HospitalInspections.org

Based on policy review, medical record review and interview, the hospital failed to ensure nursing services provided adequate oversight and supervision to ensure patient's needs were met when direct care staff failed to assess, monitor, and provide wound care treatments for 2 of 4 (Patient #21 and #25) sampled patients reviewed for wound care management.

The findings included:

1. Review of the facility's policy titled "Basic Wound Intervention Policy" dated 9/5/2024, revealed "...The purpose of the Basic Wound Intervention Policy is to provide guidelines to address skin tears, moisture management, incontinent associated dermatitis, fungal rash, pressure injuries, and patient with negative pressure therapy in progress on admission...All patients will be assessed for potential and actual alteration in skin integumentary. Patient identified as having the indicators listed below will require the initiation of the Basic Wound Policy...intervention policy. Stage I/II/SDTI [one/two/Suspected Deep Tissue Injury] Pressure injury or Partial Thickness Wounds...Cleanse area with normal saline and pat dry...Apply Board Foam ...Change every three days and PRN [as needed] for loosening...Stage III/IV [three/four; 3-4] Pressure Injury or Full Thickness Wounds...Cleanse area with normal saline...Apply Saline moist dressing...Change BID [twice a day] and PRN [as needed]...Unstable Pressure injury or Brown/Black Dry Eschar...Leave area clean and dry...Dry dressing as needed for comfort or drainage..."

Review of the facility's policy titled "Admission Assessment/Reassessment," dated 2/7/2025, revealed "...Each patient will receive an admission assessment by a Registered Nurse which will include the patient's...in order to determine care needs, the type of care to be provided, and the need for further assessment...identify those at risk for the potential for skin breakdown..."

2. Review of the closed medical record revealed Patient #21 was admitted on to the hospital on 1/2/2025 at 11:24 AM with diagnoses of Pressure Ulcer of Right heel Stage 2, Pressure Ulcer of Sacral Unstageable, Sepsis, Acute Kidney Failure, Diabetes and Pressure Wound Infection. Patient #21 was discharged from the hospital on 1/6/2025 at 2:43 PM.

Review of the Nursing Home Progress Note, dated 1/2/2025 revealed, "... right breast ulceration measuring 3.7 cm [centimeters] x [times] 8.8 cm x 0.4 cm. Wound bed consists of 100% [percent] pale pink moist tissue, edges are uneven and sharp oval shaped, induration [the hardening and thickening of the skin and surrounding tissue around a wound] palpated with erythema [redness] observed to ensure right breasts moderate amount of purulent [pearl colored] drainage and malodor when dressing removed and cleansed. UNST [unstageable] to right heel now appear as stage 2 measure 1.1cm x 0.2cm x 0.1cm wound bed 100% pink moist smooth tissue, margin is flat and uneven, no drainage or malodor observed ...UNST pressure ulcer to sacrum measures 4.2cm x 4.4cm x UTD [undetermined], wound bed consist of 75% of light yellow slough and 25% black necrotic tissue foul odor observed before and after cleansing the wound, margin sharp and circular, small amount of malodorous purulent drainage observed when dressing removed and odor continued to be present after wound was cleansed..."

Review of the Emergency Medical Services (EMS) Run Sheet," dated 1/2/2025 revealed "...Nurses states that patient has a pressure ulcer on the right hip area where humeral head meets pelvis. Nurse was performing wound care today and notice that the wound seems to be getting worse and is possibly becoming infected due to abnormal drainage and smell..."

Review of the "Pre-arrival Communication From," dated 1/2/2025 revealed "...SACRAL WOUND W[with]/FOUL SMELL..."

Review of the ED (Emergency Department) Records, dated 1/2/2025, revealed "...sent to the ED via [by] EMS ...for an evaluation of multiple wounds...Patient presenting with multiple wounds which have worsened...patient is normally bed bound..."

Review of the Physician's Orders dated 1/2/2025, revealed Wound Ostomy Referral.

