HospitalInspections.org

Based on review of medical records (MR), policies and procedures, KCI (Kinetic Concepts Incorporated) VAC (Vacuum Assisted Closure) Therapy Clinical Guidelines, and interviews, it was determined the facility failed to ensure staff:

1. Followed orders for patients with a Braden Risk Assessment score of 18 or less, per policy.

2. Repositioned immobile patients every 2 hours to prevent pressure injuries, per policy.

3. Followed physician orders to turn patient side to side every 2 hours.

4. Documented wound care, assessments and measurements per policy.

5. Obtained and provided wound care per physician's orders.

6. Placed patients in combilizer chair daily, as ordered.

7. Notified the physician with changes in patient condition as directed per policy.

8. Evaluated and treated patient's requiring wound care specialist services within 48 hours per policy.

This affected 4 of 4 MR's reviewed of patients with pressure injuries, including Patient Identifiers (PI) # 2, PI # 4, PI # 1, and PI # 3, and had the potential to affect all patients at risk for pressure injuries.

Policy: Hygiene/Pressure Ulcer Orders for Braden less than 18
Date Revised: None listed

Patient Care

Turn Patient- Every 2 hours.
...Notify MD (Medical Doctor)- for any breakdown and pressure ulcers.

...Consults/Referrals

Consult to Wound Care Specialist- For all breakdown and pressure ulcers...

Policy: Mepilex Ag (Silver) Antimicrobial Foam Dressing
Policy Stat ID (Identification): 5299763
Last Approved: 8/2018

Mepilex Ag is a soft foam dressing that absorbs wound exudate but keeps the wound sufficiently moist. The addition of silver aids in the prevention of wound infection...

Mepilex Ag requires a physician's order.

Mepilex Ag will be changed every 3-5 days during hospitalization, allowing more frequent wound assessment to ensure wound progression...

Policy: Assessment/Reassessment
Policy Stat ID: 8006322
Last Approved: 5/2020

Assessment/Reassessment of Patient

Policy: Assessment is an interdisciplinary process that includes data relevant to each patient's physical, psychological, and social status. Qualified individuals perform assessment within their scope of assessment, within their scope of practice, state licensure laws, applicable regulations or certification.

General Information:

Assessment is used to determine the care and treatment to meet a patient's initial needs. The scope and intensity of further assessment is based on the patient's diagnosis... Reassessment is used to evaluate or measure if care decisions are appropriate and effective and occurs at defined intervals or key points. (See Scope of Care Assessment and attached grid).

Scope of Assessment:

The scope of assessment/reassessment for each clinical discipline involves the use of appropriate information by qualified individuals within a department/service-specific time frame.

Nursing:

The admission includes collection of data for all patients relevant to biophysical, nutritional, functional... Nursing implements pre-determined adult screening criteria to determine need for further assessment by the following disciplines: ...Nutrition Services... and Enterostomal Therapy... The RN (Registered Nurse) verifies and analyses data to identify patient care/needs for the nursing process.

University Hospital Scope of Assessment Table (grid)

Department/Service:

Nursing-Medical Surgical:
Initiate... Assessment... Upon arrival to floor (or upon Admission /observation status)
Complete... The Admission assessment and Initial Assessment within 24 hours of admission.
Skill Level... RN
Time Frame/Key Points: Every Shift...

Nursing-Intensive Care Units:
Initiate... Assessment... Upon arrival ICU (Intensive Care Units) (or upon Admission /observation status)
Complete... The Admission assessment and Initial Assessment within 24 hours of admission.
Time Frame/Key Points: Every Shift...

Wound Care Center:
Initiate... Within 48 hours of notice
Complete... Within 48 hours of notice
Skill Level... RN or ET (Enterostomal Therapist)

Policy: Wound Cleansing
Policy Stat ID: 4304903
Date Approved: 12/2017

According to the following procedure, wounds will be cleaned prior to reapplication of sterile dressing.

...3. Use Normal Saline solution unless otherwise ordered...

Policy: Wound Measurements
Policy Stat ID: 4303157
Last Approved: 12/2017

Wound Center assessment is essential to effective management, and wounds should be measured each time the wounds are assessed. Measurements of wound size provide direct indicators of healing.

Isolated Wounds:

Measurements will be obtained using a tape measure and documented in centimeters. The measurements will include width, length, and depth of the wound...

