HospitalInspections.org

Based on review of medical records, the facility's policies/procedures, and staff interviews, it was determined that the facility's nursing staff failed to turn/reposition and perform wound care as ordered for two patients (P#1 and P#3) of three patients (P#1, P#2, and P#3) reviewed.


Findings include:


1. A review of Patient (P)#1's medical record revealed that P#1 was admitted via the facility's Emergency Department (ED) on 2/4/25 at 2:35 p.m.


Review of the History and Physical (H&P) revealed P#1 with bruising of both knees.


Review of the consultation notes dated 2/12/25 at 10:15 a.m., revealed Wound Care Nurse (WCN) BB documented a wound evaluation and treatment ordered by Hospitalist (HSP) EE. Reason for the consult was documented as a pressure injury to the coccyx (commonly referred to as the tailbone, is the final segment of the vertebral column) which was first noted on 2/6/25 at 3:36 a.m. Additional documentation revealed the wound was not present on admission.


P#1's Braden score (a tool used to predict the risk of developing pressure ulcers or injuries) was 16. (score 15-17: Mild/Moderate risk).

Review of turning and repositioning documentation in P#1's medical record revealed the following:
" No turning/repositioning documented in the Emergency Department (ED) record
" 2/7/25- no turning/repositioning documented
" 2/8/25- turned at 1:15 a.m., 7:30 a.m., and 10:15 p.m.
" 2/9/25 -turned at 7:45 a.m. and 7:45 p.m.
" 2/10/25- turned at 7:00 a.m. and 8:00 p.m.
" 2/14/25-2/17/25 - no turning/repositioning documented
" 2/18/25 -no turning/repositioning documented
" 2/19/25 turned at 2:00 a.m.
" 2/20/25 turned at 5:00 p.m.
" 2/23/25 to 2/24/25 -no turning/repositioning documented


Documentation by WCN BB dated 2/12/25 revealed that the site assessment was non-blanchable erythema; Purple (a skin lesion that does not fade away when pressed on), the periwound was ecchymotic (when blood vessels break under the skin, causing blood to leak and become trapped), and the pressure injury stage was deep tissue. The dressing recommended was a foam adhesive (applied clear zinc and recovered with a Sacral foam adhesive border dressing), reposition P#1 two-hourly, and a plan that dressing change was deferred to nursing.


Documentation failed to reveal any wound measurements or frequency of the wound dressing.


Review of wound care documentation in the medical record for P#1 revealed the following:
" 2/6/25- Foam changed at 3:36 a.m., 6:00 a.m., and 7:15 p.m.
" 2/8/25- dressing changed at 4:00 a.m.
" 2/10/25- Image taken 7:00 a.m.
" 2/12/25- Dressing changed by WCN BB
" 2/16/25- Site care, cleaned with soap and water at 1:00 a.m.
" 2/19/25- Cleansed, foam dressing at 10:17 a.m.
" 2/21/25 -Cleansed, foam adhesive dressing at 2:00 p.m.


2. P#3 was admitted to the facility on 3/19/25 at 12:35 p.m. with the diagnosis of Multifocal Pneumonia (a respiratory infection where multiple areas within one or both lungs are affected, potentially caused by viruses, bacteria, or fungi).


Review of nursing flowsheets revealed that P#3 had a Braden score of 9 and required two-hourly turning/repositioning.

Review of turning and repositioning documentation in P#1's medical record revealed the following:

" 3/20/25 at 7:30 a.m., and was not turned again until 8:00 p.m.
" 3/21/25, Documentation failed to reveal any turning/repositioning, except at 8:00 p.m.
" 3/22/25 to 3/23/25, documentation revealed turning at 8:00 p.m. on 3/23/25
" 3/24/25, documentation revealed turning at 8:00 a.m. and 8:00 p.m.
" 3/28/25, documentation revealed turning at 8:00 a.m. and 8:00 p.m.
" 3/39/25 to 3/31/25, documentation revealed turning at 8:00 a.m. and 8:00 p.m.
" On 4/2/25, documentation failed to reveal any turning/repositioning
" On 4/3/25, documentation revealed turning/repositioning at 8:00 a.m.
" On 4/6/25, documentation failed to reveal turning/repositioning during the day shift.
" On 4/7/25, documentation revealed turning at 8:00 a.m.