Review of the Incision/Wound Information, dated 1/2/2025 through 1/6/2025 revealed there was no documented wound care on the sacral wound.

Review of the "Incision/Wound Information," dated 1/3/2025 through 1/6/2025 revealed there was no documented wound care on the right heel.

Review of the "Incision/Wound Information," dated 1/3/2025 through 1/6/2025 revealed there was no documented wound care on the right breast.

Review of the "Progress Note," dated 1/3/2025 revealed "... Assessment/Plan Diagnosis... Wound of right breast with complications... Sacral decubitus ulcer...Acute kidney injury...Diabetes...Metabolic acidosis... Urinary tract obstruction...Depression..."

Review of the "Wound/Ostomy Report," dated 1/3/2025 and 1/6/2025, revealed Patient #21 had a wound to the sacral, right heel, and a wound to the right chest.

Review of the "Discharge Summary," dated 1/6/2025, revealed "...Patient reportedly has right breast ulceration measuring 3.7 cm [centimeters] x 8.8 cm x 0.4 cm...moderate amount of purulent malodorous drainage...dressed with VASHE [a topical solution primarily used for wound care. It contains hypochlorous acid...known for its antimicrobial properties, making it effective in cleansing, irrigating, and moistening wounds] applied dry. We have an accompanying ulcer to the sacrum 4.2 cm x by 4.4 cm in addition to a right heel stage II [two] decubitus ulcer 1.1 cm x 0.2 cm x 0.1 cm it is not apparent the patient has received antimicrobial treatment for these lesions due to the breast lesion. Due to breast and sacral decubitus wound care was consulted..."

Review of Hospital #2 "Office Visit in Wound Care," dated 1/7/2025, revealed "...Wound Length...2.8 cm...Wound Width...7.9 cm...Wound Depth...0.7..."

Review of the Named Hospital #3's "Progress Note, dated 1/7/2025, revealed "...ED Dx [diagnosis]...Sacral decubitus wound, infected..."

Review of the Named Hospital #3's "WOUND CARE INPATIENT CONSULT NOTE," dated 1/9/2025 "...Upon admission to the hospital patient is documented to have right breath [breast] wound with small amount of serous drainage, deep tissue injury to right heel and right 5th toe, stage 4 pressure injury to sacrum. Stage 1 to right buttock and abrasion to right elbow and left knee. Patient seen by outpatient wound clinic on 12/30/2024 for ulcers to right breast, sacrum, right ischium and right heel. Wound care treatment recommended for the right breast 3 x [times] a week with Vashe [wound cleanser] wound solution, Promogran [primary dressing for moist wound healing] and Allevyn [indicated for moderate to high exudating wounds] foam dressing. For right heel ulcer Vashe, hydrogel, Promogran and Allevyn foam dressing to be changed 3x per week. To the right ischium normal saline and small allevyn foam dressing 3 x a week. To the sacrum daily dressing changes with Vashe, Santyl [ointment used to remove damaged or burned skin], Hydrofera [offering antimicrobial protection, moisture management] blue and Allevyn foam dressing...Unable to performed skin and wound assessment on 1/8/2025 due to patient hemodynamically unstable with need of vasopressor therapy...wounds...Right breast...2.7 cm [centimeters] x 8.8 cm x 0.5...Right heel...3.6 cm x 2.4 cm x 0.1...The base is 20% bone exposed...Right lateral 5th toe...1.5 cm x 0.4 cm...Sacrum...5.0 cm x 3.5 cm x 1.0 cm...Assessment...right heel stage 4...lateral right 5th toe Deep tissue injury...Non-pressure ulcer...right breast..."

During a telephone interview on 6/2/2025 at 1:10 PM, Family Member #1 was asked to tell me about his complaint. Family Member #1 stated, "...She had a wound on her bottom...her heel...her breast...she stayed there for six days...they sent her back to the [Named Nursing Home] at the hospital here at [Named Hospital #1]...they failed to treat her wound for six days..."

