HospitalInspections.org

Based on interview and record review, the facility failed to implement precautions to prevent skin care breakdown for 1 (P-1) of 10 patients reviewed, resulting in the worsening of wound. Findings include:

On 8/6/24 at 1400, record review conducted in the conference room with the assistance of Staff D revealed, P-1 was a 59-year-old female who was admitted on 3/29/24 at 1143, chief complaints on presentation included leg swelling and right lower extremity pain, which required urgent cardiovascular surgery. A review of wound assessment documentation revealed:

On 3/30/24, P-1 was assessed with a stage II coccyx pressure injury by nursing staff.
On 4/2/24, at 1320 wound care RN documented coccyx area breakdown was a deep tissue injury evolving.
On 4/11/24, coccyx breakdown documented as stage 4.
On 4/11/24, wound care RN documented an unstageable, deep tissue injury on the left foot.

Review of sampled nursing flow sheets reviewed for documentation (P-1), revealed low Branden scores ranging between 11-13, documentation of turning and reposition was not found on 4/3/24 between 2300 and 0600 and on 4/6/24 between 2100 and 7 am. Staff D confirmed the turning and repositioning was not documented at time of record review.

Facility policy, 2 PC 201, titled, "Patient Assessment and Documentation", dated 2/23/22 revealed, "The RN documents admission and on-going and focused assessments ...intervention in the medical record".

Facility policy, 2 PC 5202, titled, "Pressure Injuries: Prevention and Care", dated 8/10/21 revealed: "Braden Scale score of < 18 ...indicates that the patient is at risk for pressure injury ...reposition patient to 30-degree side lying position ensuring sacrum/coccyx and heels are offloaded at least every 2 hours while in bed, unless contraindicated.

On 8/7/24 at approximately 1130 Interview with Chief Nursing Officer Staff S revealed it is her expectation that nursing staff follow the policies and procedures of the facility.