HospitalInspections.org

Based on review of the Medical Staff Bylaws, medical record review and interview, the governing body failed to assume responsibility for the medical staff and hold the medical staff accountable for the care and services provided and ensure evidence of care provided is in the patients medical records.

The failure of the governing body to hold the medical staff accountable for the quality of patient care resulted a SERIOUS AND IMMEDIATE THREAT to the health and safety of 3 of 3 (Patient #1, 2, and 3) patients and presented a SERIOUS AND IMMEDIATE THREAT to all patients in the hospital.

The findings included:

1. The governing body failed to ensure the medical staff was accountable to the quality of care provided.
Refer A 049

Based on review of the Medical Staff Bylaws, medical record review and interview, the governing body failed to ensure the medical staff was accountable for the conduct of the hospital including the quality of care for 2 of 3 (Patient #2 and 3) sampled patients with hospital-acquired pressure injuries.

The findings included:

1. Review of the hospital's "Medical Staff Bylaws" adopted and approved 8/31/16 and amended 5/2/17 revealed, "...Medical Records...Accountability...The attending physician is responsible for assuring that a complete and legible medical record is prepared for each patient and that it contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results of treatment and promote continuity of care among healthcare providers...Progress Notes...Pertinent progress notes shall be recorded chronologically, dated, timed, and signed. Progress notes shall be sufficient to permit continuity of care, documenting the patient's course in the hospital. There should be a progress note to reflect each visit by a physician..."

2. Medical record review for Patient #2 revealed an admission date of 4/30/19 with diagnoses which included Accident Caused by a Farm Tractor, Abrasion and/or Friction Burn on Multiple Sites, Atrial Fibrillation, Cerebral Contusion, Fractured Medial Malleolus and Metatarsal Bone Fracture.

The Physician Orthopedic Consultation note dated 4/30/19 revealed, "...[Patient #2] is an 86-year-old male who presented to [Hospital #1] earlier today as a shock trauma level 2 [unit in the Emergency Department] after being run over by a tractor...Prior to arrival, EMS [Emergency Medical Services] reported that he had significant road rash but no obvious deformities. He later, in shock trauma, reported some L [left] ankle and foot pain...LLE [left lower extremity]: Skin intact with no open wounds...XR [x-ray] Ankle Complete 3+ View Left...Impression...Medial malleolus fracture...Fractures of the head of the 2nd-5th metatarsal and proximal phalanx of the great toe...Plan for non-op [non-operative] tx [treatment] of above fxs. [fractures] NWB [non-weight bearing] in LLE splint, will transition to cast in clinic..." Nursing assessment documented left calf abrasion was present upon admission, but the Orthopedic Physician's documented skin was intact with no open wounds.

The nursing assessment dated 5/1/19 at 1:31 AM noted Patient #2 had an abrasion to the left calf which was present upon admission.

The Physician Orthopedic Progress Note dated 5/1/19 at 12:55 PM revealed, "...EXAM: NAD [no apparent distress], NLB [non-load bearing] LLE: splint. Toes up/down. SILT [sensation intact to light touch]..." There was no documentation the left calf wound was observed or description of the wound.

The Nursing Narrative Note dated 5/1/19 at 2:35 PM revealed, "...LLE splinted observed calf wound just above where splint terminates..." There was no documentation for a description of the wound or that the physician was notified about the wound.

The Nursing Narrative Note dated 5/3/19 at 9:00 PM revealed, "...Ortho [Orthopedics] on-call came and review [reviewed] left lower leg cast with dried blood stained to upper side. Bruises and abrasion noted coming out from soft cast part. They will follow up later..."

On 5/3/19 at 9:50 PM, Orthopedic Physician #1's ordered to apply silver sulfadiazine topical cream to the left calf wound at the top of the splint twice daily. There was no documentation provided by the hospital for further instructions of wound care.

An Orthopedic Physician #1's order dated 5/3/19 at 9:52 PM revealed, "...Consult to Wound/Ostomy/Continence Specialist...Reason for Wound Care Consult...Evaluate and Treat...Wound location...Left Leg...Special instructions...Initial...Wound at Superior aspect of LLE short leg splint (posteromedial)..."

There was no documentation provided by the hospital for an Orthopedic Progress Note on 5/3/19 for the visit to assess the splint, order medication to treat the wound and consult wound care to evaluate and treat the wound.

The Physician Trauma Progress Note dated 5/5/19 revealed, "...Ortho replaced splint yesterday [5/4/19] for skin breakdown noted around top of splint..."

There was no documentation provided by the hospital for an Orthopedic Progress Note on 5/4/19 when Orthopedics replaced the splint that the patient's wound had been assessed by the physician.

The Nursing Wound Assessment Details dated 5/6/19 revealed, "...Wound Location: Left Calf...Wound Type: Pressure Ulcer...Date Acquired: 5/6/2019 [there was no documentation of a description or assessment of the wound prior to 5/6/19]...Acquired at Facility: Yes...Wound Notes: pt [patient] has an unstageable pressure injury on the post [posterior] calf under the cast...Length: (cm) [centimeters] 2.5...Width: (cm) 2...Depth: (cm) 0.2...Stage: Unstageable Pressure Injury Obscured full-thickness skin and tissue loss...Exudate Amount: Moderate...Exudate Type: Sero-sanguineous...Color: Black...Eschar: 76-100%...pt has a cast on the extremity. the cast has rubbed a wound on the post leg of the calf [back of the leg]. the wound is an eschar surrounded but blanchable tissue that is weeping..."

The Nursing Narrative Note dated 5/6/19 revealed, "...Paged Ortho...about splint coming loose. [Orthopedic Staff #1] called back. I told them that the splint was coming loose. [Orthopedic Staff #1] stated they would call us back..." There was no documentation provided by the hospital that someone was coming to assess or re-apply the splint. There was also no documentation that the nurse called the orthopedic physician back to inform him/her that the issue with the splint being loose was still a problem. There was also no documentation in the medical record to indicate that the problem with the Orthopedic physician physician not coming to assess the patient was escalated to the nursing supervisor so that the patient could get care that was needed.

The Physician Trauma Progress Note dated 5/7/19 revealed, "...Pressure ulcers from LLE splint. Wound nurse following. Splint change to 3D [dimensional] boot..." There was no documentation the physician performed an assessment or observed the patient's wound.

There was no documentation provided by the hospital for any Orthopedic Progress Notes from 5/2/19 through 5/16/19 to determine if Orthopedics had observed and assessed the patient's wound.

The hospital failed to ensure that their Medical Staff Bylaws were followed for Patient #2 as evidenced by the Orthopedic physician's failure to document sufficient and pertinent notes of his/her assessment and observation of the wound, wound size, present treatment if working, use and application of the splint, and medications used to treat a wound that was acquired in the hospital. Additionally, the hospital failed to document the patient's course of treatment while in the hospital as evidenced by no observation and or assessment of Patient #2's wound from 5/2/2019 through 5/16/2019.

The Orthopedic Progress Note dated 5/17/19 revealed, "...NWB LLE, 3D boot. NWB total duration 6-8 wks [weeks]...SUBJECTIVE: Awaiting placement at SNF [skilled nursing facility]..." There was no documentation the physician assessed or observed the patient's wound.

The Nursing Wound Assessment dated 5/20/19 revealed, "...Length: (cm) 3...Width: (cm) 2.5...Depth: (cm) 0.2...Stage: Unstageable Pressure Injury Obscured full-thickness skin and tissue loss...Exudate Amount: Moderate...Exudate Type: Sero-sanguineous [containing or relating to both blood and the liquid part of the blood]...Slough: 51-75%...Eschar: None..."

Patient #2 was discharged to a skilled nursing facility on 5/21/19 with an unstageable pressure injury to the left calf.

