HospitalInspections.org

Based on interview and record review, the facility failed to ensure patients received assessments and interventions to prevent and treat pressure related injuries in 3 of 3 patients (ID#s 2, 12 and 13).

Findings included:

Review of facility document titled " Non-Institutional Handbook of Operating Procedures Nursing Service Policy 7.2.62 Pressure Injury Prevention:" showed the following information:

I. Title
Pressure Injury Prevention.

II. Policy
The purpose of this policy is to provide direction to identify individuals at risk for pressure injury development and provide guidelines for assessment and intervention.
Pressure injury is best prevented by first identifying risk with the help of a validated risk assessment tool, a comprehensive skin assessment with re-assessment at defined intervals and providing interventions in line with the risk level.
- Nurses shall assess and manage skin integrity for the prevention and treatment of pressure injuries.
- Pressure Injury is to be staged according to the National Pressure Injury Advisory Panel (NPIAP)definition of pressure injury.
-Risk for pressure injury development shall be evaluated using the Braden Scale for Adult population (> 18 years old), Braden QD Scale for pediatric population (premature to 18 years old) and Neonatal Skin Score (NSS) for Neonates (birth to 28 days).

On admission and during hospitalization, assessment/re-assessment shall include:
- Skin assessment (includes all bony prominences, under tubes, orthopedic, and positioning devices)
- The primary physician service shall be notified upon discovery of any pressure injury found on the skin assessment
-A two-person skin assessment should be utilized when a patient is admitted or transferred from another unit or procedure/surgery. Two-person skin assessment refers to two staff visualizing the patient ' s skin to identify any areas of skin breakdown.
- Risk assessment using one of the age-appropriate risk scales identified above.
- The frequency of assessment/re-assessment should be conducted as follows:
-ON ADMISSION: Skin assessment, Risk Assessment, Risk Factors
-DAILY: Risk Assessment
-EVERY SHIFT: Skin Assessment
- EVERY 2-3 HOURS: Redistribution of pressure from sacrum and heels on all immobile patients, unless unstable
-PRN: When the patient has a change in status that affects mobility, stability, nutrition, or skin integrity

Non-IHOP Nursing Policy 7.2.62
If a wound or pressure injury exists:
- Refer to the UTMB Wound Care guidelines to initiate treatment and consult recommendations
- A pressure injury shall be documented in the EMR (electronic medical record) by initiating an LDA for pressure injury upon discovery of the wound. If a Pressure Injury (PI) is present on admission document PI "present on admission" or "nosocomial" if PI developed during stay at UTMB. If discovered when patient transfers to a new unit or from a procedure, the LDA should be identified as "Upon Transfer to Current Unit", which is considered nosocomial
-Care Plan for Risk of or Actual Impaired Skin Integrity will be initiated for all patients at risk for pressure injury and all patients with pressure injury

III. Procedures
Interventions for prevention of pressure injury in moderate to very severe risk patients should be implemented and documented in the EMR.
Patients considered moderate to high risk for pressure injury should be:
-Evaluated for specialty support surface
-Turned or assisted with turn on a regular schedule (Q2-3 hours based on pt need and risk)
- Protected from friction and shear to areas of high risk (i.e. sacrum, lower buttocks, or heels) using a prophylactic silicone multi-layer foam dressing
-Cleaned promptly with appropriate moisture barriers applied after each incontinent episode
-Screened for nutrition risk per IHOP Policy 09.13.09
Referrals to other health care professionals should be completed based on the result of the risk assessment.

IV. Definitions
The standards of care that our policy is based on are from National Pressure Injury Advisory Panel International Clinical Practice Guideline.

Review of facility document titled "Wound Care Guidelines," showed the following:
The WOC Nurse will provide guidance for appropriate care/referrals, dressing selection, ostomy pouch selection, support surface selection, and coordination of care for patients with a wound, ostomy, and/or continence issues.
The WOC Nurse should be consulted for:
· Pressure injuries: Stage 3, 4, Unstageable or DTI (refer to UTMB Skin Care Guide and/or Specialty Bed Algorithm for Stage 1 & 2 pressure injury nursing interventions)
· Non-healing wounds
· Lower-extremity ulcerations
· Wounds with slough or eschar
· Moderate to heavy draining wounds
· Post-op Ostomy patients
· Ostomy pouching system evaluation
· Ostomy troubleshooting (routine pouch changes are done by bedside staff)
· Peri-stomal skin issues
· Specialty Bed Considerations
· Negative pressure dressing evaluations for appropriateness, troubleshooting or suggestions for optimizing therapy
· Skin care and prevention issues related to incontinence, excessive moisture, pressure, shear, and friction which are not responding to bedside prevention/treatment guidelines
· Other wound, ostomy, or continence-related issues
**Surgical wounds are typically managed by the surgical team that performed the procedure. The surgery team may consult the WOC Nurse for optimization of care or troubleshooting difficult wounds. Consults to specialty services such as Plastic Surgery, Podiatry, General Surgery, Dermatology, or Vascular Surgery will supersede the WOC Nurse consult as they represent a higher level of care. Please refer to the UTMB Skin Care Guide, Low Air Loss Specialty Bed Algorithm, & the Skin Care
Resources website for additional resources.


