HospitalInspections.org

Based on policy review, medical record review, and interviews, the hospital failed to follow internal hospital policies, specifically:

1. The hospital failed to document patient repositioning every two hours to prevent skin injury as indicated in policy, "Skin and Wound Care: Skin Assessment and Wound Prevention Guidelines" for one of eight medical records reviewed. (Patient #1).
2. The hospital failed to notify the provider of a new skin injury and request a referral/consult to the wound advisor for a stage two or greater pressure injury for further evaluation per policy, "Skin and Wound Care: Wound Management and Treatment," for one out of eight medical records reviewed (Patient #12).
This is evidenced by:
Findings #1:

Review on 08/15/24 of policy "Skin and Wound Care: Skin Assessment and Wound Prevention Guidelines", effective date 01/07/24, revealed "Skin injury prevention measures will be implemented for all patients identified at risk according to the Braden Pressure Injury Risk Assessment Tool. A score of 18 or less indicates the client is at risk for development of pressure injuries and a score of 9 or less indicates the patient is at a very high risk for development of pressure injuries. Preventive interventions are based on the Braden Pressure Injury Risk Assessment Tool's score, and prescriber orders. Skin inspections will be completed every shift and all abnormal findings documented. Wound treatments require a provider's order. Patients that are sedentary or spend prolonged time in bed should be repositioned at a minimum of every two hours and more often if at high risk or have immobility issues. For patients at higher risk of pressure injuries requiring additional support to manage their mobility and positioning, consider a referral and consultation with physiotherapy or occupational therapist or the wound ostomy nurse for assistance/advice on positioning, repositioning, and selection of most appropriate surface."

Review of the electronic medical record for Patient #1 revealed on 04/20/24 at 12:58 AM Patient #1 was transferred from an outside facility for surgical intervention of a gastrointestinal perforation (tear in the stomach or intestine). At 01:14 AM, the nursing admission assessment indicated no areas of skin injury or pressure injury were found during the four-eyes (two nurses assess together to verify findings) skin assessment. At 05:02 AM, the Braden Pressure Injury Risk Assessment Tool score of 12 was documented indicating Patient #1 was at high risk for development of skin/pressure injuries. Preventive interventions were based on the Braden Pressure Injury Risk Assessment Tool's score and included turn and repositioning of Patient #1 every two hours. The nursing flowsheet documentation for turning and repositioning reflected Patient #1 changed position independently until 04/22/24 at 08:00 AM and 10:00 AM when staff assisted Patient #1 with repositioning. Per Nursing and Provider progress notes Patient #1's medical condition progressively worsened. From 04/20/24 to 08/14/24 there was no documented evidence that Patient #1 was turned or repositioned for 146 out of 1,392 opportunities including no documentation that Patient #1 was turned or repositioned either independently or with assistance for the hours between 06:45 PM on 04/22/24 and 08:02 AM on 04/23/24. Additionally, on 04/24/24 turning, repositioning and/or incontinent care was documented every two hours except for the hours of 06:00 AM, 10:00 AM, 12:00 PM, and 06:00 PM. On 04/25/24 at 05:37 PM nursing assessment revealed a sacral (tailbone area) pressure injury and skin was described as "burgundy, purple, and red, and clean, dry, and intact." Pressure injuries were also noted to both heels at 05:37 PM, described as "burgundy, purple, and red, but skin was clean, dry, and intact." On 04/26/24 a nursing wound care consult assessment note indicated completion of evaluation and treatment recommendations for the sacral and heels pressure injuries. Patient #1 had a history of sacral wounds at home. The deep tissue pressure injury to the sacrum was documented, measured 10 centimeters by 10 centimeters, described as purple and red, and determined to be a deep tissue pressure injury. Both heels were assessed and documented as reddened, clean, dry, intact, and blanchable. Turning, repositioning and offloading pressure to the sacrum and both heels was part of the recommended treatment plan.

Interview on 08/15/24 at 02:38 PM with Staff (I) Nurse, revealed turning and positioning should be documented every two hours on all patients regardless of their level of mobility.

Findings #2:
Review on 08/15/24 of policy "Skin and Wound Care: Wound Management and Treatment Policy" effective date 12/28/22 revealed "the nurse/clinician will notify the provider of a new ulcer/injury to obtain treatment orders. All hospital acquired pressure injuries stage two or greater are to be referred to the wound advisors. Wound treatments require a provider's order."

Review of the inpatient medical record for Patient #12 revealed on 08/02/24 nursing documented an initial skin assessment as within normal limits and pressure points without redness. On 08/10/24 at 11:10 PM nursing assessment documentation included a Braden Pressure Injury Risk Assessment Tool score of 15 was documented indicating Patient #12 was at high risk for development of skin/pressure injuries. A stage two pressure injury (a shallow, open wound that extends into the lower layers of the skin)to the left ischium (boney part of the buttocks) was described as pink and moist. Review of the daily provider assessments and progress notes from 08/10/24 to 08/15/24 revealed no evidence that the provider was notified or addressed the stage two pressure injury. There was no evidence that a consult/referral was made to the wound advisors for further evaluation of the stage two pressure injury on Patient #12's left ischium.

Interview on 08/15/24 with Staff (C) Quality Manager verified these findings.