HospitalInspections.org

Based on record review, interview, and policy review, the facility failed to ensure nursing care for each patient was properly evaluated for 1 (Patient #1) of 3 records reviewed.

Findings included:

Review of a facility policy titled, "[Facility name] Prevention and Management of Pressure Injury [PI] Policy," last revised 04/2023, revealed, "Assess the patient's skin for any alteration in skin integrity and perform a Braden Scale pressure injury risk assessment Q [every]-shift. Pay special attention to patients who are critically ill and patient [sic] with hip fracture for early signs of pressure injury of heels. Document assessment findings and interventions implemented each shift in Epic [healthcare software company]" and:
"i. Reposition the patient every two hours while in bed using the foam wedge as needed
ii. Apply skin barrier or sacrum foam dressing
iii. Apply skin barrier and heel foam dressing
iv. Float bilateral heels with offloading boots
v. Nutritional referral for Braden Scale score less than 10
vi. Utilize nursing care plans in Epic for care of patients at risk for PI development or with skin breakdown and the patients' specific interventions from Braden scale
vii. Remove any equipment, clothing, or dressings such as but not limited to: Splint, Sequential Compression Device (SCDs) and heel booty every shift to evaluate the condition of the skin."

A review of a "Patient Information" document revealed Patient #1 was admitted on 01/21/2023 with a diagnosis of a gunshot wound.

A review of "H&P [History and Physical] Notes," dated 01/22/2023, indicated Patient #1 was admitted to the facility with a gunshot wound to the head and was admitted to the surgical intensive care unit (SICU).

A review of "Calculated Braden Risk Scale" documentation within "Braden Intervention Level" sections of Patient #1's medical record revealed the patient was assessed as high risk from 01/22/2023 to 01/25/2023, on 01/31/2023, 02/02/2023, 02/04/2023, and 02/09/2023, from 02/12/2023 to 02/14/2023, on 02/19/2023, and 02/20/2023; moderate risk on 01/26/2023 to 01/30/2023, on 02/10/2023 and 02/11/2023, and from 02/15/2023 to 02/18/2023; and severe risk on 02/01/2023 and 02/03/2023.

A review of "Positioning per patient's condition" flowsheet documentation revealed staff documented consistent turning and repositioning of Patient #1.

A review of "Hygiene" flowsheet documentation revealed staff documented no protective barrier application for Patient #1 on 01/25/2023, 01/26/2023, 01/28/2023, 01/29/2023, 01/30/2023, 02/05/2023, 02/06/2023, 02/07/2023, or 02/08/2023, or from 02/10/2023 to 02/20/2023.

A review of a "[Facility initials] Enterstomal [sic]/Wound Care Services Consult Note," dated 02/20/2023, revealed Patient #1 had a stage 2 pressure injury to their buttocks.

During an interview on 09/13/2023 at 2:50 PM, Vice President (VP) of Critical Care #26 revealed all patients in the SICU were to be turned every two hours, except for some patients with head injuries and/or spinal cord injuries. VP of Critical Care #26 stated a Braden Scale score was used to determine skin risk factors; however, VP of Critical Care #26 noted that protective interventions were to be implemented for any Braden Scale risk level because patients in the SICU were immobile. VP of Critical Care #26 stated other skin precautions used were protective barrier lotion and keeping a patient clean and dry.

An interview conducted on 11/16/2023 at 1:40 PM with Director of Wound Care #5 revealed interventions were to be applied for an at-risk patient. Per Director of Wound Care #5, the facility used the Braden Scale for Predicting Pressure Ulcer Risk to determine a patient's level of risk.

An interview conducted on 11/16/2023 at 2:10 PM with Clinical Informatics #4 revealed skin barrier application was not consistently documented by staff in January 2023 for Patient #1 and were even less consistently documented from 02/10/2023 to 02/20/2023.