HospitalInspections.org

50617

Based on a review of medical records, facility policies and procedures, and staff interviews, it was determined that medical records failed to indicate nursing documentation of turning and positioning for one patient (P) (P#1) of four (P#2, P#3, and P#4) sampled patients. As a result, it was identified that P#1 suffered a hospital-acquired pressure injury (injuries to the skin and underlying tissue that occur in patients during their stay in a healthcare facility).


Findings Included:


A review of medical records revealed that P#1 was admitted to the facility on 5/6/25 at 9:20 p.m. with the diagnosis of altered mental status (change in mental function), and diarrhea.


A review of History and Physical (H&P) done on 5/6/25 at 10:02 p.m. revealed that P#1 was bedbound (not able to move around safely or comfortably), had history of dementia, PEG tube (percutaneous endoscopic gastrostomy that is feeding tube insertion through the skin and the stomach wall) in place for feeding support, dysphagia (difficulty swallowing).


A review of initial Nursing Assessment of Integumentary (skin) system on 5/7/25 at 12:32 a.m. done by Registered Nurse (RN) AA revealed that P#1 came in with left toe wound due to ingrown toenail, wound dressing was clean, dry and intact. P#1 also had blister on the right elbow and P#1's Braden Scale score was 13 (moderate risk) (Braden Scale Risk Assessment for pressure injuries: 16-18 low/mild risk, 13-15 moderate risk and 12 or less, high risk).


Further review of medical records for P#1 revealed the routine wound care orders were placed on 5/7/25 at 7:51 a.m. and included moisture barrier cream with morning care and after each episode of incontinence.


Continued review of P#1's MR revealed initial Wound Care Consult done on 5/8/25 at 12:31 p.m. by Wound and Ostomy Care Nurse (WOCN) to evaluate the PEG insertion site.


Continued review of P#1's MR revealed Progress notes done by Registered Nurse on 5/11/25 at 5:53 a.m., 5/12/25 at 8:27 a.m., and 5/13/25 at 8:08 p.m., revealed that P#1 refused all every two hours turning and repositioning and that P#1 was educated.


Review of Nursing Assessment of Integumentary (skin) system on 5/14/25 by Licensed Practical Nurse (LPN) BB revealed that P#1 developed a pressure injury in the sacral area, WOCN consult was placed for wound evaluation. P#1's Braden Scale Score (scale used to predict a patients risk of developing a pressure injury) on 5/14/25 was 13 (moderate risk).


A review of the "Wound Care Progress Notes," on 5/14/25 at 2:14 p.m. completed by Wound and Ostomy Care Nurse (WOCN) RN CC for evaluation of wound between sacrum and base of vagina revealed that the deep tissue pressure injury was noted to P#1's sacrum with purple non-blanchable (when pressed does not turn white) discoloration, and some open areas, red and yellow necrotic (dead) tissue was noted to the right side of sacrum, no signs of infection and there was some friction injury component.


A review of flow sheets section titled "Activities of Daily Living" that includes "positioning," failed to revealed documentation of P#1 being repositioned or turned every two to three hours for following dates:

5/7/25 (day and night shifts),
5/8/25 (day and night shifts),
5/9/25 (day and night shifts),
5/10/25 (day and night shifts),
5/11/25 (day and night shifts),
5/12/25 (day and night shifts),
5/13/25 (day and night shifts),
5/14/25 (night shift), and
5/15/25 (day shift).


A review of the facility's policy titled "Patient Assessment," policy #20629, last reviewed 6/20/23, revealed that the purpose of the policy was to provide a standard approach throughout the organization for patient assessment; to include each patient's physical, psychological, and social status.
Continued review revealed, Reassessment:
1. Each patient is reassessed at regularly specified times related to the patient's course of treatment. The objective of the reassessment is to assure that the patient's status is periodically reviewed so care decisions remain appropriate.
3. Reassessment will be documented in the medical record.
4. Time of the assessment will be reflected in the medical record.


A review of the facility's policy titled "Skin Integrity Protection and Wound Management - SYSTEM," policy #12402, last revised 3/24/25, revealed that the purpose of the policy was to provide consistent care for prevention and treatment of skin breakdown and the management of acute, chronic, traumatic, and surgical wounds in an optimal wound healing environment.
Continued review revealed, Skin Integrity Interventions:
1. Assess skin every shift.
5. Reposition patient at least every two to three hours or based on individual patient need and tissue tolerance.

Continued review revealed, routine skin assessment to be performed on all patients upon admission, every shift, and whenever patient's condition or level of care changes.


An interview was conducted with Licensed Practical Nurse (LPN) BB on 6/11/25 at 10:45 a.m. in the conference room of Five C (Medical/Surgical) Unit. LPN BB stated that she did recall P#1 and on 5/14/25 she received the report from the night shift that P#1 refused to be repositioned all night due to pain. LPN BB further stated that she gave pain medicine to P#1 and waited an hour before turning P#1 so she (P#1) would tolerate being turned. LPN BB also stated that when she turned P#1 on her side, LPN BB discovered pressure injury on her (P#1) sacral area, LPN BB applied the barrier cream and consulted WOCN.


During an interview on 6/11/25 at 11:57 a.m., with Nurse Manager (NM) II in an office, NM II said that the expectation for nursing documentation of assessments is to be done every shift. NM II said that if skin changes or new wounds are noted during an assessment, then nursing staff should document it and escalate care to the Charge Nurse (CN) and physician for further direction.
During an interview on 6/11/25 at 12: 32 p.m. with Clinical Documentation Specialist (CDS) JJ in an office, CDS JJ said that nurses are expected to document a full head-to-toe assessment every shift. CDS JJ said that for wounds and any lines or drains, such as a feeding tube, they must document on it once a shift.


A phone interview was conducted with Wound Care and Ostomy Nurse (WOCN) CC on 6/12/25 at 1:59 p.m. WOCN CC stated that she had seen deep tissue injury develop in 24 to 72 hours. WOCN CC also stated that nurses can use barrier cream and mepilex (absorbent foam dressing) but if patient requires more than that then wound care consult would be required so the orders for dressing can be placed.


An interview was conducted with the Director of Accreditation and Patient Safety (DAPS) KK and Quality and Accreditation Coordinator (QAC) LL on 6/11/25 at 2:45 p.m. in the facility's conference room. DAPS KK and QAC LL reviewed several flow sheets in electronic medical record of P#1 and DAPS KK and QAC LL acknowledged that there were several gaps in the flow sheet in documenting turning and repositioning P#1 every two to three hours.