HospitalInspections.org

Based on record review, review of faciltiy policies, and staff interview the facility failed to ensure nursing staff followed the facility policy for measuring and assessing wounds (A395) and failed to ensure nursing staff implemented a care plan and followed the facility policy for prevention of pressure injuries (A396). The cumulative effects of these systemic practices resulted in the agency's inability to ensure patient care needs would be met.

Based on medical record review, policy review and staff interview, the facility failed to ensure nursing staff followed the facility policy for measuring and assessing wounds for two (Patient #10 and Patient #11) of two medical records reviewed of patients with wounds. The facility's census was 605.

Findings include:

1. Patient #10 had a sacral wound assessed as measuring 6 centimeters (cm) by 6 cm on 05/17/24. The medical record did not contain any additional measurements. Patient #10 was an active patient as of 05/29/24.

Review of the facility policy titled "Skin: Prevention and Treatment of Pressure Injuries and Wounds for Adults," effective 09/2023, stated pressure Injuries are measured, reassessed by the bedside nurse (every 7 days) to assess response to treatment interventions. All wounds are measured weekly and as needed.

Interview on 05/29/24 at 10:04 AM Staff P confirmed the findings.

2. Patient #11 was admitted ot he facility on 05/28/24. The record contained documentation of a wound on Patient #11's abdomen. An Emergency Department note from 05/28/24 at 10:17 PM stated Patient #11 has two wounds on the abdomen, present for close to two years, which have had increased drainage and erythema. The note stated two additional chronic wounds were noted on the right side of the abdomen, both with scant purulent discharge and surrounding erythema. The medical record did not contain the size or image of the wounds.

Review of the facility policy titled "Skin: Prevention and Treatment of Pressure Injuries and Wounds for Adults," effective 09/2023, stated all wounds are assessed upon admission and documentation includes a photo with scale

Interview on 05/30/24 at 9:08 AM Staff P confirmed the findings.

Based on medical record review, policy review and staff interview, the facility failed to ensure nursing staff implemented a care plan and followed the facility policy for prevention of pressure injuries for one (Patient #2) of 10 medical records reviewed. The facility's census was 605.

Findings include:

Patient #2 was a direct admit to the facility on 04/10/24 at 2:58 AM and was discharged to a skilled nursing facility on 04/15/24 at 3:20 PM. The admission history and physical dated 04/10/24 identified Patient #2 had no rashes or wounds. Patient #2's Braden scored from 04/10/24 through 04/15/24 ranged between 9 and 16, which revealed a risk for skin breakdown.

The medical record of Patient #2 contained a care plan for skin. The goal was to prevent/minimize sheer/friction injuries. Interventions included to turn/reposition every two hours/use positioning/transfer devices.

Patient #2's Basic Mobility Score, as evaluated by a physical therapist on 04/10/24 at 2:25 PM, revealed Patient #2 needed assistance with mobility, including bed mobility.

The medical record contained no documentation of Patient #2 turning or being repositioned from 04/12/24 at 9:00 PM until 04/13/24 at 7:15 AM.

Per Staff S's documentation in the medical record, Patient #2 was lying on Patient #2's right side on 04/13/24 from 7:15 AM through 5:00 PM with the foot of bed elevated.

On 04/13/24 at 7:15 AM, the medical record contained documentation stating Patient #2 had a skin tear and bruising. The location of the skin tear was not mentioned. On 04/14/24 at 9:10 PM, Staff T documented skin integrity as "bruising, skin tear, blister - blisters on the left back."

The medical record documentation revealed Patient #2 was lying on Patient #2's right side from 04/14/24 at 7:15 AM through 04/14/24 at 5:00 PM.

Additionally, the flowsheets revealed Patient #2's heels were to be elevated off the bed, which only occurred on 04/13/24 at 4:29 PM and 04/14/24 at 9:48 PM. The flowsheet also revealed bilateral heel protectors were in use only on 04/15/24 at 7:31 AM and 8:40 AM.

Interiew on 05/29/24 at 2:41 PM. Staff T reported identifying the blister on Patient #2. Staff T reported there were three blisters, with one or two of them opened, and one still formed. Staff T reported the Specified Patient was able to move around in the bed and move all extremities.

Review of the facility policy titled "Skin: Prevention and Treatment of Pressure Injuries and Wounds for Adults," effective 09/2023, stated he Braden Scale Pressure Injury Risk Assessment is reassessed daily and with change in condition. Refer to Attachments C and F for suggested interventions, tips for practice with supporting rational. Pressure Injury Prevention Standards for Adults are initiated for patients with a Braden score of less than or equal to 18. Attachment F titled "Pressure Injury Prevention Standards for Adults" stated to effectively reposition patients who are not able to completely reposition themselves at least on individualized schedule to redistribute pressure. A patient who is unable to completely reposition to offload pressure must be assisted to do so at least on a schedule best for them. Utilize positioning devices meant to off load pressure points such as heel boots, pillows for heels.

Interview on 05/29/24 at 2:06 PM Staff P confirmed the findings.