HospitalInspections.org

Based on document review and interview, the facility staff failed to ensure a plan of care was followed to prevent the development of pressure sores for one of four (4) patients, Patient #3.

The findings include:

The medical record of Patient #3 was reviewed on various days and revealed the following:
Patient #3 was admitted on 7/10/2020 and discharged on 9/30/2020. Patient #3 was transported via ambulance to the ED (Emergency Department) on 7/10/2020 with a GI (gastro-intestinal) bleed and abdominal distention. Patient #3 has a history of diabetes, hypertension, heart disease (has pacemaker), and aortic aneurysm. Patient #3 was also admitted to this facility in March 2020 with similar presentation.

7/12/2020: Patient #3's plan of care notes, "Problem: Pressure Injury -Risk of...Interventions:
Moisture Interventions: Maintain skin hydration (lotion/cream). Check for incontinence Q2 (every two) hours and as needed, absorbent underpads, apply protective barrier, creams and emollients, Internal/External urinary devices, moisture barrier.
Activity Interventions: Increase time out of bed, pressure redistribution bed/mattress (bed type).
Mobility Intervention: HOB (head of bed) 30 degrees or less, pressure redistribution bed/mattress (bed type), turn and reposition approx. every two hours (pillow and wedges).
Nutrition Interventions: Document food/fluid/supplement intake.
Friction and Shear Interventions: Apply protective barrier, creams and emollients, HOB 30 degrees or less, lift sheet, minimize layers."

Documentation indicated the following:
Patient #3 was assisted with or provided with bathing and skin care each day during their hospitalization.
Patient #3 was turned and repositioned at least every two (2) hours.
Flowsheet documentation:
7/20/2020 at 8:12 A.M. notes no pressure injuries.
7/21/2020 at 11:00 P.M. notes:
Wound Toe: Anterior Right Great Toe: unstageable; Present on Hospital Admission: Y (yes).
There were no notes in the medical record until 7/21/2020 about a pressure injury to Patient #3's toe.

Wound care nurse (Staff Member #14) consulted on 7/22/2020 and documented the following, "...Ostomy wafer and pouch intact without evidence of leakage. Buttock and scrotum with moisture associated dermatitis. L (left) great toe with unstageable pressure injury to tip and avulsion injury to toenail. Pt. states, "It happened 3 weeks ago."...We will continue to follow for ostomy teaching and support."

Wound care was contacted on 08/19/20 at 3:18 P.M. to advise on correct size and type of colostomy bag due to leakage.
There was no documentation in the medical record that supports any response from wound care until 9/28/2020.

9/28/2020 at 4:42 P.M. Wound care note documents: "...Ostomy wafer and pouch intact without evidence of leaking. Sacrum with stage 3 pressure injury measuring 9 x 11 x 0.2cm (centimeter). The wound base is 95% red, 5% yellow and dry.
L (left) ischium with deep tissue injury measuring 5 x 6 x 0.1cm. The wound base is 60% red, 40% purple and dry. Bilateral feet with dry desquamation. R heel with unstageable pressure injury measuring 7 x 9 x 0.2cm. The wound is 50% red, 50% dry stable eschar.

Recommendation: Would recommend Calmoseptine to sacral and ischial wounds BID and prn skin care. Float heels at all times. Continue Hollister 2 ¼" ostomy supplies for colostomy. Will order air fluidized bed."
There was no documentation of the description of the toe (right or left). There were pictures in the medical record documental as being taken on 9/28/2020 by Wound Care Nurse (Staff Member #14) that show the right great toe had a pressure injury with eschar. The pictures also show peeling, flaky, dry feet with blistered like areas on the bottoms of the feet.

Staff Member #1 provided the following policy on 1/4/2021. Policy titled Pressure Injury/Ulcer Prevention #401.06A, last revised 2/2020 Page 3; Section B. Skin Assessment:
1. Nurse will complete and document a dual skin assessment on admission and on transfer (including unit to unit transfers and a return from surgical procedures) within 4 hours.
2. Nurse will perform a dual focused skin assessment during bedside shift report.
3. Nurse will perform a comprehensive skin assessment with change in patient risk factors.

Staff Member #1 was interviewed via telephone on 1/21/2021 at 2:57 P.M. and stated, "I was surprised there weren't earlier notes by wound care."