In an interview in the conference room on 6/25/19 at 8:50 AM, the Nursing Director confirmed the only Orthopedic Progress Notes in Patient #2's medical record were dated 5/1/19 and 5/17/19.

In an interview in the conference room on 6/25/19 at 11:13 AM, the Interim Director of Trauma Center stated he did not see any documentation from Orthopedics why Orthopedic Physician #1 ordered the silvadene cream and no documentation the splint was changed. The Interim Director of Trauma Center stated he was concerned about Patient #1 developing a pressure ulcer from the splint, but he was more concerned about why Orthopedics did not document their activity in progress notes.

3. Medical record review for Patient #3 revealed an admission date of 5/19/19 with diagnoses which included Motor Vehicle Crash, C (cervical) 5 Vertebral Body Teardrop Fracture, Traumatic Spondylolisthesis (spinal disorder in which a vertebra slips forward onto the bone below it) C5 on C6 and Traumatic Spinal Cord Injury.

Patient #3 was brought to the shock trauma unit of the Emergency Department via EMS following a motor vehicle crash.

Patient #3 was moving bilateral upper extremities in the field but was not following commands and unresponsive after arrival.

Patient #3 was intubated and medicated. A computerized tomography scan of the C-spine revealed a C5 flexion teardrop fracture, and Patient #3 was fitted with an Aspen Cervical Collar (neck brace which helps neck to heal while supporting bones in neck; and helps to minimize skin breakdown). On the morning of 5/20/19, Patient #3 was taken off sedation and became intermittently arousable.

Patient #3 was not moving the bilateral lower extremities or withdrawing from pain but was able to flex the elbows and abduct at the shoulders.

The Physician Surgical Documentation dated 5/21/19 (date of procedure was 5/20/19 according to the Perioperative Record) revealed Patient #3 underwent a C5 corpectomy (surgical procedure that involves removing all or part of the vertebral body) with anterior instrumentation (instruments such as plates, cages or braces which are surgically inserted to provide stability for the spine) and fibular strut graft (bone graft taken from the fibula and used to support the spine) and local harvest bone graft (bone graft taken from patient).

During the procedure, cervical traction was initially placed but was released when the cervical tongs obstructed the view of the patient's injury during x-rays. An incision across the back of the neck at the crease line was made, and the incision was sutured at the close of the procedure.

The wound was dressed with Steri-Strips, Mastisol, Telfa and a Tegaderm dressing. Following the procedure, Patient #3 was brought back to Trauma Intensive Care Unit (ICU).

The Physician Trauma Progress Note dated 5/20/19 revealed, "...Closed displaced fracture of fifth cervical vertebra with routine healing, 05/19/2019..."

A Nursing Narrative Note dated 5/20/19 at 4:00 PM revealed Patient #3 arrived in Trauma ICU with pin sites to bilateral head and traction had been removed.

The Physician Trauma Progress Note dated 5/24/19 revealed, "...Exam...Head: cervical collar...incision dry..."

The physician's order dated 5/29/19 (Entered and signed by Nurse #1) revealed, "...Consult to Wound/Ostomy/Continence Specialist...Per Protocol ordered by [Physician #1]...Reason for Wound Care Consult...Evaluate and Treat...[Nurse #1 further documented the following description of Patient #3's wound]...Wound location...Head...Comment...Posterior left back head/occipital area; raised hardened area..." There was no documentation the physician had assessed or observed the patient's wound. There was no documentation provided by the hospital that Physician #1 had signed the order.

The Wound Care Nursing Progress Note dated 5/29/19 revealed, "...wocn [Wound Ostomy Continence Nurse] here on unit for consult. patient is 37 year old male s/p [status post] mvc.patient is strict spine with aspen collar. has very dark black hair and had to clip some hair in order to see wound. area is firm, dark with slight peeling edge. feels like scabbed abrasions but edge is adherent. primary care nurse present. recommend to clean with vashe then apply therahoney b.i.d. dress with 4x4,abd pads. wocn will reassess next visit..."

The physician's order dated 5/29/19 based on WOCN recommendations revealed, "...vashe (cleansing solution) topical...Route of administration...Topical...Frequency...BID [twice daily]...Responsible Party [physician to whom the order was sent for signature]...[Physician #1]...Comment...Apply to: occipital wound left lower occipital then apply therahoney b.i.d cover with gauze dressing, abd [abdominal] pad..." There was no documentation the physician had assessed or observed the patient's wound.

The Wound Care Nursing Progress Note dated 5/30/19 revealed, "...wocn here on unit to revisit left head wound, lower occipital. This is the area where patient has cervical tongs,not a pressure injury. area has dried and scabbed up..."

The Wound Care Nursing Progress Note dated 6/4/19 revealed, "...aspen collar...patient has surgical site left head where he had cervical traction. area is flat scabbed abrasions,dark and detaching from edges..."

The Wound Care Nursing Progress Note dated 6/5/19 revealed, "...wocn here on unit. wound to left side of lower occipital flat and dark with scabbing noted. recommend to d/c [discontinue] therahoney and order sulfamylon b.i.d with gauze dressing and foam padding...patient has aspen collar..."

The physician's order dated 6/5/19 revealed, "...mafenide topical (Sulfamylon 85 mg [milligrams]/g [gram] topical cream...Responsible Party...[Physician #2]...Comment...Apply twice daily to:__left side lower occipital wound clean first with vashe then apply small gauze dressing pad with foam padding..." There was no documentation the physician had assessed or observed the patient's wound on 6/5/19.

The Wound Care Nursing Progress Note dated 6/10/19 revealed, "...wound to lower left occipital also goes over to right side. hair very dark/black. cleaned with vashe and then sulfamylon applied with gauze dressing. partial scabbing partial eschar noted. separating at edges. patient has aspen collar..."

The Wound Care Nursing Progress Note dated 6/12/19 revealed, "...wocn here on unit. more hair cut from around wound and noted soft black/gray necrotic tissue starting to detach from edges where pink tissue noted. no odor. Patient has unstageable pressure injury. continue with vashe and sulfamylon b.i.d with gauze dressing. may use extra padding in aspen collar with foam dressing..."

The Nursing Wound Assessment Details dated 6/12/19 revealed, "...Wound Location: Head - occiput...Wound Type: Pressure Ulcer...Wound Measurements...Length: (cm) 7.5...Width: (cm) 3.5...Depth: (cm) 0.2...Wound Description...Stage: Unstageable Pressure Injury Obscured full-thickness skin and tissue loss...Color: Gray...Slough: 51-75%...Eschar: 1-25%..."

The physician's order dated 6/12/19 based on WOCN recommendations revealed, "...Communication Order...Responsible Party [physician to whom the order was sent for signature]...[Physician #3]...may apply foam dressing between aspen collar and gauzed dressing for extra padding. may alternate between inetrdry [sic] for any moisture control issues..." Physician #3 electronically signed the order on 6/17/19. There was no documentation the physician had assessed or observed the patient's wound on 6/12/19.

The Wound Care Nursing Progress Note dated 6/19/19 revealed the patient's wound was deteriorating and documented, "...wocn here on unit. patient has unstageable pressure injury to occipital with tan gray slough noted. starting to detach from edges. continue with vashe and sulfamylon b.i.d with gauze dressing and foam padding..."

The Nursing Wound Assessment Details dated 6/19/19 revealed the wound had worsened and, "...Wound Location: Head - occiput...Wound Type: Pressure Ulcer...Wound Measurements...Length: (cm) 7...Width: (cm) 2.5...Depth: (cm) 0.2...Wound Description...Stage: Unstageable Pressure Injury Obscured full-thickness skin and tissue loss...Color: Gray...Slough: 51-75%...Eschar: None..." There was no documentation a physician was notified the wound had deteriorated.

