HospitalInspections.org

Based on hospital policy reviews, standard order set review, medical record review and staff interviews the hospital nursing staff failed to provide preventative wound care measures for 2 of 4 sampled medical records with wound care needs. (Patient #2, Patient #12)

Findings included:

Review of the hospital policy titled "Skin Breakdown Prevention and Wound Treatment Policy" last revised May 2020 revealed "...Policy: Patients will be assessed for their risk of skin breakdown and appropriate interventions put into place... Skin abnormalities and significant wounds should be identified upon admission or as soon as evident during the hospital stay... Full assessment of wounds will be conducted and documented upon admission, every Wednesday, and first discovery... To facilitate a prompt and consistent plan of care, a nurse should initiate orders for preventive measures on patients with Braden score of < 18 or with a pressure injury (PI) present using the Skin Breakdown Prevention/Treatment (SBPT) Order Set...4. Dressing assessments: Once each shift. PRN (as needed) wound care to be completed if appropriate...5. Prevention: initiate SBPT (skin breakdown prevention/treatment) Order Set for Braden < 18 and/or if a PI (pressure injury) wounds present...7. Communication: Notify the medical provider of the presence of wounds upon discovery, especially pressure injuries (PIs), and document communication details in the EMR (electronic medical record) ...9. WOCN (wound ostomy continence nurse) consult: Place order in (named EMR) for all Hospital Acquired Pressure Injuries (HAPIs)...If uncertain, call WOCN to clarify appropriateness or order WOCN consult and describe needs..."

Review of the "Wound Ostomy Continence RN (Registered Nurse) Consult Guide" no review date, revealed "...Please use guide below to decide if a WOCN consult is warranted. Order consult in (named electronic medical record system)....Order a WOCN consult if: Hospital acquired pressure injury of any stage...Doctor has requested WOCN input...PLEASE NOTE: Doctors/NPs (nurse practitioners)/PAs (physician assistants) must be notified by unit nurses as soon as any signs of infection are present. Please do not wait for wound care RN to come, it may take 2 business days..."

