HospitalInspections.org

Based on interview and record review, the facility failed to ensure that licensed nursing personnel adhered to the facility's policy and procedure regarding the submission of an incident report when a pressure ulcer is identified, resulting in two (P-2, P-3) of 10 patients reviewed, acquiring a pressure injury, and the increased potential for harmful adverse outcomes for all patients. Findings include:

Review of facility policy titled "Tier1: Pressure Injury Prevention," #1597299, eff. 07/22, revealed that patients are assessed by two nurses for skin wounds upon or within 8 hours of admission. Additionally, a "Braden" skin risk assessment is completed within 24 hours of admission and again daily or with change in patient condition. The policy contains 5 attachments which correspond with Braden scale values, dictating the various interventions and protocols to follow. Further review under paragraph (K.) revealed "Discovery of a hospital acquired pressure injury (HAPI) must be reported using the online risk reporting process (RL Solutions Incident Reporting)."

Review of P-2's chart with wound care RN Staff BB on 01/07/24 at 1204 determined that P-2 entered the facility on 08/20/24 with no sacral wound documented and was discharged with a Stage 4 sacral wound on 11/04/24.

Review of the "Adverse Events (RL Solutions)" report log on 01/06/25 failed to demonstrate P-2's wound information being entered.

At 1500 on 01/07/24, the Chief Nursing Officer (Staff B) stated "We just looked it up and our policy says all PUI's (pressure ulcer injuries) should have an RL (incident report)."


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On 1/6/2025 at 1400 medical record review for P-3 was conducted with Staff L. The review revealed the following:

The initial inpatient nursing assessment was conducted on 7/8/24 at 2146, a 4 eyed skin assessment was documented indicating skin was within normal limits, without impairment.

Braden scale during stay ranged from 12 -16 - indicating higher risk for skin breakdown.

On 7/13/24, a deep pressure tissue injury (DTI) to the coccyx was recorded in the record in the record described at 5.5 centimeters (cm) in length, 8cm in width, on 7/16/24 coccyx wound documented as a stage 2. On day of discharge 7/22/24, wound was described as evolving DTI to sacrococcygeal area, skin moist, necrotic, non-blanchable, painful sloughing, with state of healing as worsening. (6cm x 6cm, depth 0.1cm), outpatient wound care recommended, as well as home treatment plan.

On 1/6/25, review of risk event log contained no entry for P-3. Review of the risk report log revealed, an online risk report was not filed for the pressure injury acquired by P-3 after admission.

On 1/7/25, interview conducted with Wound Care Staff BB who stated risk reports are not filled out for deep tissue injuries.

On 1/7/25, review of policy titled, "Pressure Injury Prevention", dated 7/25/24 revealed: "Discovery of a hospital acquired pressure injury (HAPI) must be reported using the online risk reporting process...A root cause analysis will be done on Stage 3, stage 4, deep tissue injuries and unstageable injuries acquired after admission...".