HospitalInspections.org

Based on policy review, medical record review and interview, nursing services failed to provide necessary care and services to reduce the incidence of adverse healthcare-associated conditions and other pressure injuries.

The findings included:

1. Nursing services failed to perform ongoing accurate assessments of patients in order to prevent healthcare-associated unstageable wounds and other pressure injures.
Refer to A 392.

Based on policy review, medical record review, and interview, nursing services failed to provide accurate assessments to identify and prevent the occurrence of healthcare associated adverse events and other pressure injuries for 2 of 4 (Patient #1 and Patient #4) sampled patients with pressure injuries.

The findings included:

1. Review of the facility's "Skin/Risk Assessment & [and] Pressure Injury Prevention Standing Orders" policy revealed, "...Only pressure injuries are staged and are usually located over bony prominences but may be caused by a medical device or other object over soft tissue...Skin Assessment is from head to toe with particular attention to bony prominences and under medical devices...Ears...Every Shift...1. Assigned nurses will assess patients every shift for risk of potential and actual skin breakdown as part of their total body assessment. 2. Skin under or in contact with a removable medical device should be assessed at least every 8 hours...DOCUMENTATION: Document skin assessment findings and any treatments implemented in the patient's record when the patient is admitted...".

2. Review of the facility's "Medical Device Related to Pressure Injury Prevention" policy revealed, "...PURPOSE: Assess skin for potential and actual skin breakdown. Pressure injuries are staged and are usually located over bony prominences but may be caused by a medical device or other object over soft tissue. Prevent skin breakdown and improve skin integrity...POLICY: 1. Assigned nurse will assess the skin under and around a medical device on admission and every 8 hours for risk of potential and actual skin breakdown. Common risk factors are: a. Use of multiple devices. b. Dependence on devices for survival. c. Prolonged use of devices...Oxygen Tubing: a. Switch rigid/hard oxygen tubing to the soft, less rigid oxygen tubing. b. Assess the skin at least every 8 hours for redness or breakdown. c. If redness or breakdown occurs, place foam dressings to protect..."

3. Medical record review revealed Patient #1 was admitted to the facility's Critical Care Unit (CCU) on 2/15/2020, after being seen in the Emergency Department (ED) of an outside facility. The patient presented to the CCU with diagnoses that included Supraventricular Tachycardia (SVT), acute on chronic Heart Failure, and an Ejection Fraction less than 25 percent (%).

Review of the initial nursing assessment performed in CCU revealed, Patient #1 was alert and oriented, was on a low air loss mattress, had preventative foam applied to his coccyx area, and his heels were floated off the bed. The patient's activity level was documented as "up with assistance with walker". The patient wore glasses and also had bilateral hearing aides.

Review of Patient #1's assessment flowsheet revealed the patient was started on oxygen via binasal cannula (BNC) on 2/15/2020 at 7:00 PM. The patient remained on oxygen until 2/21/2020, prior to discharge home.

Review of the admission skin assessment on 2/15/2020 revealed no redness or open areas were noted behind the patient's ears.

Review of skin assessments from 2/15/2020 through 2/20/2020, revealed assessments were performed and documented every shift, with no documentation of skin breakdown behind the ears.

Review of the equipment/device assessments from 2/15/2020 through 2/20/2020 revealed nursing staff documented skin checks every 8 hours, with no documentation of skin breakdown beneath medical devices (BNC).

On 2/20/2020 at 2:00 PM a note documented by the Wound Ostomy Continence Nurse (WOCN) revealed a new unstageable pressure injury had been found behind the patient's left ear. The WOCN documented the pressure point as a medical device. The injury was 0.3 centimeters (cm) in length and 0.3 cm in width. The injury was documented as having 100 % slough tissue (dead tissue). The WOCN also documented the area was under a BNC and the patient wore hearing aides and glasses with soreness at times.

Review of Patient #1's Integumentary (skin) assessments for 2/20/2020 at 2:00 PM revealed documentation that stated, "Incision, Wound comments: Noted on PIPS [Pressure Injury Prevalence Survey] rounds today per survey group...".

In an interview on 3/5/2020 at 9:30 AM in an administrative office, the WOCN manager verified the wound was initially found by a PIPS surveyor, not nursing staff on the patient's floor. These surveyors perform quarterly head to toe skin assessments on all adult patients, on an assigned floor of the facility. The WOCN manager stated Patient #1 was at increased risk for breakdown behind the ears due to wearing glasses and hearing aides.

The facility failed to ensure nursing staff performed and documented accurate skin and medical device assessments, to prevent the formation of an unstageable wound for Patient #1.

4. Medical record review revealed Patient #4 presented to the facility's ED on 2/23/2020 after falling out of her motorized wheelchair. The patient complained of left hip pain and was found to have a left hip fracture that would require surgery. The patient was admitted to a telemetry floor with diagnoses that also included Chronic Obstructive Pulmonary Disease (COPD) requiring home oxygen (via BNC), Congestive Heart Failure (CHF) and Chronic Kidney Disease.

Review of assessment flowsheets beginning at admission on 2/23/2020 through discharge on 3/2/2020 revealed Patient #1 required oxygen throughout her stay at the facility. The patient was documented as using a BNC, high flow and Bi-Pap as routes of oxygen therapy.

Review of the admission skin assessment on 2/23/2020 revealed no redness or open areas were documented behind the patient's ears.

Review of skin assessments from 2/23/2020 through 2/26/2020, revealed assessments were performed and documented every shift, with no documentation of skin breakdown behind the ears.

Review of the equipment/device assessments from 2/23/2020 through 2/26/2020 revealed nursing documented skin checks every 8 hours, with no documentation of skin breakdown beneath medical devices.

On 2/26/2020 at 2:42 PM, a note documented by the WOCN revealed a Deep Tissue Injury (DTI) that was evolving into an unstageable pressure injury, had been found behind the patient's right ear. The WOCN documented the pressure point as a medical device. The injury was 0.5 cm in length by 0.5 cm width.

In an interview on 3/5/2020 at 9:30 AM in an administrative office, the WOCN manager stated Patient #4's pressure injury had most likely been present upon admission, but was not documented. The manager stated you typically see redness or maroon colored skin to a pressure point before it becomes unstageable. The WOCN did not believe the pressure injury had developed within 3 days from admission.

The facility failed to ensure nursing staff performed and documented accurate skin and medical device assessments, to prevent skin breakdown for Patient #4.