HospitalInspections.org

Based on interview and record review the hospital failed to ensure a patient care policy was followed for one of eight sampled patients (Patient 5) when registered nurses did not accurately assess Patient 5's coccyx (small triangular bone at the base of the spine) wound upon admission. This failure resulted in a delay of coccyx wound treatment of Patient 5.

Findings:

Review of Patient 5's record indicated the patient was admitted on 10/7/24.

Patient 5's Inpatient Wound Care Notes, consulted at 10/9/24 10:19 a.m., indicated the patient in addition to a lower left leg wound had a hospital acquired Stage III chronic pressure wound (full-thickness skin loss where the fat layer is visible. an injury resulting form prolonged pressure). The same note indicated Patient 5 had stated she felt her wound at that location for over four months.

During an interview on 12/2/24 at 1:20 p.m., the wound care nurse (WCN) stated she reviewed the record upon admission and it was the floor nurses responsiblity to perform a head to toe skin assessment. WCN also stated Patient 5's coccyx wound was missed on admission.

Patient 5's Nurse's Note dated 10/9/24, indicated Patient'5 coccyx wound treatment was not started until 10/9/24.

Review of the Pressure Injury Prevention policy, 5/2/24, indicated all patients was to receive a full body assessment of their skin condition within 24 hours of admission simultaneously by two registered nurses.