HospitalInspections.org

Based on policy review, medical record review, and interviews, nursing staff did not follow facility policy for skin assessment and wound prevention for 5 of 13 patients (Patients #1, #4, #14, #16, and #17). Lack of assessment and implementation of wound care prevention strategies can lead to adverse patient events.

Findings Include:

Review of the policy "Skin and Wound Care; Skin Assessment and Wound Prevention Guidelines" effective 06/30/2020 revealed a Head to Heels skin assessment (Four Eyes Assessment) will be completed on admission, each shift, transfer to another unit/facility, and with any change in patient condition. The Braden Pressure Ulcer Risk Assessment Tool will be utilized to identify patients who are at risk for skin breakdown and to identify the risk factors which place those patients at risk. It will be completed within 4 hours of admission to medical- surgical units, 2 hours to Intensive Care Unit/Cardiac Care Unit, then daily or upon any change in patient condition. A score of 18 or less indicates the client is at risk for the development of pressure injuries, implement preventive interventions.

Review of the medical record for Patient #1 revealed she arrived on 06/10/2022 at 09:14 AM at the Emergency Department (ED) via ambulance after falling and fracturing her left hip. The physical exam noted that the skin is warm and dry. Patient # 1 was admitted. At 06:19 PM, a "Four Eyes Assessment" skin assessment revealed no areas of pressure injury were found. On 06/12/22 Patient #1 underwent a left hip arthroplasty. From 06/16/22 to 07/25/22, the Wound Care team and other Specialist followed Patient #1's gradual worsening skin integrity throughout the hospitalization. Examples:
On 06/16/22 at 8:09 PM, a Wound Flowsheet Note indicates Coccyx with break in skin noted, thin tissue covering wound edges, center of wound red and moist. No further breaks noted around open area. The wound area measures 2cm x 3cm. Foam dressing was applied.
On 07/07/22 at 05:19 PM Endocrinology/Infectious Disease Provider Note indicates an infected Stage III sacral wound. On 07/25/22 at 02:25 PM, the Wound Care note indicates a Stage 4 wound 4.5 cm x 4 cm x 2.5 cm requiring a Vacuum (remove fluid from wound) dressing three times a week.
On 8/2/2022 at 07:03 AM, the Discharge Summary indicates that a pressure ulcer on the sacrum that became infected with VRE, which was treated with antibiotics. Patient # 1 had advance dementia and testing was very difficult. Patient # 1 ' s family opted for comfort measures. On 08/02/22, Patient #1 was pronounced deceased.

Review of Braden Scale scores for Patient #1 revealed he was identified as a high risk for pressure injury with a Braden score of 13 on 6/10/2022, and a pressure injury identified on 6/16/2022. On 08/01/22, a Braden Score of 9 is documented. Braden score assessments were not documented on 6/25/2022, 7/15/2022, and 7/28/2022.

Review of Four Eyes Assessment (Skin Assessments) for Patient #1 revealed no assessments were documented on 6/12/2022 at 12:14 PM, when Patient # 1was transferred from the operating room (OR) to three (3) West, and on 6/16/2022 at 3:16 AM Patient #1 was transferred from three (3) West to three (3) South.

Flow sheets and nursing notes for Patient #1 revealed turning and positioning is not documented every 2 hours from 6/12/2022- 6/18/2022; 6/23/2022-6/26/2022; 7/03/2022-7/05/2022; 07/16/2022-7/17/2022; and from 7/21/2022-07/28/2022. On 06/17/22 at 10:49 AM and 07/29/22, Provider orders are obtained to turn and position every 2 hours, or more frequently as needed (PRN), on alternating sides to offload bony prominences.

Review of the medical record for Patient # 3 revealed an admission on 04/27/22 with a pressure injury to the sacrum from 4/27/2022 to 5/25/2022, there is no evidence of turning and positioning every two (2) hours per policy.

Review of the medical record for Patient #4 revealed an admission on 5/24/22 and a Four Eyes Assessment was performed. On 05/26/22 and 05/30/2022, Patient #4 was transferred to other floors, however, no Four Eyes Assessment is documented on this day.

Review of the medical record for Patient # 14 revealed an admission on 01/05/23 and a Four Eyes Assessment was performed. On 01/10/23 at 12:40PM, Patient #14 was transferred from room 346 to the operating room and transferred back to room 346 on 1/10/2023 at 4:23 PM. No Four Eyes Assessment was documented on this day.

Review of the medical record for Patient #16 revealed an admission on 11/21/22 and a Four Eyes Assessment was performed. On 11/23/22 at 4:30 PM Patient # 16 was transfer to the Intensive Care Unit (ICU). No Four Eyes Assessment was documented on this day.

Review of the medical record for Patient #17 dated 12/28/22 for Patient #17 revealed upon admission, a pressure injury to the coccyx was noted. At 02:00 PM, a Four Eyes Assessment was performed. On 01/06/23 at 3:05 PM, Patient #17 was transferred from room 429 to the operating room, and transferred back to room 429 at 4:37 PM. No Four Eyes Assessment was documented on this day. Additionally, from 12/26/2022 to 1/11/2023, there is no evidence of turning and positioning every two (2) hours per policy.

Interview on 01/11/2023 at 02:30 PM with Staff (A), Director of Quality, verified the findings.