During an interview on 6/3/2025 at 1:01 PM, with the Wound Care Nurse was asked during Patient #21's hospitalization should she have documentation of wound care treatments. The Wound Care stated, "...we have no wound care documentation..." The Wound Care Nurse was asked if have a patient admitted with wounds how do they get on your list. The Wound Care Nurse stated, "...we get a list essentially of our patients in the morning...first thing we do is come in and look at our list...our list will have consults from hospitalists...surgeons...doctors...who are following up on them [patient]...there will be a nurse referrals... system referrals...that populates our list...we kind of prioritize who we're seeing based on the type of referral or consult...what kind of wounds... diabetic wounds...pressure ulcers...surgical wounds...dermatology with rashes..." The Wound Care Nurse was asked how many pressure ulcers are currently being treated in the hospital. The Wound Care Nurse stated, "...I know for certain roughly 4 patients that we're following..." The Wound Care Nurse was asked if how does a patient that admitted through the Emergency Room (ER) with multiple wounds that have worsening and infected and there's no documentation of any wound care for six days. The Wound Care Nurse stated, "...if it was just a system referral consult that's lowest priority...the system will kick a referral to us based on what is charted in by a nurse or by an LPN [Licensed Practical Nurse]...if they charted a wound...it'll automatically shoot a referral to us...it's all based on charting...those are lower priority...if we get a direct consult from the hospitalist or a surgeon...we go and see the patient..." The Wound Care Nurse was asked when that patient go to the floor are the nurse doing a head to toe assessment to identify the wounds. The Charge Nurse stated, "...Yeah, so essentially if they document something on their skin assessment it will trigger a system referral versus an actual order in the system...an actual surgeon or physician requesting a wound care...the wound care nurse goes to see them versus just a system referral...that could be anything that a nurse documented under that skin assessment...a lot of times it'll trigger saying they got a pressure injury..." The Wound Care Nurse was asked should the patient have been missed treatments/wound care. The Wound Care Nurse stated, "...it was just a system referral based on that first skin assessment...there was no actual physician order..." The Wound Care Nurse was asked if the patient was admitted on Thursday at on 1/2/2025 at 11:24 AM and discharged on Monday at 1:45 PM. The Wound Care Nurse stated, "...I believe she was admitted on Thursday night they were not here...they had Friday to see her...they had several other higher priority patients...they were not here on weekends..." The Wound Care Nurse was asked when you go in on an initial assessment what is involved. The Wound Care Nurse stated, "...It's based on kind of the consult or whatever type of referral...if it's the first time we see them...we get an idea of what the wound is...if it's an actually a pressure ulcer...it's a different type of wound...a pressure ulcer we'll stage it...get measurements and then come up with a treatment plan...then follow them...we will write wound care orders for the bedside nurses to accomplish with a kind of schedule...if it's a more complex wounds...we stick with it...we are the ones that will go back either daily or every other day depending on the schedule..." The Wound Care Nurse was asked if you have a patient admitted with infected wound and not to have wound care for six days is that acceptable practice. The Wound Care Nurse confirmed typically no. The Wound Care Nurse was asked should Patient #21 have had wound care complete. The Wound Care Nurse stated, "...Probably, I will say even though they did not necessarily get to her because of the timing of the schedule...we also have a policy as far as standard dressings changes that the nursing staff should be doing...to change the dressing regularly...that's something that also should have been done while she was here...obviously it's very important that these wounds be changed, cleansed, and assessed...it's also part of our policy...they do have standing orders or standing for policy what can be done in the meantime throughout the weekend...so yes if they're admitted throughout the weekend...the wound care should have been done...it should be completed and cleansed per our policy by the bedside nursing..."

3. Review of the medical record revealed Patient #25 was admitted on 5/19/2025 with diagnoses of Pleural Effusion, Constipation, Small Bowel Obstruction, Liver Abscess and Fractured Femur.