The Wound Care Nursing Progress Note dated 6/21/19 revealed, "...wocn here on unit for rounding. unstageable pressure injury to occipital improving with detachment of slough in process with partial slough and partial granulation tissue noted. no odor and small amt. [amount] of serosanguineous drainage noted. continue with present tx. patient has aspen collar in use. extra padding to occipital with foam dressing..."

The Wound Care Nursing Progress Note dated 6/24/19 revealed, "...wocn here on unit for rounding. patient pressure injury is now stage three with 25 percent slough and 75 percent red granulation tissue..."

The Nursing Wound Assessment Details dated 6/24/19 revealed, "...Wound Location: Head - occiput ...Wound Type: Pressure Ulcer ...Wound Measurements...Length: (cm) 7...Width: (cm) 2.3...Depth: (cm) 0.2...Wound Description...Stage: Stage 3 Pressure Injury...Color: Bright Red...Slough: 1-25%...Eschar: None..."

The physician's order dated 6/21/19 revealed, "...vashe topical...Route of administration...Responsible Party...[Physician #4]...Comment...Apply BID for occipital wound. Ordered by wound care per note..." There was no documentation the physician had assessed or observed the patient's wound.

The Physician Orthopedic Progress Notes dated 5/20/19, 5/25/19, 5/27/19, 5/28/19, 5/30/19, 6/2/19, 6/3/19, 6/5/19, 6/7/19, 6/8/19, 6/9/19, 6/17/19, 6/18/19 and 6/22/19 revealed, "...Dsg [dressing] c/d/I [clean, dry and intact]..." There was no documentation the physician had removed the dressing to assess or observe the patient's wound.

Review of all physician progress notes dated 5/19/19 through 6/24/19 revealed there was no documentation provided by the hospital that any physician assessed or documented on Patient #3's occipital pressure injury.

In an interview in the conference room on 6/26/19 at 9:00 AM, the Performance Improvement Coordinator confirmed all physician progress notes for Patient #3 were provided to the surveyor. When asked if there was any documentation by any physician about Patient #3's occipital pressure injury, the Performance Improvement Coordinator and Information Technology Senior Application Analyst were unable to provide the documentation.

In a phone interview on 6/26/19 at 11:40 AM, the Chair of the Orthopedic Department stated he would expect to see documentation by physicians if a patient had any issues. The Chair of the Orthopedic Department stated if a physician consulted the Wound Care Nurse, he would expect to see documentation by the physician who ordered the consult.

Based on policy review, medical record review and interview, nursing service failed to meet patient needs and administer all drugs and biologicals according to the physician's order.

The failure to meet patient needs and administer drugs according to the physician's order for Patient #1, 2 and 3 to prevent, evaluate and treat pressure injuries constituted a SERIOUS AND IMMEDIATE THREAT to the health and safety of the patients.

The findings included:

1. Nursing staff failed to meet patient needs by ongoing assessments of patient's needs and providing nursing staff to meet those needs.
Refer to A 392

2. Nursing staff failed to administer all drugs and biologicals according to the physician's order.
Refer to A 405

Based on policy review, medical record review and interview, nursing service failed to meet patient needs by ongoing assessments of patient's needs and provide nursing staff to meet those needs for 3 of 3 (Patient #1, 2 and 3) sampled patients with hospital-acquired pressure injuries.

The findings included:

1. Review of the hospital's "Pressure Injury Prevention Guidelines" policy revealed, "...Assessment/Interventions...Reassessment should also occur under the following conditions...Per unit policy...Patients with a Braden Score of 16 or less may have the following interventions implemented if not contraindicated...Turn and reposition at least every two hours while in bed (utilize pillows to separate pressure areas and foam wedges for positioning). Turning should be documented in the medical record..."

Review of the hospital's "Acute Care Initial Physical Assessment and Re-assessment" policy revealed, "...The physical assessment and re-assessments that follow are based on the patient acuity and may include physical, psycological [sic], and social assessment, nutrition, hydration status as appropriate, and functional status as appropriate...Purpose...To define the scope of patient assessments performed by clinical disciplines...To provide guidelines for the appropriate care, treatment, and services to meet the patient's initial and continuous needs...Area...Intensive Care Units [ICU]: BICU (Burn)...GICU (General)...TICU (Trauma)...Re-assessment...Routine - Every 2 hrs [hours] unless ordered more frequently...Area...Intermediate Care Units: PCU (Progressive)...Trauma Step Down...Burn Step Down...Re-assessment...Routine - Every 4 hrs unless ordered more frequently..."

Review of the hospital's "Care of the Orthopedic Patient" policy revealed, "...Standard of Practice...The nurse will (documenting as appropriate)...Assess traction systems every 2-4 hours...Assess casted extremities every 2-4 hours for adequacy of circulation/neurovascular function (i.e. [for example], skin color/temperature, capillary refill, movement, sensation, compartmental firmness, pain...) cast integrity (i.e., cracks, discoloration, odor...) and proper alignment of casted extremities...The nurse will (documenting as appropriate)...Change the patient's position every two (2) hours...Aim: To prevent joint stiffness and skin breakdown from impaired physical mobility, neurovascular compromise from pressure on major blood vessels and nerves caused by immobilization devices or compartmental edema, infection of surgical wounds, or skeletal pin tracts, and pain management issues..."

2. Medical record review for Patient #1 revealed an admission date of 4/28/19 with diagnoses which included Complete Lesion of Thoracic Spinal Cord at T11 Level, T12 Fracture with Paraplegia Status/Post Fusion, Multiple Rib Fractures, and Right Femoral Neck Fracture. There was no documentation provided by the hospital of impaired skin integrity to the buttocks upon admission for Patient #1.

The Wound Ostomy Continence Nurse (WOCN) Progress Note dated 5/9/18 at 8:49 AM revealed, "...Wocn on unit to assess buttocks, pt [patient] has a small open area on the lt [left] intergluteal area recommend critic aid..."

A physician's order dated 5/9/19 at 8:42 AM revealed, "...pt has an open area on the intergluteal space lt side, recommend a light coat of critic aid bid [twice a day]..."

The WOCN Progress Note dated 5/13/19 at 8:56 AM revealed, " ...pt has a small abrasion near the superior intergluteal space. Pt has optifoam in place no change in recommendation [for critic aid] ...wocn will follow one more week..."

The Nursing Wound Assessment Details dated 5/20/19 revealed, "...Wound Location: Sacral...Wound Type: Pressure Ulcer...Length: (cm) [centimeters] 3...Width: (cm) 3...Depth: (cm) 0.2...Stage: Unstageable Pressure Injury Obscured full-thickness skin and tissue loss...Exudate Amount: Small...Exudate Type: Sero-sanguineous...Eschar: 76-100% [percent]..Assessment Notes...Unstageable pressure injury to sacrum has large amount of slough with small amount of pink nongranular tissue to edges. Recommendation: Cleanse wound with Vashe, pat dry. Apple Therahoney, cover with gauze and secure with Medipore tape bid and prn..."

The Nursing Wound Assessment Details dated 5/29/19 revealed, "...Wound Location: Sacral...Wound Type: Pressure Ulcer...Length: (cm) 5.5...Width: (cm) 4.5...Depth: (cm) 0.2...StageWound Condition: Deteriorating ...In for follow-up visit for unstageable pressure injury. Wound bed is covered with more than 90% of slough/eschar material. Very small amount of pink non-granular tissue. Wound is much larger than noted on last visit. Will continue with Therahoney for now and reevaluate on next visit for burn plastic consult ..." There was no documentation the physician was notified by the wound care nurse that Patient #1's wound was deteriorating.

