HospitalInspections.org

Based on record review and interview, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for 1 of 1 (Patient #1) patients, in that, Patient #1 did not receive accurate assessment and care for skin breakdown as required by hospital policy and procedure.

Findings were:

Review of Patient #1's medical record revealed that Patient #1 was admitted to the Geri-Psych Unit at Facility A on 1/18/2023 for Psychosis. Initial nursing assessment reflected the following, generalized weakness, gait unsteady, incontinent of urine, non-ambulatory, 2 person assist, skin condition: warm and dry, skin color: color within expectations for ethnicity, assistive devices used: wheelchair, and malnutrition risk. At admission and each day following, there was no documented sacral breakdown until 2/14/2023. There was no heel breakdown documented from admission, 1/18/2023, through day of discharge, 2/16/2023.

Nursing skin assessments for the excoriation posterior buttock bilaterally were done on 2/14/2023, 2/15/2023, and 2/16/2023 for Patient #1. The nursing skin assessments/nursing documentation during Patient #1's admission did not document any skin issues with the patient's heels.

The 2/14/2023 nursing assessment time at 4:00 AM reflected the following, " ...Skin alteration/Procedure site: Present/Exists, Skin alteration: Excoriation Posterior Buttock bilateral, Instant list status: Active, Related Clinical Factors: Incontinent bowel/bladder, Tissue type-worst: Red/moist/smooth/shallow, Wound base visible: No, Intact skin: Yes, Intact skin blanchable: Yes, Any open areas: No, Altered level/stage: Partial Thickness, Wound exudate amount/type: None, Date of last dressing change: 2/14/23, Time of last dressing change: 0400, Cleansed/applied: Perineal/skin cleanser, Dressing reinforcement type: barrier cream, Document advanced wound measurements: No, cm2 area: Cannot Calculate Area Yet, Worst tissue type score: 2, Intact value score: 0."

The 2/15/2023 nursing assessment time at 8:11 AM reflected the following, " ...Skin alteration/Procedure site: Present/Exists, Skin alteration: Excoriation Posterior Buttock bilateral, Instant list status: Active, Related Clinical Factors: Incontinent bowel/bladder, Tissue type-worst: Red/moist/smooth/shallow, Wound base visible: Yes, Intact skin: Yes, Intact skin blanchable: Yes, Any open areas: No, Altered level/stage: Partial Thickness, Date of last dressing change: 2/15/23, Time of last dressing change: 0830, Wound/skin alteration comments: Cleansed and applied barrier cream liberally. Q (every) 2 hr (hour) turns, Document advanced wound measurements: No, cm2 area: Cannot Calculate Area Yet, Worst tissue type score: 2, Intact value score: 0"

The 2/16/2023 nursing assessment time at 7:22 AM reflected the following, " ...Skin alteration/Procedure site: Present/Exists, Skin alteration: Excoriation Posterior Buttock bilateral, Instant list status: Active, Related Clinical Factors: Incontinent bowel/bladder, Tissue type-worst: Pink/red/moist/erythema/intact, Wound base visible: Yes, Intact skin: Yes, Intact skin blanchable: Yes, Any open areas: No, Altered level/stage: Superficial, Date of last dressing change: 2/16/23, Time of last dressing change: 0700, Wound/skin alteration comments: Applied barrier cream liberally. Encouraged q2h turns, redness decreased, Document advanced wound measurements: No, cm2 area: Cannot Calculate Area Yet, Worst tissue type score: 1, Intact value score: 0."

Patient #1 was discharged 2/16/2023 to a long-term care facility, Facility B, and noted by Facility B to have large wounds to her back, buttocks, and bilateral heels. On 2/17/2023, Patient #1 was transported back to the emergency room at Facility A and found by the wound care physician on 2/18/2023 to have, "1. Over the sacral area, there is a deep tissue injury measuring approximately 2 cm x 1.5 cm. There is also a small stage II right buttock decubitus ulcer measuring approximately 0.3 cm x 1 cm x 0.1 cm. There is no discharge from either wound. 2. Over the right heel, there is a deep tissue injury measuring approximately 4 cm x 4 cm. Over the left heel, there is a deep tissue injury approximately 5 cm x 5 cm. No drainage from either wound."