Policy: Vacuum Assisted Closure Therapy (V.A.C.)
Policy Stat ID: 4303064
Last Approved: 12/2017

The V.A.C. therapy system assists in wound closure by applying localized negative pressure to the surface and margins of the wound...

Follow KCI VAC Therapy Clinical guidelines for application, maintenance, and removal of Wound VAC dressings and system.

KCI VAC Therapy clinical guidelines:

...Points to remember when using V.A.C. Therapy-

...Always count the total number of pieces of foam used in the wound. Document the foam quantity and dressing change date... in the patient's chart.

Keep V.A.C. Therapy on for at least 22 hours in a 24 hour period. Do not leave the V.A.C. Dressing in place if the therapy unit is switched off for more than two hours in 24.

Monitor continuously and check and respond to alarms.

When dressing is removed, count the number of foam pieces removed, correlate the count with the number of pieces previously placed in the wound and verify the complete removal of V.A.C. Foam dressing pieces.

Policy: Guidelines for Documentation
Policy Stat ID: 8008126
Last Approved: 5/2020

...Shift Assessment

Complete all sections of the assessment for each shift as appropriate.

...Documentation

...All results should be verified as correct to become part of the patient's permanent record.

1. PI # 2 was admitted to the facility on 6/6/2020 with diagnoses including ATV (All Terrain Vehicle) Accident- Major, C (Cervical) 3 Cervical Fracture, C4 Cervical Fracture, and Sensory Loss.

Review of the MR revealed an initial Braden Score on 6/6/2020 of 10.

Review of the MR revealed the following physician's order dated 6/6/2020 at 10:14 PM, "Turn patient q (every) 2 hr (hours)."

Review of the Plan of Care dated 6/8/2020 at 7:51 AM revealed "Hygiene/Pressure Ulcer Orders for Braden less than 18" was initiated.

Review of the physician's order dated 6/25/2020 at 9:51 AM revealed an order to "Place in combilizer chair daily please." The order was discontinued on 7/20/2020 at 8:38 AM.

Review of the MR revealed the patient was documented in the combilizer chair on 6/26/2020, 6/27/2020, and 7/17/2020. There was no documentation the patient was placed in the combilizer chair on the other 26 days the order was in effect. There was no documentation the physician was notified the patient was not placed in the chair.

Review of the MR revealed a Pressure Injury Alert document dated 7/7/2020 at 10:10 AM by Employee Identifier (EI) # 2, WOCN (Wound, Ostomy, and Continence Nurse) Supervisor, with the following documentation: "Present on Admission: No... Stage 2: Partial thickness loss with expose (exposed) dermis. Site: Sacrum... Allevyn intact to sacrum. Removed to reveal partial thickness skin loss. Wound bed is pink/red, moist and viable. Consistent with a stage 2 injury/ulcer. Center of wound bed does appear to be developing a film covering, will monitor closely..." There was no documentation the new stage 2 pressure wound was measured, per policy.

Review of the MR revealed the following order for wound care dated 7/7/2020 at 2:51 PM, "Sacrum: Clean red area with NS (Normal Saline) and allow to dry, apply Iodosorb Gel, apply Allevyn, change Tue (Tuesday), Thur (Thursday), and Sat (Saturday), and if soiled.

Review of the nursing documentation on 7/9/2020 revealed the patient was positioned on his/her back from 6:00 AM to 8:00 PM, a total of 14 hours, and not turned every 2 hours as ordered.

Review of the Nursing Narrative Notes dated 7/11/2020 at 10:29 AM and 6:21 PM, revealed both nurses documented, "Wound care completed per order." The surveyor was unable to determine what specific wound care was provided. There was no assessment of the wound.

Review of the MR revealed a Nursing Narrative Note authored by EI # 2, dated 7/14/2020 at 9:30 AM, with the following documentation, "Follow-up to assess wound progress... Previous stage 2 injury has deteriorated to a stage 3. Full thickness loss that measures approximately 1.5 cm (centimeter) x (by) 1.5 cm x 1 cm. Edges are irregular. No undermining. Tunneling at 7 o'clock measure 1 cm. Moderate amount of seropurulent exudate. Faint odor... This nurse redressed in 1/4 inch Iodoform packing, skin prep to periwound skin, covered with dry gauze and secure with Allevyn... Primary nurse updated on treatment plan and will complete wound care once Dakin's received..."

New wound care orders were written on 7/14/2020 at 12:39 PM: "Sacrum: Clean with NS and allow to dry, lightly pack with 1/4 Dakin soaked coarse mesh gauze, cover with ABD (Abdominal) pad, bid (twice daily), until Fri (Friday) July 17th."

