HospitalInspections.org

Based on interview, medical record review, and policy review, the provider failed to implement interventions promptly to prevent pressure ulcers from developing and worsening while under their care for one of two sampled patients (1). Findings include:

1. Review of patient 1's 2/2/24 through 3/13/24 electronic medical record (EMR) revealed:
*He was admitted on 2/2/24 for further rehabilitation and nutritional support for generalized weakness after a kyphoplasty procedure to treat compression fractures in the spine.
*His diagnoses included the following: peripheral neuropathy, Charcot-Marie-Tooth (CMT) disease (disease that damages the nerves in the arms and legs), bilateral foot drop (difficulty lifting the front part of foot), atrial fibrillation (irregular heartbeat), hypertension, and generalized arthritis.
*He:
-Required the use of a TSLO (thoracic lumbar sacral orthosis) brace for back stabilization.
-Had increased pain from his recent back procedure.
-Wore orthotic braces on both legs to assist with his foot positioning.
*An admission skin assessment was completed on 2/2/24 with no documentation of wounds on both of his heels.
-Upon admission, the left heel was intact with dry skin identified.
*On 2/9/24 documentation of both the left and right heel skin variances began.
-The nursing staff documented intact blisters on both his left and right heels.
-Those wounds had been discovered seven days after his admission date.
*A foam dressing was applied to the left heel.
*There was no other documentation to support the size and appearance of those wounds until 2/14/24 when they were initially assessed by registered nurse (RN) C.
-The RN C had not observed the wounds until five days after they had been discovered by the nursing staff to ensure appropriate treatment and interventions had been initiated to promote healing.
-The size of the wound to his left heel was 5 centimeters (cm) x 4 cm.
-The right heel wound was an intact blister and remained open to air.
*On 2/21/24 RN C documented the wound had worsened and now measured 5 cm x 5 cm in diameter.
*On 2/22/24 the nursing documentation indicated the left heel had opened.
-The wound base had necrotic (dying tissue) tissue with eschar (dead tissue falling off healthy skin).
*He was dependent upon the staff for:
-The development of his plan of care to ensure that interventions were implemented for the quality of care.
-Assistance with activities of daily living to include bed mobility, repositioning, toileting, and positioning of pressure relieving devices.
*Heel boots were not ordered to assist with offloading pressure on his heels until 2/26/24.
-That was twenty-four days after his admission and seventeen days after the wounds had been discovered.

Review of patient 1's 2/2/24 through 3/11/24 physician's progress notes revealed no documentation to support the physician's awareness of the wounds to his heels.

Review of patient 1's 3/13/24 physician discharge summary revealed a pressure ulcer to his left heel.
-That was the first documentation from the physician to support the physician's awareness of the wound to his left heel.
-There was no documentation to support the physician's awareness of the blister on his right heel.

Review of patient 1's 2/2/24 through 2/26/24 Braden Scale assessment (risk assessment form to assist with determining a patient's pressure ulcer risk level) revealed:
*A score that fluctuated between fourteen to sixteen and placed him at mild to moderate risk for skin breakdown.
*The scores supported that his heels should have been protected and offloaded while in bed to aid in the prevention of skin breakdown.

Review of patient 1's 2/2/24 through 3/13/24 rehab nurse technician (RNT) documentation revealed:
*On 2/6/24 was the first documentation that his heels were offloaded.
-That was four days after his admission.
*His heels were offloaded for eleven days out of a forty-one day hospitalization.

Interview on 4/26/24 at 10:20 a.m. with chief nursing officer (CNO) A revealed she:
*Confirmed the wound nurse had assessed and documented on the patient's wounds every week on Wednesday.
*Expected the licensed care staff to assess and implement wound care interventions per their wound care protocol.
*Expected those interventions to have been documented and implemented promptly to promote healing and prevention of further skin breakdown.

Interview on 4/26/24 at 2:30 p.m. with RN C revealed she:
*Confirmed:
-There were no issues identified with his heels on admission.
-She had not observed and assessed the wounds for proper treatment and interventions until 2/14/24.
-The heel boots had not been implemented for pressure relieving until 2/26/24.
*Stated:
-"It would not have hurt to add them earlier."
-"Yes" when asked if that had been reactive versus proactive.
*Had not classified his wound as a stage 2 related to his CMT to his legs and feet.
*Stated:
-"Interventions are dependent upon the day."
-"If they don't document it, the patients would not need it at the time."
-"Hard to say if these would be avoidable wounds."

Interview on 4/26/24 2:54 p.m. with RN D revealed:
*The licensed staff can implement pressure relieving interventions for wound prevention.
*He would have expected wound care documentation and interventions in the medical record.
*The wound nurse would have kept track of what the wounds are and interventions for them.

Interview on 4/26/24 at 3:13 p.m. RNT E revealed:
*He confirmed they have a repositioning program and the patients should have been repositioned at a minimum of every two hours.
*The RNTs document in the medical record.
*He confirmed that if it was not documented the intervention would have been considered not done.
*There would have been documentation in the medical record when an intervention was used such as off-loading heels.

Interview 4/26/24 at 3:30 p.m. with chief executive officer B and CNO A revealed they were in agreement that resident 1's wounds were acquired during his hospitalization and under their care and services.

Review of the provider's 9/6/23 Wound Assessment and Documentation policy revealed:
*Purpose:
-"To improve patients' skin integrity through timely and consistent clinical practices for assessment and prevention of wounds."
-"To ensure standard documentation related to the assessment of skin and wounds."
*Responsibility: "It is the responsibility of the Chief Nursing Officer to implement and sustain compliance with this policy."
*Policy:
-"For a Braden Score of 18 or less, the Pressure Injury Prevention Protocol will be initiated and incorporated into the plan of care.
-Each patient's wound care will be under the direction of a physician.
-Findings are recorded upon admission and weekly at a minimum.
-Category/Stage 2: May also present as an intact or open/ruptured serum-filled blister.
-Daily documentation will be recorded by the RN as part of the daily nursing assessment. The type of specialty bed or support surface used to assist with preventing and/or treating skin breakdown will be included in documentation."
*Responsibilities:
-"The physician assumes leadership over clinical interventions and wound care treatment.
-"The Wound Care Coordinator has responsibility for oversight of the wound program."