On 2/27/2023 at 9:30 AM Personnel #1 was interviewed and was asked to review the medical record for documentation indicating Patient #1's physician or wound care nurse had been notified prior to discharge from the Geri-Psych Unit. Personnel #1 stated that review of physician orders and nursing notes for 1/18/2023-2/16/2023 revealed there was no documentation that the physician or wound care nurse was ever notified of altered skin integrity and there were no orders written for altered skin integrity. Personnel #1 was asked to review the medical record for documentation indicating Patient #1's wound identification. Personnel #1 stated that sacral wound in nursing documentation is first documented on 2/14/2023 and no documentation of heel wounds was found.

On 2/27/2023 at 11:30 AM Personnel #2 was interviewed and was asked about medical record documentation for repositioning/turning of a patient. Personnel #2 stated that "if a patient needs to be turned every 2 hours it falls under EBCD (evidence-based clinical documentation) which means it is assumed it's already being done so there will not be any documentation in the medical record. We chart by exception."

On 2/27/2023 at 12:30 PM Personnel #4 was interviewed and acknowledged that the patient care policy, "Pressure Injury Prevention" was not followed by nursing personnel when Patient #1's skin breakdown was identified. Personnel #4 stated that if there is a wound identified the nurse should order a wound care consult to evaluate the wound and have measuring and pictures done. Personnel #4 stated a wound care consult was not entered on Patient #1 while admitted to the Geri-Psych Unit.

On 2/27/2023 at 12:30 PM Personnel #3 was interviewed and asked to review the medical record for documentation indicating Patient #1's family had been notified per hospital policy of the wound development. Personnel #3 stated there is no documentation that Patient #1's family was notified of the wound development. Personnel #3 was asked to review the medical record for documentation that Patient #1 had a nursing plan of care for impaired skin integrity. Personnel #3 stated there is no documentation that Patient #1 had a nursing plan of care for impaired skin integrity.

The facility policy on "Pressure Injury Prevention" effective date February 2022 required, "POLICY AND PROCEDURE STATEMENTS: 1. All patients will be evaluated for skin breakdown through completion of a risk assessment process. This will occur upon admission; minimum of once per shift; following a change in medical condition and/or level of care; and at discharge. 2. Based on the level of skin risk, nursing interventions will be initiated and will be captured on the patient's plan of care ...RISK ASSESSMENT: 1. Each patient with admission orders will be assessed for skin risk and the presence of any alterations in skin integrity. If a wound is identified, the following should be included in documentation: a. Wound type, b. Anatomic location of the wound; c. NE1 facilitated staging of wounds; d. Wound length and width; and e. Description of wound bed, drainage, tissue type present. 2. Reassessment of skin risk will occur, at minimum, once per shift; following a change in medical condition and/or level of care; and at discharge. STANDARD OF CARE: 1. Comprehensive skin and tissue assessments will be performed as outlined above and recorded in the electronic medical record. 2. The nurse will use visual, touch, palpation techniques to differentiate temperature and tissue differences ...3. Interventions and an individualized plan of care will be implemented and documented as appropriate. 4. The nurse should notify the provider/practitioner of any new or existing wound. 5. The nurse will consult the Skin Care Champion or Wound Care professional for all pressure injuries stage 3 and above (including Deep Tissue Injuries) ...HOSPITAL ACQUIRED PRESSURE INJURY ...3. The attending provider/physician, unit-based leader, and patient's guardian will be notified as soon as possible. a. All notifications will be documented in the EHR (electronic health record). 4. Pressure injuries acquired throughout the hospital stay should be reported via the facility-specific event reporting system."