The Physician Plastic Surgery Note dated 6/19/19 revealed, " ...Subjective:Poor appetite has not been eating much. Per wife, has not been consistently turned by nurses ...Large stage IV sacral decubitus ulcer with exposed bone, otherwise appears clean. Back wound is healed. Assessment and Plan: ...Patient's nutrition is poor, although improved from last visit ...He has not been turned appropriately per patient and family. He is consistently lying with head of bed elevation on back. He has fecal incontinence and wound is frequently contaminated. This ulcer has developed despite orders to avoid pressure on the back. Recommend fecal diversion by surgery to control wound moisture. Recommend nutrition optimization and weekly nutrition labs. Further debridement per general surgery. Needs more consistent turning. Keep head of bed flat. No laying on back. Side lying or on buttock at all times..."

There was no documentation provided by the hospital that Patient #1 was turned every 2 hours from 5/9/19-6/5/19.

The hospital failed to ensure that their policies, "Pressure Injury Prevention Guidelines" and "Acute Care Initial Physical Assessment and Re-Assessment," were followed as evidenced by failing to provide documented evidence of turning and repositioning the patient every 2 hours; failing to notify the physician of documented wound deterioration, increasing size of wound likely due to poor nutrition and hydration status; and failing to effectively communicate with all clinical disciplines involved regarding the patient's hospital acquired sacral wound. These failures by the hospital resulted in the failure to provide appropriate care, treatment and services to meet Patient #1's initial and continued needs as stated in their policies.

3. Medical record review for Patient #2 revealed an admission date of 4/30/19 with diagnoses which included Accident Caused by a Farm Tractor, Abrasion and/or Friction Burn on Multiple Sites, Atrial Fibrillation, Cerebral Contusion, Fractured Medial Malleolus and Metatarsal Bone Fracture.

The Physician Orthopedic Consultation note dated 4/30/19 revealed, "...[Patient #2] is an 86-year-old male who presented to [named hospital] earlier today as a shock trauma level 2 [unit in the Emergency Department] after being run over by a tractor...Prior to arrival, EMS [Emergency Medical Services] reported that he had significant road rash but no obvious deformities. He later, in shock trauma, reported some L [left] ankle and foot pain...LLE [left lower extremity]: Skin intact with no open wounds...XR [x-ray] Ankle Complete 3+ View Left...Impression...Medial malleolus fracture...Fractures of the head of the 2nd-5th metatarsal and proximal phalanx of the great toe...Plan for non-op [non-operative] tx [treatment] of above fxs. [fractures] NWB [non-weight bearing] in LLE splint, will transition to cast in clinic..."

The nursing assessment dated 5/1/19 at 1:31 AM noted Patient #2 had an abrasion to the left calf which was present upon admission.

The Physician Orthopedic Progress Note dated 5/1/19 at 12:55 PM revealed, "...EXAM: NAD [no apparent distress], NLB [non-load bearing] LLE: splint. Toes up/down. SILT [sensation intact to light touch]..." There was no documentation the left calf wound was observed or description of the wound.

The Nursing Narrative Note dated 5/1/19 at 2:35 PM revealed, "...LLE splinted observed calf wound just above where splint terminates..." There was no documentation for a description of the wound or that the physician was notified about the wound.

The Nursing Narrative Note dated 5/3/19 at 9:00 PM revealed, "...Ortho [Orthopedics] on-call came and review [reviewed] left lower leg cast with dried blood stained to upper side. Bruises and abrasion noted coming out from soft cast part. They will follow up later..."

On 5/3/19 at 9:50 PM, Orthopedic Physician #1's ordered to apply silver sulfadiazine topical cream to the left calf wound at the top of the splint twice daily. There was no documentation provided by the hospital for further instructions of wound care.

An Orthopedic Physician #1's order dated 5/3/19 at 9:52 PM revealed, "...Consult to Wound/Ostomy/Continence Specialist...Reason for Wound Care Consult...Evaluate and Treat...Wound location...Left Leg...Special instructions...Initial...Wound at Superior aspect of LLE short leg splint (posteromedial)..."

There was no documentation provided by the hospital for an Orthopedic Progress Note on 5/3/19 for the visit to assess the splint, order medication to treat the wound and consult wound care to evaluate and treat the wound.

The Physician Trauma Progress Note dated 5/5/19 revealed, "...Ortho replaced splint yesterday [5/4/19] for skin breakdown noted around top of splint..."

There was no documentation provided by the hospital for an Orthopedic Progress Note on 5/4/19 when Orthopedics replaced the splint that the patient's wound had been assessed by the physician.

The Nursing Wound Assessment Details dated 5/6/19 revealed, "...Wound Location: Left Calf...Wound Type: Pressure Ulcer...Date Acquired: 5/6/2019...Acquired at Facility: Yes...Wound Notes: pt [patient] has an unstageable pressure injury on the post calf under the cast...Length: (cm) [centimeters] 2.5...Width: (cm) 2...Depth: (cm) 0.2...Stage: Unstageable Pressure Injury Obscured full-thickness skin and tissue loss...Exudate Amount: Moderate...Exudate Type: Sero-sanguineous...Color: Black...Eschar: 76-100%...pt has a cast on the extremity. the cast has rubbed a wound on the post leg of the calf. the wound is an eschar surrounded but blanchable tissue that is weeping..."

The Physician Trauma Progress Note dated 5/7/19 revealed, "...Pressure ulcers from LLE splint. Wound nurse following. Splint change to 3D [dimensional] boot..."

The Orthopedic Progress Note dated 5/17/19 revealed, "...NWB LLE, 3D boot. NWB total duration 6-8 wks [weeks]...SUBJECTIVE: Awaiting placement at SNF [skilled nursing facility]..."

Review of the "Incision/Wound/Skin" nursing assessment from 5/1/19 through 5/21/19 revealed there was no documentation provided by the hospital nursing staff assessed Patient #2's left calf wound every 4 hours per hospital policy.

Review of the "Incision/Wound/Skin" nursing assessment from 5/6/19 (date left calf wound was identified by Wound Care Team as unstageable pressure injury) through 5/21/19 revealed the nursing staff failed to accurately identify and document Patient #2's left calf wound as a pressure injury "Abnormality Type" but instead documented it as an abrasion.

The Nursing Wound Assessment dated 5/20/19 revealed, "...Length: (cm) 3...Width: (cm) 2.5...Depth: (cm) 0.2...Stage: Unstageable Pressure Injury Obscured full-thickness skin and tissue loss...Exudate Amount: Moderate...Exudate Type: Sero-sanguineous [containing or relating to both blood and the liquid part of the blood]...Slough: 51-75%...Eschar: None..."

There was no documentation provided by the hospital that Patient #2 was turned every 2 hours from 5/1/19-5/21/19.

Patient #2 was discharged to a skilled nursing facility on 5/21/19 with an unstageable pressure injury to the left calf.

In an interview in the conference room on 6/25/19 at 8:50 AM, the Nursing Director stated nursing staff should document a pressure injury under "Abnormality Type" as a "pressure ulcer." The Nursing Director confirmed nursing staff documented Patient #2's left calf wound as an abrasion from 5/6/19 through 5/21/19 although the Wound Care Team had identified the wound as a pressure injury on 5/6/19.

4. Medical record review for Patient #3 revealed an admission date of 5/19/19 with diagnoses which included Motor Vehicle Crash, C (cervical) 5 Vertebral Body Teardrop Fracture, Traumatic Spondylolisthesis (spinal disorder in which a vertebra slips forward onto the bone below it) C5 on C6 and Traumatic Spinal Cord Injury.

Patient #3 was brought to the shock trauma unit of the Emergency Department via EMS following a motor vehicle crash.

Patient #3 was moving bilateral upper extremities in the field but was not following commands and unresponsive after arrival.