Medical record for patient (ID# 2) showed the following:
Initial Skin Assessment when arriving to the unit 11D on 12/16 2024 showed assessment not completed by two RNs as required. Documented skin assessments were inconsistent. Deep Tissue Injuries were noted 12/20/2024 to the patients bilateral heel and sacrum. Wound care was consulted on 12/20/2024.
WOC Nurse Note 12/20/24
RECOMMENDATIONS: Sacrum: Cleanse with foam cleanser or saline and pat dry. Dress with Medihoney and cover with mepilex daily. Heel wounds, protect with mepilex heel. Float heels off mattress at all times while in bed. Will order a low air loss mattress. Continue to turn and reposition pt every 2 hours while in bed.
Optimize nutrition for healing. Dietary consult if not done.
12/20/2024 2:14 PM

Order placed for honey (MEDIHONEY (HONEY)) 80 % topical gel
Frequency: PRN
Admin Instructions: To be applied at least 3mm in depth, unless otherwise specified by provider.
Wound care note written 12/27/24 showed the following:
WOC Nurse Note
Follow up per daughter request to talk to wound care. Daughter concerned because she has been getting differing instructions from different staff members. States the nurses haven't been putting a dressing on, stated they did not have dressing orders so Medihoney dressing was not started. Instructions provided in WOCN note and sticky note.
ASSESSMENT: Sacral wound transitioning as expected, improved appearance today with epidermal sloughing, purple discoloration fading. Pink tissue exposed in some area. No signs of infection. Heel pressure injury remains intact.
Review of skin care and pressure ulcer prevention done. Discussed the importance of turning off of pressure area frequently every 2-3 hours. Continue Medihoney and mepilex every 1-2 days. Please send enough dressing supplies home with pt to last until home care readmits pt. Please write dressing orders for bedside RN or write to follow wound care instructions posted on sticky note..
12/27/2024 5:42 PM
Interventions and assessments were not consistently performed and documented. Wound care recommendations were not consistent with orders written.

Medical record review for patient (ID#12) showed the following:
Initial skin assessment performed on 11/18/2024 was not completed by 2 Regestered Nurses (RNs) as required. Skin assessments were documented inconsistently throughout her stay. Offloading Prevalon boots were ordered 11/18/2024, the medical record showed no documentation of intervention until 12/1/2024, the day prior to discharge. There was inconsistent documentation of turning the patient every 2-3 hours as per policy and recommendation of wound care team.

Medical record for patient (ID# 13) showed the following:
Initial skin assessment on 1/11/2025 showed skin abnormality but it not documented where or what the abnormality is. There are no pictures of wound or skin abnormality in the medical record. No wound care consult was placed.
On 1/12/2025 a blister is noted on the patient's buttock and dressing change was performed. Throughout the patients inpatient stay there is inconsistent charting of skin assessments and interventions performed.

Interview with quality staff (ID#51) on 3/5/2025 at 12:30 PM confirmed the above findings.

Interview 3/4/25 at 10:35 am with ACNO (ID#96). She described herself as Asst Chief Nursing Officer and stated that wound care was her selected/appointed leadership project. She was asked to discuss wound care with surveyors. She stated there had been considerable work efforts and attempts to build infrastructure surrounding wound care program and to decrease hospital acquired pressure injury. She stated that the facility utilizes Braden assessments to determine which patients are at higher risk for HAPI. She stated Braden scores > 13 are identified as higher risk populations. She stated presently there was not a pathway or guideline which provided clinical decision making or specific clinical interventions for patients. She stated the wound care policy provided many options for implementation. She stated they had implemented the process which required 2 RNs on admission to perform and document a head to toe skin assessment. She stated that she believed we would still find opportunities surrounding this process. She stated UTMB had implemented "skin care champions" which she described as unit based clinical RNs who had received additional education on skin assessment and wound care. She confirmed there remains inconsistency with nursing practice and documentation related to their goals for 2 person assessments on admission. She stated that the expectation was that patients who were new admissions, transferred to new level of care/new unit and patients at discharge, would receive comprehensive skin assessment with accurate documentation of their wounds. This included photographs of aberrant skin lesions/wounds. She stated she believed there was still opportunities with the assessments, adherence to performing and documenting turning/repositioning every 2 hours and inclusion of PT/OT/nutrition for high-risk patients.

