HospitalInspections.org

Based on record review and interviews the facility failed to ensure the nursing staff develops and keeps current a nursing care plan for an identified pressure injury of one (SP #1) out of 3 sample patients (SP).

Findings include:


Sample Patient (SP) # 1 was admitted on 05/05/2020 and discharged on 06/18/2020.

Review of the Discharge Transfer Form showed At Risk Alert: Pressure ulcer.

Phone interview with the Attending Physician of SP #1 revealed she developed the pressure ulcer in the hospital. One of those problems that despite all the preventive measures implemented, the patient developed pressure ulcer in the sacrum. Her coronary artery disease and diabetes---a systemic problem, meaning her circulatory system is compromised.

Review of Patient Care Plan Report showed it was initiated on 05/06/2020 and the following needs were identified: High risk for injury; Ineffective breathing pattern; alteration in comfort, pain; incontinence; discharge. There was no plan of care related to skin integrity.

Review of the written document provided by the Risk Manager on 09/16/2020 at 10:00 AM from [name of wound specialist] Wound Care Consult notes revealed: On 06/08/2020 to 06/11/2020 - documents a Stage 2 pressure injury. On 06/15/2020, and 06/17/2020 - documents a Stage 3 pressure injury.


Review of Policy Name: Tissue and Pressure Injury Management, states Patients with a Braden score (less than/equal to) <=18 will have skin breakdown nursing prevention protocol/ care plan initiated. The policy also states that changes in the patient condition requires changes in the plan of care and subsequent interventions/ protocols.

Review of SP #1 Braden Scale (from Daily Assessment Inquiry) showed Braden Scales scores during hospital stay ranges from 10-22 out of 23.

There were no care plan formulated related to pressure injury and the Braden Scale <= 18 for SP #1.


In an interview with the Chief Executive Officer on 09/16/2020 at 9:10 AM revealed the patient was very high risk for skin breakdown. Patient came in with skin intact. She has other comorbidities included was a respiratory problem. We acknowledge that wound documentation is an area that we need improvement.