HospitalInspections.org

Based on policy review, medical record review, and interview, nursing services failed to provide accurate assessments to identify and prevent the occurrence of healthcare associated adverse events and other pressure injuries for 1 of 1 (Patient #1) sampled patient with wounds.

The findings included:

Review of the Hospital #1's "Wound Care" policy revised on 9/2019 revealed, "...Pressure Injury Documentation: Once a pressure injury is identified, an assessment must be documented. This must reflect that the Physician and family were notified and what treatment/interventions were initiated. B. The Weekly Wound Progress Note must be initiated by the nurse. The Date of Onset and the Location must be documented. This will be completed weekly and PRN [as needed]. C. Pressure injuries must be assessed and measured weekly...E. Weekly documentation is to be recorded on a Weekly Wound Progress Note. This form is to be used to document pressure injuries...A separate form must be completed for each wound. Complete an assessment block for each weekly assessment. This is a permanent part of the patient's medical record..."

Medical record review for Patient #1 revealed the patient was admitted to Hospital #1 on 12/24/2020 with diagnoses that included Dementia with Behavioral Disturbance, Delirium, Bipolar disorder, and Post-traumatic stress disorder (PTSD).

Past medical history includes Schizoaffective Disorder, Diabetes type 2, Hypertensive Heart Disease, Tremors, Hyperlipidemia, Gastroesophageal Reflux Disease, Vitamin D Deficiency, Osteoarthritis, Covid-19 positivity along with Covid 19 pneumonia.

Review of the Initial Nursing Assessment dated 12/24/2020 at 7:35 PM, revealed Nurse #3 documented Patient #1 required assistance with all Activites of Daily Living (ADL), ambulated per walker or needs wheelchair, and incontinent of bowel and bladder. (ADL: Bathing, eating, toileting, walking, and medication administration)

Review of Physician #2's order sheet dated 12/24/2020 revealed, " ...Cleanse open area to left buttock with wound cleanser. Pat dry and cover with island dressing BID (two times a day) and PRN (as needed) until resolved ..."

The Initial Skin Assessment sheet dated 12/24/2020 revealed Registered Nurse (RN) #1 documented a wound to the Left Buttock, 1 centimeter (cm) by 1 cm with red, beefy wound bed and no drainage. There was no documentation of the stage of the wound or treatment provided. There was no documentation the family was notified of the wound.

Review of the 12/24/2020 Interdisciplinary Treatment Plan for Patient #1 revealed, "...potential for infection related to impaired skin integrity...start date 12/24/2020...short term goal: decubitus ulcer to left buttock, will show healing improvement, and will not have signs or symptoms of infection over the next seven days...Interventions: monitor for effectiveness of ordered medications, cleanse decubitus left buttock with wound cleanse, pat dry, cover with island dressing BID (two times a day) until healed. There was no documentation the family was notified of the treatment plan.

Review of Patient #1's Admission History and Physical dated 12/25/2020 revealed Physician #2 documented, "... Stage II (2) to the Left Buttock with appropriate treatment in place..." (Stage 2 wounds are shallow with a reddish base. Stage 2 are typically caused by prolonged pressure, shear, friction or moisture.)

Review of the Patient Care note dated 12/30/2020 revealed Patient #1 was in the dining room lethargic responding mildly to sternal rub but not to verbal commands. Vital signs were documented as blood pressure: 58/38, heart rate:138, and oxygen saturation: 98% (percent) on room air. The patient was sent via Emergency Medical Services (EMS) to Hospital #2 and the family (sister) was notified.

Review of Hospital #2's Integumentary flowsheet dated 1/4/2021 revealed the RN documented Patient #1 had a Stage 1 Pressure Ulcer to Left Buttock.

Review of Hospital #2's Wound Care Document dated 1/4/2021 for Patient #1 revealed, the RN documented, "...abrasion open to left buttock, "dime size", partial thickness. Mepilex foam per wound protocol..."

Medical record review revealed Patient #1 was readmitted on 1/8/2021 to Hospital #1 from Hospital #2 with an admitting diagnosis of Dementia with Behavioral Disturbance.

Review of Physician #2 order's dated 1/8/2021 at 10:00 PM, revealed, "...Cleanse coccyx with wound cleanser and pat dry. Cover with Duoderm every 3 days and PRN..."

Review of the Nursing Shift Assessment dated 1/8/2021, revealed Nurse #1 documented under skin assessment, "...pressure wound to coccyx length 2 width .5, linear, Stage II noted to coccyx. There was no documentation of accurate measurements, the description of the wound or type of wound treatment provided.

The Admission Nutrition Assessment dated 1/8/2021 for Patient #1 revealed RN #1 documented, "...Pressure Injury Present; Stage 2..."

Review of the Nursing Shift Assessment dated 1/9/2021 at 5:53 PM, revealed the DON documented under skin assessment, "...wound type: skin tear left buttock.." There was no documentation of the description of the wound, stage of the wound or type of wound treatment provided.

The Weekly Skin Integrity Tool dated 1/9/2021 for Patient #1 revealed the DON documented under Skin condition, "...Left Buttock, redness, non blanching..." There was no documentation of the description of the stage of the wound or type of wound treatment provided.

There was no documentation on the treatment record for 1/11/2021 and 1/14/2021 indicating the wound was assessed or treatment was given per physician orders.

Review of the progress note dated 1/14/2021 revealed RN #2 documented, "...Mental Health Technician (MHT) reported that the pt (patient) was non-responsive to verbal and tactile stimuli, skin warm and dry ...assessed patient and the patient did not respond to stimuli The patient left arm was flaccid, and mouth was twisted to the right side. Pupil was sluggish, respirations 15 and labored, BP 97/54. Sats (oxygen concentration) 93 oxygen applied at 2 lit via NC (nasal cannula), MD notified, order to send pt to Hospital Emergencey Room for evaluation. Pt is a DNR with limited intervention. The patient's sister was notified of transfer ..."

Patient #1 was transferred via EMS to Hospital #2 on 1/14/2020 and admitted for Decreased Mental Status.

Review of Hospital #2's Integumentary flowsheet dated 1/15/2021 revealed the RN documented Patient #1 had an unstageable pressure ulcer to the sacrum, red and purple in color -suspect deep tissue injury evolving and Bilateral heel deep tissue injury, black and purple in color present upon admission.

Review of Hospital #2's Wound Care Document dated 1/18/2021 revealed the Wound Care RN documented Left/Right buttock/Sacrum with suspected deep tissue injury measures 12.0 cm by 10.0 cm.

There was no documentation in Patient #1's medical record from Hospital #1 that the patient had Bilateral heel deep tissue injury.

In a telephone interview on 1/25/2021 at 5:50 PM, When asked about Patient #'1's wound, RN #1 stated, "...on the 1st [first] admission the report from the VA was a Stage II to the coccyx. The medical doctor here stages wounds. There was a Mediplex dressing on the wound. During the initial assessment I removed the Mediplex. The wound was linear in shape and it looked more like a shear tear. We continued with wound care per the doctor's order. When I asked if she spoke to the Patient #1's sister related to the wound, RN #1stated, "... yes, she called me almost daily and I would give her an update on his status. She asked me about the sore on his bottom and I told her we were treating it. When asked if she remembered telling the sister that it was a bad wound she stated, "...no I don't recall saying anything like that. I just told her he had the wound and it was being treated..."