1. A closed medical record review was completed on 07/20/2022 for Patient #2, an 85-year-old male who was admitted on 05/16/2022 for weakness and right foot discoloration. Review of the History and Physical dated 05/16/2022 at 1638 by Physician's Assistant (PA) #1 revealed "...Probable occlusion of the right dorsalis pedis artery..." Review of the initial Nursing Skin Assessment completed 05/16/2022 at 1709 by RN #2 revealed "...Wound due to pressure on admission?...No...Braden Score (a score of 18 or less indicates at risk status for pressure injury), 16..." Record review revealed there were no skin pressure injuries documented on admission. Review of the Skin Breakdown Prevention/Treatment (SBPT) Order Set for Patient #2 dated 05/16/2022 at 1759, implemented by RN #2 and signed by MD #11 revealed 4 orders indicated for Patient #2: "...1. Communication: Notify provider of the presence of any wounds due to pressure...2. Patient Care: Turn Patient POC (plan of care) 12X (times)/Day, Remind or assist patient in repositioning every 2 hours....3. Offload Heels, q (every) shift-8 hours, Elevate heels continuously while in bed...4. GeoMatt (Chair cushion when up in chair)." Review of the Nursing Skin Assessment for Patient #2 dated 05/21/2022 at 2134 by RN #3 revealed "...change in skin color-reddened RLL (right lower leg)...Braden score 16..." Record review of the Wound Assessment dated 05/23/2022 at 1900 by RN #9 revealed Wound #1: a surgical incision status post an Angiogram to the right lower leg, "open to air -R lower leg, coban wrap applied per (named physician) orders", and Wound #2: "... R anterior-multiple scattered foot, blister..." Review of Physician Order dated 05/26/2022 at 1503 by Family Nurse Practitioner (FNP) #4 revealed "...Physician ordered, Dr. (named) podiatry recommending betadine painting to Rt. (right) toes necrosis to avoid wet necrosis; also has other open areas related to ischemia (surgical intervention pending), Consultation and Management...Wound Care Daily, Paint rt. toes with betadine solution daily..."(3 days after discovered by the nurse.) Record review revealed the 05/26/2022 WOCN consult ordered by the provider for the right toes was not completed. Review of Nursing Progress Note dated 05/27/2022 at 0757 by RN #5 revealed Wound #3: "...(Right Anterior, Multiple scattered Foot) : Other: popped blister/skin tear, Skin Symptoms: Change in skin color, Other: change in skin color BLE, top of right foot-skin tear, right shin mepilex (wound dressing)" Record review revealed a WOCN consult was not initiated by the nurse for Wound #3, and no physician notification was documented. Review of Nursing Progress Note dated 05/30/2022 at 0850 by Licensed Practical Nurse (LPN) #7 revealed "Skin Symptoms: Change in skin color, Other: change in skin color BLE, top of right foot-skin tear, right shin mepilex, right buttocks has dark color area with a little break in skin." Review of Wound Assessment of Wound #4: dated 05/27/2022 at 1345 by RN #9 revealed " Right Toe, Other: gangrene." Record review revealed Patient #2 had surgery on 06/01/2022 for a right above the knee amputation. Review of Wound Assessment for Wound #5 first documented on 06/01/2022 at 1600 by RN #2 revealed the surgical incision from above the knee amputation of the right lower extremity: "Right upper leg: gauze bandage C&D (clean and dry), surgical incision-pressure dressing" Record review of surgical wound dressing care for Wound #5 was completed by the surgeon from 06/01/2022 through 06/08/2022. Record review revealed Surgeon, MD #17 transferred care to the Hospitalist, MD #16 on 06/09/2022 and dressing care for Wound #5 was not ordered. Record review revealed dressing care for the surgical Wound #5 was inconsistent from 06/09/2022 through 06/17/2022. Review of the Wound Assessment for Wound #6 first documented on 06/02/2022 at 0745 by RN #10 revealed "R buttock, pressure injury", Wound #7: "Posterior Penile, Stage II, cleaned with soap and water" and Wound #8: "L (left) Plantar heel-purple heel-boot, unstageable..." Record review revealed a WOCN consult was not initiated by the nurse for Wounds #6, #7, and #8, and no physician notification was documented. Record review failed to reveal an assessment or wound care provided for Wound #7 from 06/09/2022 through 06/12/2022 (4 days). A WOCN consult was ordered on 06/06/2022 at 1032 by MD #12 "consult WOCN, sacrum" Review of the Wound Care Note dated 06/06/2022 at 2000 by WOCN RN #15 revealed "...1) Right buttock has an unstageable PI...2) Left Buttocks (Wound #9), 3)Left posterior heel, has an unstageable, 4) Right thigh...Rec's (recommendations)-Bil (bilateral) buttocks-clean with gauze and wound cleanser or bath cloth and allow to dry, then apply Triad Coloplast (skin protectant) cream to bil. buttocks and medial thigh, TID (three times a day) and prn after toileting...Rec's - Left posterior heel-Leave open to air and keep heel floated as much as possible on pillows..." Record review revealed Wounds #6, #7, #8, and #9 were hospital acquired pressure injuries with no provider communication/notification when initially documented by the nurse. Record review revealed 06/06/2022 was the only visit by the WOCN to follow up on pressure injury progress for wounds #6, #7, #8, and #9 from 06/06/2022 through 06/17/2022 (11 days). Turning and repositioning for Patient #2 was reviewed from 05/17/2022 through 5/30/2022 and revealed 7 of 12 days Patient #2 was not turned per SBPT order set (12X/Day). Record review revealed Patient #2 was discharged to a skilled nursing facility on 06/17/2022 at 1839.

Request to interview RN #10 revealed she was unavailable for interview.

Interview on 07/20/2022 at 1510 with WOCN, RN #15 revealed "...when I went to see Patient #2 after the first WOCN consult was ordered I learned Patient #2 had refused right foot skin care and I did not complete the consult..." Interview revealed RN #15 did not notify a provider the consult was not completed. Interview revealed RN #15 consulted with Patient #2 on 06/06/2022 per physician order and did not follow up on hospital acquired pressure injuries #6, #7, #8, and #9 the following 11 days until discharged. Interview revealed ". I normally do follow up on hospital acquired pressure injuries every 3 days, but I didn't, and I don't recall why..." Interview revealed the WOCN did not complete a consult for Patient #2 as ordered on 05/26/2022.

