HospitalInspections.org

Based on a review of documents and interview, the facility failed ensure that nurses who provide services in the hospital must adhere to the policies and procedures of the hospital, as evidence by failing to consistently implement policies related to pressure injuries and wound documentation.

Findings included:

Facility Policy entitled "Pressure Injury Prevention" (Last Revised 3/5/2025) stated in part,

"PURPOSE:

Outline expectations for risk assessment, physical assessment, application of interventions, and documentation for the prevention of pressure injuries.

TOOLS:

Adult patients ? 18 years of age will be assessed using the Braden II scale
o AT RISK = score ? 18

POLICY:

SKIN RISK AND PHYSICAL SKIN ASSESSMENT:
1. All patients will be assessed for pressure injury risk level using a standardized, evidence based risk assessment tool.
2. A full physical skin assessment must be routinely performed on all patients.
3. Skin risk and physical assessment will occur at the following intervals:
a. Upon admission;
b. Once per shift ...

PROCEDURE STATEMENTS:
1. Skin risk assessment will be documented ...for each patient.
2. Ongoing skin assessments will be as follows:
a. For patients determined ...AT RISK (per risk scale), skin assessments are completed with daily, comprehensive patient assessments ...
3. Skin assessment changes and presence of any skin alterations or wounds will be documented in the EHR for all patients ..."

Facility Policy entitled "NE1 Wound Assessment Tool" (Revised 10/5/2022) stated in part,

"POLICY:

DEFINITION:

A standardized, evidence based skin and wound assessment tool used to assess patients who have been admitted with or develop skin injuries. This method and tool is primarily focused on pressure injury/ulcer) assessments and follow up through discharge ....

PROCEDURE:
A. All patients receive a head-to-toe skin inspection. The inspection is done on admission and at least once per shift.
B. Patient's nurse or wound care team member takes a digital image of skin injury that is caused by pressure on admission, occurrence, and at the discretion of the clinician, prior to discharge (beginning with stage 1 pressure injuries/ulcers) ...

D. Pressure injuries/ulcers will be photographed using iMobile shared device, GE Media Manager Application, and the NE1 Tool ...

2. Peel off NE1 Wound Assessment Tool from the adhesive backing.
3. Frame the tool around the wound, placing it at the 12 o'clock position ....

5. Use guidelines on the tool to assist with wound evaluation. Always use professional judgement and consult appropriate medical professionals as needed ...."

Review of documentation revealed the following:

Review of the medical record for Patient #1 revealed the following:
· For all Braden Skin Assessments performed from 07/24/25 through 08/18/25, the patient scored less than 18, which according to the Braden II scale places the patients at risk for pressure injuries ("Pressure Injury Prevention" policy).
· Skin assessments from 07/20/25 to 07/23/25 include documentation regarding a surgical incision sites, and an abrasion to the right posterior foot.
· Skin assessments on 07/24/25 (1420 and 2020) and 07/25/25 (0900) included no documentation for any "skin alteration".
· The first skin assessment that references a pressure injury to the scrum occurs on 07/25/25 at 2130 which includes documentation of a wound care consult. Skin Assessments are adequately documented on 07/26/25, 08/5/25 at 08:15, 08/7/25 at 08:38, 08/8/25 to 08/13/25, 08/15/25 at 07:50, and 08/16/25 to 8/18/25.
· 07/27/25 - 0700 No documentation of sacral wound. No PM Skin assessment.
· 08/05/25 - 20:40 - "present, exists."
· 08/06 /25 - 19:30 - "present, exists".
· 08/07/25 - 20:00 - "present, exists".
· 08/14/25 - 08:00 - "present, exists"
· 08/15/25 - 20:30 - "present, exists"

Based on medical record review, Patient #1 did sustain a pressure injury while inpatient. Once identified a wound consult was place and this pressure injury was treated and addressed. However, it does appear the skin assessments on 07/24/25 (1420 and 2020) and 07/25/25 (0900) included no documentation for any "skin alteration", at this time Patient #1 had a sizable surgical incision on their back that was not assessed or documented. On at 07/25/25 at 2130, a sacral wound was noted on the skin assessment. It is unclear why for over 24 hours, the skin assessments on 07/24/25 (1420 and 2020) and 07/25/25 (0900) indicated no skin alterations. It appears that skin assessments were not performed in a consistent manner due Patient #1's surgical incision not being noted on the skin assessments completed on 07/24/25 (1420 and 2020) and 07/25/25 (0900). Also, after the sacral injury was noted on 07/25/25 at 2130 one shift skin assessments was missing (07/28/25 Evening shift) and several skin assessments only documented "present, exists" with no details of the skin issue indicated.

Review of medical records for 9 current inpatients at the time of the survey revealed 4 patients were missing shift skin assessments and/or did not have details of the skin issue documented:
· Patient #4 had a pressure injury to the sacrococcyx identified on 08/14/25. The shift skin assessment on 08/18/25 at 2200 only documented "present, exists" with no details of the skin issue indicated.
· Patient #7 had an abdominal incision noted on 08/12/25. On 08/12/25 no day shift skin assessment was documented. The skin assessment on 08/15/25 at 1400 only documented "present, exists" with no details of the skin issue indicated.
· Patient #8 had a pressure injury to the sacrococcyx identified on 08/18/25. The skin assessment on 08/17/25 at 2200 only documented "present, exists" with no details of the skin issue indicated.
· Patient #9 had a sheering injury to the back noted on 08/15/25. The skin assessment on 08/18/25 at 2200 only documented "present, exists" with no details of the skin issue indicated.

Review of Wound Photos for Patient #1 revealed the NE1 Wound Assessment Tool not used per policy for sacral wound photos taken by on 7/25/25, 7/28/25, 7/30/25, 8/7/25, 8/8/25, and 8/11/25.
· 07/25/25 - 20:11-Photo of Coccyx Pressure Injury- NE1 Wound Assessment Tool not used
· 07/28/25 - 10:11-Two Photos of Above Pressure Injury - NE1 Wound Assessment Tool not used
· 07/30/25 - 9:22- Photo of Buttock/Coccyx Pressure Injury-NE1 Wound Assessment Tool not used
· 08/07/25 - 15:05 - Photo of Buttock/Coccyx Pressure Injury-NE1 Wound Assessment Tool not used
· 08/08/25 - 11:57-Photo of Buttock Pressure Injury- NE1 Wound Assessment Tool not used
· 08/11/25 - 11:21-Photo of Sacral Pressure Injury- NE1 Wound Assessment Tool not used

Review of medical records for 9 current inpatients at the time of the survey with pressure injuries revealed 4 patients had wound photos that did not use the NE1 Wound Assessment tool, per facility policy:
· Patient # 3 had a pressure injury to the coccyx identified on 08/08/25. There was a photo of the wound, but it did not include the NE1 Wound Assessment tool.
· Patient # 4 had a pressure injury to the sacrococcyx identified on 08/14/25. There was a photo of the wound, but it did not include the NE1 Wound Assessment tool.
· Patient #6 had a pressure injury to the sacrum identified on 08/12/25. There was a photo of the wound, but it did not include the NE1 Wound Assessment tool.
· Patient #8 had a pressure injury to the sacrococcyx identified on 08/18/25. There was a photo of the wound, but it did not include the NE1 Wound Assessment tool.

Based on the above findings, the facility nursing staff was not documenting pressure injuries and wounds in a manner consitent with their policies, "Pressure Injury Prevention" and "NE1 Wound Assessment Tool" (Revised 10/5/2022). The above findings were verified on 08/19/25 with staff member #4.