Based on interviews and record review, the facility failed to ensure patient's discharge plans were re-evaluated and updated by the multi-disciplinary team to reflect occurrences/care/education provided at the facility in preparation for discharge. (Patient ID # 1, 12, 13, 24 and 32).
Therefore, patients and/or families failed to receive:
1) thorough comprehensive disease, complex wound care and tracheostomy specific care instructions prior to discharge home (Patient 1)
2) wound care instructions and follow-up instructions related to hospital acquired pressure wounds (Patient ID # 12 and 13).
3) safe discharge planning from the Emergency Department after a Childrens Protective Services case was called in post-discharge (Patient ID # 32)
4) follow-up for and safe discharge planning for a positive meconium drug screen test result in a newborn (Patient ID #24).

Findings included:

Record review of facility policy # 09.01.14 titled "Patient Discharge", last reviewed, 03/21/2020, stated "Policy: To optimize compliance with a patient's post-hospital plan of care, an assessment of the patient's actual and potential discharge planning needs shall be initiated upon admission. A multidisciplinary team that may include the physician, registered nurse, care manager, and social worker, together with the other members of the health care team, shall perform the assessment. A plan to meet these needs shall be developed, and interventions to meet specific discharge planning goals shall be designed. The plan shall be monitored and revised as necessary throughout the patient's hospital stay. Verbal communications concerning discharge or the discharge planning process shall be conducted in layman's terms using the patient's preferred language. Written discharge instructions shall also be provided, using materials that have been translated into the patient's preferred language whenever possible. If the patient is a minor, the preferred language of the responsible parent or guardian shall be used." It further stated "Roles in Discharge Planning At the time of discharge, the following tasks will be accomplished by the disciplines indicated, as 2 necessary: Nurse Care Manager (NCM) or Social Worker (SW): 1. Complete a Case Management Social Functional Assessment to evaluate and reassess post discharge needs. 2. Identify payor to determine discharge options based on the patient needs. 3. Refer unfunded patients and patients with limited resources to government program(s) or other community resource options. 4. Verify and confirm the patient/family discharge plan is safe, smooth, and sustainable. Provide education regarding continuing care, treatment, and services that the patient will need. Confirm transportation, DME, supplies, and medications. 5. Confirm understanding of discharge plan with patient/family. 6. Document discharge plan/disposition in the EMR. Physicians: 1. Inform the patient and family/caregiver(s) of the discharge date (except for TDCJ offender patients). 2. Discuss the post-discharge plan of care. 3. Establish time for follow-up appointment(s), if applicable. Nurses: 1. Complete the discharge planning screening to identify those patients identified as being at risk for adverse health consequences upon discharge without adequate discharge planning. 2. Ensure that all necessary patient teaching has occurred. 3. Assist in contacting the patient's family or caregiver(s) to inform them of the discharge date and confirm transportation arrangements. 4. The nurse caring for the patient must complete the discharge instructions. 5. Provide patient and family/caregiver(s) with the discharge instruction sheet on prescribed treatments, medications, diet, activity level, and scheduled follow-up appointments, if any. Provide written discharge instructions to discharged TDCJ offender patients and their health unit providers using Patient Discharge Instructions Medical Record Form. 4. Ask the patient and family/caregiver(s) to verbalize their understanding of the discharge instructions and give a demonstration of any care procedures. 5. For follow-up appointments at UTMB clinics, verify that a follow-up appointment has been made. 6. Document discharge in the medical record. 7. Confirm correct discharge status completed in the medical record. Respiratory Therapists: 1. Determine home respiratory medical equipment needs. 2. Provide patient/family education on medications, medical equipment, and therapy procedures to be performed at home. 3. Participate in interdisciplinary assessments to help determine necessity of home oxygen. 4. Participate in interdisciplinary discharge planning rounds and conferences." The discharge policy stated "Required Documentation The following information must be documented in the patient's discharge note or on appropriate approved forms in the medical record: 1. Provision of all discharge-related patient/family/caregiver education. 2. Availability of transportation. 3. Assessment of availability and readiness of family or other caregiver(s) to assist with the care of the patient at home. 4. Availability of assistance from community resources, including referrals to other health care agencies, as appropriate. 5. Availability of medical equipment, supplies, and medication as indicated. 6. Follow-up plan."