Interview on 07/21/2022 at 1505 with RN #5 who cared for Patient #2 and identified Wound #3 revealed "...new wounds require us to notify the physician. We are able to treat stage I and II wounds on the floor. We consult the WOCN for stage III, IV, and V. If the Braden score is 18 or below, we turn patients every 2 hours. I try to document communication and turning, I don't recall if I documented or not...I don't remember if I reported the wound ..." Interview revealed hospital policy was not followed.

Interview on 07/22/2022 at 1115 with Director of (named) floor revealed her expectation for following skin breakdown prevention/treatment (SBPT) order set: "...it does seem we dropped the ball...Nurses should be notifying physicians with any change in condition to see if anything needs to be addressed, skin breakdown in this case. All care should be documented..." Interview revealed hospital policy for reporting hospital acquired pressure injuries and implementing WOCN consults were not met.

Interview on 07/22/2022 at 1145 with Chief Nursing Officer revealed "...the WOCN should see all consults. The RN should notify the provider of any stage hospital acquired pressure injury, and document it. The Skin Breakdown/Wound Treatment Order Set/ was to be followed, and all interventions documented. When the nurse identified a HAPI (hospital acquired pressure injury) they should consult the WOCN immediately, notify the physician and document it..." Interview revealed hospital policy was not followed.

Interview on 07/20/2022 at 1120 with Hospitalist, MD #16 revealed patients are seen daily by the physician, and are available to the nursing staff in house and by phone for any patient needs. Interview revealed if the nurse needed dressing care orders she would notify the hospitalist for orders. Interview revealed nursing staff should report any hospital acquired pressure injuries or changes in condition to the physician as soon as they are discovered.



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2. Open medical record review on 07/21/202 revealed Patient #12 was a 51-year-old male admitted on 05/27/2022 at 0916 with a diagnosis of Small Bowel Obstruction. Review of the History and Physical (H&P) dated May 27, 2022 at 0827, completed by the admitting medical provider revealed "...Skin: warm and dry. Negative for open wounds nor skin ulcers ..." Record review revealed the hospital admission Nursing Assessment for Patient #12 was documented to have skin intact, no skin impairments. Record review of the Nursing Flowsheet on 06/09/2022 at 0800 revealed "Patient Position Semi-Fowler's." The next documented position was on 06/09/2022 at 2000 as "Patient Position: Foot of bed elevated, Head of bed elevated, Lying on left side." Record review of the Nursing Flowsheet on 06/10/2022 at 1904 revealed Patient #12 was noted to have a left buttocks skin tear treated with a Mepilex (for wounds) dressing. Record review revealed on 06/25/2022 the Hospital Acquired Pressure Injury (HAPI) was documented as "Bilateral Coccyx, unstageable injury" by the patient's primary day-shift RN # 12. Record review failed to reveal a consult for the Wound Ostomy and Continence Nurse (WOCN) until 07/20/2022 for "Sacral/coccyx wound" for Patient #12. Record review revealed documentation of turning and repositioning was not consistent with policy. Review revealed on 07/20/2022 at 1144, the WOCN documented "...pt. (patient) had a stage 2 wound to the sacral/coccyx aspect ...Reason for Consult to assess sacral/coccyx wound ..." Review of the WOCN Progress Notes revealed on 07/20/2022 at 1144, Patient #12 was written for recommendation of care for the Hospital Acquired Pressure Injury.

Interview with Patient #12 on 07/20/2022 at 1000, revealed the patient had developed a Hospital Acquired Pressure Injury during his admission. Interview revealed Patient #12 had varying levels of strength and at times needed assistance from staff to reposition in bed. Interview revealed assistance with turning and repositioning had been inconsistent since admission.

Interview with a Wound Champion RN #13 on 07/20/2022 at 0948, revealed " ...If an RN identified a HAPI, it should be reported to the WOCN for verification ..."

Interview on 07/22/2022 at 1145 with Chief Nursing Officer revealed "...the WOCN should see all consults. The RN should notify the provider of any stage hospital acquired pressure injury, and document it. The Skin Breakdown/Wound Treatment Order Set/ was to be followed, and all interventions documented. When the nurse identified a HAPI (hospital acquired pressure injury) they should consult the WOCN immediately, notify the physician and document it..." Interview revealed hospital policy was not followed.

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