Review of the MR revealed there was no documentation the primary nurse redressed the wound with the ordered treatment, or that any other wound care was performed on 7/14/2020, as ordered.

Review of the Nursing Narrative Note dated 7/15/2020 at 6:39 AM revealed no documentation of wound care. The Integumentary, Incision/Wound assessment dated 7/15/2020 at 9:10 AM documented wound dressing, "Clean, Dry, Intact." Dressing Activity, and Wound Cleansing were left blank. There was no AM wound care documented.

Review of the Integumentary, Incision/Wound assessment dated 7/15/2020 at 5:50 PM revealed the wound was covered with an Allevyn dressing, and not an ABD pad as ordered.

Review of the Nursing Narrative Note dated 7/16/2020 at 5:46 AM revealed the following documentation, "...wound care provided to sacral wound." The surveyor was unable to determine what care was provided.

Review of the Integumentary Incision/Wound assessment dated 7/16/2020 at 5:10 PM documented Dressing Activity: Changed. There was no documentation the nurse lightly packed the wound with 1/4 Dakin's soaked coarse gauze, or covered with an ABD pad, as ordered.

On 7/17/2020 at 2:00 PM, EI # 2 documented the following ET (Enterostomal) /Wound Services Narrative Note: "NPWT (Negative Pressure Wound Therapy) applied to sacral wound to help remove slough, contain exudate and help with granulation tissue formation... Full thickness skin and tissue loss. Base obscured by slimy brown/ yellow slough. Consistent with an unstageable injury/ulcer. Measures 4 cm x 4.5 cm x 3 cm. This nurse was able to removed (remove) loosely adherent tissue using tweezers and scissors. No bleeding with care.... Previous tunneling of 1 cm at 7 o'clock has open (opened) up with increase in wound size..."

The following wound care orders were documented on 7/17/2020:

3:01 PM: "Left Buttock: Apply Mepilex (Mepilex) Ag to red area, change Tue and Fri or if soiled."

3:43 PM: "Vacuum assisted closure (VAC), Wound Care Sharp Debridement PRN (as needed), Constant order, Apply NPWT to sacral injury/ulcer using black granufoam at 125 mmHg (millimeters of Mercury) low continuous suction with changes 2 x (times) / week and PRN leakage.

There was no assessment documented of the new wound on the left buttock, and no measurement, per policy.

Review of the Integumentary Incision/Wound: Sacrum documentation dated 7/17/2020 at 7:35 AM and 8:01 PM revealed the nurses failed to document the presence of the wound vac. In the Nurses Narrative Note at 4:48 PM, the nurse documented the wound vac was on the left buttock, not sacrum as ordered.

Review of the Integumentary Incision/Wound: Sacrum documentation dated 7/18/2020 at 7:40 AM through 7/20/2020 at 7:55 AM, revealed all 5 assessments for both day and night shifts failed to document the presence of the wound vac. For wound dressing, "Allevyn" was documented. The surveyor was unable to determine if the wound vac was connected to 125 mm (millimeters) Hg (Mercury) low continuous suction, as ordered.

Review of the Nursing Narrative Note dated 7/19/2020 at 5:31 PM revealed the nurse documented, "...Patient has a small area of breakdown near trach (trachea) collar, mepilex applied during trach care." There was no documentation the physician or wound specialist was notified, per policy, and no order documented for the Mepilex Ag until 7/22/20 at 7:57 AM, which was two days later.

Review of the ET/Wound Services Nursing Narrative Note dated 7/20/2020 at 3:30 PM revealed the following documentation: "...Full thickness skin and tissue with palpable bone. Consistent with a stage 4 injury/ulcer. Measures 5 cm x 5 cm x 2 cm... Tunneling with deepest at 3 o'clock measuring 4.5 cm. Moderate amount of dark sanguinopurulent exudate. Foul odor." There was no documentation the physician was notified of the increase in the size and stage of the wound, or the change in wound odor.

Review of the Nursing Narrative Note date 7/21/2020 at 6:35 PM revealed the nurse documented, "...Wound Vac dressing reinforced during shift, Dressing changed..." There was no documentation how many pieces of foam were removed, how many pieces of foam were placed in the wound, the appearance of the wound bed, or what settings were used to set the wound vac.

