HospitalInspections.org

Based on Based on "National Pressure Ulcer Advisory Panel" (NPUAP) reference guide, facility policy review, medical record review, observation and interview, nursing services failed to accurately assess pressure injury wounds, ensure timely revision of interventions for declining wounds, and failed to use a consistent method for measuring pressure injury wounds for 2 of 3 (Patients #1 and 3) sampled patients with pressure injuries.

The findings included:

1. Review of the NPUAP quick reference guide revealed, "...A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear...Assessment of Pressure Ulcers and Monitoring of healing...Reassess the individual, the pressure ulcer and the plan of care if the ulcer does not show signs of healing...Expect some signs of pressure ulcer healing within two weeks...Adjust expectations for healing in the presence of multiple factors that impair wound healing...Pressure Ulcer Assessment...With each dressing change, observe the pressure ulcer for signs that indicate a change in treatment is required (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications)...Address signs of deterioration immediately...Signs of deterioration (e.g., increase in wound dimensions, change in tissue quality, increase in wound exudate or other signs of clinical infection) should be addressed immediately...Select a uniform, consistent method for measuring wound length and width or wound area to facilitate meaningful comparisons of wound measurements across time...Older Adults... Ensure pressure ulcers are correctly differentiated from other skin injuries, particularly incontinence associated dermatitis or skin tears..."

2. Review of the facility's "Pressure Injury Prevention and Treatment-Adult" policy revealed, "...Purpose: To assess and manage skin care related to pressure injury prevention for all adult patients...RNs assess skin integrity and pressure injury risk factors within 8 hours of patient admission...ongoing monitoring and assessment occur every shift...Document the following in the patient's medical record: A. Wound characteristics: 1. Location; 2. Size/Depth; 3. Exudate...4. Wound tissue-color, presence of eschar, slough; 5. Condition of surrounding skin...B. Pressure injury prevention interventions to include but not limited to...3. Shear/friction reduction...
A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence...The injury can present as intact skin or an open ulcer...The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear...
Stage 1 Pressure Injury: Non-blanchable erythema of intact skin...
Stage 2 Pressure Injury: Partial-Thickness skin loss with exposed dermis...The wound bed is viable, pink r [or] red, moist, and may also present as an intact or ruptured serum-filled blister...Granulation tissue, slough and eschar are not present...
Stage 3 Pressure Injury...Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible...
Stage 4 Pressure Injury: Full thickness skin and tissue loss...with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer...
Unstageable Pressure Injury...Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar...
Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration...Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister...If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4)..."

Review of the facility's "Wound Care, (Advanced) Specialty Dressings" policy revealed, "...To provide guidelines for maintenance or improvement of skin/wound integrity and/or wound healing...Clinical Implications: Notify attending MD service (or Complex Wound Service when applicable) of any deterioration...Necrotic tissue...Loss or change in granulation tissue...Document in the medical record...Wound characteristics: 1. Location; 2. Size/Depth; 3. Exudate...4. Wound tissue-color, presence of eschar, slough; 5. Condition of surrounding skin..."

Review of the facility's "Braden Scale for Predicting Pressure Ulcer Risk" policy revealed a patient is at risk of developing pressure injuries with a score of 18 or less and the should should initiate pressure injury prevention guideline.

3. Medical record review revealed Patient #1, an 80 year old male, was transferred to Hospital #1 from Hospital #2 as a direct admit on 2/2/19 with diagnoses that included Basal Cell Carcinoma, Lymphoma, Hypertension, Diabetes, Deep Vein Thrombosis, Urinary Retention, Diarrhea and Back Pain/Cord Compression.

Review of the nursing assessment flowsheet dated 2/2/19 (Saturday) at 8:23 AM revealed Registered Nurse (RN) #1 documented Patient #1 had a urinary catheter, a Braden Score of 15 and "...erythematous; buttocks; groin; perineal; pink; diffuse; moisture associated skin breakdown, bilateral buttocks" skin impairment. RN #1 documented the interventions of "absorbent underpad [incontinent pad]; barrier ointment; barrier cloths...heel foam dressing; pillows wedges; sacral foam dressing; turn and reposition system..." The intervention of "slick sheets" was also documented. There was no documentation of the wound characteristics in accordance with the facility policy.
At 12:33 PM, RN #1 documented a wound ostomy (WOCN) consult order, "...Reason for Consult: Wound-Stage 1, Stage 2 and Deep Tissue injuries [DTI] (nonblanchable skin, shallow wound, deep purple discoloration)... Wound-Moisture associated skin breakdown/dermatitis...buttocks, groin, feet..."
There was no documentation of the characteristics of the wounds referred to as Stage 1, Stage 2 and DTI in the above wound consult order.

