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Based on hospital policy review, medical record review, and staff interviews the hospital staff failed to notify family/caregiver of hospital acquired wounds in 1 of 5 patients. (Patient #4)

Findings included:

Review of the hospital policy titled "Patient Rights" revised 03/2020, "26. The patient has the right to participate in the development and implementation of his plan of care, including his inpatient treatment care plan..."

Review of hospital policy titled, "Interdisciplinary Care Planning and Documentation" with the last approval date of 11/28/2018, revealed "...I. POLICY Planning for care, treatment, and services is individualized to meet the patient's unique needs...III. INTERVENTION F. Patients and caregivers should be involved whenever possible and kept informed in all stages of assessment, planning, implementation and reassessment of the patient's Plan of Care. 3. Reassessment/Evaluation a. The reassessment of the patient's plan of care will be ongoing throughout hospitalization and updated when there is a change in patient's condition, diagnosis, and needs..."

1. Closed medical record review on 05/25/2021 revealed Patient #4, a 58-year-old female admitted to the hospital for acute urinary tract infection and altered mental status (general changes in brain function, such as confusion and memory loss). Review of the History and Physical for 09/29/2020 by Nurse Practitioner (NP) #1 revealed Patient #4 had a history of neuro sarcoidosis (disease of the central nervous system which affects the brain, spinal cord and optic nerve), diabetes (high blood sugar), normal pressure hydrocephalus (a brain disorder in which excess cerebrospinal fluid accumulates in the brain causing reasoning problems). Review of the Nursing Admission Assessment: Skin: for 09/30/2020 at 0232 by Registered Nurse (RN) #1 revealed a Braden Score (an assessment that predicts pressure ulcer risk, a score of 18 or less) of 18 (mild risk), and "no impairment-bedfast." Review of the Orders on 09/30/2020 at 0232 revealed that a system generated Pressure Prevention Protocol (prevention practices for at risk patients) was placed due to a Braden Score of 18 documented by RN #1. Review of the Daily Flowsheet Skin: for 10/02/2020 at 1330 by RN #2 revealed "wound right heel: blister, foam and topical agent/blister intact, raised intact-pink-exudate-none, status stable." Review of the Nursing Flowsheet Skin: for 10/07/2020 at 1927 by RN #3 revealed new wounds: right lateral ankle "blister-intact, foam, bony prominence, localized, left heel: pressure ulcer-dressing: clean dry and intact, foam dressing, unstageable-bony prominence." Review of Orders on 10/07/2020 at 1952 revealed a system generated order for a Wound Care Ostomy Nurse (WOCN) consult for documentation of an "unstageable- pressure ulcer" placed by RN #3. Review of the WOCN Consult conducted 10/08/2020 at 0725 by WOCN #4 revealed "Cavilion no sting barrier film to be applied BID (twice daily) to BIL (bilateral) heels and malleor (bony prominence on each side of the human ankle). BLE (bilateral lower extremities) to be elevated." Review of the Nursing Flowsheet, Skin: for 10/12/2020 at 1930 by RN #5 revealed a new wound "left lateral foot, blister open to air, intact." Review of the medical record for Patient #4 revealed no documentation by hospital staff of communication, education teaching, or plan of care discussions with Patient #4 nor with her family for the hospital acquired wounds.

Interview on 05/26/2021 with ICU RN #3 revealed "working nights it's not routine that I call family at that time, at night. We try to let family rest...I don't call family to report my assessment. I listen if they call me and reply appropriately." Interview revealed the doctor's round during the day, and RN #3 completed a "rounding sheet" for the day nurse to discuss during interdisciplinary rounds. Interview revealed RN #3 did not know if new wounds were discussed during the interdisciplinary rounding with family or if the family.

Interview on 05/26/2021 with Director of Intensive Care, RN #6 revealed "the expectation for wound care was to follow the hospital policies/guidelines." Interview revealed that if a patient grants permission...or did not have capability for making decisions, the family should be included and updated in skin condition changes. Interview revealed that either during or after the daily interdisciplinary rounds, the family should be communicated with either face to face or by telephone. Interview revealed the communication should be documented in the medical record. Interview revealed the hospital policy was not followed.

Interview on 05/27/2021 at 1535 with Chief Nurse Executive, RN #9 revealed "the expectation is hospital policy and guidelines for care planning and documentation should be followed." Interview revealed that family should be updated and included in the plan of care. Interview revealed that hospital policy was not followed.

Based on hospital policy review, medical record review, and staff interviews the hospital staff failed to document communication of discharge wound care instructions in 3 of 5 patients. (Patient #4, Patient #13, Patient #14) and failed to provide wound care per orders in 2 of 5 patients (Patient #13, Patient #14)

Findings included:

Review on 05/25/2021 of the hospital policy titled "Assessment of Skin Integrity" revised 05/29/2019 revealed "...D. Educate the patient and or family any interventions or preventative measures used as outlined in the (Named) Pressure Ulcer Prevention Practices and Treatment Guidelines..."

