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Based on interview and record review, the facility failed to ensure care and services were provided to prevent the development/worsening of pressure injury for 1 of 5 patients reviewed for quality of care (#1).

Findings

Patient #1 was a 79-year-old-male who presented to the Emergency Department (ED) on 7/24/22 with complaint of hip pain. The ED Provider Notes revealed the patient's skin was "Negative for rash and wound," and X-ray of the patient's right femur showed a right femoral neck fracture. Orthopedic medicine was consulted, and the patient was admitted to the hospital for "surgical intervention."

Orthopedic consultation dated 7/25/22 revealed the patient was scheduled for a right hip arthroplasty, and his skin was intact, with "no open wounds". "Arthroscopy is a surgical procedure to restore the function of a joint" (retrieved from www.hopkinsmidicine.org 10/21/22).

"Wound Care Consult" documentation on 8/10/22 read, "Received consult for inpatient wound mgmt (management), however consult entered as a protocol order. Inpatient wound management cannot operate under protocol order. Notified Primary RN (Registered Nurse) D and advised to obtain physician order if inpatient wound management is still requested. Will cancel invalid protocol order."

Review of the "Wound Care Consult" documentation with a date of service on 8/12/22 revealed that the reason for the consultation was, "Patient with wound to coccyx. Not charted on admission. Unstageable. Center covered with yellow/tan/slough. Moderate amount of tan drainage. Peri wound skin callused (approximately) 3 cm. (centimeter) x (by) 2 cm. x 0.3 cm.; recommend santyl to debride, dakin's to manage bioburden. Stage 1 pi's (pressure injury) to right and left heel. Offloaded with boots. Patient utilizing turning wedge. Incontinent of bowel and bladder. Primofit in use. The wound team plan was for "nursing to do dressing and WOCN (Wound, Ostomy, and Continence Nurse) to follow as needed." "Primofit is an external urine management for the male anatomy. It's design to address the factors required to effectively manage urinary incontinence." (retrieved from sageproducts.com>primofit 10/21/2022).

"Stage 1 ulcers have not yet broken through the skin. Stage 2 ulcers have a break in the top two layers of skin. Stage 3 ulcers affect the top two layers of skin, as well as fatty tissue. Stage 4 ulcers are deep wounds that may impact muscle, tendons, ligaments, and bone . . . Unstageable pressure ulcers are also hard to diagnose because the bottom of the sore is covered by: slough: debris that appears tan, yellow, green, or brown in color; eschar: hard plaque that's tan, brown, or black in color." (retrieved 1021/2022 healthline.com).

The "Wound Team Summary Assessment" on 8/23/22 read, "Patient with stage 4 PI to coccyx. Not documented on admission. On previous assessment wound was covered with yellow/gray slough. Santyl was ordered and now wound has (approximately) 30% yellow slough . . . moist, pink tissue. Continue with Santyl."

Review of the Nursing Flowsheet dated 8/05/22 at 7 PM revealed documentation for Prevention/Treatment read, "Apply foam dressing to prevent skin breakdown: Assess under dressing each shift. Continue to assess every shift . . . Reposition devices; Reposition patient; Specialty mattress." Additional documentation regarding the patient's skin could not be identified until 8/11/22, twelve days after the resident was transferred to the Vascular step-down unit.

On 10/10/22 at 4:49 PM, Risk Manager (RM) B stated patient #1's clinical record revealed the first documentation by nursing regarding the gluteal cleft wound was on 8/11/22 at 7:02 AM.

On 10/11/22 at 10:27 AM, the Nurse Manager (NM) of Orthopedics stated the skin assessment was conducted by nurses on admission, transfer, and every shift, and the expectation was that a Braden scale assessment would be completed every shift. She recalled patient #1 went to a higher level of care, came back to the Orthopedic unit, and was again transferred to higher level care. The NM stated she did not recall if the patient had a specialty mattress, and she was not aware of any skin concerns/issues with the patient.

On 10/11/22 at 10:40 AM, Registered Nurse (RN) E stated she cared for patient #1 briefly for a day. She explained that after bedside shift report, the patient's nurse communicated that the patient was not responsive and was not following commands. RN E stated she did an assessment of the patient and spoke to his wife to establish the patient's baseline and called a rapid response. RN E verbalized she assisted the rapid response team with transfer of the patient for a diagnostic test. She said she assessed his incision site, moved him, and did not observe any PI.

On 10/11/22 at 11:19 AM, the NM for the Vascular Step-down unit stated on admission to the unit, nurses conduct a head-to-toe assessment on the patient within an hour of admission. Every four hours, a focused assessment which included fall risk, skin assessment, pain, opiates risk assessment as needed would be completed. He explained that a skin assessment was conducted on admission, with any change in condition, and any transfer in or out of the unit. The NM stated patient #1 was transferred to the Vascular step-down Unit from another floor for a higher level of care and was on the Vascular unit from 7/29/22 to 8/17/22. The NM explained that RN D found the wound in patient's gluteal fold and contacted the physician who ordered a wound consultation. He stated RN D came to his office because patient #1's family was upset about the wound. The NM stated the wound care nurse visited on 8/12/22 and placed interventions and recommendations. He stated that prior to the wound being identified, the positioning for the patient was rotated every two hours. He said staff was able to get patient #1 to a chair occasionally, but he spent most of the time in his bed. The NM stated the wound was not found when the patient was transferred to the unit on 7/29/22, and when identified on 8/10/22, and assessed by wound care on 8/12/22 it was documented as unstageable. He said they do not know when the PI occurred, turning and positioning were charted as being completed, and pillows were being used to offload the patient's heels.

On 10/11/22 at 11:56 AM via telephone, RN D recalled observing patient #1's skin and documented the wound as a stage III pressure injury measuring 1 cm. x 1 cm. RN D stated he reported the incident to management, notified the physician, and placed an order for a wound care consultation. RN D stated the patient could not voice his needs and was disoriented.

On 10/11/22 at 12:15 PM, the Nurse Operation Manager (NOM) for wound management stated when a wound consult was requested, they try to see the patient within 24 hours of the request for consult. The NOM stated she recalled patient #1's PI was found on 8/10/12, and on 8/12/22, a formal consultation was done by wound care. Prevention protocols, in place for patient #1 prior to the PI being identified, included a low air loss mattress, and turning and positioning. She verbalized the wound was unstageable due to necrotic tissue, and when the tissue was removed, it was then staged as a stage III. She confirmed the PI did not happen overnight and stated she could not speak to why the wound was not identified before 8/10/12.

On 10/11/22 at 2:45 PM, RM A stated the hospital had some learning opportunity with patient #1. She said other preventive interventions were done, but she could not deny that the patient developed a PI.

The policy and procedure "Skin Care/Skin Integrity (Adult and Pediatric Inpatient) issued 6/1994 with revision date 2/2022 read, "Skin is assessed: on admission from community . . . upon transfer from unit . . . skin is assessed every shift in the acute care setting utilizing the Braden . . . scale." "Braden Scale for predicting pressure score risk was developed to foster early identification of patients at risk for forming pressure sores." (retrieved from pubmed.ncbi.nlm.nih.gov 10/21/2022).