HospitalInspections.org

Based on policy review, medical record review and interview the hospital's nursing service failed to provide oversight and supervision to ensure care was provided to meet the patient's needs by providing accurate wound assessment and documentation for 1 of 9 (Patient #3) sampled patients.

The findings included:

Medical record review revealed that Patient #3 presented to the ER on 1/14/2023 with a chief complaint of being unable to verbalize and was admitted to the hospital with a diagnosis of Pneumonia.

Patient #3 did not have an inital skin assessment completed and documented within the first 24 hours of hospitalization.

Patient #3 was admitted on 1/14/2023 without any pressure injuries. The initial skin assessment completed was not documented according to the facility's policy.

Patient #3 had physician's orders to be turned every two hours; however documentation revealed Patient #3 was not turned every 2 hours.

On 1/29/2023 documentation revealed Patient #3 had a Stage II on the Sacrum. The wound documentation did not document a complete description of the Stage II pressure ulcer on the sacrum.

On 2/6/2023 documentation revealed a wound care assessment for a Stage II on the Sacrum, a Trochanter/Right Hip with a Suspected Deep Tissue Wound and a Trochanter/Left hip with a Suspected Deep Tissue Wound that included measurements for the three pressure injuries.

Review of the skin assessment on 2/20/2023 revealed the Sacrum Stage II pressure ulcer had developed into a suspected deep tissue injury.

Review of the skin assessment on 2/28/2023 at 7:15 PM revealed the three area had developed into Stage IV pressure ulcers:
(a) Sacrum
(b) Right Trochanter/Hip
(c) Left Trochanter/Hip with a deep tissue injury.

Interview on 5/30/2023 with RN #1 revealed that after the initial assessment the facility does not have the staff to go back to reassess the wounds.

Based on facility policy review, medical record review, and interview, the facility's nursing services failed to accurately and completely document wounds and wound assessments for 1 of 2 (Patient #1) sampled patients reviewed with wounds. The facility's nursing services also failed to document pressure relief and offloading for 1 of 2 (Patient #1) sampled patients with skin problems and pressure injuries.

The findings included:

1. Review of the facility's "Pressure Injury Wounds: Staging Prevention and Treatment" policy with a revised date of "9/21/2021" revealed, "...Purpose...to prevent, treat and/or improve pressure injuries...Definitions and Descriptions. A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear... Stage 1 Pressure Injury: Non-blanchable erythema of intact skin...Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis...Stage 4 Pressure Injury: Full; thickness skin and tissue loss...Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration...The Braden Scale and the Braden Q Scale are tools to systematically assess for risk for potential development of pressure injuries and skin breakdown. A lower Braden or Braden Q scale indicate greater risk...Referral to Wound Care is initiated for: Stage 3, Stage 4, DTPI [Deep Tissue Pressure Injury], unstageable pressure injury and mucosal pressure injury. Stage 1 and Stage 2 pressure injuries, skin tears or other non-pressure wounds, or a Braden score of less than 18 are treated by the bedside RN...Consult wound care for worsening wound or staging discrepancies...Prevention Measure Options...Use gel pads, pillows, foam dressings...Change dressing every 5 days and PRN [as needed] if soiled...Consult Wound Care nurse or House Supervisor after hours if a specialty bed is needed...Limit layers of linen...Stage 1 Clinical Nutrition Consult (automatic)...Notify physician /provider...Stage 2 Clinical Nutrition Consult (automatic)...Notify provider...Redistribute pressure off of area when patient unable to reposition self...Stage 3 or 4...Implement prevention interventions Redistribute pressure...Clinical Nutrition Consult (automatic)...Notify provider...Consult Wound Care Nurse...Deep Tissue Injury...Implement prevention interventions...Redistribute pressure interventions..Clinical Nutrition Consult (automatic)...Notify provider...Consult Wound Care Nurse...Skin assessments, dressings, and the Braden scale are documented in the Medical Record. Document repositioning for patients who cannot reposition themselves..."

Review of the facility's "Admission Screening for Nutritional Risk" policy with a revision date of 9/6/2022 revealed, "...Nursing services screen patients for nutritional risk upon admission...To define roles, time frames, and criteria to screen, assess, and intervene nutritional risk upon admission to the hospital...Nursing services complete the admission nutrition screen in the electronic medical record (EMR) within twenty-four (24) hours of admission to identify nutritional risk..."

Review of the facility's "Skin Assessment" policy, with a revision date of 2/8/2023 revealed, "...The patient's skin is inspected within the first 8 hours of admission, daily and PRN [as needed]. The patient's initial skin assessment is a two-person assessment. The RN conducts the primary assessment. An RN or nursing assistant III can be the second set of eyes... Evaluate the following... Color... Uniformity... Thickness... Symmetry... Hygiene... Presence of integrity variation... Skin assessment documentation includes a description of any integrity variations after visually inspecting the entire body surface. The RN is responsible for documenting skin assessment..."

2. Medical record review revealed Patient #3 was admitted to the hospital on 1/14/2023 with the diagnosis of Pneumonia. The medical record documented Patient #3's mobility was very limited, nutrition was probably inadequate and tissue perfusion and oxygenation compromised.

