HospitalInspections.org

Based on document review and interview, the facility failed to ensure a Registered Nurse followed facility policy related to notifying the physician of patient presenting with a pressure injury for 1 of 10 medical records reviewed (Patient #1).

Findings include:

1. Facility policy titled "PRESSURE INJURY ASSESSMENT, PREVENTION, AND TREATMENT INCLUDING BRADEN SCALE/BRADEN Q - ADULT AND PEDIATRIC (Observations and Inpatients)"with a review/revision date of 2/2020 indicated the following: "...MANAGEMENT OF PRESSURE INJURY: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Initial Steps to take when a Pressure Injury is found...2. Inform physician of any patient presenting with a pressure injury, and of injury advancement (worsening)..."

2. Review of Patient #1's medical record indicated the following:

(a) A review of a provider progress note dated 1/6/22 at 1734 hours indicated the following: "...SKIN: Skin normal color, texture..."

(b) A review of a nurse note dated 1/7/22 at 0930 hours indicated the patient had a pressure ulcer/injury non-surgical to his/her right buttock and staged as a 2. The nurse's note indicated that the wound base was pink 100%, surrounding tissue had maceration/wet white edges with no drainage and/or odor noted. The nurse's notes lacked documentation that a physician was notified of Patient #1's wound.

(c) A review of a provider progress note dated 1/7/22 at 1810 hours indicated the following: "...Objective...SKIN: Skin normal color, texture..." The provider note lacked documentation that the physician was notified of Patient #1's wound.

(d) A review of a nurse note dated 1/7/22 at 2200 hours indicated the patient had a pressure ulcer/injury non-surgical to his/her right buttock and staged as a 2. The nurse's note indicated that the wound base was pink 100%, surrounding tissue had maceration/wet white edges with no drainage and/or odor noted. The nurse's notes lacked documentation that a physician was notified of Patient #1's wound.

(e) A review of a nurse note dated 1/8/22 at 0930 hours indicated the patient had a pressure ulcer/injury non-surgical to his/her right buttock and staged as a 2. The nurse's note indicated that the wound base was pink 100%, surrounding tissue had maceration/wet white edges with no drainage and/or odor noted. The nurse's notes lacked documentation that a physician was notified of Patient #1's wound.

(f) A review of Patient #1's discharge summary dated 1/8/22 at 2200 hours lacked documentation that a physician was notified of Patient #1's wound.

3. During an interview with A2 (Safety & Accreditation Coordinator) on 2/8/22 at 3:50 p.m., he/she verified the medical record information for Patients #1.