Patient #3 was intubated and medicated. A cat scan of the C-spine revealed a C5 flexion teardrop fracture, and Patient #3 was fitted with an Aspen Cervical Collar. On the morning of 5/20/19, Patient #3 was taken off sedation and became intermittently arousable.

Patient #3 was not moving bilateral lower extremities or withdrawing from pain but was able to flex the elbows and abduct at the shoulders.

The Physician Surgical Documentation dated 5/21/19 (date of procedure was 5/20/19 according to the Perioperative Record) revealed Patient #3 underwent a C5 corpectomy (surgical procedure that involves removing all or part of the vertebral body) with anterior instrumentation (instruments such as plates, cages or braces which are surgically inserted to provide stability for the spine) and fibular strut graft (bone graft taken from the fibula and used to support the spine) and local harvest bone graft (bone graft taken patient).

During the procedure, cervical traction was initially placed but was released when the cervical tongs obstructed the view of the patient's injury during x-rays. An incision across the back of the neck at the crease line was made, and the incision was sutured at the close of the procedure.

The wound was dressed with Steri-Strips, Mastisol, Telfa and a Tegaderm dressing. Following the procedure, Patient #3 was brought back to Trauma Intensive Care Unit (ICU).

The Physician Trauma Progress Note dated 5/20/19 revealed, "...Closed displaced fracture of fifth cervical vertebra with routine healing, 05/19/2019..."

A Nursing Narrative Note dated 5/20/19 at 4:00 PM revealed Patient #3 arrived in Trauma ICU with pin sites to bilateral head and traction was gone.

The Physician Trauma Progress Note dated 5/24/19 revealed, "...Exam...Head: cervical collar...incision dry..."

The Wound Care Nursing Progress Note dated 5/29/19 revealed, "...wocn [Wound Ostomy Continence Nurse] here on unit for consult. patient is 37 year old male s/p [status post] mvc.patient is strict spine with aspen collar. has very dark black hair and had to clip some hair in order to see wound. area is firm, dark with slight peeling edge. feels like scabbed abrasions but edge is adherent. primary care nurse present. recommend to clean with vashe then apply therahoney b.i.d. dress with 4x4,abd pads. wocn will reassess next visit..."

The physician's order dated 5/29/19 revealed, "...Consult to Wound/Ostomy/Continence Specialist...Per Protocol ordered by [Physician #1]...Reason for Wound Care Consult...Evaluate and Treat...Wound location...Head...Comment...Posterior left back head/occipital area; raised hardened area..."

The physician's order dated 5/29/19 revealed, "...vashe topical...Route of administration...Topical...Frequency...BID [twice daily]...Responsible Party...[Physician #1]...Comment...Apply to: occipital wound left lower occipital then apply therahoney b.i.d cover with gauze dressing, abd [abdominal] pad..."

The Wound Care Nursing Progress Note dated 5/30/19 revealed, "...wocn here on unit to revisit left head wound, lower occipital. This is the area where patient has cervical tongs,not a pressure injury. area has dried and scabbed up..."

The Wound Care Nursing Progress Note dated 6/4/19 revealed, "...aspen collar...patient has surgical site left head where he had cervical traction. area is flat scabbed abrasions,dark and detaching from edges..."

The Wound Care Nursing Progress Note dated 6/5/19 revealed, "...wocn here on unit. wound to left side of lower occipital flat and dark with scabbing noted. recommend to d/c [discontinue] therahoney and order sulfamylon b.i.d with gauze dressing and foam padding...patient has aspen collar..."

The physician's order dated 6/5/19 revealed, "...mafenide topical (Sulfamylon 85 mg [milligrams]/g [gram] topical cream...Responsible Party...[Physician #2]...Comment...Apply twice daily to:__left side lower occipital wound clean first with vashe then apply small gauze dressing pad with foam padding..."

The Wound Care Nursing Progress Note dated 6/10/19 revealed, "...wound to lower left occipital also goes over to right side. hair very dark/black. cleaned with vashe and then sulfamylon applied with gauze dressing. partial scabbing partial eschar noted. separating at edges. patient has aspen collar..."

The Wound Care Nursing Progress Note dated 6/12/19 revealed, "...wocn here on unit. more hair cut from around wound and noted soft black/gray necrotic tissue starting to detach from edges where pink tissue noted. no odor. Patient has unstageable pressure injury. continue with vashe and sulfamylon b.i.d with gauze dressing. may use extra padding in aspen collar with foam dressing..."

The Nursing Wound Assessment Details dated 6/12/19 revealed, "...Wound Location: Head - occiput...Wound Type: Pressure Ulcer...Wound Measurements...Length: (cm) 7.5...Width: (cm) 3.5...Depth: (cm) 0.2...Wound Description...Stage: Unstageable Pressure Injury Obscured full-thickness skin and tissue loss...Color: Gray...Slough: 51-75%...Eschar: 1-25%..."

The physician's order dated 6/12/19 revealed, "...Communication Order...Responsible Party...[Physician #3]...may apply foam dressing between aspen collar and gauzed dressing for extra padding. may alternate between inetrdry [sic] for any moisture control issues..."

The Wound Care Nursing Progress Note dated 6/19/19 revealed, "...wocn here on unit. patient has unstageable pressure injury to occipital with tan gray slough noted. starting to detach from edges. continue with vashe and sulfamylon b.i.d with gauze dressing and foam padding..."

The Nursing Wound Assessment Details dated 6/19/19 revealed, "...Wound Location: Head - occiput...Wound Type: Pressure Ulcer...Wound Measurements...Length: (cm) 7...Width: (cm) 2.5...Depth: (cm) 0.2...Wound Description...Stage: Unstageable Pressure Injury Obscured full-thickness skin and tissue loss...Color: Gray...Slough: 51-75%...Eschar: None..."

The Wound Care Nursing Progress Note dated 6/21/19 revealed, "...wocn here on unit for rounding. unstageable pressure injury to occipital improving with detachment of slough in process with partial slough and partial granulation tissue noted. no odor and small amt. [amount] of serosanguineous drainage noted. continue with present tx. patient has aspen collar in use. extra padding to occipital with foam dressing..."

The Wound Care Nursing Progress Note dated 6/24/19 revealed, "...wocn here on unit for rounding. patient pressure injury is now stage three with 25 percent slough and 75 percent red granulation tissue..."

The Nursing Wound Assessment Details dated 6/24/19 revealed, "...Wound Location: Head - occiput ...Wound Type: Pressure Ulcer ...Wound Measurements...Length: (cm) 7...Width: (cm) 2.3...Depth: (cm) 0.2...Wound Description...Stage: Stage 3 Pressure Injury...Color: Bright Red...Slough: 1-25%...Eschar: None..."

The physician's order dated 6/21/19 revealed, "...vashe topical...Route of administration...Responsible Party...[Physician #4]...Comment...Apply BID for occipital wound. Ordered by wound care per note..."

Review of the "Incision/Wound/Skin" nursing assessment from 5/21/19 through 6/24/19 (35 days) revealed there was no documentation by nursing staff of a nursing assessment of Patient #3's left occipital wound every 2 hours per hospital policy.

Review of the "Incision/Wound/Skin" nursing assessment from 6/12/19 (date left occipital wound was identified by Wound Care Team as unstageable pressure injury) through 6/24/19 revealed the nursing staff failed to accurately identify and document Patient #3's left occipital wound as a pressure injury "Abnormality Type" but documented it as a surgical incision from 6/12/19 at 8:00 PM through 6/20/19 at 6:00 PM.

There was no documentation provided by the hospital that Patient #3 was turned every 2 hours from 5/21/19-6/24/19.

5. In an interview in the conference room on 6/25/19 at 2:20 PM, the Nurse Manager of TICU and GICU stated nursing staff in the intensive care units should document assessments, including assessments for a pressure injury, every 2 hours.