Further review of P#3's medical record revealed that P#3 had a wound consultation for the left buttock shearing (pressure and friction) with bruise on 3/31/25 at 3:19 p.m. with the plan of:

" PRN dressing change deferred to Nursing
" Site Assessment Friable; Red
" Peri-Wound Assessment- Ecchymotic
" Wound Length (cm) 5 cm
" Wound Width (cm) 4 cm
" Wound Depth (cm) 1 cm
" Drainage Description Serosanguineous
" Drainage Amount Small
" Drainage Odor None
" Treatments Cleansed with wound cleanser
" Dressing Alginate; Foam adhesive; Xeroform
" Treatments: Applied Gauze Xeroform, Aquacel Extra calcium alginate covered with a Sacral foam adhesive border dressing.
" Other Treatments: Reposition Q2H (every two hours).


Documentation also revealed that the wound was first noted on 3/23/25 at 11:44 a.m.


P#3 had wound dressing done on the following days:
" 3/23/25 at 8:00 a.m.
" 3/25/25 at 2:55 a.m.
" 3/26/25 at 12:40 p.m.
" 3/30/25 at 4:00 a.m.
" 3/31/25 at 3:15 p.m.
" 4/2/25 at 10:45 a.m.
" 4/6/25 at 9:00 a.m.
"

A review of the facility's policy titled "Skin Assessment-Prevention of Skin Breakdown-Patient," Policy #GOR.DEP.109, effective date 11/17/23, revealed that a Braden Scale Assessment would be performed to determine if a patient was "at risk." The nurse, in accordance with the physician's plan of treatment, would implement interventions to reduce the risk.
The nurse would complete the Braden Scale Assessment and initiate appropriate interventions per the patient's Braden score. The EMR (Electronic Medical Record) automatically sent a consult to nutritional services as well as planning an IPOC (Inpatient Plan of Care) for risk of skin integrity at a score of 12 or less. The lower the score, the greater the risk.
For bed-bound patients:
- Reposition at least every two hours.
- Use pillows or foam wedges to keep bony prominences from direct contact.
- Use devices to keep heels off the bed (i.e., pillow placed under the calves with heels hanging free).
- Avoid positioning directly on the trochanter.
- Elevate the head of the bed as little and for as short a time as possible. Less than 30 degrees if able.
- Use a draw sheet to move during transfers and position changes (use two or more persons to prevent friction and shear).
- For at-risk patients who can be turned and have at least two intact turning surfaces, initiate the use of static air overlay over a standard mattress.
- For at-risk patients who cannot be turned or who only have one intact turning surface, use a high-level support surface (i.e., low air loss mattress with low shear, low friction).
Skin Care:
- Inspect skin each shift and PRN (as required).
- Use hospital approved skin care products.
- Nursing assistant is responsible to inform staff/charge of any skin breakdown noted during care.


A review of the facility's document, titled "2025 Plan of Care, Intensive Care Unit," last revised on 10/23/24, revealed that Registered Nurse assessments were performed within two hours of admission. This assessment included physical, psychosocial, emotional, and spiritual aspects. A nursing history was also obtained on admission. This information was used as a baseline to develop the patient's plan of care. Reassessments were done every four hours or more frequently with a change of condition. Care plans were reviewed and updated every 12 hours and with a change in condition.


A review of the facility's policy titled "Assessment/Reassessment of Patient - Nursing and Multidisciplinary," Policy #GOR.ORG.490, last reviewed 9/19/23, stated that the assessment process would be a continuous, collaborative effort with all departments functioning as a team. Patient assessment was a multidisciplinary function. The importance of input by various members of the healthcare team was valued and supported by the organization.


A review of the facility's policy titled "Wound Grading," Policy #GOR.DEP.1417, last reviewed 1/31/27, stated that the Center for Wound Care and Hyperbaric Medicine would use standard Gordon Hospital policy to grade and stage all wounds, except for diabetic wounds existing below the malleolus of the lower extremity.
The healing progress, including the noted changes in wound measurements and in the percentage healed to baseline volume, would be documented within the electronic medical record (EHR).
A patient's wound grade, however, may be changed in the event of a wound's deterioration and should be documented as such.


