HospitalInspections.org

Based on document review, medical record review and interview, in 3 of 5 (Patient #1, Patient #2, Patient #3), medical records reviewed, documention of pressure injuries was inadequate, i.e., it lacked description of skin breakdown appearance, measurements of pressure injury, treatment implemented, etc.) This lack could lead to difficulty in determining changes in pressure injuries.

Findings include:

-- Review of the facility's policy and procedure titled, "Admission History and Assessment," reviewed 7/2023, "Nurses should remove all dressings to accurately assess pressure injuries and document all findings. If a patient has an open wound the registered nurse should ensure a referral to the wound ostomy continence nurse is ordered. If patients have reddened areas, blisters, necrotic areas, pressure injuries, nonsurgical, surgical or vascular wounds, the nurse should identify initial plans of care (dressings, creams, etc.) by entering wound care orders within their scope of practice. The "Pressure Injury Flow Record" should be used to document all injuries identified. Once pressure injuries are documented, these form are maintained with the Care Path/Flow Record, facilitating ongoing documentation. ... Nurses should complete a full reassessment within the first half of the shift assigned. Registered nurses working 12 hour shifts are expected to complete a full assessment during the first half of the shift and a second assessment in the second half of the shift that includes all required assessments (for example, risk for falls, injury from falls, skin breakdown and pain) and a focused assessment for any changes.

-- Review the education provided to nursing staff (registered nurses, licensed practical nurses and patient care technicians) in May 2023 titled, "Pressure Injury Prevention and Stages," not dated, indicated wound documentation should include the following: type of wound and location, description of the wound in tissue color percentage, drainage amount, color, odor and periwound (area around the wound) appearance, wound measurement in length x width x depth upon admission and weekly (every Wednesday), interventions for wound treatment and healing plan, patient care activity; turning and position, pressure reducing devices, offloading heels etcetera, and patient and caregiver education.

-- Review of Patient #1's (80-year-old female) medical record revealed, she presented to the hospital on 6/21/2023 with a chief complaint of right hip pain. Past medical history included included hypertension (high blood pressure), dyslipidemia (high cholesterol), myocardial infarction (heart attack) and macular degeneration (condition that results in loss of central vision).

-- The admission assessment on 6/22/2023 at 2:30 am indicated Patient #1 had erythema to the right lower leg and bruising to the right lower and upper leg.

-- Skin assessment on 6/25/2023 at 6:54 pm indicated erythema to the right lower leg, bruising to the right lower and upper leg, and blisters to the midline coccyx region. (No description of wounds documented).

-- Skin assessment on 6/27/2023 at 4:21 am indicated erythema to the right lower leg, bruising to the right lower and upper leg, and blisters to the midline coccyx region with Allyven (water and bacterial proof) dressing intact. (No description of wounds documented).

-- Discharge assessment on 6/28/2023 at 3:00 pm indicated erythema to the right lower leg, bruising to the lower and upper leg, blisters to the midline coccyx region, and a 5 millimeter superficial skin breakage to the right dorsal pedalis (top of foot). (No description of wounds documented).

-- Review of Patient #2's (71-year-old male) medical record revealed, he presented to the hospital on 2/6/2024 with a chief complaint of increasing weakness and decreased oral intake for the last 3 days. Past medical history included tonsillar squamous cell carcinoma (throat cancer) treated with chemotherapy, atrial fibrillation (irregular and rapid heart rate), hypertension, chronic obstructive pulmonary disease (lung disease) and was diagnosed with lung cancer 6/2023. He had chemotherapy and radiation, he now has recurrence of lung cancer diagnosed 10/2023.

The admission assessment on 2/6/2024 at 11:04 pm indicated Patient #2 had a Stage 2 pressure injury on his sacrum with scant serosanguinous (clear/bloody) drainage, surrounding tissue intact, foam adherent dressing applied. No measurements of the pressure injury were documented.

On 2/7/2024 at 10:03 am a wound ostomy continence nurse received a referral automatically generated through the medical record system based on the patient's skin assessment. Following the automatic referral, the wound ostomy continence nurse contacted Patient #2's nurse and gave recommendations for treatment, Aquaphor to radiation burns on neck, thick moisture barrier paste to buttock, upgrade to Triad paste (indicated for the local management of partial-and full-thickness pressure and venous stasis ulcers, dermal lesions/injuries, and first and second-degree burns) if patient is incontinent and if paste is not holding or skin begins to breakdown. The nurse was instructed to place a new referral to the wound ostomy continence nurse, if further evaluation was needed or if the patient needed to be seen.