In an interview in the conference room on 6/26/19 at 12:10 PM, the Performance Improvement Coordinator stated nursing staff should document turning a patient every 2 hours either in the "Activity - ADLs [activities of daily living]" or "Patient Status Rounding" sections of the flowsheet. The hospital was unable to provide documentation for Patient #1, 2 or 3 were turned every 2 hours.

Based on medical record review and interview, the hospital failed to ensure nursing staff administered all drugs and biologicals according to the physician's order for 2 of 3 (Patient #1 and 2) sampled patients with hospital-acquired pressure injuries.

The findings included:

1. Medical record review for Patient #1 revealed an admission date of 4/28/19 with diagnoses which included Complete Lesion of Thoracic Spinal Cord at T11 Level, T12 Fracture with Paraplegia Status/Post Fusion, Multiple Rib Fractures, and Right Femoral Neck Fracture.

The Wound Ostomy Continence Nurse (WOCN) Progress Note dated 5/9/18 at 8:49 AM revealed, "...Wocn on unit to assess buttocks, pt [patient] has a small open area on the lt [left] intergluteal area recommend critic aid..."

The "Communication Order" dated 5/9/19 at 8:42 AM entered and signed by the WOCN and Cosigned by the physician revealed, "...pt has an open area on the intergluteal space lt side, recommend a light coat of critic aid bid [twice a day]..."

The WOCN Progress Note dated 5/13/19 at 8:56 AM revealed, " ...pt has a small abrasion near the superior intergluteal space. Pt has optifoam in place no change in recommendation [for critic aid] ...wocn will follow one more week..."

The hospital was unable to provide a physician's order for the optifoam dressing prior to 5/13/19.

There was no documentation provided by the hospital that critic aid was applied to Patient #1's intergluteal area wound as ordered by the physician for 11 days, from 5/9/19 through 5/20/19.

The Nursing Wound Assessment Details dated 5/20/19 revealed, "...Wound Location: Sacral...Wound Type: Pressure Ulcer...Length: (cm) [centimeters] 3...Width: (cm) 3...Depth: (cm) 0.2...Stage: Unstageable Pressure Injury Obscured full-thickness skin and tissue loss...Exudate Amount: Small...Exudate Type: Sero-sanguineous...Eschar: 76-100% [percent]..Assessment Notes...Unstageable pressure injury to scrum has large amount of slough with small amount of pink nongranular tissue to edges. Recommendation: Cleanse wound with Vashe, pat dry. Apple Therahoney, cover with gauze and secure with Medipore tape bid and prn..."

The Nursing Wound Assessment Details dated 5/29/19 revealed, "...Wound Location: Sacral...Wound Type: Pressure Ulcer...Length: (cm) 5.5...Width: (cm) 4.5...Depth: (cm) 0.2...StageWound Condition: Deteriorating ...In for follow-up visit for unstageable pressure injury. Wound bed is covered with more than 90% of slough/eschar material. Very small amount of pink non-granular tissue. Wound is much larger than noted on last visit. Will continue with Therahoney for now and reevaluate on next visit for burn plastic consult ..."

The nursing staff failed to apply the Therahoney to Patient #1's sacral wound as ordered to Patient #1's sacral wound as ordered by the physician from 5/29/19 through 5/31/19.

2. Medical record review for Patient #2 revealed an admission date of 4/30/19 with diagnoses which included Accident Caused by a Farm Tractor, Abrasion and/or Friction Burn on Multiple Sites, Atrial Fibrillation, Cerebral Contusion, Fractured Medical Malleolus and Metatarsal Bone Fracture.

The Physician Orthopedic Consultation note dated 4/30/19 revealed, "...[Patient #2] is an 86-year-old male who presented to [named hospital] earlier today as a shock trauma level 2 [unit in the Emergency Department] after being run over by a tractor...Prior to arrival, EMS [Emergency Medical Services] reported that he had significant road rash but no obvious deformities. He later, in shock trauma, reported some L [left] ankle and foot pain...LLE [left lower extremity]: Skin intact with no open wounds...XR [x-ray] Ankle Complete 3+ View Left...Impression...Medial malleolus fracture...Fractures of the head of the 2nd-5th metatarsal and proximal phalanx of the great toe...Plan for non-op [non-operative] tx [treatment] of above fxs. [fractures] NWB [non-weight bearing] in LLE splint, will transition to cast in clinic..."

The Physician Orthopedic Progress Note dated 5/1/19 revealed, "...EXAM: NAD [no apparent distress], NLB [non-load bearing] LLE: splint. Toes up/down. SILT [sensation intact to light touch]..." There was no documentation the left calf wound was observed.

The Nursing Narrative Note dated 5/1/19 revealed, "...LLE splinted observed calf wound just above where splint terminates..."

The Nursing Narrative Note dated 5/3/19 revealed, "...Ortho [Orthopedics] on-call came and review [reviewed] left lower leg cast with dried blood stained to upper side. Bruises and abrasion noted coming out from soft cast part. They will follow up later..."

An Orthopedic Physician #1's order dated 5/3/19 at 9:50 PM revealed, "...silver sulfadiazine topical (Silvadene 1% topical cream)...Order Comment...Apply to: wound at posteromedial aspect of superior splint...[twice daily]"

An Orthopedic Physician #1's order dated 5/3/19 at 9:52 PM revealed, "...Consult to Wound/Ostomy/Continence Specialist...Reason for Wound Care Consult...Evaluate and Treat...Wound location...Left Leg...Special instructions...Initial...Wound at Superior aspect of LLE short leg splint (posteromedial)..."

There was no documentation provided by the hospital for an Orthopedic Progress Note on 5/3/19 for the visit to assess the splint, order medication (silvadene) to treat the wound and consult wound care to evaluate and treat the wound.

The Physician Trauma Progress Note dated 5/5/19 revealed, "...Ortho replaced splint yesterday [5/4/19] for skin breakdown noted around top of splint..." However, there was no documentation of an Orthopedic Progress Note that an orthopedic provider replaced the splint on 5/4/19.

The Nursing Wound Assessment Details dated 5/6/19 revealed, "...Wound Location: Left Calf...Wound Type: Pressure Ulcer...Date Acquired: 5/6/2019...Acquired at Facility: Yes...Wound Notes: pt [patient] has an unstageable pressure injury on the post calf under the cast...Length: (cm) [centimeters] 2.5...Width: (cm) 2...Depth: (cm) 0.2...Stage: Unstageable Pressure Injury Obscured full-thickness skin and tissue loss...Exudate Amount: Moderate...Exudate Type: Sero-sanguineous...Color: Black...Eschar: 76-100%...pt has a cast on the extremity. the cast has rubbed a wound on the post leg of the calf. the wound is an eschar surrounded but blanchable tissue that is weeping..."

The Nursing Narrative Note dated 5/6/19 revealed, "...Paged Ortho...about splint coming loose. [Orthopedic Staff #1] called back. I told them that the splint was coming loose. [Orthopedic Staff #1] stated they would call us back..."

The Physician Trauma Progress Note dated 5/7/19 revealed, "...Pressure ulcers from LLE splint. Wound nurse following. Splint change to 3D [dimensional] boot..."

The Orthopedic Progress Note dated 5/17/19 revealed, "...NWB LLE, 3D boot. NWB total duration 6-8 wks [weeks]...SUBJECTIVE: Awaiting placement at SNF [skilled nursing facility]..."

The Medication Administration Record (MAR) dated 5/5/19 revealed, "...silver sulfadiazine [silvadene] topical...Not Given: per burn not needed @ [at] 2229 [10:29 PM]..."

The Burn/Plastics Progress Note dated 5/5/19 revealed there was no documentation which noted Patient #2's left calf wound or for the silver sulfadiazine topical to be held from administration to the wound.

