HospitalInspections.org

Based on medical record review, document review, and interview, in one (1) of 14 medical records reviewed, the Wound Nurse Specialist failed to complete a timely assessment of a patient with a stage 2 Pressure Injury in accordance with the Staff's job duties and responsibilities to ensure adequate wound management for Patient #1.

Findings include:

Review of the Medical Record documented a 39-year-old with history of Psoriasis, Ulcerative Colitis, liver cancer, IgG related disease, and autoimmune hemolytic anemia admitted for evaluation for liver transplant on 5/16/22. At 2:23 AM, Physician History and Physical documented: Skin: Jaundiced, normal texture and turgor. At 2:45 AM, RN documented Braden score = 12 (high risk for pressure injury). The patient experienced a change in mental status with increased work of breathing and was transferred to the Surgical Intensive Care Unit where she was emergently intubated at 12:34 AM on 5/17/22.
At 8:52 PM RN documented: "Received patient with +2 generalized edema and sacrum intact."

On 6/2/22 at 8:00 AM, RN documented Pressure Injury stage 2. Site assessment: pale pink. Exudate: Light/scant, sanguineous. Presents as an abrasion. Tunneling.

On 6/3/22 at 12:46 PM, Staff A, Wound Care Specialist, documented: "Patient referred to wound care for validation of pressure injury to coccyx. Attempted visit but patient deferred visit due to inability to have the bed lowered to assess coccyx area ..."

On 6/27/22 at 11:11 AM, Staff C Wound Care Specialist documented: Wound #1 sacrococcygeal. Wound Type: Stage 3 pressure injury. Dimensions:4 X 4.5cm. Wound bed: full thickness wound, an area covered with thin slough. Undermining erosion under the skin bed: None. Tunneling: None. Peri-wound skin: Intact. Drainage: Minimal Serous. Braden Score: 14.

There is no documentation in the medical record by Staff A, Wound Specialist, of an identified clinical status or a patient limitation causing the lack of an assessment on 6/3/22. The patient did not receive an assessment of her pressure injury until 06/27/22, 24 days later, when her pressure injury had progressed to a stage 3.

Review of job description for Wound, Ostomy, and Continence Nurses Society (WOCN) states: Duties and Responsibilities:
6.6: Conducts health assessment interview focused on wound, ostomy, continence related care.
6.7: Performs focused physical assessment.

Review of facility's policy titled: "MSHS Pressure Injury Wound Management Prevention and Treatment for Adults" Effective September 2021 states: "If the RN is unable to assess due to patient's clinical limitations/instability-the RN must document a reason in the medical record."

During interview on 09/12/22 at 10:32 AM, Staff A, Wound Care Specialist stated:
"The bed was very high, and I am short ...No, I did not follow up. We wait for the nurse. We don't necessarily follow patients. We put the 'onus' on the nurse to let us know what's going on ..."

At interview on 9/12/22 at 2:59 PM Staff D, VP of Nursing stated: "...The Wound Care Nurse (WCN) is supposed to contact the primary Nurse, and both assess together ...If patient refuse would try again. There should have been an escalation either by the WCN or the primary Nurse. What should have happened is the WCN shouldn't have closed out the consult ..."

This finding was shared with Staff I, Director of Quality and Regulatory Affairs and Staff D, Vice President of Nursing during the survey.