HospitalInspections.org

Based on facility policy and procedure review, medical record review, and staff interviews, the facility failed to ensure adequate supervision by nursing to perform and document an assessment of a coccyx (tailbone) for 1 of 3 sampled patients with wounds (Patient 6) from a sample of 11. This failed practice had the potential to affect all patients of the hospital. On 10/24/2024 the inpatient census was 81.

Findings are:

A. Review of the facility policy titled Pressure Injury Prevention/Wound Care Protocol (Last approved 5/2024) revealed: ..."all wounds are documented with assessments to include:
-Location
-Size (length, width, depth)
-Characteristics, and appearance of the wound to include tunneling or undermining.
-Characteristics of the skin around the wound.
-Drainage characteristics and amount.
-Document wound assessments and treatments with each dressing change in the EHR (electronic health record).
-On consulted inpatients, the wound nurse will see the patient weekly to measure, assess, apply dressing, and document wounds in the EHR. The wound nurse will partner with floor nursing staff for this dressing change to ensure understanding of dressing changes throughout the week."

B. Review of Patient 6's medical record (10/29/2024) revealed the patient was admitted on 10/15/2024 from a nursing home for a left foot infection. Review of the 10/15/2024 History and Physical, identified the diagnosis to included "severe sepsis (blood infection) secondary to a complicated left foot infection, diabetes, hypertension (high blood pressure, depression, peripheral artery disease.)"

-Review of Patient 6's coccyx wound orders and flowsheet documentation identified the following:
1) That upon admission on 10/15/24 the admission registered nurse (RN) did a head-to-toe assessment of the patient's skin. That assessment revealed a gluteal cleft (coccyx) wounds.
2) On 10/15/24, the admission RN requested a wound care consult. The physician order dated 10/15/25 at 2:08 PM "Inpatient consult to Wound Care Nurse Other, Pressure ulcer; left foot wound, COCCYX PU (pressure ulcer), left foot wound."
3) Review of the initial wound integrity flowsheet dated 10/15/24 at 12:28 PM identified "3 small S2 (stage 2-a shallow open sore with a red or pink wound bed) areas < (less than) 2 cm (centimeter)". The flowsheet identified the Peri-wound (skin surrounding open area) Assessment - Erythema (red); wound bed color "pink"; no drainage; cleansed and left open to air.
4) Review of the wound integrity flowsheet (documented every 4 hours) identified 10/16/24 at 11:05 AM identified peri-wound; wound bed and wound drainage as: UTA (unable to assess) and open to air. On 10/16/24 at 11:10 AM the documentation identified peri-wound: Erythema; bleeding due to taking brief off and ripping off a scab.
5) Review of the every 4 hour wound integrity flowsheet documentation from 10/16/24-10/26/24 identified the peri-wound area as erythema; wound bed color as pink/red/or UTA; and open to air. The every 4-hour documentation from 10/15/25 12:28 AM-10/26/24 at 7:38 AM lacked measurements or description of the progress of the wound.
6) Review of the wound integrity flowsheet 10/26/24 at 7:58 PM -10/30/24 identified the peri-wound area and wound bed color as UTA; and covered with a Mepilex (a foam dressing). These assessments lacked measurements or a description of the progress of the wound.

-Review of the Wound Nurse Consult (RN-W) documentation dated 10/28/2024 at 5:01 PM stated, "Pt seen for assessment of wound to coccyx. Pt has an unstageable pressure injury to the coccyx. This has been covered with a foam border." "Patient would benefit from an EHOB mattress overlay (an air-filled mattress placed on bed) for pressure reduction and will need to follow up outpatient for wound care for the coccygeal pressure injury. Wound Care will follow up with patient weekly during hospital stay."

C. Interview with RN-W (10/30/2024 at 10:12 AM) revealed, "I went to the floor and looked at it on 10/28/24." When inquired why it wasn't assessed prior to that when the 10/15/2024 physician order was placed, RN-W replied, "I just saw it, it was on my list, and I missed it when it was ordered." "Not sure how that happened." When asked where the measurements were documented, RN-W replied, "I lost them, so I didn't get them documented." When inquired if the reason the wound was described as an unstageable pressure injury if it was covered with an eschar (Leathery area on wound bed), RN-W replied, "No, it was covered in yellow slough (a fibrinous tissue that is formed by dead cells and/or bacteria in a wound).

-Interview with RN-A (10/30/2024 at 12:30PM) confirmed RN-W's 10/28/2024 5:01PM wound consult note lacked evidence of measurements, characteristics, and appearance of patient 6's coccyx pressure injury.