Review of the MR revealed no documentation of dressing change to Left Buttock on Tuesday, 7/21/2020 or Friday, 7/24/2020, as ordered.

Review of the MR revealed an Operative Report dated 7/23/2020. Indication: "... sacral decubitus ulcer..." Procedure performed: "Excisional debridement, bone (including epidermis, dermis, subcutaneous tissue, muscle and fascia)..."

Review of the Nursing Narrative Note dated 7/24/2020 at 5:09 PM revealed the following documentation, "...Dressing change to wounds on sacrum..." The surveyor was unable to determine what wound care was provided.

An interview was conducted on 8/10/2020 at 1:10 PM with EI # 1, Manager, Regulatory Compliance, who confirmed staff failed to follow physician's orders, provided care without orders, and failed to follow facility policy for wound care assessment and documentation.

2. PI # 4 was admitted to the facility on 6/28/2020 with diagnoses including ATV Accident Causing Injury, Traumatic Brain Injury, Acute Respiratory Failure, and Loss of Consciousness.

Review of the Braden Assessment dated 6/29/2020 at 1:00 AM revealed a score of 11, with the following documentation:

Sensory Perception Braden: Completely limited.
Moisture Braden: Occasionally moist.
Activity Braden: Bedfast.
Mobility Braden: Completely immobile.
...Friction and Shear Braden: Potential problem.

Review of the MR revealed the following physician's orders:

6/28/2020 at 6:30 PM, "Turn Patient, q2 hr."

7/8/2020 at 9:10 AM, "Place in combilizer chair daily." Order end date: 7/20/2020.

Review of the nurse Positioning Report revealed the following:

7/2/2020: The patient was positioned on his/her right side from 12:00 AM to 6:00 AM, a total of six hours.

7/15/2020: The patient was positioned on his/her back from 5:00 AM to 2:34 PM, a total of 9 hours and 34 minutes, and positioned on his/her left side from 2:34 PM to 8:15 PM, a total of 5 hours and 11 minutes.

7/16/2020: The patient was positioned on his/her right side from 10:53 AM to 8:20 PM, a total of 9 hours and 27 minutes.

7/21/2020: The patient was positioned on his/her left side from 12:00 PM to 6:00 PM, a total of 6 hours.

Staff failed to turn the patient every 2 hours as ordered.

Review of the nursing narrative notes from 7/8/2020 to 7/20/2020 revealed the patient was placed in the combilizer chair on 7/10/2020 and 7/11/2020. There was no documentation the patient was placed in the combilizer chair the other 12 days, or that the physician was notified the patient had not been placed in the chair as ordered.

Review of the MR revealed the following physician's order dated 7/21/2020 at 12:20 PM: "Sacrum: Clean with NS, apply skin prep and place Allevyn, change Tues and Fri, ensure place wedge higher than hip bones."

There was no documentation in the nurse shift assessments or nursing narrative notes on 7/21/2020 or 7/22/2020 regarding the wound, if the wound care was performed, or an assessment of a wound dressing.

An interview was conducted on 8/10/2020 at 2:45 PM with EI # 1, who confirmed staff failed to follow physician's orders for turning and repositioning, placing the patient in combilizer chair, and performing wound care. Staff failed to document wound assessments or care provided.



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3. PI # 1 was admitted to the facility on 6/25/2020 with diagnoses including, MVC (Motor Vehicle Crash), Traumatic Subdural Hematoma with Loss of Consciousness, Brain Compression and Subdural Hemorrhage Traumatic.

Review of the MR revealed an initial Braden Score on 6/25/2020 of 11.

Review of the Nursing Integumentary, Incision/Wound assessment dated 7/3/2020 at 10:00 PM revealed the following: Buttock Midline 3; Incision/Wound Activity: New; Skin Abnormality Type: Blister; Surgical Incision Detail: Opened; Skin Abnormality Pattern: Clustered, Raised; ...Number of Sites: 3; Pressure Ulcer Present on Admission: No; Incision, Wound Dressing: Absorbent pad; Incision, Wound Cleansing: Cleaned with soap and water; ...Wound Bed Tissue Type: Beefy red; Wound Exudate: Serous.

There was no documentation the physician was notified of PI # 1's new wound to the buttock and no order documented for the wound care provided. There was no documentation the new wound to the buttocks was measured, per policy. There was no documentation of a consult to the Wound Care Specialist for breakdown to the buttock on 7/3/2020 as directed per facility orders for Hygiene/Pressure Ulcer Orders for Braden less than 18.

