HospitalInspections.org

BASED ON record review and interview, the registered nurse failed to follow their policies to supervise and evaluate the nursing care for Patient #1's identified care needs from 4/28/2024 through 5/15/2024. Patient #1 developed a large pressure injury that did not resolve prior to discharge on 6/05/2024.

FINDINGS

Patient #1 admitted on 4/22/2024 to Medical Surgical 5 (MS5) for clinical overload with pitting edema in his legs, acute kidney injury versus chronic kidney disease, renal lesion, large left pleural effusion, pulmonary nodules, and deconditioning. On 4/27/2024 he had a code stroke and was ordered complete bedrest. On 5/05/2024 he was transferred to the Intensive Care Unit and discharged 6/05/2024 to a Skilled Nursing Facility.

On 5/16/2024, the Wound Evaluation included photos and documented the size of the Coccyx Pressure Injury. It measured 6 x 5.5 x 0.2. (Length/width/dept; CM/Centimeters)

There were no further measurements of the pressure injury after the initial Wound Evaluation to document on-going worsening/improvement of the pressure injury prior to discharge.

Subsequent photos of the wound (5/20/2024; 5/24/2024, 5/27/2024 and 5/30/2024) did not follow policy including a measurement reference for the wound.

Patient #1's Nurse Shift Assessments reflected:
~ Pressure Injury Risk Score dropped below 18/AT RISK on "4/29/2024 15...Out of bed activity: 2-Chairfast In bed activity: 2-Very limited Nutrition 2-Probably inadequate Friction and sheer: 2-Potential problem..." and "5/01/2024 Out of bed activity: Bedfast" with Patient #1's Risk becoming greater as the admission continued.

~ Skin Alteration "4/28/2024 skin alteration: present/exits...Redness Coccyx" then increasing to "5/08/2024 Stage 2" then increasing to "5/09/2024 Stage 3" then again increasing to "5/16/2024 Stage 4" until the patient discharge on 6/05/2024.

The 5/08/2024 Nutrition Assessment reflected, "Nutrition intake: Not meeting estimated needs...Skin: Abscess Post Coccyx...Patient with 9% WEIGHT LOSS in past 2 weeks. Significant...Patient now meets criteria for severe malnutrition in the context of acute illness...NO BM (bowel movement) documented throughout stay (4/22/2024 to 5/8/2024: 15 days)...5/06/2024 Multiple strokes. Transferred to ICU due to lethargy..."

During record review and interview on 9/25/2024 at 9:40 AM, Personnel #1, #2, and #3 verified the above information documented in the record. They were unable to find the following:

There was no Physician notification documented by nursing, no Wound Care Evaluation, no photos, no orders for cleaning, enzymatic medication, or dressings for the care of the pressure injury when the skin alteration/pressure injury began from 4/28/2024 to 5/15/2024.

There was no vigilance report when the skin alteration/pressure injury began from 4/28/2024 through 5/15/2024.

There were no skin alteration/pressure injury intervention orders (cleaning agent, medication/enzymatic/ medihoney, dressing, frequency) for the care of the pressure injury began from 5/15/2024 to discharge.

They were asked for education of the floor nurses for pressure ulcer prevention, care, and staging. Personnel #3 stated the floors have skin champions who get the information. They are to bring the information back to the floor nurses. Personnel #3 was asked for evidence of this education. Personnel #3 stated I think that has been informal. Our gap is documentation of education. It is an opportunity.

The Health Stream education reports were provided.

The Health Stream report for "NDNQI Pressure Injury Training" reflected only 28 learners which included management were assigned from 9/01/2022 through 9/25/2024.

The Health Stream report for "Braden II Scale and Skin Alteration for Inpatient Nursing" reflected a 7.56% completion rate for 9/01/2022 through 9/25/2024.

During an interview on 9/25/2024 at 1:28 PM, Personnel #5 came to help navigate for the wound photos. Personnel #1, #2, and #3 were present. Personnel #3 asked Personnel #5 about the initial wound protocol. Personnel #5 stated it is initiated on all patients, so the nurse has the ability/permission to order an evaluation and/or direct wound care needs. Personnel #5 navigated each of the wound photos. The surveyor's description of the photos:

~ 5/30/2024 "Sacrum Wound" photo reflected no measuring reference. It showed a large full thickness pressure injury covering the coccyx up to approximately the lower back area above the top of the intergluteal cleft including the width of the right and left buttocks down to the opening level. The bed of the injury was black and brownish eschar with pink edge around the injury.

~ 5/27/2024 "Sacrum Wound" photo was similar the 5/24/2024 photo with no measurement reference.

~ 5/24/2024 "Sacrum Wound" photo reflected no measuring reference. It showed a large full thickness pressure injury covering the coccyx up to below what appears to be the top of the intergluteal cleft including the width of the right buttock and part of the left buttock just above the opening level. The bed of the injury was black and brownish eschar with peeling skin all around the wound bed/injury.

~ 5/20/2024 "Sacrum Wound" photo reflected no measuring reference. It showed a pressure injury below the top of the intergluteal cleft down to just above the opening and approximately 1 to 1 ½ inches onto the right and left buttocks. The wound bed included red epithelial tissue, areas of white, yellow slough, and brown eschar.

~ 5/16/2024 "Sacrum Wound" photo reflected the NE1 wound measurement reference tool required by the policy. It showed a measured pressure injury with pink, white, and brown wound bed.

The 5/20/2024, 5/24/2024, and 5/27/2024 photos reflect the progression of the pressure injury.