Review of the skin assessment on 1/16/2023 revealed this was the initial skin assessment. The assessment documented the patient's skin integrity was intact. The skin assessment was verified by a second Registered Nurse (RN). Patient #3 had a Braden Score of 13 (Moderate Risk 13-14) and the pressure ulcer criteria was not met.

The initial skin assessment was not completed within the first 24 hours.

The daily skin assessments, dated from 1/16/2023 - 3/1/2023 did not document an evaluation for Patient #3 in each of the following areas: color, uniformity, thickness, symmetry, hygiene, presence of integrity variation. The hospital failed to follow it's skin assessment policy.

A Physician's orders dated 1/16/2023 revealed an order to turn the patient every 2 hours.

The daily skin assessment dated from 1/16/2023 - 3/1/2023 did not document Patient #3 was turned every two hours.

Review of the skin assessment documentation for position changes from 1/14/2023 to 3/1/2023 revealed the following documentation:
(1) On 1/17/2023 (a) 1:19 PM Pressure distribution, (b) 1:36 PM Left,(c) 3:00 PM Pressure distribution.

(2) On 1/19/2023 position change...Chair.

(3) On 1/18/2023 (a) 6:58 AM Pressure redistribution, (b) 2:00 AM Left, (c) 8:33 AM Supine, (d) 1:19 PM Pressure redistribution, (e) 3:00 PM Pressure redistribution, (f) 5:19 PM Pressure redistribution, (g) 7:40 PM Right, (h) 9:30 PM Left (i) 11:27 PM Pressure redistribution.

(4) On 1/26/2023 (a) 9:15 AM Pressure redistribution, (b) 11:01 AM Pressure redistribution, (c) 12:11 PM Pressure redistribution, (d) 2:03 PM Pressure redistribution, (e) 6:03 PM Pressure redistribution, (f) 6:19 PM Pressure redistribution.

(5) On 2/18/2023 (a) 12:18 PM Pressure distribution, (b) 2:38 PM Pressure distribution.

(6) On 2/26/2023 (a) 1:35 AM Pressure redistribution, (b) 3:30 AM Pressure redistribution, (c) 5:30 AM Pressure redistribution, (d) 12:00 PM Pressure redistribution, (e) 2:00 PM Pressure redistribution, (f) 4:00 PM Pressure redistribution, (g) 6:00 PM Pressure redistribution.

There was no documentation in the skin assessments the patient's position was changed from right, left, and supine.

Review of the skin assessment on 1/29/2023 at 11:30 PM revealed, "...Pressure Ulcer Stage Active...Sacrum Pressure Ulcer Stage II...Pressure Ulcer Comment Stage 2 with some escar..."

There was no documentation a complete wound assessment was done on this Pressure Ulcer Stage II of the Sacrum.

Review of the skin assessment on 1/30/2023 at 7:10 AM revealed, "...active Stage II pressure ulcer on the sacrum..."

There was no documentation a complete wound assessment was done on this Pressure Ulcer Stage II of the Sacrum.

Review of the skin assessment on 2/6/2023 at 2:23 PM revealed a wound care assessment of the following Sacrum Stage II with measurements of - Length 7 cm x Width 4 cm x Depth 0.1 cm.
Trochanter/Hip Right Lateral - Suspected deep tissue injury with measurements of Length 11 cm x Width 6 cm x Depth 0. Pressure ulcer bed appearance maroon. Asked for a initial consult with WOCN [Wound, Ostomy, and Continence Nurse].
Trochanter/Hip Left Lateral - Suspected deep tissue injury with measurements of Length 8 cm x width 4 cm x depth 0.1 cm. Pressure ulcer bed appearance peeling black tissue with red wound bed.

There was no documentation after the 2/6/2023 a complete wound care assessment was done with measurements on the following three pressure injuries:
(a) Sacrum Stage II
(b) Right Trochanter/Hip
(c) Left Trochanter/Hip.

Review of the skin assessment on 2/20/2023 revealed the status of the Sacral wound had developed from a Stage II to a Active pressure ulcer stage of suspected deep tissue injury.

There was no documentation a complete wound assessment was done on this pressure injury developing from a Stage II to a deep tissue injury.

Review of the skin assessment on 2/28/2023 at 7:15 PM revealed the three areas, (a) Sacrum (b) Right Trochanter/Hip (c) Left Trochanter/Hip with a deep tissue injury had deteriorated and developed into Stage IV's.

Interview in the conference room on 5/30/2023 beginning at 12:05 PM, RN #1 was asked if she was certified in Wound Care, RN #1 stated, "...No she was not but was in the process of getting certified...RN #1 stated they received wound care consults for anything that was a Deep Tissue Injury and greater than a Stage II. We measure all the wounds and document measurements and put our information in the wound care notes...if the wound needs to be debrided we consult a doctor...if the wound progresses the wound care nurses are called and then we go back and reassess...we do not go back and do anything unless it gets worse..." RN #1 was asked who measures the wounds. RN #1 stated, "...The floor nurses do not measure the wounds. If we see a patient we receive a 7 day notice to go back and see the patient but we do not have the man power right now to all the assessments..."