HospitalInspections.org

Based on review of medical records, tour of 3rd floor Medical Surgical Unit, staff and family interviews, facility policies and procedures, it was determined that nursing staff failed to appropriately document the repositioning status of patients who are unable to reposition themselves in a hospital bed when two (P#1 and P#5) of five (P#1, P#2, P#2, P#4, P#5) sampled patients were missing reposition charting for every two hours throughout hospitalization.
Additionally, the nursing staff at the facility failed to appropriately document wound care dressing changes per the provider's order when one (P#1) out of five (P#1, P#2, P#3, P#4, P#5) sampled patients developed a pressure injury while under the care of the facility and was ordered to have a daily dressing change.

Findings Included:

A review of the facility policy titled "Wound Care and Wound Documentation," policy # 16324409, last reviewed 7/31/24, revealed that the purpose was to identify and document skin impairments, prevent further skin breakdown, and promote wound healing.
A. Documentation
1. Wound stages will be documented on admission and on assessment/reassessment in Meditech.
2. Notify MD of Stage 2, 3,4, unstageable

B. Pressure Relief:
1. Obtain appropriate specialty bed as appropriate to the provided algorithm.
2. For lower extremities ulcers, offload heels on pillows or apply protective heel boot.

A tour was conducted on the inpatient 3rd floor Medical Surgical Unit, Three Main, on 9/18/24 at 4:00 p.m. with Director of Nursing (DON) HH. An observation revealed no magnet was noted on any of the patient doors to identify patients who needed assistance or had to be turned every two hours.
A review of the medical record for P#1 revealed that on 1/22/2024 at 7:36 a.m., a nurse documented an integumentary (skin) assessment as all normal.

A review of the medical record revealed that on 1/22/2024 at 9:21 a.m., a nurse documented a skin risk assessment, Braden Scale (a scale predicting a pressure sore risk that has six subscales, and the total scores range from six to 23, a lower score indicates a higher level of risk for pressure ulcer development), P#1's score was 13 - at risk for developing pressure injury.

A review of a "Consultation Note - Brief" dated 1/24/24 at 2:57 p.m. by Nurse Practitioner (NP) BB for wound care (WOC) revealed an assessment of a four by five open blistered area along P#1's right buttock, deep purple, non-blanching discoloration, unstageable wound. Continued review revealed that NP BB ordered to have the wound treated with Santyl (a collagen ointment used to treat damaged tissue) daily and to offload the wound.

Continued review of the medical record for P#1 revealed the following:
On 1/24/24 at 8:21 p.m., a nurse documented an integumentary (skin) assessment as all normal.
On 1/25/24 at 3:15 p.m., a nurse documented that P#1 had an unstageable pressure injury that was not present on admission. The wound was cleansed with Santyl, and dressing was changed. Continued review revealed that P#1 had a Braden Score of eight - at risk for developing a pressure injury.
On 1/25/24 at 10:53 p.m., a nurse documented that P#1's wound dressing was intact.
On 1/26/24 at 10:00 a.m., a nurse documented that P#1's wound dressing was cleansed and changed. Continued review revealed that P#1 had a Braden Score of seven - at risk for developing a pressure injury.
On 1/26/24 at 9:00 p.m., a nurse documented that P#1's wound dressing was intact.
On 1/27/24 at 7:15 a.m., a nurse documented an assessment of P#1's wound, but no dressing change was noted.
On 1/27/24 at 9:21 p.m., a nurse documented an assessment of P#1's wound and that P#1's dressing was intact, but no dressing change was noted.
On 1/28/24 at 7:42 a.m., a nurse documented n assessment of P#1's wound and that P#1's dressing was intact, but no dressing change was noted.
On 1/28/24 at 9:14 p.m., a nurse documented an assessment of P#1's wound, but no dressing was noted.
On 1/29/24 at 8:10 a.m., a nurse documented an integumentary (skin) assessment on P#1 as all normal. There was no assessment of P#1's wound or dressing change noted.
On 1/29/24 at 8:45 p.m., a nurse documented an assessment of P#1's wound but no dressing change was noted.
On 1/30/24 at 8:04 a.m., a nurse documented an assessment of P#1's wound but no dressing change was noted.

