HospitalInspections.org

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Based on medical record (MR) review, document review, and interview, the facility failed to ensure nursing staff assessed patients at risk for hospital-acquired pressure injuries (HAPIs) as per facility protocol, in one (1) of four (4) medical records reviewed.

This failure placed all patients at risk for adverse patient outcomes.

Findings:

Review of the facility's policy and procedure (P&P) titled, "Pressure Injury: Prevention, Assessment, and Management System," last approved 10/27/2022, stated, " ... the nurse will assess and inspect skin daily and as indicated by patient's condition. Assess for history of prior pressure injury (PI) and/or presence of current injury on admission to the health care setting. Assess and monitor pressure injury (s) on admission to health care setting, at minimum weekly, and with any signs of skin/wound deterioration."

The facility's "Pressure Injury Process Map," dated 8/2023, stated the following: "Pressure injury (PI) - Hospital Acquired: Stage 2, Stage 3, Stage 4, DTI [Deep Tissue Injury: A pressure-related injury to the subcutaneous tissue under intact skin], or Unstageable - two (2)-RN [Registered Nurse] assessment: Document with measurements. Refer to nurse driven wound management protocol, notify nurse manager and assistant nurse manager, and place wound care consult ..."

Review of Patient #2's MR identified that Patient #2 was evaluated for altered mental status in the Emergency Department (ED) on 1/11/2024 at 1:52 PM and placed in the ED holding area.

On 1/11/2024, nursing staff documented that a pressure injury was present on admission. There was no documented evidence of an assessment or treatment of Patient #2's pressure injury until 1/14/2024 at 12:11AM, when nursing staff performed an initial skin assessment (72 hours after arrival) which indicated Patient #2 had a Stage II pressure injury on the coccyx region. No wound measurements of the injury were documented.

On 1/17/2024 at 8:15 AM, nursing staff documented " ...Patient with sacral coccyx suspected DTI [deep tissue injury]. There is new pressure injury identified on left heel, Stage 1." No wound measurements, two (2)-RN assessment/verification, or wound care consult were found for the new hospital-acquired pressure injury on the left heel.

During interview of Staff K (Registered Nurse/RN) on 5/10/2024 at 10:41 AM, Staff K confirmed the 2-RN verification for skin assessment was not performed.

On 1/19/2024, Patient #2 was admitted to the Medical-Surgical Unit. The Admission Assessment at 5:32PM stated Patient #2 had a "DTI [deep tissue injury] noted...and a Stage 4 to the sacrum area." Nursing staff did not document a description of the pressure injury, nor complete wound measurements, as per facility policy.

During interview of Staff M (Registered Nurse/RN) on 5/10/2024 at 11:33 AM, Staff M stated they received Patient #2 to the medical surgical unit. Staff M stated Patient #2 had a suspected deep tissue injury / Stage 4 to the coccyx region, and that the wound was measured in length and width, but not depth. Staff M was not able to provide an explanation why the full measurements were not completed and documented when the Stage 4 pressure injury on the coccyx area was assessed.

On 1/24/2024 at 8:27 AM, nursing staff documented, "Pressure Injury #2: sacral/coccyx area Stage IV measuring length 10 cm x 8 cm width ...Pressure Injury #4 on left heel; Pressure Injury #5 on right heel. The documentation lacked pressure injury depth, wound characteristics, and an assessment of pressure injury #1 on the sacrum/coccyx. In addition, no wound care consults were found for the new hospital-acquired pressure injuries.

During interview of Staff D (Quality Assurance Registered Nurse) and Staff E (Quality Assurance Registered Nurse) on 5/10/2024 at 2:25 PM, Staff D and E confirmed these findings.