Further review of the Nursing Integumentary, Incision/Wound assessment's dated 7/3/2020 through 7/15/2020, which included all 18 assessments for both day and night shifts, revealed the wound was cleaned with soap and water. The staff failed to cleanse the wound with Normal Saline solution per facility policy.

Review of the Nursing Narrative Notes dated 7/4/2020 at 6:52 AM revealed, "Pt (Patient) has an allevyn to sacrum, and new blisters that burst."

Review of the Nursing Integumentary, Incision/Wound assessment's dated 7/4/2020, and 7/5/2020 at 8:00 AM and 7:00 PM revealed the following: Buttock Midline 3; Skin Abnormality Type: Blister; Surgical Incision Detail: Opened; Skin Abnormality Pattern: Clustered; ...Number of Sites: 3; Incision, Wound Dressing: Absorbent pad; Incision, Wound Dressing Assessment: Clean, Dry, Intact; Incision, Wound Dressing Activity: Changed Incision, Wound Cleansing: Cleaned with soap and water.

There was no order documented for the wound care provided on the above dates and times.

Review of the Nursing Integumentary, Incision/Wound assessment documentation revealed, "Incision, Wound Dressing: Other: Allevyn; ...Incision, Wound Dressing Activity: Changed; Incision, Wound Cleansing: Cleaned with soap and water," on the following dates and times:

7/8/2020, 7/9/2020, and 7/14/2020: 8:00 AM and 8:00 PM
7/10/2020 and 7/11/2020: 7:15 AM and 8:00 PM
7/13/2020: 8:00 AM and 7:30 AM
7/15/2020: 7:15 AM

There was no order documented for the wound care provided on the above dates and times.

Review of the MR revealed a physician's order's dated 7/9/2020 at 4:31 PM: "Consult to Wound Care Specialist ...Evaluate and treat. For all breakdown and pressure ulcer(s)."

There was no documentation the Wound Care Specialist evaluated and treated PI # 1's wound from 7/9/2020 to 7/15/2020, which was 6 days later, and not within 48 hours per policy.

Review of the Nursing Integumentary, Incision/Wound assessment's dated 7/12/2020 at 7:15 AM and 8:00 PM revealed the following: Buttock Midline 3; Skin Abnormality Type: Blister; Surgical Incision Detail: Opened; ...Number of Sites: 3; Incision, Wound Dressing: Other: Allevyn ...Incision, Wound Dressing Activity: Changed; Incision, Wound Cleansing: Cleaned with soap and water; Wound Status: Deteriorating

There was no order documented for the wound care provided and no documentation the physician was notified of the deteriorating wound status. There was no documentation the wound was measured, per policy on 7/12/2020.

Review of the Nursing Integumentary, Incision/Wound assessment's dated 7/15/2020 at 2:00 PM revealed the following: Buttock Midline 3; Skin Abnormality Type: Pressure Injury; Surgical Incision Detail: Opened; ...Number of Sites: 3; Incision, Wound Dressing: Other: Allevyn ...Incision, Wound Dressing Activity: Changed; Incision, Wound Cleansing: Cleaned with soap and water; Wound Status: Deteriorating.

There was no documentation the physician was notified of the deteriorating wound status and no order documented for the wound care provided on 7/15/2020.

Review of the MR revealed a physician's order's dated 7/15/2020 at 4:07 PM: "Wound-Care-Basic (Nursing):" ...Strict offloading with side to side positioning, pad hips with Allevyn, place on low air loss overlay, clean sacrum wound with saline, pat dry, apply collagenase ointment ..."

Review of the nurse positioning report dated 7/17/2020 from 12:00 PM to 2:00 PM revealed the patient was positioned on his/her back for 2 hours and not side to side per physician orders.

Review of the nurse positioning report dated 7/18/2020 from 6:00 AM to 8:00 AM, 12:00 PM to 2:00 PM, and 4:00 PM to 6:00 PM revealed the patient was positioned on his/her back for 6 hours and not side to side per physician orders.

Review of the nurse positioning report 7/19/2020 from 12:00 AM to 2:00 AM, 6:00 AM to 8:00 AM, 12:00 PM to 2:00 PM, and 6:00 PM to 8:00 PM revealed the patient was positioned on his/her back for 8 hours and not side to side per physician orders.

