HospitalInspections.org

Based on interview and record review the hospital failed to ensure there was an ongoing evaluation of wounds along with daily skin assessments for 1 of 1 patient (Patient #1) The patient was admitted to the hospital with a sacrum wound. The wound deteriorated during the patient's admission to the hospital, and the patient acquired several additional wounds.

Findings included:

Hospital A
Patient #1 was an 82-year-old male who was admitted to the hospital on 10/07/2023 with a past medical history significant for congestive heart failure, hypertension, type-2 diabetes, osteoarthritis and suspected dementia who presents to the hospital with dyspnea on exertion, short of breath and lower extremity swelling. Imaging studies confirmed bilateral pleural effusions and pulmonary edema.

Patient #1 was admitted with a sacral wound. During the patient's admission, the nursing notes reflected that there was only one wound on the patient's sacrum. There were no measurements or photos of the wound. There were no additional wounds noted.

A physician's order for a Wound Care Consult was requested by the provider on 10/07/2023 for a stage II wound on Patient #1's sacrum. The wound care nurse did not assess Patient #1 throughout the patient's entire admission to the hospital.

On 10/27/2023 Patient #1 was transferred to a local acute care hospital (Hospital B) at the request of the patient's family.

Hospital B
A skin assessment was completed at Hospital B on 10/27/2023. The following wounds were identified:
Skin/wounds: Wounds present on admission on 10/27/2023.
Wound 10/27/23 Buttocks-Pressure injury stage 3.
Wound 10/27/23 Buttocks-Right buttocks DTI (Deep Tissue Injury).
Wound 10/27/23 Chest-Mid chest wound.
Wound 10/27/23 Elbow Posterior; Right elbow dry wound.
Wound 10/27/23 Forearm Anterior; Distal; Left wrist unstageable pressure injury.
Wound 10/27/23 Left; Plantar left heel DTI.
Wound 10/27/23 Upper Arm Anterior; Right right upper arm hematoma.
There were photos of each of the wounds that were identified.

During an interview on 02/13/2024 at 12:25 PM with Personnel #2 Wound Care Nurse she confirmed that measurements were not documented for Patient #1's wounds during his admission. She stated that there should have been measurements documented and photos taken of all wounds. She stated she never received the provider's wound consult order.

Pressure Ulcer Injury Prevention Program dated 05/2022.
"...The patient shall be assessed:
Whenever there is a change in the patient's cognition or functional ability. At least every 24 hours by a Registered Nurse. The assessment of care and treatment needs of the patient shall be ongoing throughout the patient's hospital stay. Nursing staff shall take pictures (per protocol and with facility-approved camera) of a patient's pressure injuries initially and throughout the patient's hospitalization. Pictures shall be dated and timed, and placed in the patient's medical record... At least weekly, the pressure ulcer (injury) wound shall be assessed and documented. This is will be performed by a physician, advanced practice nurse, physician assistant, certified wound care specialist, or designated Wound Care nurse..."