The MAR dated 5/7/19 revealed, "...[silvadene] Not Given: per burn np [Nurse Practitioner] not to use @0722 [7:22 AM]..."

There was no documentation provided by the hospital from the Burn/Plastics Nurse Practitioner or Physician as to why the silver sulfadiazine (silvadene) topical was held from administration to Patient #2's left calf wound on 5/5/19 and 5/7/19.

The MAR revealed the following, "...Not Done: Not Appropriate at this Time..." on 5/6/19 at 10:00 AM, 5/7/19 at 10:00 AM, 5/8/19 at 10:00 AM, 5/9/19 at 10:00 AM, 5/11/19 at 10:00 AM, 5/12/19 at 10:00 PM, 5/13/19 at 10:00 AM and 5/16/19 at 10:00 PM. There was no documentation provided by the hospital why the silver sulfadiazine was not administered as ordered at these times, or physician orders to hold the silvadene cream until further notice.

The MAR revealed the following scheduled doses of silvadene were not documented as administered: on 5/6/19 at 10:00 PM and 5/17/19 at 10:00 AM. There was no documentation why the silver sulfadiazine was not administered as ordered at these times.

The Nursing Wound Assessment dated 5/20/19 revealed, "...Length: (cm) 3...Width: (cm) 2.5...Depth: (cm) 0.2...Stage: Unstageable Pressure Injury Obscured full-thickness skin and tissue loss...Exudate Amount: Moderate...Exudate Type: Sero-sanguineous [containing or relating to both blood and the liquid part of the blood]...Slough: 51-75%...Eschar: None..."

Patient #2 was discharged to a skilled nursing facility on 5/21/19 with an unstageable pressure injury to the left calf.

3. In an interview in the conference room on 6/25/19 at 8:50 AM, the Nursing Director stated she did not know what "Not Done: Not Appropriate at this Time" meant which was documented in the MAR. The Nursing Director confirmed there was no documentation why the silver sulfadiazine was not administered as ordered by the physician.

Based on policy review, medical record review and interview, the hospital failed to ensure individual patient nutritional needs were met for 2 of 3 (Patient #2 and 3) sampled patients with hospital-acquired pressure injuries.

The findings included:

1. Review of the hospital's "Pressure Injury Treatment Guidelines" policy revealed, "...Related Factors...Poor nutrition...Assessments/Interventions...Consult Nutritional Support Services ..."

2. Medical record review for Patient #2 revealed an admission date of 4/30/19 with diagnoses which included Accident Caused by a Farm Tractor, Abrasion and/or Friction Burn on Multiple Sites, Atrial Fibrillation, Cerebral Contusion, Fractured Medial Malleolus and Metatarsal Bone Fracture.

The Physician Orthopedic Consultation note dated 4/30/19 revealed, "...[Patient #2] is an 86-year-old male who presented to [named hospital] earlier today as a shock trauma level 2 [unit in the Emergency Department] after being run over by a tractor...Prior to arrival, EMS [Emergency Medical Services] reported that he had significant road rash but no obvious deformities. He later, in shock trauma, reported some L [left] ankle and foot pain...LLE [left lower extremity]: Skin intact with no open wounds...XR [x-ray] Ankle Complete 3+ View Left...Impression...Medial malleolus fracture...Fractures of the head of the 2nd-5th metatarsal and proximal phalanx of the great toe...Plan for non-op [non-operative] tx [treatment] of above fxs. [fractures] NWB [non-weight bearing] in LLE splint, will transition to cast in clinic..."

The Nursing Narrative Note dated 5/1/19 revealed, "...LLE splinted observed calf wound just above where splint terminates..."

The Nursing Narrative Note dated 5/3/19 revealed, "...Ortho [Orthopedics] on-call came and review [reviewed] left lower leg cast with dried blood stained to upper side. Bruises and abrasion noted coming out from soft cast part. They will follow up later..."

An Orthopedic Physician #1's order dated 5/3/19 at 9:50 PM revealed, "...silver sulfadiazine topical (Silvadene 1% topical cream)...Order Comment...Apply to: wound at posteromedial aspect of superior splint..."

An Orthopedic Physician #1's order dated 5/3/19 at 9:52 PM revealed, "...Consult to Wound/Ostomy/Continence Specialist...Reason for Wound Care Consult...Evaluate and Treat...Wound location...Left Leg...Special instructions...Initial...Wound at Superior aspect of LLE short leg splint (posteromedial)..."

The Physician Trauma Progress Note dated 5/5/19 revealed, "...Ortho replaced splint yesterday [5/4/19] for skin breakdown noted around top of splint..."

The Nursing Wound Assessment Details dated 5/6/19 revealed, "...Wound Location: Left Calf...Wound Type: Pressure Ulcer...Date Acquired: 5/6/2019...Acquired at Facility: Yes...Wound Notes: pt [patient] has an unstageable pressure injury on the post calf under the cast...Length: (cm) [centimeters] 2.5...Width: (cm) 2...Depth: (cm) 0.2...Stage: Unstageable Pressure Injury Obscured full-thickness skin and tissue loss...Exudate Amount: Moderate...Exudate Type: Sero-sanguineous...Color: Black...Eschar: 76-100%...pt has a cast on the extremity. the cast has rubbed a wound on the post leg of the calf. the wound is an eschar surrounded but blanchable tissue that is weeping..."

The Physician Trauma Progress Note dated 5/7/19 revealed, "...Pressure ulcers from LLE splint. Wound nurse following. Splint change to 3D [dimensional] boot..."

The Nutrition Note dated 5/7/19 revealed, "...Skin: L [left] knee and calf abrasions..."

The Nutrition Note dated 5/10/19 revealed, "...Skin: Abrasions..."

The Nutrition Note dated 5/17/19 revealed, "...Bruising and abrasions noted..."

The Nursing Wound Assessment dated 5/20/19 revealed, "...Length: (cm) 3...Width: (cm) 2.5...Depth: (cm) 0.2...Stage: Unstageable Pressure Injury Obscured full-thickness skin and tissue loss...Exudate Amount: Moderate...Exudate Type: Sero-sanguineous [containing or relating to both blood and the liquid part of the blood]...Slough: 51-75%...Eschar: None..."

Patient #2 was discharged to a skilled nursing facility on 5/21/19 with an unstageable pressure injury to the left calf.

There was no documentation provided by the hospital that Nutritional Services noted the presence of a pressure injury or evaluated Patient #2's nutritional needs based on the presence of a pressure injury.

3. Medical record review for Patient #3 revealed an admission date of 5/19/19 with diagnoses which included Motor Vehicle Crash, C (cervical) 5 Vertebral Body Teardrop Fracture, Traumatic Spondylolisthesis (spinal disorder in which a vertebra slips forward onto the bone below it) C5 on C6 and Traumatic Spinal Cord Injury.

Patient #3 was brought to the shock trauma unit of the Emergency Department via EMS following a motor vehicle crash.

Patient #3 was moving bilateral upper extremities in the field but was not following commands and unresponsive after arrival.

Patient #3 was intubated and medicated. A cat scan of the C-spine revealed a C5 flexion teardrop fracture, and Patient #3 was fitted with an Aspen Cervical Collar. On the morning of 5/20/19, Patient #3 was taken off sedation and became intermittently arousable.

Patient #3 was not moving bilateral lower extremities or withdrawing from pain but was able to flex the elbows and abduct at the shoulders.

The Physician Surgical Documentation dated 5/21/19 (date of procedure was 5/20/19 according to the Perioperative Record) revealed Patient #3 underwent a C5 corpectomy (surgical procedure that involves removing all or part of the vertebral body) with anterior instrumentation (instruments such as plates, cages or braces which are surgically inserted to provide stability for the spine) and fibular strut graft (bone graft taken from the fibula and used to support the spine) and local harvest bone graft (bone graft taken patient).

