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Based on medical record review, document review, and interview, in one (1) of ten (10) medical records reviewed, nursing staff failed to appropriately manage pressure injury in accordance with the facility's policy for Skin Assessment, Pressure Injury Assessment, and Treatment Guidelines. Specifically, the patient risk for pressure injury, descriptions of the wound were not consistently documented by staff, and wound consultation was not implemented (Patient #2).

Findings include:

See Tag: 0392
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Based on medical record review, document review, and interview, in one (1) of ten (10) medical records reviewed, nursing staff failed to appropriately manage pressure injury in accordance with the facility's policy for Skin Assessment, Pressure Injury Assessment, and Treatment Guidelines. Specifically, the patient risk for pressure injury, descriptions of the wound were not consistently documented by staff, and wound consultation was not implemented.

Findings include:

The facility's policy and procedure titled "Skin Assessment, Pressure Injury Assessment, and Treatment Guidelines," effective February 2011, states," ... All medical-surgical and critical care patients will be assessed for pressure injury risk on admission, and each shift using the Braden Scale ... Any alteration in skin integrity is to be documented. All open wounds will be described in detail, including location, size, color, drainage and odor, and peri-wound tissue ... Inform the physician of any changes or alterations in skin integrity. The LIP [Licensed Independent Practitioner] must order a Wound Care consultation as needed ..."

A review of the medical record for Patient #1 identified a 77-year-old who was admitted to the facility on 12/12/2023 with an admitting diagnosis of non-purulent cellulitis of the right lower leg.

The initial nursing assessment on 12/12/23 at 8:00 PM revealed the following:
The patient was alert and oriented to person, place, time, and situation. The Braden score for predicting pressure sore was 19/23-not at risk (Mild risk: Total score 15-18; Moderate Risk: Total score 13-14; High Risk: Total score 10-12; Severe Risk: Total score less than or equal to 9). The patient had redness and swelling in the right lower extremity, but the skin was intact.

Nurse on 12/25/2023 at 9:00 AM documented "red blanchable buttocks." Braden score: 15 (Mild Risk).

On 12/25/2023 at 8:00 PM, the nurse documented Braden score: 20 (No Risk). "Patient demonstrates the ability to reposition self, assistance provided for comfort. Patient declines turning and repositioning at this time." Bilateral +3 edema to bilateral lower extremities.

On 12/28/2023 at 8:10 AM, the nurse documented Braden score: 12 (High Risk). Coccyx wound with pale yellow wound base and excoriated peri-wound; no drainage noted-scattered areas of linear deep purple discoloration.

12/28/2023 at 7:20 PM, Braden score: 16 (Mild Risk). "Patient with an unstageable wound to the coccyx and another pressure area to the bottom."

12/29/2023 at 8:10 AM - Braden score 14 (Moderate Risk). Coccyx wound with pale yellow wound base and excoriated peri-wound; no drainage noted.

The physician documented an order for wound consultation on 12/29 at 12:50 PM.

No documentation was found that indicated the patient was evaluated by a wound consultant prior to discharge on 1/4/2024.

On 1/1/2024 at 7:47 PM, the nurse documented Braden score 14 (Moderate Risk)-patient with stage 2 to left buttock and an unstageable wound to the coccyx.

On 1/3/2024 at 5:30 PM, the nurse documented an unstageable coccyx wound (yellow/tan slough noted), a small (1" diameter) stage II wound in the left buttock, and a 1" scab on the left heel of the foot.

On 1/4/2024 at 8:00 AM, a nurse assessment revealed a Braden score of 16 (Mild Risk): "Skin is intact; skin protection intervention implemented."

The patient was discharged to a sub-acute facility on 1/04/2024.

Nursing documentation of the patient's Braden score for predicting pressure sore risk revealed the patient was assessed as mild to moderate risk after they developed a stage I pressure injury to the buttocks on 12/25/2023. The patient's pressure injuries progressed to an unstageable wound on 12/28/2023. On the day of discharge on 1/04/2024, the nurse documented at 8:00 AM that the patient was at a mild risk for pressure injury with intact skin.

Nurses' assessments of the patient's ability to position themselves in bed on 12/21/2023, 12/24/2023, 12/26/2023, 12/27/2023, 12/30/2023, 12/31/2023, 1/2/2024, and 1/4/2024 indicated that the patient could reposition self. These assessments were inconsistent with the daily Physical Therapist evaluation from 12/20/2023 to 1/04/2024, which stated that the patient was dependent on turning in bed and needed maximum assistance with mobility.

No documentation was found that all open wounds were described in detail, including location, size, color, drainage, odor, and peri-wound tissue, per the facility's "Skin Assessment, Pressure Injury Assessment, and Treatment Guidelines."

There was no nursing documentation that indicated the physician was informed of the patient's skin condition at discharge.

During an interview with Staff T (Physician Assistant) on 03/29/2024 at 1:00 PM, the staff stated he was unaware the patient had pressure injuries at discharge on 1/04/2024.

During an interview on 04/03/2024 at 11:30 AM with Staff Dd (Regional VP, Nurse Executive), she acknowledged the findings. She stated wound consultation was unavailable on the weekend [12/30/2023 to 12/31/2023] and that Monday [1/01/2024] was a holiday.

At an interview with Staff V (RN, Wound Care) on 04/04/2024 at 10:56 AM, the staff stated she sees patients based on her availability and that there is no specified time frame for implementing an order for wound consultation.

No information was provided for the lack of implementation of the wound consult before the patient was discharged on 1/04/2024.

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Based on medical record review and interview, in one (1) of three (3) medical records reviewed, the facility failed to provide medical information pertaining to the patient's pressure injury and treatment plan to the post-acute care service provider at the time of discharge (Patient #1).

Findings include:

A review of the medical record for Patient #1 identified the following information:

The patient was admitted on 12/12/2023 with a diagnosis of non-purulent cellulitis of the right lower leg.

On 12/25/2023, at 09:00 AM, the nurse documented "red blanchable buttocks."
As per nursing progress notes on 12/28/2023 at 08:10 AM, the wound progressed to "coccyx unstageable with pale yellow, dry wound base multiple scattered linear purple discolorations."

The patient was discharged to a sub-acute facility on 01/04/2024.

A review of the Patient Review Instrument (PRI) dated 01/04/2024 revealed documentation of a stage II pressure ulcer and the need for wound care.

The PRI did not accurately document the stage of the patient's pressure wounds at discharge.

The discharge instructions documented by Staff T (Physician Assistant) revealed no documentation of the patient's pressure injury, the severity of the wound, and a treatment plan for management of the wound.

During an interview with Staff T on 03/29/2024 at 1:00 PM, the staff stated that he was unaware of the patient's wounds at discharge on 01/04/2024.

During an interview with Staff U (Attending M.D.) on 3/29/2024 at 1:05 PM, staff reported that she was not aware of the patient's wounds and the need for post-hospital care. She stated that she relied on the information from the mid-level provider when she co-signed the discharge instructions.