Review of the nurse positioning report dated 7/20/2020 from 6:00 AM to 8:00 AM, 12:00 PM to 2:30 PM, and 6:00 PM to 8:00 PM revealed the patient was positioned on his/her back for 6.50 hours and not side to side per physician orders.

Review of the nurse positioning report dated 7/21/2020 from 12:00 AM to 2:00 AM, 12:00 PM to 2:00 PM, and 6:00 PM to 8:00 PM revealed the patient was positioned on his/her back for 6 hours and not side to side per physician orders.

Review of the nurse positioning report dated 7/22/2020 from 6:00 PM to 8:00 PM revealed the patient was positioned on his/her back for 2 hours and not side to side per physician orders.

Review of the nurse positioning report dated 7/23/2020 from 12:00 AM to 2:00 AM and 6:00 AM to 8:00 AM revealed the patient was positioned on his/her back for 4 hours and not side to side per physician orders.

Review of the Nursing Narrative Note dated 7/23/2020 at 3:10 PM documented by EI # 3, Registered Teaching Nurse (RTN), revealed, "Pt seen during skin rounds for follow up to assess wound progress. Softsorb pad present ...removed to reveal sacral injury/ulcer remains unstageable with base obscured 100% yellow/black slough. Edges are attached and defined. No undermining or tunneling. ...Wound bed cleansed with Normal Saline and patted dry. Slough cross-hatch using #10 blade. Light bleeding noted..." There was no documentation the wound was measured, per policy on 7/23/2020.

Review of the nurse positioning report dated 7/24/2020 from 12:00 AM to 2:00 AM, 6:00 AM to 8:00 AM, and 6:00 PM to 8:00 PM revealed the patient was positioned on his/her back for 6 hours and not side to side per physician orders.

Review of the nurse positioning report dated 7/25/2020 from 6:00 AM to 8:00 AM, 12:00 PM to 2:00 PM, and 6:00 PM to 8:00 PM revealed the patient was positioned on his/her back for 6 hours and not side to side per physician orders.

Review of the nurse positioning report dated 7/26/2020 from 12:00 AM to 2:00 AM, 6:00 AM to 8:00 AM, 12:00 PM to 2:00 PM, and 6:00 PM to 8:00 PM revealed the patient was positioned on his/her back for 8 hours and not side to side per physician orders.

Review of the nurse positioning report dated 7/27/2020 from 12:00 AM to 2:00 AM and 6:00 AM to 8:00 AM revealed the patient was positioned on his/her back for 4 hours and not side to side per physician orders.

Review of the Nursing Narrative Note dated 7/30/2020 at 4:42 PM documented by EI # 3 revealed, "Pt seen during skin rounds for follow up to assess wound progress. ...sacral injury/ulcer remains unstageable with base obscured 100% yellow/black slough. Edges are attached and defined. No undermining or tunneling. Scattered open areas surrounding wound noted as well with scant bleeding. ...Wound bed cleansed with normal saline and patted dry. Slough cross-hatch using #11 blade. Light bleeding noted..." There was no documentation the wound was measured, per policy on 7/30/2020.

An interview was conducted on 8/10/2020 at10:46 AM with EI # 1, who confirmed staff failed to consult the Wound Care Specialist per Hygiene/Pressure Ulcer Order set, notify the physician of patient's new wound and deterioration in wound status, and obtain physician's orders for wound care provided. EI # 1 also verified the staff failed to offload the patient side to side as ordered, and the Wound Care Specialist failed to evaluate and treat the patient within 48 hours per policy.

4. PI # 3 was admitted to the facility on 6/8/2020 with diagnoses including, MVC, Mandibular Fracture, Maxillary Fracture, Multiple Facial Fractures, Traumatic Subarachnoid Hemorrhage, and Zygomatic Fracture.

Review of the Registered Nurse (RN) Patient History dated 6/8/2020 at 10:02 AM revealed the following:

General Info (Information):
Chief Complaint: ...MCV driver, intubated PTA (Post-Traumatic Amnesia) with head trauma... only responsive to pain. Lacerations to head and face.

Present On Admission:
Pressure Ulcer POA (Present On Admission): No

Braden:
Sensory Perception: Completely limited
...Activity: Bedfast
Mobility: Very limited
...Friction and Shear: Potential Problem
Skin Integrity Risk Score: 11

Review of the Nursing Integumentary, Incision/Wound assessment dated 6/10/2020 at 4:00 PM revealed the following: Sacrum; Skin Abnormality Type: Flaking, Tear; Incision/Wound Dressing: Other: allevyn; Incision/Wound Dressing Assessment: Clean, Dry, Intact".