Record review of facility policy titled "Case Management/ Social Services/ Pastoral Care Consult (Angleton Danbury campus)" last revised 5/31/2024, stated "Social Services Consultation shall be obtained on a routine basis if any concern for the patient/family's financial welfare or personal safety exists; physicians, nurses, and ancillary health care providers may initiate a consultation. Additionally, Social Services function as a support and referral source for the following:
1) History of maternal drug use in pregnancy with a positive Urine Drug Screen in the mother.
2) History of maternal drug use other than marijuana in pregnancy with a negative maternal Urine Drug Screen.
3) History of Post-Partum Depression with previous child or children.
4) Previous CPS (Child Protective Services) history and mother's previous children no longer in the care of the mother or if there is an ongoing CPS case currently.
5) Maternal history of anxiety, depression, schizophrenia and/or bipolar when mother's mental condition is not currently stable and additional resources may need to be provided. This includes but is not limited to suicidal/homicidal ideation and need for treatment when mother has not established care and needs resources for mental healthcare. If a mother does not have a diagnosis of a mental illness, but is displaying psychotic features, a Social Services Consult is warranted.
6) Social Services Consult is not warranted for a history of anxiety and/or depression in the past that is not an issue anymore. It is also not warranted if mother's condition is stable, and she is receiving ongoing mental health care.
7) No PNC (Prenatal Care) - not limited but no PNC ....
Safety Concerns and CPS Referral
Texas Mandatory Reporting Law (261.101 of the Texas Family Code) Healthcare Providers are mandated reporters. Texas Law requires anyone with knowledge of suspected child abuse or neglect to report it to the appropriate authorities. This mandatory reporting applies to all individuals and is not limited to teachers or healthcare professionals. The law even extends to individuals whose personal communications may be otherwise privileged, such as attorneys, clergy members and health care professionals. "Professionals must make a report of first suspecting that a child has or may have been abused or neglected. " duty to report be delegated, and the professional cannot rely on another person to make the report.
CM/SW will make the reports as soon as reasonably possible with clear documentation by the provider regarding the concerns. If there are imminent concerns, evening hours or over the weekend the CM/SW may not be available, and the provider may need to make their own report. Please notify CM/SW if you make a CPS report to complete the follow up.
" Abuse
" Neglect
" Non-accident injury ..."

Interview with Respiratory Educator Staff ID # 70 on 3/4/25 at 12:30 pm while reviewing patient ID #1 medical record. He confirmed there was no tracheostomy education guideline, checkoff tool or framework which was utilized by multi-disciplinary team to ensure comprehensive patient/caregiver tracheostomy education prior to discharge home. He confirmed that staff document education in the medical record however the medical record stated "Education provided. Verbalized Understanding." He confirmed he was unable to ascertain what elements of education were provided for each entry. He confirmed that tracheostomy written instructions were included in the after-visit summary provided to the patient on the day of discharge.

Interview with Nurse Manager Staff ID # 73 on 3/5/2025 at 12:20 pm during record review for Patient ID #32. He confirmed that Patient ID # 32 was seen in the Facility B emergency department on 2/9/2025. He confirmed the patient was discharged 2/9/25 at 5:45 pm by ED nurse practitioners Staff ID #94 and dispositioned out of the ED by staff RN ID # 92. He confirmed that ED staff charge nurse ID # 93 documented "CPS intake number #(redacted) on 2/9/25 at 5:53 pm (after the patient was discharged.) He confirmed there is no provider discussion of the CPS notification and no evidence of social work consultation or involvement ID #32 medical record.

Interview with Case Management Director Staff ID # 95 on 3/5/2025 at 1:35 pm. She confirmed that the facility policy requires social work consultation/notification for cases of Childrens Protective Services (CPS) involvement due to concern for non-accidental trauma to ensure proper follow-up/safe discharge planning. She confirmed that patients who had concern for inflicted injuries should not be allowed to discharge home from the facility without CPS engagement/instructions.

Interview with Nurse Manager Staff ID #72 on 3/5/2025 at 11:20 am. She confirmed the facility has a policy in place which required Childrens Protective Service (CPS) notification for infant's who are born to mothers with no prenatal care and infants who have meconium positive drug screens at the facility. She confirmed there was no evidence of CPS notification for the lack of prenatal care for Patient ID #24's mother and the positive drug screen in Patient ID # 24. She confirmed there was no evidence of lab notification to facility staff that the meconium positive drug screen resulted after patient was discharged home from the facility. There was no evidence of social work awareness of meconium drug positive status for Patient ID #24.

Interview with Quality Staff ID # 51 with record review of Patient ID #12 and 13 records on 3/5/2025 at 12:30 pm. She confirmed there was no evidence of wound care instructions, dressing changes and post-discharge follow-up for the patient/caregiver related to the hospital acquired skin injuries for Patient ID #12 and 13 per record review.