HospitalInspections.org

Based on medical record (MR) review, document review, and interview, Patient #1's MR lacked documentation that they received a nutritional supplement as ordered. This could lead to patients having adverse outcomes.

Findings include:

-- Review of Patient #1's MR revealed on 11/29/2024, a physician ordered Pro-Stat (a nutritional supplement) 30 milliliters to be administered to Patient #1 four times a day.

-- The MR lacked documentation indicating that nursing staff provided the Pro-Stat to Patient #1 as ordered.

-- Review of the facility's policies and procedures (P&P) revealed that there was no nurisng P&P for the administration of the nutritional supplement Pro-Stat.

-- Per interview of Staff A, Nurse Practioner (NP) on 3/19/2025 at 12:45 pm, there is no facility P&P on the administration of Pro-Stat.

-- Per interview of Staff B, NP on 3/20/2025 at 10:00 am, the facility does not have a P&P on the administration of Pro-Stat.

-- Per interview of Staff C, Registered Nurse (RN) on 3/19/2025 at 1:30 pm, there is no P&P on Pro-Stat, and it would be helpful for nursing to reference if there was one.

-- During interview of Staff D, Director of Nursing, on 3/19/2025 at 4:00 pm, they confirmed the above findings.

Based on medical record (MR) review, document review and interview, Patient #1 developed a pressure injury during hospitalization and the facility policy and procedure (P&P) was not followed. Specifically, a wound consult was not ordered, wound measurements were not documented and there was no provider documention of the wound. This could lead to patients having adverse outcomes.

Findings include:

-- Per review of the facility's P&P titled "Skin Assessment Pressure Ulcer Prevention and Assessment," (revised 10/2024), "every patient admitted will be assessed daily for risk of pressure ulcers, using the Braden Scale for predicting pressure ulcers. A score of 14 points or below will receive a skin care consult for potential areas of concern during any part of the patients stay. ... the provider will be notified for all pressure ulcers stage 2 through 4. ... measurements will be taken on any reddened, pink, bruised, scratches, skin tears, open sores or pressure ulcers. Length (head to toe) x width (hip to hip) x depth (tunneling/undermining)."

-- Per MR review, Patient #1 was admitted to the hospital on 11/26/2024 with the diagnosis of a left hip fracture and left shoulder fracture. The nursing admission assessment documentation noted that skin was intact with no deviations from normal. A skin risk scale noted a total Braden scale score of 14 (severe risk - less than or equal to 9, high risk - 10-12, moderate risk - 13-14, and mild risk - 15-18). Risks pertaining to Patient #1 included bedfast, confined to a bed, very limited mobility, occasionally moist skin, and potential for friction and shearing of skin.

On 11/29/2024, Patient #1 had hip surgery. Skin risk assessment remained at a total score of 14.

On 11/30/2024, nursing documentation noted a skin tear to the right buttock which is documented as appearing pink and reddened. Allevyn (highly absorbent foam dressing) was applied to the site. A skin risk assessment remained at a score of 14.

On 12/1/2024, nursing documentation noted a right buttock skin tear which appeared pink and reddened with an Allevyn dressing placed. Provider documentation noted a stage 1 skin tear to the right buttock, and an Allevyn dressing placed.

On 12/2/2024 nursing documentation noted a right buttock skin tear which appeared pink and reddened with an Allevyn dressing applied.

On 12/4/2024 nursing documentation noted a right buttock skin tear which appeared pink and reddened with an Allevyn dressing placed. New orders were placed which included application of Magic Butt Paste (protective ointment) to be applied to macerated skin areas of the skin tear on the buttocks and covering with an Allevyn dressing to be changed daily.

On 12/7/2024 nursing documentation noted a stage 2 decubitus to the coccyx, with an Allevyn dressing placed and Magic Butt Paste applied to surrounding macerated (softening and breakdown of skin due to prolonged exposure to moisture) skin. Nursing documentation also noted a lesion to the left upper back with an Allevyn dressing placed. Lastly, nursing documentation noted a right buttock skin tear which appeared pink and reddened with an Allevyn dressing placed

On 12/8/2024 - 12/10/2024 nursing documentation noted a hard and warm to the touch area to the left buttock, appearing pink with erythema (redness of skin) present. A lesion to the upper left back with an Allevyn dressing placed is documented. A stage 2 pressure ulcer to the coccyx with an Allevyn dressing and Magic Butt Paste applied. A possible right buttock boil/abscess is documented.

On 12/11/2024 the discharge summary documented "a skin tear to the left and right buttock stage 2 decubitus coccyx from a shearing injury and upper back disrupted blisters."

-- Per interview of Staff E, Registered Nurse (RN) on 3/19/2025 at 2:30 pm, if a skin tear or pressure injury were found, they would reach out to the wound care service. If the wound care service was unavailable to see the patient that day, the process is then to reach out to a general surgeon to see the patient.

-- Per interview of Staff F, RN on 3/19/2025 at 3:30 pm, they would notify the provider right away if a new skin wound were identified.

-- Per interview of Staff G, General Surgeon on 3/20/2025 at 9:45 am, they cover for the wound care service, when the wound care provider is unavailable. When a consultation is requested, they usually speak to the ordering provider to get a sense of the situation. The facility has a secure photo system through the electronic MR to view photos. Staff G indicated that they will see the patient in person if deemed necessary.

-- Per interview of Staff B, Nurse Practitioner (NP) on 3/20/2025 at 10:00 am, they will reach out to the wound care service when a skin injury is identified. Orders are obtained and sometimes an in-person consultation is performed.

-- During interview of Staff D, Director of Nursing, on 3/19/2025 at 4:00 pm, they acknowledged the above findings.