Personnel #5 was asked about Patient #1. Personnel #5 stated he was lethargic, not tolerating his tube feeding, and vomiting. He had to have a thoracentesis. Personnel #5 was asked for Patient #1's wound care dressing orders. Personnel #5 stated we don't have orders. PT (Physical Therapy) change the dressing and will leave dressing supplies at bedside for us if we have to redress it. We can look in their note to see what they determined about the wound and dressing. Personnel #5 was asked if the nurse had to redress it where would they document it. Personnel #5 stated the nurse would go back and update their shift assessment.

During an interview on 9/25/2024 ending at 4:45 PM, Personnel #1 and #2 were asked for the Health Stream pressure injury training for the named nurses (Personnel #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18) in the 5/16/2024 Vigilance report. Personnel #1 stated they have not had the training assigned to them. A report for each of the nurses was not provided. Personnel #1 stated the Education Manager says they do some check offs with hire/onboarding, but Pressure Injury and Staging has not been a yearly education for the staff nurses.

The printed record was reviewed on 9/26/2024, it was determined that the Pressure Injury Risk was not completed every four hours per policy. (See below: For patients determined to be AT RISK per risk scale, focused skin assessments are completed at least every four (4) hours, or more frequently if ordered.)

There were no pressure relief interventions indicated in the record including timely position changes.

The facility's June 2023 reviewed/revised "Wound Evaluation Orders" required, "facilitate timely and efficient patient care in regard to skin and wound assessments...Physicians, Registered Nurses, or Physical Therapist may enter wound care orders upon patient admission should there be an indication for skilled intervention...I) Physician A) Order wound care on admission for all patients as indicated. B) Consult Physical Therapy Wound Care as needed. II) Enter wound care evaluation orders when a wound is noted during skin assessment. III) Nursing A) Notify Physical Therapist of wounds noted upon assessment. B) Regularly communicates with Physical Therapy regarding wound changes C) Perform skin assessment on admission, each shift, transfer to new unit or changes in status and perform basic wound care techniques and implement pressure injury prevention tactics..."

The facility's January 2022 reviewed/revised "Care Plan Documentation" policy required, "provide and document effective, efficient, and individualized care based on the needs identified...a registered nurse to supervise, plan and evaluate each patient's care. Documentation reflects the plan of care is initiated within 24 hours of admission and is consistently re-evaluated to ensure the patient's needs are met through an interdisciplinary, collaborative manner involving patients, families, and qualified healthcare individuals...identification of interventions addressing the patient's actual or potential risk for health problem...Interventions are implemented to prevent potential problems or to intervene in actual patient problems. The patient's record specifies what interventions are implemented, when and by whom they are performed. Documentation of interventions promotes continuity of patient care and improves communication among healthcare team members..."

The facility's January 2023 review/revised "Pressure Injury Prevention Program Requirements" required, "Braden Scale II *AT RISK = score <18; * Not at risk = score >18...Skin risk assessment will be documented...For patients determined to be AT RISK per risk scale, focused skin assessments are completed at least every four (4) hours, or more frequently if ordered...Skin assessments and presence of any skin alterations or wounds will be documented in the EHR (Electronic Health Record)...should include...Staging...alteration details...surrounding tissue appearance...wound closure...drainage description, amount, and odor...Wound cleanings...Dressing status, intervention, and type...Packing status...Photo capture...Wound measurements...New wounds should be reported to a provider and documentation capture in the Manage/Refer/Contact/Notify intervention within the EHR...Pressure Injury interventions and an individualized plan of care, including education, will be implemented and documented in the EHR, for all AT RISK patients..."

The facility's October 2022 "NE1 Wound Assessment Tool" policy required, "to increase documentation accuracy and consistency for skin and wound documentation....NE1 Tool (measurement and guidelines printed on the tool used in photos)...correct identification and assessment for level of tissue damage and healing progression and regression...clinician 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...Pressure injuries will be photographed using iMobile Shared phones in the GE Media manager application and the NE1 Tool...frame the tool around the wound...ensure the camera is perpendicular to the wound. Take a picture...Use guidelines on the tool to assist in wound evaluation...References: National Pressure Ulcer Advisory Panel www.npuap.org...American Professional Wound Care Association Proposed APWCA Photographic Guidelines for Wounds www.APWCA.org..."

The facility's undated "Skin Alteration Assessment & Documentation" teaching tool in the Skin Champion resource book required, "significant change in condition that could lead to skin breakdown. This requires removal of the dressings...taking photographs of any pressure injury...ongoing assessment shall include photograph of a newly developed skin injury utilizing the NE1 Wound Assessment Tool (measurement)...Document...Skin Alteration Assessment - the wound care team does not automatically receive notification. The nurse has to put in an order for wound consult...Patients identified as at risk for skin breakdown or those with wounds will have referrals based on their assessment to: Physician should be notified of alteration in skin integrity that may require a change to the plan of care...Wound Care should be notified of all new skin integrity issues and for guidance on skin integrity issues not responding to treatment...Physical Therapy should be consulted for any patient with decreased activity level...Turn patient as indicated for patient condition...Position using foam wedge or pillows, rotating to a 30 degree lateral position from right to left then supine...Keep HOB at 30 degrees or less unless medically contraindicated..."

The facility's 4/01/2022 effective "Facility Event and Close Call Reporting Policy and Procedure" required, "mitigate risk and improve the quality of services...Facility staff will provide the needed data elements through a formal, documented event reporting system. Events should be completed as soon as possible after the event, but no later than the end of the shift...review and actions should be thorough, credible, complete...The responsibility for reporting an event or close call rests with any person who witnesses, discovers, or has direct knowledge of that event or close call..."