Review of the nursing "Default Flowsheet Data (all recorded)" notes dated 2/4/19 at 10:45 AM revealed moisture associated skin damage (MASD) to the left and right buttocks measuring 6 centimeters (cm) x 5 cm x 0.2 cm. At 9:05 PM the left and right buttock area "...Incision/Wound Appearance...Pink/red; Open, Healing..."

Review of the Wound Ostomy Continence Nurse (WOCN) note dated 2/4/19 at 10:45 AM revealed WOCN #1 saw Patient #1. WOCN #1 documented, "Reason for Visit: skin tears and masd feet thighs buttocks groin...Wound Type: Moisture associated skin damage Location: Buttocks Wound Location Descriptor: Left; Right...Wound Appearance Clean; Moist; Pink; Red...Peri-wound Assessment Fragile; Maceration; Pink; Red; Rash; Scaly/flaky...MASD and fungal rash..." The WOCN documented the wound to the buttocks measured 6 centimeters (cm) x 5 cm x 0.2 cm and the wound dressing was Silicone and Foam.
Review of the 2/4/19 wound pictures revealed the buttocks had red/purple discoloration with small open areas. It was not clear what 6cm x 5cm x 0.2cm area was described in the wound measurements.

Record review revealed an order dated 2/8/19 (Friday) for a complex wound consult.

Review of the nursing assessment flow sheet dated 2/9/19 (Saturday) at 6:00 PM revealed, "Sacral wound worsened today compared to media images from 2/4...Sacral mepilex removed d/t [due to] frequent stool ooze...Unable to place BMS [Bowel Management Services]...d/t impaction..."

Record review revealed on 2/9/19 (Saturday) Advanced Practice RN (APRN) #1 ordered, "Venelex added q [every] 6 h [hours]...Complex wound consulted for eval of suspected deep tissue injury [sdti]...Consider pressure injury w/ impaired skin integrity as entry point for infection..."

Review of the nursing "Default Flowsheet Data (all recorded)" notes dated 2/9/19 revealed moisture associated skin damage to the left and right buttocks with the "Incision/Wound Appearance...purple, red, full thickness open in areas..."

Review of the 2/9/19 wound pictures revealed bilateral buttock involvement with areas of black/purple skin, open areas with red wound bed, and open areas with black/purple deep tissue discoloration underneath the open areas. The right buttock area had a larger area of involvement and the sacral/coccyx area had darkened discoloration.

Review of the nursing assessment flow sheet dated 2/10/19 revealed, "...Sacral wound not worsened but does appear to be devolving to reveal deeper injury, applying venelex..."

Review of the nursing "Default Flowsheet Data (all recorded)" notes dated 2/10/19 revealed moisture associated skin damage to the left and right buttocks with the "Incision/Wound Appearance...Open; Pink/red...dark purple insome [in some] areas..."

Review of Registered Dietitian (RD) #1's nutritional consult dated 2/10/19 documented, "...Skin: stage 3 sacral ulcer..." There was no documentation how the RD identified the patient had a stage 3 sacral ulcer.