An interview took place in the facility's conference room on 4/8/25 at 11:15 a.m. with Wound Care Nurse (WCN) BB who stated that she did not get P#1's wound consultation until 2/12/25, and that she (WCN BB) expected that the floor nurses should have sent in a wound consultation earlier. WCN BB stated that cards were kept in the supply room to aid the floor nurses on the protocol to follow regarding wound care. WCN BB stated that dressings were to be checked daily by the nurses, and she (WCN BB) also tried to follow-up with patients once a week, however, she (WCN BB) did not follow up with P#1.
WCN BB also stated that she did not do wound measurements on P#1's wound because she (P#1) was difficult to turn and did not comply. WCN BB further stated that nurses received wound care training on hire and annually.


An interview took place in the facility's conference room on 4/8/25 at 1:00 p.m. with Registered Nurse (RN) CC, who stated that P#1 originally was a hospice patient who came in for care. RN CC stated that she only had one encounter with P#1 and could not recall in detail what happened. However, nurses were supposed to check the patient's skin every shift and turn them every two hours, especially if the patient could not turn themselves. RN CC stated that turning of patients was teamwork between the nurses and the certified nursing assistants (CNAs), but the nurses were fully responsible for ensuring the turning was done.


An interview took place in the facility's conference room on 4/8/25 at 1:40 p.m. with Registered Nurse (RN) DD, who stated that she could recall P#1 had been extubated and was ready to go home on hospice. RN DD stated that P#1 did not like to be turned, and if turned, she (P#1) would wiggle back unto the pressure points.
RN DD stated that patients were turned as per protocol, but it may not have been documented.
An interview took place in the conference room on 4/8/25 at 2:00 p.m. with Hospitalist (HSP) EE, who stated that she may have initiated the wound consultation for P#1 because the nurses reported it to her (HSP EE) or the wounds were visible. However, she could not recall what happened in P#1's case.


A telephone interview took place in the facility's conference room on 4/8/25 at 3:00 p.m. with Registered Nurse (RN) FF, who stated that the emergency department (ED) nurses do not necessarily strip down a patient to do a head-to-toe assessment because they do not expect the patient to stay long in the ED. RN FF stated that if the patient's skin was broken, a wound consultation would be initiated, but if not, then the floor nurses would manage the wound according to protocol.


A telephone interview took place in the facility's conference room on 4/8/25 at 3:50 p.m. with Registered Nurse (RN) GG, who stated that the ED nurses did not carry out a skin assessment in the ED unless the patient's chief complaint was related to a wound or injury. RN GG also stated that if the patient had a hold in the ED longer than 24 hours, the ED staff would try to do the head-to-toe assessment or transfer the patient to the designated unit as per the order.


A telephone interview took place in the facility's conference room on 4/9/25 at 9:30 a.m. with Registered Nurse (RN) HH, who stated that P#1 was required to be turned every two hours, but she (P#1) liked to stay on her right side and would turn back whenever turned. RN HH stated that he could not recall if P#1 had a wound. However, if there was any concern regarding the skin on an initial assessment, documentation would be done and photographs taken, and a wound care consultation would be required if the pressure injury was a stage 2 or greater.


An interview took place in the facility's conference room on 4/9/25 at 12:30 p.m. with Certified Nursing Assistant (CNA) KK who stated that the staff had assessed a skin breakdown in P#1's skin on admission to the Intensive Care Unit (ICU), which P#1's son confirmed she (P#1) had from home. CNA KK stated that the staff did their best to rotate P#1, but she was not compliant and would roll back to lie down on the pressure point. CNA KK also stated that the turning/repositioning of patients was teamwork, however, the Registered Nurses were solely responsible for patients' wound care.


In an interview with WCN BB on 4.8.25 at 11:30 a.m., she stated that P#3 had a skin tear on admission and the floor nurses were managing the dressing change, but they (the floor nurses) decided to put in a wound consultation when they felt the wound was getting worse. WCN BB also stated that P#3's wound had improved .
In an interview with RN CC on 4/8/25 at 1:15 p.m., she stated that a wound consultation would not necessarily be put in for a skin tear. However, she would mention it to the doctor just to be sure there was nothing to worry about. RN CC stated that a wound consultation would be put in for any pressure injuries or diabetic sores.