HospitalInspections.org

Based on record reviews, observations, and interviews, the hospital failed to ensure the RN supervised and evaluated the care of each patient as evidenced by:
1. failure to ensure skin condition/wounds were accurately assessed with the appearance documented in descriptive terms every shift, per hospital policy, for 2 (#2, #3) of 3 (#1, #2, #3) patients sampled for skin breakdown risk/wounds from a total patient sample of 5.; and
2. failure to maintain documentation of performance of every 2 hour turning/repositioning of patients at risk for skin breakdown, as per hospital policy, for 3 (#1, #2, #3) of 4 (#1, #2, #3, #4) patients sampled for skin breakdown risk/wounds from a total patient sample of 5.

Findings:

1.Failure to ensure wounds were accurately assessed with the appearance documented every shift.

Review of the hospital policy titled, "Wound Care Assessment, Staging, and Treatment of Pressure Injury", revealed the following, in part:
4. An order for the Pressure Injury Prevention and Management Adult order set is initiate: a. with a Braden score of 18 and below, b. patients age 70 and above, c. maximum risk in any category, and d. actual or suspected tissue injury.
Note: Braden score (Adult) of: 19-23 - not at risk; 15-18 - mild risk; 13-14 - moderate risk; 10-12 - high risk; 9 or below- very high risk.
5. During skin assessment: a. Remove sacral and heel foam, dressings, stockings, socks, SCDs, and other occlusive devices for skin assessment and re-applied after inspection. b. Special attention is given to bony prominences.
Note: Document a description of the pressure injury to include location, measurements, appearance, odor, amount, and color of drainage, and presence of undermining/tunneling.
Document in EMR: 1. Skin assessment and Braden score with initial admission assessment and then every shift.

Patient #2
Review of Patient #2's EMR revealed an admission date of 03/06/2022 with a chief complaint of altered Mental Status, a fever of 104.8 degrees Fahrenheit, and Septic Encephalopathy. Further review revealed the following co-morbid diagnoses: ESRD, Diabetes Mellitus Type 2, Hypertension, Neuropathy, great toe amputation, chronic skin ulcer, and history of multiple foot infections.

Review of Patient #2's wound care notes revealed the following:
03/15/2022 12:15 p.m.: Consulted for sacral wounds extending to bilateral buttocks. Wounds viewed in assessment photo. Recommendations: Assess wound/wounds every shift and document appropriately.

03/17/2022 2:27 p.m.: Assessed in wound care clinic. Consulted for right heel and sacrum.
Right heel deep tissue injury with blister measures 6 cm x 7 cm. Maroon and deep purple in color, boggy center.

Sacrum extending to bilateral buttocks deep tissue injury measures 7.5 cm x 12 cm, deep purple in color, friable texture, beginning to open to allow clean superficial wound base.

Recommendations: Assess wounds every shift and document appropriately. Continue repositioning by staff at least every 2 hours.

03/21/2022 4:45 p.m.: Right heel DTI with reabsorbed blister. Dark purple and maroon in color and remains with boggy center. Measures 8 cm x 9 cm.

Left plantar foot with DTI with re-absorbed blister dark purple and maroon in color.

Left heel: extending to Achilles DTI with re-absorbed blister. Dark purple maroon in color with dry, yellow, peeling center. Measures 8 cm x 3 cm.

Sacrum extending to bilateral buttocks and right ischium DTI measures 19.5 cm x 15.1 cm declaring itself with areas of black, soft, leathery eschar and clean red/pink, moist wound bed. Peri-wound remains dark purple in color with friable texture.

Recommendations: Consult surgery for evaluation. Assess wounds every shift and document appropriately. Continue re-positioning by staff every 2 hours.

03/24/2022 7:50 a.m.: Right heel DTI with re-absorbed blister now dark purple in color.
Right lateral ankle with superficial red, dry wound bed.

Left plantar foot DTI now dark purple in color.

Left Achilles DTI wound bed now dark purple in color with yellow peeling center.

Sacrum extending to bilateral buttocks and right ischium remains with area of black, soft leathery eschar and mixed areas of red, pink moist wound bed. Peri-wound remains dark purple in color with friable texture.