Continued review of P#1's medical record failed to review repositioning documentation on whether P#1 was turned and repositioned at intervals throughout hospitalization. P#1 was documented as a bedrest patient with a two-person level of assistance and had total dependence for hygiene care.

A review of P#5's medical record dated 9/12/2024 through 9/17/2024 failed to reveal documentation that P#5 was repositioned by nursing staff.

Continued review revealed that on 9/18/24 at 7:53 a.m. through 9/19/24 at 8:00 a.m., P#5 was noted as a bedfast patient with a Braden Score of eight to 11- at risk for developing pressure injury.

During an interview on 9/18/2024 at 1:03 p.m. in the conference room, Registered Nurse (RN) CC said that she has been an RN for 25 years and employed at the facility for 23 years in the intensive care unit (ICU). RN CC said that during the skin assessment, the RN has access to a mobile device to capture any pictures for wounds that are present on admission. RN CC said that if a patient develops a wound when they are at the facility, staff can use the pictures to compare it and determine that it was a hospital-acquired pressure injury.
RN CC said that if a new pressure ulcer was found while the patient was at the facility, then she would document it, capture a photo, alert her manager, provider, and the wound care (WOC) nurse. RN CC said that that RNs follow orders placed by the provider and WOC RN for wound treatment and management. RN CC said that RNs should document each wound, interventions performed, and if the dressing change was performed. RN CC said that staff have many preventative measures to prevent pressure ulcers such as foam dressings, turning the patients every two hours, and the hospital beds provide off-loading pressure and turn. RN CC said that there is a spot for RNs to document repositioning, but it is probably not a practice that everyone utilizes.

During a telephone interview on 9/18/24 at 2:12 p.m. in the conference room, RN GG said that if there are any wounds present, then she would take a photograph, document it, and notify the provider. RN GG said that this would be the same process if she discovered a wound that was not present-on-admission with the exception that she would also file an incident report. RN GG said that she would follow whatever wound care order is ordered for the patient and to document that the dressing was changed with the appropriate solutions in the electronic medical record (EMR).

During an interview on 9/18/24 at 2:25 p.m. in the conference room, RN EE said that she has been an RN for 31 years and employed at the facility for 16 years in the intensive care unit (ICU). RN EE said that when she gets a new patient admission, she would document and photograph and wounds. RN EE said that she would do the same process for any wounds that were not present on admission but instead discovered while hospitalized. RN EE said that she would also inform the provider and wound care (WOC) nurse and be sure to document it in the patient's medical record.
RN EE said that there is not a dedicated spot to chart repositions and turns for patients in the current charting system that staff utilize. RN EE said that the beds in the ICU do turn patients according to what the clinical staff set it to.

An in-person interview was conducted on 9/18/24 at 4:00 pm with P#5's family member on the in-patient nursing unit's 3rd floor. P#5 was admitted to the facility on 9/12/2024 through the Emergency Department (ED) for a rectal abscess (a collection of pus that has built up within the tissue of the body) and underwent surgery. The family member of P#5 stated that the nurses had been busy and yesterday never changed (P#5) wound dressing. P#5's family member said she spoke to the nurse today about making sure they would change P#5's wound dressing today. P#5's family member expressed concern that (P#5) was not eating and that no one comes in regularly to turn P#5 off his back since P#5 could not turn himself.

During a telephone interview on 9/18/24 at 4:08 p.m., RN DD said that she has been an RN and employed at the facility for six years. RN DD said that when she gets a new patient admission, she conducts a general nursing assessment, which includes a skin assessment. RN DD said that if a patient does have a wound, she would document and photograph it. RN DD said that all wound care interventions should be charted in the medical record. RN DD said that patients who are unable to turn themselves, must be turned every two hours. RN DD said that RNs should chart this in the section of routine care, and list it as either reposition or turns.