HospitalInspections.org

Based on policy review, medical record review, and interview, the facility failed to ensure nursing staff appropriately reassessed a patient's skin and documented a skin injury for 1 of 3 (Patient #1) sampled patients with wounds.

The findings included:

1. Review of the facility's policy, "Standards of Practice Guidelines for Patient Care Units," revealed, "...Purpose: To establish guidelines for standard patient care for each area of nursing care...SKIN INTEGRITY ...Evaluate skin condition with each shift assessment...Monitor skin integrity...Inspect/assess pressure points...Any identified skin integrity problem document using NE1 (wound assessment tool) can stage..."

Review of the facility's policy, "Assessment and Reassessment of Patients," revealed, "...Reassessment: Ongoing data collection, which begins upon initial assessment, comparing the most recent data with the data collected at earlier assessments. The process of reassessment determines whether the care, treatment and services provided are meeting the patient's needs over time...The Registered Nurse is responsible for overall care of the in-patient and select out-patient...Patient assessments are completed according to the accepted standard of care and includes...Collection of health data...Evaluation of the patient's progress toward achieving desired outcomes...Bio-Physical System Data ..Integumentary, using NE1 can stage for Wounds..."

Review of the facility's policy, "NE1 Wound Assessment Tool," revealed, "...PURPOSE: To increase documentation accuracy and consistency for skin and wound documentation...All patients receive a head-to-toe skin inspection. The inspection is done on admission and at least once per shift..."

2. Medical record review for Patient #1 revealed an admission date of 5/17/2022 with diagnoses which included Ischemic Necrosis of Foot, Coronary Artery Disease, Uncontrolled Type 2 Diabetes Mellitus with Hyperglycemia, Acute Renal Failure Superimposed on Stage 4 Chronic Kidney Disease, Anemia of Chronic Disease, Ischemic Cardiomyopathy, and Chronic Systolic Congestive Heart Failure. Patient #1 had a medical history of Coronary Artery Disease Status Post Bypass Surgery, History of Deep Vein Thrombosis, Chronic Obstructive Pulmonary Disease, Hypertension, and Congestive Heart Failure with and Ejection Fraction of 30-35%.

A Occupational Therapy Reassessment note dated 5/27/2022 revealed, "...Time In: 0936 [9:36 AM]...Time Out: 0959 [9:59 AM]...PT [Patient] WITH SIGNIFICANT SKIN BREAKDOWN TO PERI AND BUTTOCKS AND STARTING TO DEVELOP PRESSURE SORES. PICTURES TAKE VIA IMOBILE AND SHOWN TO RN [Registered Nurse], HOSPITALIST..."

The Clinical Documentation Record dated 5/27/2022 at 1:04 AM revealed Nurse #1 did not document any wound to the buttocks on the shift skin assessment (shift skin assessment prior to documentation of the wound on 5/27/2022 by Occupational Therapist #1).

The Clinical Documentation Record dated 5/27/2022 at 10:27 AM revealed Nurse #2 did not document any wound to the buttocks on the shift skin assessment (first shift skin assessment following the documentation of the wound on 5/27/2022 by Occupational Therapist #1).

The Clinical Documentation Record dated 5/28/2022 at 12:48 AM revealed Nurse #1 did not document any wound to the buttocks on the shift skin assessment (shift skin assessment following the documentation of the wound on 5/27/2022 by Occupational Therapist #1).

The first documentation in the shift skin assessment by nursing staff of the wound to the buttocks was documented by Nurse #3 on 5/28/2022 at 9:30 AM (23 hours 31 minutes to 23 hours 54 minutes after the documentation of the wound on 5/27/2022 by Occupational Therapist #1).

The Clinical Documentation Record dated 5/30/2022 at 12:04 PM revealed Wound Ostomy Care Nurse #1 documented, "...NEW CONSULT FOR EXCORIATION/SKIN BREAKDOWN ON BILAT [bilateral] BUTTOCKS...PT HAS SCATTERED SUPERFICIAL OPEN AREAS OVER BILAT BUTTOCKS AND SACRUM. RED INTACT SKIN PRESENT AS WELL. ENTIRE AREA SLOW TO BLANCH. PT REPORTS TENDERNESS. INCREASED WITH PALPATION..."

A physician's progress note dated 5/28/2022 at 7:14 AM revealed Hospitalist #1 documented, "...diffuse skin breakdown of back/buttocks with extensive cream coating..."

The Clinical Documentation Record dated 6/9/2022 at 11:31 AM revealed Wound Ostomy Care Nurse #2 documented, "...NEW CONSULT RECEIVED ...LEFT PATELLA - 6CM [length in centimeters] X [by] 6CM [width] X 0.3CM [depth] OPEN AREA COVERING THE PATELLA. FAMILY SHARED PHOTO WITH WOUND CARE TEAM SHOWING KNEE WITH PURPLE DISCOLORATION AND EPITHELIAL LOSS. NOW AREA IS OPEN AND EXTREMELY TENDER. ESCHAR AND SLOUGH PRESENT...CONSISTENT WITH STAGE 3 PRESSURE INJURY...UNKNOWN ETIOLOGY...RIGHT LATERAL ANKLE - OPEN AREA APPROXIMATELY 4.5CM X 1 CM X 0.1CM. PINK/RED WOUND BASE. UNKNOWN ETIOLOGY...RIGHT LATERAL HEEL - BLANCHABLE ERYTHEMA. CLOSE MONITORING REQUIRED..."

The Clinical Documentation Record dated 6/10/2022 at 4:49 AM revealed Nurse #4 documented in the shift skin assessment, "...OPEN AREA TO LT [left] BKA [below the knee amputation] VASCULAR RELATED. MEPELEX [Mepilex] IN PLACE...Worst tissue type score: 2 [pink/red/erythema/intact]..." There was no documentation in the note of the eschar or slough in the wound.

The Burn Consultation Noted dated 6/10/2022 at 2:46 PM revealed Physician Assistant #1 documented, "...wound/burn team consulted for wound to the left patella...Skin: multiple areas of eschar to left lower extremity stump and over the anterior knee. No separation of eschar. Periwound normal. No drainage or bleeding...Assessment: Multiple area [sic] of eschar to left lower leg/amputation site and left knee - likely vascular in nature..."

There was no other documentation in the shift skin assessments by nursing staff of the wound or assessment of the wound to the left knee, right lateral ankle, or right lateral heel.

3. During an interview on 8/1/2022 at 1:45 PM, Nurse Manager #1 stated Patient #1's daughter filed a complaint with the hospital. Nurse Manager #1 stated she received and email from the Quality Department, and she looked at the wound to Patient #1's buttocks the next day. Nurse Manager #1 stated the skin was excoriated which she believed was from moisture and stool. Nurse Manager #1 stated nursing staff placed a rectal tube to help manage Patient #1's diarrhea, and she asked the Burn Team to assess the wound.

During an interview on 8/11/2022 at 8:52 AM, Nurse Manager #1 stated nurses should do a full skin assessment each shift and document any change in the skin condition.

During a telephone interview on 8/11/2022 at 11:55 am, Wound Ostomy Care Nurse #2 stated when she assessed Patient #1's knee, the wound was black with eschar and slough, and the wound was separate from the incision from the amputation. Wound Ostomy Care Nurse #2 stated a staff member told her about the wound on Patient #1's knee, but she could not remember who told her.