On 2/10/2024 at 6:20 pm, nursing documented Stage 2 pressure injury sacrum, erythema, non blanchable, Mepilex dressing and turn and position every 2 hours (no additional information about the wound was documented).

On 2/13/2024 at 4:57 pm, nursing documented Stage 2 pressure injury sacrum, erythema, non blanchable, surrounding tissue intact (no treatment or additional information about the pressure injury was documented).

On 2/14/2024 at 4:47 pm, nursing documented Stage 2 pressure injury sacrum, boggy, erythema, non blanchable (no measurements, treatment, or additional information about the wound was documented).

On 2/21/2024 at 11:22 am, the wound ostomy continence nurse documented inpatient provider requested wound consult. The nurse documented a Stage 2 pressure injury, bilateral sacrum, partial thickness, scant serosanguinous drainage and surrounding tissue fragile. Pressure injury present on admission, measurements length 11 centimeters, width 5 centimeters and depth 0.2 centimeters. Recommended continue current treatment orders and pressure relief specialty bed. Patient refused Triad paste to sacrum, requested only foam border dressing be used. Wound photos uploaded to chart. Reconsult if needed.

From 2/21/2024 - 3/5/2024 Patient #2's pressure injury to the sacrum continued to be monitored and treated. Patient #1 frequently refused turning and positioning and the use of Triad paste. No repeat measurements of the pressure injury were documented on Wednesdays.

On 3/6/2024 at 12:45 am, nursing documented Stage 3 pressure injury, present on admission to coccyx and sacrum, bilateral midline. The wound progressed from a Stage 2 to a Stage 3 pressure injury. No other wound description was documented. (Patient was still an inpatient on 3/6/2024.)

-- Review of Patient #3's (79 year-old female) medical record revealed, she was admitted to the facility on 3/3/2024 with a chief complaint of weakness and pneumonia. The skin assessment on admission at 2:42 pm indicated the following: Wound 1 - skin tear on the left elbow edges separated, moderate amount of sanguineous drainage
Wound 2 - Stage 2 pressure injury on buttock/sacrum bilateral, erythema, blanchable, no drainage, present on admission. There were no pressure injury measurements documented.

On 3/4/2024 12:02 pm, nursing documented, Wound 1 - skin tear on the left elbow edges separated, present on admission, dressing clean, dry and intact. Wound 2 - Stage 2 pressure injury on buttock/sacrum bilateral, present on admission, turn and reposition every 2 hours, pillow placed to elevate right side. There was no pressure injury description documented.

On 3/5/2024 9:48 am, nursing documented, Wound 1 - skin tear on the left elbow, present on admission, scabbed.
Wound 2 - Stage 2 pressure injury, present on admission, black percentage 0-25%, purple percentage 26-50%, wound drainage none, surrounding tissue intact, Triad applied, dressing covering wound. (Patient was still an inpatient on 3/5/024.)

-- Per interview of Staff A, Registered Nurse on 3/6/2024 at 10:45 am, pressure injuries that are a stage 1 or 2, may need a dressing or a zinc oxide based cream applied. Pressure injuries that are stage 3 or 4 trigger a wound care nurse consultation automatically. Each individual nurse is responsible for the skin assessment and management of their patients. Staff A discussed that there is currently one pressure injury prevention certified licensed practical nurse on the unit. There is also a wound care nurse available to consult within the hospital. Staff A discussed that he/she/they rely on the wound care nurse for accurate staging of pressure injuries.

-- Per interview of Staff B, Registered Nurse on 3/6/2023 at 11:00 am, he/she/they discussed pressure injury prevention measures include using protective dressings, frequent repositioning and keeping the patient's heels elevated. There is a wound care nurse in the hospital that helps with more complex pressure injuries/wounds. Each nurse is responsible to document a head to toe skin assessment and the management of pressure injuries. A wound care nurse consultation is triggered for stage 3 and 4 pressure injuries. There are no in person competencies provided to staff on staging pressure injuries. Staff use a pressure injury reference binder available at the front desk, but usually call the wound care nurse to stage all wounds.

-- Per interview of Staff C, Nurse Manager of Wound Care on 3/6/2024 at 9:25 am, there is not a specific policy and procedure pertaining to pressure ulcers and the required documentation. There are binders on each unit to help staff identify and stage pressure injuries along with treatment recommendations. When staging a pressure wound, it is expected that all nursing staff will document measurements of the wound. Staff C acknowledged the above findings.