03/29/2022 12:40 p.m. Right heel with re-absorbed blister, dark purple in color. Measures 7.7 cm x 4.5 cm.

Right lateral heel wound resolved.

Left plantar foot DTI remains dark purple in color. Measures 4 cm x 4.5 cm.

Left Achilles DTI wound bed remains dark purple in color. Measures 8 cm x 10 cm.

Sacrum extending to bilateral buttocks DTI now with area of 80 % black, leathery eschar and 20% mixed areas of pink, moist wound bed. Peri-wound remains dark purple in color with friable texture.

Right Ischium now with 80% pink and 20 % yellow colored wound bed.

Review of Patient #2's nurses' notes revealed the following skin assessments:

03/06/2022 7:52 p.m. Initial admit Braden Skin Risk Assessment Score: 13; Patient is at increased risk of pressure injury: Yes; Deep Tissue Injury: Dry flaky, peeling, bilateral heels and old scabbing and scarring to sacrum.

03/07/2022 at 8:00 a.m. skin was noted to be dry flaky, scaly, with scarring to left arm. Coccyx was documented as scaling and a left foot ulcer was noted. Braden Score: 14. Further review revealed no descriptive asssessment of the left foot ulcer.
Additional review revealed the skin assessment documented on 03/07/2022 at 8:00 p.m. indicated the patient's skin was intact with no mention/descriptive assessment of the left foot ulcer; Braden Score: 13.

03/07/2022 10:18 p.m.: Peri-wound assessment documented as unable to assess with dressing clean, dry and intact. No reason documented for wound being unable to be assessed.

Patient #2 was moved back to medical surgical floor on 03/08/22 at 4:41 p.m. after having been in ICU

03/08/2022 4:45 p.m.: 1st skin assessment: after patient returned from ICU to the medical surgical floor: Sacrum ABD dressing; left foot ulcer, scaling to coccyx, right heel pressure injury documented as unable to assess (noted upon arrival back to floor). Dressing clean dry intact gauze to right heel; Braden Score: 14. Further review revealed no documented reason for failure to assess appearance of dressed areas/reason for being unable to assess right heel pressure injury upon arrival to the unit.

03/09/2022 8:00 p.m.: No skin assessment documented. Further review revealed no reason for failure to perform skin assessment.

03/10/2022 8:00 a.m.: Skin assessment documented as unable to assess with no reason for being unable to perform the assessment.

03/10/2022 10:18 a.m. Patient #2's heel was documented as dressing clean, dry, and intact to heel with no skin/wound assessment performed.

03/12/2022 8:00 a.m.: Skin: No documentation regarding sacrum with no reason documented for failure to assess sacral area. Right heel documented as dressing clean, dry, intact with Kerlix with no documentation of appearance of the heel.

03/12/2022 8:00 p.m.: Left heel deep tissue injury, right heel - dressing clean, dry, and intact with no documentation of appearance of wounds.

03/13/2022 9:00 a.m.: Deep tissue injury bilateral heels, right heel dressing changed with no description of wound appearance with dressing change.

03/13/2022 Night shift: No documented skin assessment. There was no reason documented for failure to perform an assessment.

03/14/2022 1:00 a.m.: Night shift: skin assessment: left heel deep tissue injury, right heel dressing clean, dry, intact, with no description of wounds documented. No assessment of sacrum documented. . There was no reason documented for failure to perform assessment.

03/14/2022 8:00 a.m.: Bilateral lower extremities scaling, and flaky. Bilateral heels and sacrum referenced with no other assessment/description - Braden skin risk assessment: 11. There was no reason documented for failure to perform skin/wound assessments.

03/14/2022 6:06 p.m. Pressure injury sacrum had foam on it as clean, dry, and intact, wife removed it. No assessment of sacrum documented.

03/16/2022 12:50 p.m.: Right heel documented as unable to assess with dressing documented as gauze clean, dry, and intact. Further review revealed no documentation of reason for wound being unable to be assessed.

