HospitalInspections.org

Based on review of facility policy, medical record review, and interviews the facility failed to assess skin pressure areas and failed to prevent development of a pressure ulcer for 1 patient (Patient #4) of 3 patients reviewed for pressure ulcers of 9 patients reviewed.

The findings include:

Review of the facility's policy "Skin and Wound Care" effective 6/2020 showed "...Skin and Wound Care Protocol Algorithms Prevention Protocol...Assess-Categorize-Intervene...Assess...On admission...Every shift...Consider the interventions below for prevention as indicated by patient assessment...Turn patient every 2 hours or encourage activity/turning...Stage 1-Non-blanchable, Suspected Deep Tissue Injury...Prevention Protocol Plus...Assess wounds Daily and Change dressing Q [every] 7 days or PRN [as needed]..."

Medical record review of an Inpatient Rehabilitation Center (IRC) history and physical showed Patient #4 was admitted to the IRC on 9/14/2023 after undergoing an Ascending Aortic Repair and Aortic Valve Replacement on 8/22/2023. The patient had a prolonged hospital course post operatively complicated by post op Acute Kidney Injury. The patient had a prior medical history of Chronic Obstructive Pulmonary Disease on home oxygen 3-4 Liters (flow of oxygen) via nasal cannula and BiPap (used for sleep disorder in which breathing repeatedly stops and starts) at night, Gastroesophageal Reflux Disease, Type 2 Diabetes Mellitus, Congestive Heart Failure, Hypertension, Atrial Fibrillation on Eliquis (blood thinner), and Depression. Patient #4 also developed Hypernatremia (increase sodium levels in blood), Delirium (confusion), and Anemia (low blood) which required blood transfusions. during the hospitalization. On admission to the IRC, Patient #4 had swelling of both lower extremities and her left arm was swollen and weeping (leaking fluid). Patient #4's rehabilitation barriers included "...Debility with decrease in functional mobility, gait [walking] impairment, risk for falls, infection, immobility, impaired ADLs [activities of daily living], injury, skin breakdown..." Patient #4 required partial to moderate assistance (Helper lifts, holds or supports trunks or limbs, but provides less than half the effort) for rolling left and right, sit to lying, lying to sitting on edge of bed; and Substantial/Maximal Assistance (Helper lifts or holds trunk or limbs and provides more than half the effort) for sit to stand, chair/bed to chair transfer, toilet transfers, and walking.

Medical record review of nursing daily wound assessments showed Patient #4 had a pressure ulcer (wound caused by prolonged pressure)/ injury on her coccyx (tailbone) on admission on 9/14/2023. The wound description showed the area was soft and blanchable (becomes pale with pressure). A silicone foam dressing (may be used to prevent pressure ulcers) was placed over the site. On 9/16/2023, the area was described as red, blanchable, and intact (no skin breakdown). The site was covered with a silicone foam dressing. There was no documentation to indicate the skin under the silicone foam dressing was assessed from 9/17/2023-9/21/2023.

Medical record review of an ADL flowsheet for 9/14/2023-9/21/2023 showed no documentation to indicate Patient #4 had been turned and repositioned.

Medical record review of an Intensive Care Unit daily wound assessment dated 9/23/2023 showed Patient #4 had a Stage 1 Pressure Ulcer and Deep Tissue Injury to the Sacral (bony area at the base of the spine), Coccyx, and left and right buttocks.

During an interview on 10/11/2023 at 4:06 PM, in the conference room, the Wound Care Nurse stated the foam silicone dressings placed for pressure ulcer prevention purposes were left on for 7 days. The wound care nurse stated the dressings were designed to be able to lift the edge of the dressing and assess the skin underneath the dressing.

During an interview on 10/11/2023 at 4:22 PM, in the conference room, the Quality Director confirmed there was no documentation Patient #4's pressure area on the coccyx had been assessed from 9/17/2023-9/22/2023 and confirmed there was no documentation to show the patient had been turned and repositioned every 2 hours.

During a telephone interview on 10/12/2023 at 1:45 PM, the IRC Director stated he had reviewed Patient #4's medical record and the "...documentation wasn't very good..." with the coccyx area. The IRC Director agreed there was no documentation to show the area on Patient #4's coccyx had been checked by nursing staff from 9/17/2023-9/22/2023. The IRC Director confirmed the skin under foam dressings was to be assessed every shift and confirmed the policy for wound and skin assessments was not followed for Patient #4.