There was no documentation the physician was notified of PI # 3's new wound to the sacrum and no order documented for the wound care provided. There was no documentation the new wound to the sacrum was measured, per policy. There was no documentation of a consult to the Wound Care Specialist for breakdown to the sacrum on 6/10/2020 as directed per facility orders for Hygiene/Pressure Ulcer Orders for Braden less than 18.

Review of the Nursing Integumentary, Incision/Wound assessment dated 6/11/2020 at 8:00 AM revealed the following: Sacrum; Skin Abnormality Type: Flaking, Tear; Incision/Wound Dressing: Other: allevyn; Incision/Wound Dressing Assessment: Clean, Dry, Intact; Incision/Wound Dressing Activity: Changed". There was no order documented for the wound care provided. There was no documentation the staff cleansed the wound with Normal Saline solution per facility policy.

Review of the Nursing Integumentary, Incision/Wound assessment dated 6/16/2020 at 8:00 PM revealed there was no documentation the sacral wound was assessed every shift per policy.

An interview was conducted on 8/10/2020 at 1:54 PM with EI # 1 who verified the aforementioned findings which included no documentation of wound care orders for the wound care provided, no notification to the MD/Wound Care Specialist for the new sacral wound, and staff failing to follow the policy for wound care provided to PI # 3's wound.

Based on review of medical records (MR), facility policy, and interviews, it was determined the facility failed to ensure the staff developed and updated the plan of care to include Pressure Ulcer Prevention as directed per the facility policy.

This affected 2 of 4 patients reviewed with pressure injuries, including Patient Identifiers PI # 1 and PI # 4, and had the potential to negatively affect all patients at risk for pressure injuries.

Facility Policy: Guidelines for Documentation
Policy Stat ID (Identification): 8008126
Last Approved: 5/2020
Policy Area: Patient Care Manual

Guidelines for Electronic Documentation:

Individualized Plans of care (IPOC)

IPOCs are initiated upon admission and as problems are identified and resolved or updated appropriately every shift.

IPOC problems may be auto-generated based upon order sets in the assessment.

Each IPOC is individualized to the patient and should include at least one patient specific goal.

Multidisciplinary Patient Care Plans

Multidisciplinary Patient Care Plans serve to identify specific patient problems with corresponding patient goals to guide patient care in the attainment of goals and resolution of problems.

Based on admission assessment, appropriate patient problems are printed from the ..."Patient Care Plans" forms on the intranet. Each entry in the Problem/Focus column dated, timed, initialed and the discipline identified.

Revision of goals or additional problems goals may be identified throughout the course of the patient's hospitalization ...

1. PI # 1 was admitted to the facility on 6/25/2020 with diagnoses including, MVC (Motor Vehicle Crash), Traumatic Subdural Hematoma with Loss of Consciousness, Brain Compression and Subdural Hemorrhage Traumatic.

Review of the Braden Assessment dated 6/25/2020 at 10:08 PM revealed a score of 11.

Review of the nursing documentation dated 7/3/2020 at 10:00 PM revealed the following:

Buttock Midline 3
Incision/Wound Activity: New
Skin Abnormality Type: Blister
Surgical Incision Detail: Opened
Skin Abnormality Pattern: Clustered, Raised
...Number of Sites: 3
Pressure Ulcer Present on Admission: No
...Wound Bed Tissue Type: Beefy red
Wound Exudate: Serous

Review of PI # 1's IPOCs revealed there was no documentation Pressure Ulcer Prevention was developed on 6/25/2020 for a Braden Assessment Score of 11 as directed per the facility policy. There was no update to the IPOC on 7/3/2020 when PI # 1 developed an opened wound to the buttocks as directed per the facility policy.

An interview was conducted on 8/10/2020 at 10:46 AM with Employee Identifier (EI) # 1, Manager, Regulatory Compliance, who verified there was no documentation staff developed a plan for Pressure Ulcer Prevention or updated the POC for PI #1's pressure injury.



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2. PI # 4 was admitted to the facility on 6/28/2020 with diagnoses including ATV (All Terrain Vehicle) Accident Causing Injury, Traumatic Brain Injury, Acute Respiratory Failure, and Loss of Consciousness.

Review of the Braden Assessment dated 6/29/2020 at 12:47 AM revealed a score of 13.

