, abrasions, burns, etc.) while hospitalized and complex wounds as deemed by the physician or nursing assessment.

References:

According to a facility document titled Respiratory Device Assessment for Prevention of Medical Device Related Pressure Injury - Save Face Campaign: any redness or breakdown, speak with the nurse, consult wound care, and document. For tracheotomies (surgical opening created through the neck into the trachea to allow breathing) practice expectation to place dressing e.g. Allevyn Pad (adsorbent foam dressing) placed under trach flange (part of the trach that rests on the neck) to alleviate pressure and decrease moisture. Done by Respiratory Technician (RT) every shift and Registered Nurse (RN) change as needed for moisture. Apply Aquacel Ag (anti-microbial dressing) when redness, tears, or ulcer are identified. If the patient has breakdown or redness that does not resolve after four-hour, place a wound care consult.

The Lippincott Procedures (2021) "Tracheostomy patient assessment, respiratory therapy" article read, inspect the tracheostomy ties and dressing to make sure it's clean and dry. If the dressing is moist or saturated with secretions or drainage, remove the dressing, perform stoma care and apply a clean dressing to reduce the risk of skin breakdown. Inspect the tracheostomy dressing for moisture, secretions, or other drainage. Inspect the tracheostomy site and surrounding area for signs of infection, bleeding, and skin breakdown.

1. The facility failed to ensure nursing staff implemented measures and notified the physician with changes in skin condition in order to prevent skin breakdown or prevent continued injury to an existing pressure wound.

a. Patient #2's medical record was reviewed. Patient #2 was admitted on 11/6/21 with a COVID diagnosis. Subsequently, Patient #2 was intubated on 11/10/21. Due to prolonged intubation, Patient #2 had a tracheostomy tube (a tube inserted through a hole in the neck to assist with breathing) placed on 12/8/21, which was secured with four sutures to the tracheostomy flange. MD #1 placed tracheostomy care orders on 12/8/21. The orders read tracheostomy care was to be done every 12 hours which included to clean the stoma, assess skin and report skin breakdown to the MD, assess for drainage, and perform inner cannula care as needed with increased secretion.

On 12/11/21 at 8:21 p.m., four days after the tracheostomy was placed, a respiratory therapist (RT) documented redness to the peristomal (skin around the tracheostomy site) area. In addition, RT notes documented the redness to be a change in condition compared to previous documentation. There was no documentation of physician notification in regards to the change in condition or wound consultation done by the RT.

On 12/13/21 at 8:01 p.m., the night shift registered nurse (RN) documented skin breakdown/open skin under the tracheostomy. There was no documentation of physician notification in regards to the change in condition or wound consultation done by the RN.

On 12/14/21, three days after the first documentation of a change in skin condition was noted, an RN note entry at 3:06 p.m. documented a physician was notified of ulceration under the tracheostomy and a wound care consultation was placed at 11:14 a.m.

On 12/14/21 at 4:30 p.m., wound care orders entered by the wound care RN were placed which read to place Aquacel Ag (anti-microbial dressing) on the ulceration and to place an Allevyn pad (foam dressing) on top.

On 12/15/21 at 10:45 a.m., a bedside wound care evaluation was performed by the Wound Care RN. The Wound Care RN documented an ulceration under the tracheostomy that measured 1.5 cm x 2.5 cm x 1 cm. Treatment for the ulceration included wound packing (dressing applied into a deep or tunneled wound) with Aquacel Ag.

The document review was in contrast to the physician's order that read, physician must be notified of any skin breakdown.

b. On 3/30/22 at 10:02 a.m., an interview with medical doctor (MD) #1 was conducted. MD #1 stated he was an ear, nose and throat (ENT) specialist who was consulted to place a tracheostomy for Patient #2 due to prolonged intubation. He stated new tracheostomies were sutured in placed for about week to prevent dislodgement of tracheostomy tube. MD#1 stated it was difficult to put any dressing under the tracheostomy flange due to the sutures; therefore, he placed tracheostomy care orders to be done every 12 hours which included to clean the stoma, assess skin and report skin breakdown to the MD. MD #1 stated the usual treatment for wounds near a tracheostomy included: wound packing, application of an Allevyn pad for pressure relieve, and wound dressing changes.

c. On 3/30/22 at 2:02 p.m., an interview with RT #2 was conducted. RT #2 stated shift assessments were expected to be done once per shift. RT #2 explained the tracheostomy area assessment was done by the removal all barriers around the tracheostomy in order visually assess tracheostomy. RT #2 stated if there was a problem area any RT could add additional protection care like Aquacel Ag, an Allevyn pad and they could consult wound care. RT #2 stated any changes should be reported to RN and that RTs worked in conjunction with wound care orders and RNs.

d. On 3/31/22 9:45 a.m., an interview with Wound Care RN #3 was conducted. RN #3 stated for tracheostomy assessments the RN must remove any dressings, look at the edges of the tracheostomy flange (the plate of the trach that rests against the neck), assess the skin and look for redness or skin breakdown. RN #3 stated typically, skin redness was the first sign the skin was irritated and an indication of the beginning of skin breakdown. RN #3 further stated excessive moisture increased the risk for skin breakdown like the area around a tracheostomy site. RN #3 then stated wound care consultation could be done at any time and any staff member could request a wound care consultation. RN #3 stated consultations were usually seen the next day unless prioritized by physician or RN. RN #3 stated if interventions were not done in 24 hours there could be further and potential skin breakdown.

The interviews were in contrast to the facility's Respiratory Device Assessment For Prevention of Medical Device Related Pressure Injury Document that read, if there is breakdown or redness that does not resolve after four-hour place a wound care consult.