Review of the "History of Physical," dated 5/19/2025, revealed "...70-year-old male with a past medical history of adenocarcinoma on chemotherapy, liver access with drain in place, atrial flutter, and type 2 diabetes mellitus, who presented in the ER with abdominal pain and distention, associated with nausea and vomiting over the past few days. The patient underwent knee surgery three days ago and was started on oxycodone. Since then, he has not had a bowel movement for two days, though he reports passing gas recently as of yesterday..."

Review of the "Physicians Orders," dated 5/19/2025, revealed Skin Care Interventions...Skin Care intervention ordered based on Nursing Documentation..."

Review of the "Physicians Orders," dated 5/21/2025, revealed "...Wound Care...Site...Midline coccyx...Cleanse with...Saline...Apply...medihoney [when applied to the skin, honey might serve as a barrier to moisture and keep skin from sticking to wound dressing...Frequency...QDay [every day]...Special Instructions...apply medihoney and cover with border foam dressing..."

Review of the "CT (Computed Tomography) AbdomenPelvis (Abdomen Pelvis) With Contrast dated 5/29/2025, revealed "...IMPRESSION...Small region of induration at the base of the coccyx which could relate to developing decubitus ulcer..."

Review of the "Progress Note," dated 5/30/2025, revealed "...No over night events of note...Discussed plan for wound care to come evaluate the patient for his decubitus ulcer noted on the CT [computed tomography]..."

Review of the "Orders Detail," dated 5/31/2025, revealed "...to Coccyx...Cleanse with Wound Cleanser Spray, Apply Normlgel AG [antimicrobial hydrogel that assists in debridement and desloughing in dry necrotic wounds...the gel creates a barrier against bacterial penetration], petroleum gauze, boarder foam, QDay [every day]..."

Review of the "Wound Ostomy Services," dated 5/20/2025, revealed "...Location...Coccyx...Description...yellow necrotic tissue, slough (100% [percent] of wound bed covered)...Bone is palpable under slough...Stage...unstageable...length 1 cm [centimeters], Width 1 cm, dept 0.3 cm..."

Review of the "Wound Ostomy Services," dated 5/30/2025, revealed "...Location...Coccyx...Description...yellow necrotic tissue, slough (100% [percent] of wound bed covered)...Bone is palpable under slough...Stage...unstageable...length 2 cm [centimeters], Width 1.8 cm, dept 0.5 cm..."

Review of the "Wound Ostomy Services," dated 6/2/2025, revealed "...Location...Coccyx...Description...yellow necrotic tissue, slough (100% [percent] of wound bed covered)...Bone is palpable under slough...Stage...unstageable...length 1.8 cm [centimeters], Width 1.6 cm, dept 0.6 cm..."

Review of the "Incision/Wound Assess/Care," revealed on the following day there was no wound care treatments performed 5/21/2025, 5/23/2025, and 6/3/2025.

Review of the "Quality of Care Meeting Minutes," for the November 11/15/2024, 1/19/2025, 2/21/2025, 3/21/2025, and 4/25/2025 revealed the facility had no documentation of the wound management.

Review of the "QUALITY AND PATIENT SAFETY MANAGEMENT PLAN FISCAL YEAR 2025," revealed there was no documentation of the wound management.

During an interview on 6/4/2025 at 1:20 PM, with the Director of Wound Care was asked what it means in the documentation under the wound information, clean, covered, intact, dry and boarder foam. The Director of Wound Care stated, "...they would have looked under the dressing make sure the wound is clean covered dressing dry intact..." The Director of Wound Care was asked does it mean the wound care treatment was provided. The Director of Wound Care stated, "...No, they would document applied if the wound care was provided..." The Director of Wound Care was asked about Patient #25 treatment orders. The Wound Care Director stated "...he had an ostomy order for 5/19/2025...there was one on 5/23/2025 ...an order placed on 5/21/2025 and on 5/31/2025 for daily dressing changes..." The Director Wound Care was asked should Patient #25 have missing treatment. The Director Wound Care Director stated, "No."

The facility failed to follow their policy for wound care treatment for Patient #21 and #25. The facility failed to ensure the patient's were provided the care and services while admitted to the facility.