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Based on interview and record review, the hospital failed to ensure a specialty bed was provided to one of five sampled patients (Patient 1) as per the hospital's P&P. This failure created the increased risk of poor health outcomes to the patient.

Findings:

Review of the hospital's P&P titled Skin Integrity dated June 2024 showed the purpose of this P&P is to provide the guidelines for the care of the patient with wounds and/or pressure injuries; to define interventions for prevention of pressure injury; to provide educational information for prevention and treatment for pressure injuries, wounds, and those patients at risk for developing aimed at all healthcare providers. Patients with a pressure injury (PI), suspected PI or who are identified at risk for skin breakdown (Braden scale is 16 or less than 16) shall have the appropriate interventions and documented. Initiating and maintaining pressure prevention strategies may include but are not limited to inquiring about placement onto a specialty surface as appropriate (see Attached B).

Review of the Attachment B showed the Integrated Pressure Relief Surface with Advance Micro-Climate Management and Active Therapy Citadel C200 Therapy System with Skin IQ Cover is the bed that can be used for patient with Deep Tissue Injury (DTI) on the trunk and pelvis.

According to the National Pressure Injury Advisory Panel, a pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. A Deep Tissue Pressure Injury the intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister

On 10/9/24 at 0859 hours, the ICU was toured with the CNO, Director of ICU, Director of Quality, Quality PI/ Review RN, ICU Charge Nurse 1, ICU Educator, and ICU RN 1. ICU Charge Nurse 1 stated Patient 1 was admitted to the ICU on 9/24/24 due to the respiratory distress; the patient's Braden Scale was 10. The patient received wound care services due to having multiple skin issue including a community acquired pressure injury to the sacrum. The patient was on a basic Stryker bed (a type of bed) and was waiting to have a Citadel bed (a specialty mattress provides an integrated pressure redistribution surface).

Review of Patient 1's medical record was initiated on 10/9/24.

Review of the Wound/Burn Treatment Note signed on 8/29/24 at 0706 hours, for the date of service as of 8/27/24, showed Patient 1 had a suspected DTI to the sacrum. The recommendations included to use the pressure reduction mattress.

Review of the Wound/Burn Treatment Note dated 10/8/24 at 1724 hours, showed Patient 1 had a suspected DTI with open skin to the sacrum.

Review of the Progress Note dated 10/8/24 at 0800 hours and 10/9/24 at 0800 hours, showed a Citadel bed was requested and was not available. The charge nurse and Director were aware.

On 10/9/24 at 1316 hours, during a follow-up interview with the Director of ICU, the Director of ICU stated she was aware of the request and addressed the issue during the morning leadership safety huddle. The Director of ICU stated the morning leadership safety huddle included all department leaders, was informal, and no notes were documented. She stated the hospital did not track or trend the locations or usage of specialty beds. The Director of ICU stated that the directors could have used the Management Text to communicate with other units about specialty bed availability, but there was no documented evidence that a text was sent to request a specialty bed for Patient 1.

On 10/9/24 at 1316 hours, an interview and concurrent review of Patient 1's medical record was conducted with the Wound Care Consultant (WCC). The WCC stated the most recent evaluation and treatment for Patient 1 was on 10/8/24. The WCC stated the initial wound consult for the patient was on 8/27/24; the patient had a community acquired pressure injury to sacrum; and the recommendation was to use a pressure reduction mattress.

On 10/9/24 at 1528 hours, an interview was conducted with the Director of Material Management regarding to the request for Citadel bed. The Director of Material Management stated if they received a request for that mattress, the vendor could provide it in four to six hours. When asked, the Director of Material Management could not locate the request of a Citadel bed for Patient 1.