03/17/2022 8:30 p.m.: Deep tissue injury right heel and sacrum. No assessment of sacrum documented. Documentation for right heel was unable to assess with gauze dressing with no reason documented for being unable to assess wounds.

03/23/2022 8:00 p.m. Right heel deep tissue pressure injury - dressing changed - new dressing, gauze, clean, dry, and intact. Further review revealed there was no description of the wound when the dressing was changed.

S2RNNav, assisting with Patient #2's EMR review on 04/11/2022, confirmed the above referenced findings.

03/26/2022 6:01 p.m. Pressure injury sacrum unable to assess clean, dry, intact.
8:00 p.m.: Deep tissue injury sacrum- no further assessment of wound appearance documented.
10:18 p.m.: Right heel - Clean, dry, intact dressing and peri-wound - no further assessment of wound appearance documented. Further review revealed no documented reason for being unable to perform an assessment of the appearance of the wounds.

03/29/2022 Night shift: No skin assessments documented. Further review revealed no documented reason for being unable to perform a skin assessment.

Findings referenced above for 03/26/2022 - 03/29/2022 for Patient #2 were verified per S3RNNav during EMR review on 4/12/22 at 9:50 a.m.

Patient #3
Review of Patient #3's EMR, assisted by S3RNNav and S4RNNav, revealed Patient #3 is a paraplegic (below T-7) who was admitted on 03/23/2022 with chief complaints of nausea, vomiting, and subjective fever and chills. Further review revealed the patient has a co-morbid diagnosis: of a 5.8 cm x 2.4 cm abscess around left hip, with osteomyelitis of left hip, left femur, and left acetabulum.

On 04/11/2022 at 11:40 a.m. Patient #3's wound care was observed being performed by S6Wound. Further observation revealed Patient #3 has the following wounds assessed/measured as follows:
Right proximal lateral ankle pressure injury measures 1cm x 0.8cm, superficial, 100% granulation.

Right distal lateral malleolus pressure injury measures 2cm x 1.8cm x 0.4cm, 25% slough and 75% clean red moist. No odor. Minimal drainage.

Left lateral ankle pressure injury measures 1.8cm x 1.5cm x 0.2cm. 10% slough and 90% clean
red moist. No odor. Minimal drainage.

Left lateral lower leg DTI is linear, dark purple brown in color, measures 5cm x 0.5cm and 3.5cm x 0.8cm, skin bridge between measures approximately 1cm.

Sacrum stage 4 measures 5.2cm x 4.5cm x 3cm, undermining from 4 o'clock to 5 o'clock with
Max depth of 2 cm at 5 o'clock, tunnel at 9 o'clock measures 2.8cm. Wound base is 75% clean
red moist, 25% slough (on Left)
Recommendations included: Assess wounds every shift and document appropriately. Continue repositioning every 2 hours per staff.

Review of Patient #3's EMR, assisted by S3RNNav and S4RNNav, revealed the following nursing skin assessments:
03/25/2022 8:23 a.m.: Skin assessment left heel wound not assessed.

03/28/2022 8:00 a.m.: Skin documented as follows: Sacrum and heels dressing clean, dry, intact with no documentation of appearance of wounds.

03/29/2022 Day shift: No skin assessment documented and no reason documented for failure to perform skin assessment. Further review revealed there was no documented skin assessment until 8:00 p.m.

03/31/2022 Night shift: Skin assessment: Stage 4 sacrum, bilateral ankles. Further review revealed no documented assessment of the appearance of the wounds.

04/01/2022 8:00 a.m.: Skin assessment sacrum dressing clean, dry, intact; Right pre-tibial - foam dressing; Left ankle - foam dressing. Further review revealed no documented assessment of the appearance of the wounds.

04/02/2022 Night shift: No documentation of appearance of wounds on patient's bilateral ankles and sacrum. Further review revealed no reason documented for failure to document appearance of the patient's wounds.

04/03/2022 Night shift: Left ankle - new dressing applied; Right ankle - new foam dressing; Sacrum Stage 4 - new gauze packed, ABD dressing clean, dry, intact. Further review revealed the appearance of the referenced wounds was not documented. Additional review revealed no reason documented for failure to document appearance of the patient's wounds.