Record review revealed on 2/11/19 the complex wound consult order was canceled and replaced with an order for a Simple wound consult. The wound was reclassified from "Moisture Associated Skin Damage Buttocks Left; Right" to "Pressure Injury Buttocks Left; Right." On 2/11/19 WOCN #2 conducted the simple wound consult, documented the patient probably had inadequate nutrition, a Braden Scale of 13 and the wound was treated with Venelex 4 times daily. WOCN #2 documented, "...Pressure Injury Buttocks Left; Right...Staging Deep tissue injury...Appearance Red; Purple; Moist; Partial Thickness...Peri-wound Assessment Scaly/flaky; Purple...The right and left buttocks appears as deep tissue injury from pressure or possibly moisture associated skin damage with shear/friction damage...currently has partial thickness skin loss over buttocks with some dark purple discoloration...Nursing...apply Venelex QID [four times daily] to buttocks...apply Ketoconazole BID [twice daily] to the erythema and scaly rash areas to buttocks...may apply a layer of triple paste BID to buttocks/perineum for incontinence..." WOCN #2 documented the right and left buttock wound measured 13 cm x 10 cm.
There was no documentation of additional interventions for the shear/friction damage.

Review of APRN #4's note dated 2/12/19 revealed, "...Unstageable skin breakdown on sacrum. Black/red dried areas of skin with quarter sized open area draining scant amount of sero-sang fluid. Yellow wound bed..."

Review of APRN #4's note dated 2/13/19 revealed, "...Unstageable skin breakdown on sacrum. Black/red dried areas of skin with quarter sized open area draining scant amount of sero-sang fluid. Yellow wound bed..."

Review of APRN #5's note dated 2/14/19 revealed, "...Unstageable skin breakdown on sacrum. Black/red dried areas of skin with quarter sized open area draining scant amount of sero-sang fluid. Yellow wound bed..."There was no documentation the signs of deterioration, black areas and yellow wound bed, were immediately addressed in accordance with the facility policy.

Review of the nursing "Default Flowsheet Data (all recorded)" notes dated 2/14/19 at 8:00 PM and 9:30 PM revealed, "...Pressure Injury Buttocks Left; Right...Deep tissue injury...Appearance Pink/red...Drainage Scant; Serosanguinous..."

Review of the nursing "Default Flowsheet Data (all recorded)" notes dated 2/15/19 at 9:00 AM revealed, "...Pressure Injury Buttocks Left; Right...Deep tissue injury...Appearance Pink/red...Drainage Scant; Serosanguinous..." The 2/15/19 note at 9:30 PM revealed, "...Pressure Injury Buttocks Left; Right...Deep tissue injury...Appearance Pink/red; Black..."

Review of RD #1's nutritional consult dated 2/15/19 documented, "...Skin: stage 3 sacral ulcer..." There was no documentation how the RD identified the patient had a stage 3 sacral ulcer.

Review of the nursing assessment flow sheet dated 2/18/19 at 6:17 AM revealed a message sent to wound care, "...Can wound care come see patient again? sacral wound seems to be getting worse..."

Review of WOCN #1's note dated 2/18/19 at 1:47 PM revealed documentation the patient's Braden scale was 13 and friction and shear was a problem. WOCN #1 documented an unstageable pressure injury to the right and left buttocks that measured 10.5 cm x 11 cm. WOCN #1 documented the wound appearance was "Moist; Pink; White; Yellow; Dry; Brown; Eschar; Full thickness..." and the peri-wound assessment was "Blanchable erythema; Fragile Maceration; Non-blanchable erythema; Purple..." WOCN #1 applied Venelex to the wound, triple paste anti-fungal to the peri-wound and a silicone foam dressing to the buttock wound. WOCN #1 documented, "...His wife and daughter are at bedside and upset because they had wanted additional wound follow up at the end of last week for wound decline, and they were concerned about the mepilex sacral dressing causing stool trapping and excess moisture to his wound bed..." There was no documentation of additional interventions for the shear/friction damage, the patient's wound continued to deteriorate and developed eschar (dead tissue).

Review of APRN #2's note dated 2/18/19 at 1:47 PM revealed the patient was seen for a plastic surgery wound initial eval. The APRN documented, "...Per family last week he [Patient #1] went to CT [computerized tomography] and during transfer his 'bottom got bumped' since then they have noticed the appearance of the eschar..." The APRN documented a coccyx wound measuring 4 cm x 6 cm with black eschar and the periwound tissue was excoriated and had erythema. The APRN ordered the coccyx pressure injury to be cleansed with Normal Saline, pat dry, apply Santyl two times daily, cover with ABD [abdominal dressing] and secure with medipore tape; Venelex to moisture associated breakdown 4 times a day. The APRN documented, "...will see pt again later this week to eval for possible debridement after performing wound care consistently to hopefully soften the eschar..."
The note revealed, "...The wound care team is here Monday - Friday 6am-3pm and will not answer pages/messages during non business hours, weekends or holidays. If there is a surgical urgency/emergency, consider consultation with the appropriate surgical service..."