During the procedure, cervical traction was initially placed but was released when the cervical tongs obstructed the view of the patient's injury during x-rays. An incision across the back of the neck at the crease line was made, and the incision was sutured at the close of the procedure.

The wound was dressed with Steri-Strips, Mastisol, Telfa and a Tegaderm dressing. Following the procedure, Patient #3 was brought back to Trauma Intensive Care Unit (ICU).

The Physician Trauma Progress Note dated 5/20/19 revealed, "...Closed displaced fracture of fifth cervical vertebra with routine healing, 05/19/2019..."

A Nursing Narrative Note dated 5/20/19 at 4:00 PM revealed Patient #3 arrived in Trauma ICU with pin sites to bilateral head and traction was gone.

The Physician Trauma Progress Note dated 5/24/19 revealed, "...Exam...Head: cervical collar...incision dry..."

The Wound Care Nursing Progress Note dated 5/29/19 revealed, "...wocn [Wound Ostomy Continence Nurse] here on unit for consult. patient is 37 year old male s/p [status post] mvc.patient is strict spine with aspen collar. has very dark black hair and had to clip some hair in order to see wound. area is firm, dark with slight peeling edge. feels like scabbed abrasions but edge is adherent. primary care nurse present. recommend to clean with vashe then apply therahoney b.i.d. dress with 4x4,abd pads. wocn will reassess next visit..."

The physician's order dated 5/29/19 revealed, "...Consult to Wound/Ostomy/Continence Specialist...Per Protocol ordered by [Physician #1]...Reason for Wound Care Consult...Evaluate and Treat...Wound location...Head...Comment...Posterior left back head/occipital area; raised hardened area..."

The physician's order dated 5/29/19 revealed, "...vashe topical...Route of administration...Topical...Frequency...BID [twice daily]...Responsible Party...[Physician #1]...Comment...Apply to: occipital wound left lower occipital then apply therahoney b.i.d cover with gauze dressing, abd [abdominal] pad..."

The Wound Care Nursing Progress Note dated 5/30/19 revealed, "...wocn here on unit to revisit left head wound, lower occipital. This is the area where patient has cervical tongs,not a pressure injury. area has dried and scabbed up..."

The Wound Care Nursing Progress Note dated 6/4/19 revealed, "...aspen collar...patient has surgical site left head where he had cervical traction. area is flat scabbed abrasions,dark and detaching from edges..."

The Wound Care Nursing Progress Note dated 6/5/19 revealed, "...wocn here on unit. wound to left side of lower occipital flat and dark with scabbing noted. recommend to d/C [discontinue] therahoney and order sulfamylon b.i.d with gauze dressing and foam padding...patient has aspen collar..."

The physician's order dated 6/5/19 revealed, "...mafenide topical (Sulfamylon 85 mg [milligrams]/g [gram] topical cream...Responsible Party...[Physician #2]...Comment...Apply twice daily to:__left side lower occipital wound clean first with vashe then apply small gauze dressing pad with foam padding..."

The Wound Care Nursing Progress Note dated 6/10/19 revealed, "...wound to lower left occipital also goes over to right side. hair very dark/black. cleaned with vashe and then sulfamylon applied with gauze dressing. partial scabbing partial eschar noted. separating at edges. patient has aspen collar..."

The Wound Care Nursing Progress Note dated 6/12/19 revealed, "...wocn here on unit. more hair cut from around wound and noted soft black/gray necrotic tissue starting to detach from edges where pink tissue noted. no odor. Patient has unstageable pressure injury. continue with vashe and sulfamylon b.i.d with gauze dressing. may use extra padding in aspen collar with foam dressing..."

The Nursing Wound Assessment Details dated 6/12/19 revealed, "...Wound Location: Head - occiput...Wound Type: Pressure Ulcer...Wound Measurements...Length: (cm) 7.5...Width: (cm) 3.5...Depth: (cm) 0.2...Wound Description...Stage: Unstageable Pressure Injury Obscured full-thickness skin and tissue loss...Color: Gray...Slough: 51-75%...Eschar: 1-25%..."

The Wound Care Nursing Progress Note dated 6/19/19 revealed, "...wocn here on unit. patient has unstageable pressure injury to occipital with tan gray slough noted. starting to detach from edges. continue with vashe and sulfamylon b.i.d with gauze dressing and foam padding..."

The Nursing Wound Assessment Details dated 6/19/19 revealed, "...Wound Location: Head - occiput...Wound Type: Pressure Ulcer...Wound Measurements...Length: (cm) 7...Width: (cm) 2.5...Depth: (cm) 0.2...Wound Description...Stage: Unstageable Pressure Injury Obscured full-thickness skin and tissue loss...Color: Gray...Slough: 51-75%...Eschar: None..."

The Wound Care Nursing Progress Note dated 6/21/19 revealed, "...wocn here on unit for rounding. unstageable pressure injury to occipital improving with detachment of slough in process with partial slough and partial granulation tissue noted. no odor and small amt. [amount] of serosanguineous drainage noted. continue with present tx.patient has aspen collar in use. extra padding to occipital with foam dressing..."

The Wound Care Nursing Progress Note dated 6/24/19 revealed, "...wocn here on unit for rounding. patient pressure injury is now stage three with 25 percent slough and 75 percent red granulation tissue..."

The Nursing Wound Assessment Details dated 6/24/19 revealed, "...Wound Location: Head - occiput ...Wound Type: Pressure Ulcer ...Wound Measurements...Length: (cm) 7...Width: (cm) 2.3...Depth: (cm) 0.2...Wound Description...Stage: Stage 3 Pressure Injury...Color: Bright Red...Slough: 1-25%...Eschar: None..."

The Nutritional Support Progress Note dated 5/20/19 through 6/6/19 (date of last Nutritional Support Progress Note provided by hospital) revealed there was no documentation by Nutritional Support for Patient #3's occipital pressure injury.

The Nutrition Note dated 6/19/19 (7 days after the wound was identified as an unstageable pressure injury by the Wound Care Team) revealed, "...patient has unstageable pressure injury to occipital with tan gray slough noted..."

There was no documentation that a nutritionist had based Patient #3's nutritional needs on the presence of pressure injury prior to 6/19/2019.

There was no documentation provided by the hospital that Nutritional Services noted the presence of a pressure injury or evaluated Patient #3's nutritional needs based on the presence of a pressure injury prior to 6/19/19.

4. In an interview in the conference room on 6/26/19 at 9:00 AM, the Performance Improvement Coordinator confirmed all Nutritional Support Progress Notes for Patient #3 were provided to the surveyor. The Performance Improvement Coordinator confirmed there was no documentation by Nutritional Support Services which noted the presence of a pressure injury or evaluated Patient #3's nutritional needs based on the presence of a pressure injury prior to 6/19/19.

In an interview in the conference room on 6/26/19 at 10:00 AM, Clinical Dietitian #1 stated a patient's nutritional needs increase when the patient develops a pressure injury. Clinical Dietitian #1 stated an evaluation for the nutritional needs of a patient with a pressure injury should be documented in the progress notes. Clinical Dietitian #1 stated nutritional services would get a consult to evaluate a patient's nutritional needs if nutrition services were not already seeing the patient. Clinical Dietitian #1 stated they received a consult on 6/17/19 for Patient #3 after his enteral nutrition had been discontinued. Clinical Dietitian #1 stated Patient #3 was already being seen by the Nutritional Support Team (which included a Pharmacist, Pharmacy Residents, Surgeon and Surgery Residents) who managed the patient's enteral nutrition. Clinical Dietitian #1 stated she would review the nurse's notes or wound care notes to see if the patient had a pressure injury.