Above referenced findings were verified during EMR review on 04/12/2022 and 04/13/2022 by S3RNNav and S4RNNav, who were assisting with Patient #3's record review.

In an interview on 04/12/2022 at 3:00 p.m. with S1SrDrMedSrg, she confirmed, per policy, dressings should be removed every shift to visualize and assess skin/wounds in order to document the appearance of the skin/wound. She said the dressing could then be re-applied after performing the assessment.

In an interview on 04/13/2022 at 9:34 a.m. with S7RN, she confirmed skin assessments and Braden skin risk assessments were performed every shift. She further confirmed if a wound is dressed the dressing should be removed in order to assess and document the appearance of wound.

2.Failure to maintain documentation of every 2 hour turning/repositioning of patients at risk for skin breakdown, as per hospital policy.

Review of the hospital policy titled, "Wound Care Assessment, Staging, and Treatment of Pressure Injury", revealed the following, in part:
4. An order for the Pressure Injury Prevention and Management Adult order set is initiate: a. with a Braden score of 18 and below, b. patients age 70 and above, c. maximum risk in any category, and d. actual or suspected tissue injury.
Document in EMR: 1. Skin assessment and Braden score with initial admission assessment and then every shift. 3. Repositioning of patient every two (2) hours.

Patient #1
Review of Patient #1's EMR, assisted by S3RNNav and S4RNNav, revealed an admission date of 04/07/2022 with admission diagnosis of urinary tract infection. Further review revealed the patient was a 71 year old male who had a co-morbid diagnosis of Diabetes Mellitus and had a history of stroke in 2014. Additional review revealed the patient's level of assist was moderate for Activities of Daily Living and he needed assistance with dressing, grooming, bathing, feeding, toileting, and getting in/out of bed. He uses a walker and has weakness in both legs.

On 04/11/2022 at 10:31 a.m. Patient #1's skin assessment, performed by S6Wound, was observed. The patient was noted to have redness, excoriation, and denuded areas on his sacrum and scrotum. The patient was heard expressing that he was raw "on his backside."

Review of Patient #1's turn/repositioning nurses' note entries revealed the following:

04/09/2022 Day shift: Patient documented at 7:45 a.m. as turned self, semi-fowlers. No further documentation of position change/turning until 12:08 p.m. with no explanation for not documenting turning/repositioning the patient.

04/09/2022 Night shift: 9:00 p.m. entry documented as position change every 2 hours with no position indicated. Further review revealed no other documentation of position change/turning until 7:00 a.m. (day shift) with no explanation for not turning/repositioning the patient.

04/11/2022 Day and Night shift: Patient documented as sitting at 6:00 p.m. with no further documentation of turning/position changing until 4:00 a.m. on 04/12/2022. Further review revealed no explanation for not turning/repositioning the patient.

Above referenced findings were verified during EMR review on 04/12/2022 by S3RNNav and S4RNNav, who were assisting with Patient #1's record review.


Patient #2
Review of Patient #2's EMR, assisted by S3RNNav and S4RNNav, revealed Patient #2's Braden skin risk assessments ranged from mild to high risk for skin breakdown throughout his hospital stay and the patient also had an actual deep tissue injury to his heel and further developed a deep tissue injury to his sacrum during his hospitalization.

Review of Patient #2's turn/repositioning nurses' note entries revealed the following:

03/09/2022 Night shift: No documentation of having been turned/repositioned from 10:00 p.m. - 7:00 a.m. Further review revealed no documentation of refusal to be turned/repositioned or any other reason for not turning the patient.

03/10/2022 Day shift: Documented as being in semi-fowlers position from 8:00 a.m. - 6:00 p.m. with no documented reason for not changing Patient #2's position every 2 hours.

03/11/2022 Day shift: Documented in semi-fowlers at 8:00 a.m. and 10:00 a.m. Further review revealed no documentation of every 2 hour turns/position changes until 8:00 p.m. Additional review revealed no documented reason for not turning/repositioning patient every 2 hours.

