HospitalInspections.org

Based on document review and interview, the facility failed to ensure that all medical records are documented accurately; for skin-wound entries; for 1 of 5 closed medical records reviewed. (Patient # 8).

Findings:

1. Review of established hospital policy titled: "Documentation Guidelines - Content of the Legal Medical Record", indicated on page 1, under I. POLICY, "will contain sufficient information unique to the patient ... and to enable another clinician to assume and enable the care of the patient and ensure continuity of care among providers", and under The following rules apply, B., "Each patient record will contain all information required to provide patient care, treatment, and services ... nurses notes"; continued on page 2, "treatments and any other information necessary to monitor the patient's condition". Last reviewed 1/2021.

2. Review of established hospital policy titled: "Medical Record Completion Requirements", indicated on page 1, under I. POLICY, "to assure that the patient records have a ..., meaningful, ... description of the clinical condition and hospital course". Last reviewed 1/2021.

3. Review of closed medical record (MR) for patient # 8, indicated the following:
A. Patient admitted to AH # 40 (Acute Care Hospital) on 6/29/2021, from SNF (Skilled Nursing Facility) # 70.
B. Patient's admission skin assessment reflected no skin issues; skin intact; with a Braden score = 13.
C. Nurse note and/or flowsheet documentation; reflected, for skin and/or Braden scores as follows:
1. On 7/11/2021, skin tear to gluteal fold; Braden score = 10. On 7/12/2021, abrasion/tear to sacrum; Braden score = 11. On 7/13/2021, tear & excoriation to sacrum; Braden score = 13. On 7/14/2021, skin tear to sacrum; Braden = 13. On 7/15/2021 am, skin tears to sacrum "(Stage 2 pressure ulcer)"; Braden = 11; 7/15/2021 pm, tear/fragile to sacrum; Braden = 11. On 7/20/2021, Braden = 12. On 8/6/2021, Braden = 10. On 8/10/2021, Braden = 9.
D. A # 4 (Registered Nurse - Certified Wound Care Nurse) note on 7/1/2021, reflected "per RN" (Registered Nurse) "assessment -Skin intact no wounds reported as present". Prevention measures noted and pressure relief measures per protocol. "No acute care" wound care "needs at this time". "Re-consult if needs arise".
Note on 8/10/2021, by N # 10 (RN - Wound Care Nurse), saw patient for follow up; reflected a Stage III - full thickness tissue loss. Wound length = 7 cm (centimeter), width = 9 cm, depth = 0.2 cm. Dressing = Foam ("idoflex"), dressing changed; wound cleansing = Normal saline; Braden = 13.

4. Review of event/occurrence report, dated 8/10/2021, indicated the following:
A. Skin integrity - Pressure injury. Open case status.
B. Patient # 8 seen for follow up. Patient found to have Stage III pressure ulcer to sacrum. A HAPU (Hospital acquired pressure ulcer) to Sacrum.
C. "Unclear charting back-forth between" within defined limits and sacral tear, excoriation, or wound.

5. In interview with A # 4 (Registered Nurse - Certified Wound Care), on 9/9/2021, at approximately 9:30 am, confirmed the following:
A. Saw patient # 8, on 7/1/2021; order for consult to evaluate and treat; due to Braden score < 18. Patient did not require follow ups; no wounds on admission.
B. Noticed patient still in hospital on 8/10/2021; follow up on own; found charting from nursing that area developed on patient's sacrum. N # 10 completed the follow up on the patient, saw the patient on 8/10/2021.
C. Patients with Braden score of 18 or less, are seen for consult, or if patient admitted with existing wound. Follow ups are based on needs. If changes in wound - odor/size; then can reconsult.
D. There is a order set for skin; use of barriers, mattress, activity, turning and repositioning; prevention.
E. Nurses responsible for weekly documentation on wounds. When patient's skin started to breakdown, any area, should have been reconsulted.

6. In interview with A # 2 (Director Critical Care), on 9/9/2021, at approximately 9:50 am, and at approximately 3:00 pm, confirmed the following:
A. That the patient did develop a Stage III pressure ulcer during his/her hospital stay.
B. Charting in patient # 8's MR, not matching, not accurate; for wound that developed.

7. In interview with A # 1 (Assistant Vice President - Nursing), on 9/9/2021, at approximately 10:00 am, confirmed that patient risks not recognized soon enough.