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Based on record review, interview and policy review, the facility failed to ensure pressure ulcer prevention was implemented consistently and failed to ensure the wound nurse was consulted. This affected one (Patient #2) of ten records reviewed. The hospital census was 238.

Findings include:

Review of the medical record of Patient #2 revealed the patient was admitted to the facility's Acute Rehabilitation Unit on 05/04/23 at 1:08 PM for intense therapy after a sternal dehiscence, fracture, and repair.

The Wound Prevention flow sheet revealed a staff nurse performed wound prevention on 05/04/23 at 1:30 PM by repositioning the patient off her coccyx and elevating the heels. The flow sheet lacked documentation of wound prevention tasks during night shift hours on 05/04/23. Wound prevention tasks to the coccyx occurred on 05/05/23 at 8:54 AM and 8:04 PM as required. A staff nurse applied zinc paste to the patient's coccyx on 05/06/23 at 10:35 AM and 8:15 PM to prevent and protect the patient's coccyx from a pressure injury. Zinc paste was again applied to the patient's coccyx on 05/07/23 at 7:30 PM, however, the flow sheet lacked documentation interventions were performed to prevent and protect the patient's coccyx from a pressure injury. Neither day shift hours nor night shift hours on 05/08/23 listed interventions to prevent and protect the patient's coccyx from a pressure injury. On 05/09/23 at 7:41 PM, a staff nurse performed wound prevention tasks to the patient's coccyx. The flow sheet revealed that the patient was repositioned. The flow sheet lacked documentation interventions occurred during day shift hours. On 05/10/23 at 7:57 AM, the patient was repositioned to prevent a pressure injury to the coccyx. Interventions also occurred at 7:35 PM.

On 05/11/23, the patient's coccyx was red and blanchable at 08:30 AM and 7:30 PM. Although zinc paste was applied, the medical record lacked documentation a wound consult was placed to assess the patient's coccyx. On 05/12/23 at 4:00 PM, a staff nurse applied a foam silicone dressing to the patient's coccyx. The redness to the patient's coccyx continued on 05/13/23 and 05/14/23. Foam silicone dressings were applied. On 05/15/23 at 10:12 AM an abrasion to the coccyx was noted. Although zinc paste was applied, the medical record lacked documentation a wound consult was ordered. Abrasions to the patient's coccyx were noted on 05/16/23 at 11:58 AM and 7:57 PM. The medical record lacked documentation a wound consult was ordered. A red abrasion to the patient's coccyx was again noted on 05/17/23 at 8:24 AM and 7:44 PM. A red abrasion to the patient's buttocks was noted on 05/18/23 and 05/19/23. On 05/20/23 the flow sheet lacked documentation wound interventions occurred during day shift hours. The medical record also lacked documentation a wound consult was ordered prior to her discharge on 05/21/23.

These facts were confirmed with Staff G, Staff H, and Staff I during an interview on 09/06/23 at 2:38 PM.

The facility policy titled "Save Our Skin (SOS) Documentation Tips" documented the nurse should be consulted with any facility acquired pressure injury.