Review of the IPOC revealed there was no documentation Pressure Ulcer Prevention was added to the plan of care for a Braden Assessment Score of 13, as directed per the facility policy. There was no update to the IPOC on 7/21/2020 following the documentation of sacral wound care orders.

An interview was conducted on 8/10/2020 at 2:45 PM with EI # 1, who confirmed staff failed to add Pressure Ulcer Prevention to the plan of care, and failed to update the plan of care after the patient developed a sacral pressure injury.

Based on review of medical records (MR), policy, and interview with staff it was determined staff failed to document accurate and complete information in the medical record. This affected 2 of 4 medical records reviewed and did affect Patient Identifier (PI) # 2, and PI # 3, and had the potential to affect all patients admitted to the facility.

Policy: Guidelines for Documentation
Policy Stat ID: 8008126
Last Approved: 5/2020

...Shift Assessment

Complete all sections of the assessment for each shift as appropriate.

...Documentation

...All results should be verified as correct to become part of the patient's permanent record.

1. PI # 2 was admitted to the facility on 6/6/2020 with diagnoses including ATV (All Terrain Vehicle) Accident- Major, C (Cervical) 3 Cervical Fracture, C4 Cervical Fracture, and Sensory Loss.

Review of the nursing documentation revealed the following Sensory Perception scores in the Braden Assessment for the quadriplegic patient with a diagnosis of Sensory Loss:

6/18/2020 8:00 AM: 3- Slightly limited
6/19/2020 8:00 AM: 4- No Impairment
6/20/2020 8:00 AM: 4- No Impairment
7/15/2020 9:19 AM: 4- No Impairment
7/15/2020 7:00 PM: 4- No Impairment
7/16/2020 9:00 AM through 7/20/2020 8:00 AM 4- No Impairment.

The skilled nurse failed to document an accurate Braden Assessment on the above dates.

The following wound care orders were documented on 7/17/2020:

3:01 PM: "Left Buttock: Apply Mepilex (Mepilex) Ag to red area, change Tue (Tuesday) and Fri (Friday) or if soiled."

3:43 PM: "Vacuum assisted closure (VAC), Wound Care Sharp Debridement PRN (as needed), Constant order, Apply NPWT (Negative Pressure Wound Therapy) to sacral injury/ulcer using black granufoam at 125 mmHg (millimeters of Mercury) low continuous suction with changes 2 x (times) / week and PRN leakage.

Review of the nurse's documentation on 7/17/2020 at 4:48 PM revealed the nurse documented, "WV (wound vacuum) to left buttock...," and not to the sacrum, as ordered.

On 7/18/2020 at 6:30 PM, the nurse documented, "Pt (patient) WV to left buttock reinforced and has Mepilex Ag to right buttock." The WV was on the sacrum, and there was no wound on the right buttock.

Review of six Integumentary Assessments: Incision/Wound for Sacrum location, dated 7/17/2020 at 8:01 PM through 7/20/2020 at 8:00 AM revealed "Allevyn" for wound dressing, not the ordered wound vac.

An interview was conducted on 8/10/2020 at 1:10 PM with Employee Identifier # 1, Manager, Regulatory Compliance, who confirmed the above mentioned documentation was inaccurate.



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2. PI # 3 was admitted to the facility on 6/8/2020 with diagnoses including, Motor Vehicle Crash (MVC), Mandibular Fracture, Maxillary Fracture, Multiple Facial Fractures, Traumatic Subarachnoid Hemorrhage, and Zygomatic Fracture.

Review of the Nursing Integumentary, Incision/Wound assessment dated 6/15/2020 at 10:00 AM revealed there was no documentation the nurse assessed the sacral wound.

Review of the Nursing Integumentary, Incision/Wound assessment dated 6/15/2020 at 8:00 PM revealed there was no documentation the nurse assessed the sacral wound.

Review of the Nursing Integumentary, Incision/Wound assessment dated 6/16/2020 at 9:00 AM, 6/18/2020 at 7:11 PM and 6/19/2020 at 9:04 AM revealed, "Sacrum: Incision/Wound Activity: "Assess". There was no documentation of the sacral wound assessment.

Review of the Nursing Integumentary, Incision/Wound assessment dated 6/17/2020 at 7:15 AM revealed there was no documentation the nurse assessed the sacral wound.

An interview was conducted on 8/10/2020 at 1:54 PM with EI # 1 who verified the nursing staff failed to document complete nursing assessments on PI # 3's sacral wound every shift per policy.