Review of the hospital policy titled "Pressure Injury Prevention" revised 02/19/2020 revealed "...Patient Teaching, Make sure that the patient, family members, and caregivers learn pressure injury prevention strategies so that they understand the importance of care, the available choices, the rationales for treatments, and their role in selecting goals and shaping the care plan..."

Review of hospital policy titled "Pressure Ulcer Prevention Practices and Treatment Guidelines, revised 10/2020 revealed "...stage I pressure ulcer: Measure area of non-blanchable erythema (Length X Width) in cm (centimeters) and document. For sacral/coccyx ...pressure ulcers, use foam seating cushion or other approved alternate cushion..."

1. Closed medical record review on 05/25/2021 revealed Patient #4, a 58-year-old female admitted to the hospital for acute urinary tract infection and altered mental status (general changes in brain function, such as confusion and memory loss). Review of the History and Physical for 09/29/2020 by Nurse Practitioner (NP) #1 revealed Patient #4 had a history of neuro sarcoidosis (disease of the central nervous system which affects the brain, spinal cord and optic nerve), diabetes (high blood sugar), normal pressure hydrocephalus (a brain disorder in which excess cerebrospinal fluid accumulates in the brain causing reasoning problems). Review of the Nursing Admission Assessment: Skin: for 09/30/2020 at 0232 by Registered Nurse (RN) #1 revealed a Braden Score (predicts pressure ulcer risk, a score of 18 or less) of 18, and "no impairment-bedfast" was documented. Review of the Orders on 09/30/2020 at 0232 revealed that a system generated Pressure Prevention Protocol was placed due to a Braden Score of 18 (low risk) documented by RN #1. Review of the Daily Flowsheet Skin: for 10/02/2020 at 1330 by RN #2 revealed "wound right heel: blister, foam and topical agent/blister intact, raised intact-pink-exudate-none, status stable." Review of the Nursing Flowsheet Skin: for 10/07/2020 at 1927 by RN #3 revealed new wounds: right lateral ankle "blister-intact, foam, bony prominence, localized, left heel: pressure ulcer-dressing: clean dry and intact, foam dressing, unstageable-bony prominence." Review of Orders on 10/07/2020 at 1952 revealed a system generated order for a Wound Care Nurse Consult (WOCN) for documentation of an "unstageable- pressure ulcer" placed by RN #3. Review of the WOCN Consult conducted 10/08/2020 at 0725 by WOCN #4 revealed "Cavilion no sting barrier film to be applied BID (twice daily) to BIL (bilateral) heels and malleor. BLE (bilateral lower extremities) to be elevated." Review of the Nursing Flowsheet, Skin: for 10/12/2020 at 1930 by RN #5 revealed a new wound "left lateral foot, blister open to air, intact." Review of the medical record for Patient #4 revealed no documentation of communication, education or teaching for hospital acquired wounds by hospital staff. Review of Patient #4's Patient Summary Discharge Instructions for 10/13/2020 at 1315 revealed there was no documented interventions, preventative measures, education or teaching for wound care. Review revealed that Patient #4 was discharged by RN #7 from intensive care unit (ICU) on 10/13/2020 at 1502 to home with home health care services.

Interview on 05/26/2021 at 1410 with ICU RN #7 revealed that she did remember Patient #4. Interview revealed RN #7 did go over wound care with patients being discharged, and sometimes gave them dressing supplies to go home if needed before home health will visit. Interview revealed discharge teaching was documented in the Education Teaching Record. Interview revealed that RN #7 did not include a narrative or instructions for wound care for Patient #4 in the Patient Discharge Summary. Interview revealed that hospital policy was not followed.

Interview on 05/26/2021 with Director of Intensive Care, RN #6 revealed "the expectation for wound care was to follow the hospital policies/guidelines." Interview revealed it was decided at the daily interdisciplinary rounds who would communicate with the family and that family would be communicated with either during rounds or after rounds by the doctor or nurse and that it should be documented in the record. Interview revealed "the nurse can type or write in a narrative into the Patient Discharge Summary if needed to ensure discharge instructions are completed." Interview revealed that "documentation of the patient leaving, if by ems (emergency services) or wheelchair, and who was present, who received the discharge instructions, and that there was understanding of the discharge instructions and would document the date and timed." Interview revealed that discharge instructions should have been included and reviewed for Patient #4 and should have been documented. Interview revealed that the hospital policy was not followed.