03/13/2022 Night shift: No documentation of having been turned/repositioned every 2 hours from 6:58 p.m. - 1:00 a.m. Further review revealed no documentation of refusal to be turned/repositioned or any other reason for not turning/repositioning the patient.

03/30/2022 Night shift: No documentation of the patient having been turned/repositioned every 2 hours from 12:00 a.m. - 4:30 a.m. with no documentation of refusal to be turned. Nurses note entry documented at 5:00 a.m. was noted as turned with no position indicated.

Above referenced findings were verified during EMR review on 04/12/2022 by S3RNNav and S4RNNav, who were assisting with Patient #2's record review.

Patient #3
On 04/11/2022 at 11:40 a.m. Patient #3's wound care was observed being performed by S6Wound. Patient #3 was supine in the bed with the head of bed elevated. Further observation revealed Patient #3 has On 04/11/2022 at 11:40 a.m. Patient #3's wound care was observed being performed by S6Wound. Further observation revealed Patient #3 has the following wounds:
Right proximal lateral ankle pressure injury
Right distal lateral malleolus pressure injury
Left lateral ankle pressure injury
Left lateral lower leg DTI
Sacrum stage 4 measures

Review of Patient #3's Braden skin risk assessments revealed the patient's risks ranged from mild to high risk for skin breakdown. Patient #3 is a paraplegic (below T-7) and he is unable to turn/reposition himself without staff assistance. Wound care nurse assessments included recommendations to assess wounds every shift and document appropriately. Continue repositioning every 2 hours per staff.

Review of Patient #3's turn/repositioning nurses' note entries revealed the following:

03/24/2022 Night shift: Patient documented as being in semi fowlers position at 8:00 p.m. with no other documentation of turning/repositioning until 8:00 a.m. on 03/25/2022. Further review revealed no documented evidence of refusal to be turned.

04/04/2022 Day shift: patient repositioned at 10:30 a.m. and no further turns/repositioning documented until 8:00 p.m. Further review revealed no documented reason for failure to turn the patient.

04/05/2022 Day shift: Patient documented as turned at 9:42 a.m. and no further turns/repositioning documented until 8:00 p.m. Further review revealed no documented reason for failure to turn the patient.

04/06/2022 Day and Night Shift: Patient repositioned at 9:00 a.m. and no further turns/repositioning documented until 1:00 a.m. Further review revealed no documented reason for failure to turn the patient.

04/07/2022 Day and Night Shift: Patient repositioned at 4:00 p.m. and no further turns/repositioning documented until 3:00 a.m. Further review revealed no documented reason for failure to turn the patient.

04/08/2022 Night shift: No documentation of turns/repositioning until 2:00 a.m. and the entry only indicated turn every 2 hours. Further review revealed no documented reason for failure to turn the patient.

04/10/2022 Night shift: Patient documented as able to turn self (patient is paraplegic) at 8:00 p.m. and no further turns/repositioning documented for the rest of that shift. Further review revealed no documented reason for failure to turn the patient.

Above referenced findings were verified during EMR review on 04/12/2022 and 04/13/2022 by S3RNNav and S4RNNav, who were assisting with Patient #3's record review.

In an interview on 04/12/2022 at 3:00 p.m. with S1SrDrMedSrg, she confirmed, per policy, patients were to be turned/repositioned every 2 hours and the turns should be documented in the EMR.

In an interview on 04/13/2022 at 9:34 a.m. with S7RN, she confirmed patients were to be turned/repositioned every 2 hours to help prevent skin breakdown and it should be documented in the record. S7RN further confirmed refusals/other reasons for not turning the patients should also be documented in the EMR.

In an interview on 04/12/2022 at 4:33 p.m. with S5RNChg, she confirmed the patient turn schedule was every 2 hours. She further confirmed refusals/other reasons for not turning the patients should also be documented in the EMR.

In an interview on 04/13/2022 at 11:57 a.m. with S6Wound, she confirmed pressure ulcer preventive measures included turning/repositioning patients every 2 hours to offload pressure on areas that could be prone to breakdown.