There was no documentation the incident of the patient's bottom being bumped during transfer to CT was addressed or preventative interventions implemented to prevent further incidents.

Review of the 2/20/19 wound pictures revealed the buttocks, sacral and coccyx area were discolored; a large brown/black necrotic area over the sacrum; an open area to the left buttock; and an open area to the right buttock.

Review of APRN #3's note dated 2/20/19 revealed APRN #3 performed a debridement procedure to the patient's coccyx wound. The APRN documented, "...Excisional debridement of coccyx wound of devitalized, necrotic tissues using scissors and forceps down to bleeding muscle...Wound measurements before debridement 4x6. Wound measurements after debridement 4x6x1.5cm..."

Review of RD #1's nutritional consult 2/20/19 revealed, "...Skin: stage 3 sacral ulcer..." There was no documentation how the RD identified the patient had a stage 3 sacral ulcer.

Review of the nursing "Default Flowsheet Data (all recorded)" notes dated 2/22/19 revealed, "...Pressure Injury Buttocks Left; Right...unstageable...open; Pink/red; Black; Yellow..."

Review of RD #1's nutritional consult dated 2/25/19 revealed, "...Skin: stage 3 sacral ulcer..." There was no documentation how the RD identified the patient had a stage 3 sacral ulcer.

Review of the nursing "Default Flowsheet Data (all recorded)" notes dated 2/25/19 revealed, "...Pressure Injury Buttocks Left; Right...unstageable...open; Pink/red; Yellow; Black..."

Review of the nursing "Default Flowsheet Data (all recorded)" notes dated 2/26/19 revealed, "...Pressure Injury Buttocks Left; Right...unstageable...open; Healing..."
There was no documentation the pressure injury wound was assessed in accordance with the facility policy.

Review of the Discharge Summary dated 2/26/19 revealed Patient #1 was discharged to a Rehab facility.

Review of the receiving Rehab facility's wound and pressure injury assessment dated 2/26/19 revealed Patient #1 had a sacral pressure injury. The pressure injury was assessed to be 10.5 cm x 9.0 cm and the wound bed was 75 % covered with necrotic eschar tissue and a moderate amount of serosanguinous drainage.

In an interview on 2/28/19 beginning at 9:15 AM, in conference room #151, WOCN #2 stated she measured/assessed the wound on 2/11/19. WOCN #2 stated she measured the patient's entire buttock area as 1 wound. WOCN #2 stated that WOCN #1 saw the patient on 2/4/19, measured the wound as 5 cm x 6 cm and does not know how or what was measured during that visit. WOCN #2 stated on 2/8/19 ordered a wound consult. We work Monday-Friday and we will not see a patent until Monday.

4. Medical record review revealed Patient #3, a 39 year old male, was was admitted to the hospital on 1/30/19 with diagnoses that included Pneumonia, Hodgkin lymphoma, Anxiety, Palliative Care and Dyspnea.

Record review revealed on 2/17/19 a sacral pressure injury was identified and described as a stage 2.
Review of the 2/15/19 wound pictures revealed a triangular type area approximately 1.5 inches x 1 inch, a yellow material in the center and surrounded by pink tissue.

Record review revealed a wound assessment dated 2/28/19 at 7:53 AM that documented the sacral pressure ulcer was a stage 2. There were no documented measurements for this sacral pressure wound.

Observations on 2/28/19 at 2:02 PM revealed Patient #3 had a triangular type sacral area with a small yellow material in the center. The yellow material was surrounded by pink closed skin.

In an interview on 2/28/19 at 2:50 PM, in conference room 151, the Director for Adult Performance Management and Improvement stated there were no measurements performed on the sacral pressure injury and no one from WOCN had seen the patient.

5. In an interview on 2/28/19 at 2:50 PM, in conference room 151, the Director for Adult Performance Management and Improvement stated skin assessments should be performed every shift.