2. Closed medical record review on 05/27/2021 revealed Patient #13, an 84-year-old male patient admitted on 05/13/2021 at 0106 for sepsis (infection that causes injury to tissue and organs). Review of the History and Physical for 05/12/2021 at 2341 by Physician's Assistant (PA) #1 revealed Patient #13 had a history of hypertension (high blood pressure) and diabetes (high blood sugar). Review of the Nursing Skin Assessment for 05/13/2021 at 0200 by RN #10 revealed "Midline Sacrum (tail bone), abnormality type: Undiagnosed, dressing assessment clean, dry and intact, dressing activity: applied, dressing type: Foam,...pressure point: bony prominence." Review of Orders for 05/13/2021 at 0705 revealed a system generated WOCN consult for charting of "pressure ulcer." Review of the Wound Assessment Form for 05/13/2021 at 1300 by WOCN RN #4 revealed "Wound Assessment Details: System Consult: Undiagnosed P.I. (pressure injury). Stage 1 P.I. charted to sacrum with foam in place-suggest continuation of foam dressing and change two times weekly and PRN (as needed). If stool incontinence becomes an issue, may switch from foam to moisture barrier cream/paste daily and PRN with peri care. Suggest frequent T/P (turning and positioning) and offloading. Wound Care will delist (remove from the WOCN's care). Wound care to be reconsulted if site deteriorates or does not improve within 5-7 days." On 05/14/2021 at 0431 RN #1 placed a second WOCN consult "wound coccyx." Review of the WOCN/PT Wound Assessment Form for 05/14/2021at 0832 by WOCN RN #4 revealed "Wound Assessment Details: Repeat Consult: Orders in system. Orders not changed. Discussed with primary nurse this a.m. Patient skin not declining. Continue with foam dressing. May change from foam to barrier cream if stool incontinence an issue." Review of nursing skin assessments and wound care nurse consults for Patient #13 revealed no wound measurements documented. Patient #13 was discharged on 05/20/2021 at 1426 to a skilled nursing facility. Review of the record revealed no documentation that communication of the discharge wound care instructions was written, or verbally given at discharge to the SNF.


Interview on 05/26/2021 with Director of Intensive Care, RN #6 revealed "the expectation for wound care was to follow the hospital policies/guidelines." Interview revealed "the nurse can type or write in a narrative if needed in the patient discharge summary to ensure discharge instructions are completed for the patient." Interview revealed that "the nurse should document a patient leaving, if by ems (emergency services) or wheelchair, and who was present, who received the discharge instructions, and that there was understanding of the discharge instructions, and all would be dated and timed in the record" Interview revealed there was no evidence of communication of the discharge instructions for Patient #13 documented in the record. Interview revealed that the hospital policy was not followed.

Interview on 05/27/2021 at 1535 with Chief Nurse Executive, RN #9 revealed that any interventions in wound care should be documented. "the expectation is hospital policy and guidelines for wound care should be followed. We should see wound measurements in the chart. This is an opportunity. We will make sure all nursing staff have access to a measuring tape as well." Interview revealed that hospital policy for wound care was not followed.

3. Closed medical record review on 05/27/2021 revealed Patient #14, a 50-year-old male patient admitted on 05/06/2021 at 1908 for severe sepsis (infection is severe enough to affect organ function) and pyelonephritis (kidney infection). Review of the History and Physical for 05/06/2021 at 1908 by Medical Doctor (MD) #1 revealed Patient #14 had a medical history of seizure disorder, cervical-4 quadriplegic (paralyzed from the neck down) and was from a skilled nursing facility. Review of Orders for 05/07/2021 at 0718 revealed a system generated wound consult for a pressure ulcer left inner leg documented on admission. Review of the wound consult for 05/07/21 at 0810 revealed that WOCN #4 saw Patient #14 and wrote "May utilize foam dressings as wound/pressure injury treatment and ulcer prevention-change two times a week/PRN (as needed)." Review of Patient #14's record revealed no documentation of wound measurements or wound dressing changes. Review revealed that Patient #14 was discharged to a skilled nursing facility 05/12/2021 at 1143. Review of the record revealed no wound care documentation for dressing changes or documentation that communication of discharge wound care instructions was given at discharge.

Interview on 05/27/2021 at 1535 with Chief Nurse Executive, RN #9 revealed that any interventions in wound care should be documented. "the expectation is hospital policy and guidelines for wound care should be followed. We should see wound measurements in the chart. This is an opportunity. We will make sure all nursing staff have access to a measuring tape as well." Interview revealed that hospital policy for wound care was not followed.

Interview on 05/27/2021 at 1215 with MD #1 revealed "normally during examination the nurse documents about the wound and tells us during physician rounding that a patient has a wound need. We involve the WOCN for exam and pictures, we involve the surgeon if needed, or at discharge the nurse gives the discharge instructions. Physician/Nurse rounding occurs every day, during the Covid era we phoned the family daily but focused on the life-threatening. If there was a question or a need to know we would go into detail. It would be difficult to cover everything. If the family was in the room, then we could review 1. 2.. 3.. (sic) or could ask do you have questions. For wound care we expect to have instructions for dressings at discharge, we will tell family what to change and yes give education to the family." Interview revealed that physician orders to change the dressings BID for Patient #14 were not followed.

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