HospitalInspections.org

Based on review of medical records, policies and procedures, and staff interviews, it was determined that the facility failed to ensure that wound care preventative measures and treatment was implemented as per physician orders for two patients (P#1 and P#2) out of five sampled patients.


Findings:

A review of Patient (P) #1's medical record revealed that P#1 was admitted to the facility on 10/24/21 at 9:05 p.m. with a stage 2 pressure injury to the sacrum. In addition, P#1 also had a stage 2 pressure injury to the left heel, present on admission.

A review of the physician History and Physical (H&P) examination dated 10/24/21 at 5:10 p.m. revealed that P#1 had a diagnosis of osteomyelitis and was being followed by the wound care clinic. Continued review of the H&P revealed that P#1 had a right heel ulcer that was well-appearing and healing. A stage 2-3 ulcer with some purulent drainage was noted on the left heel.

A review of the "Clinical Documentation Record" "Admission/Shift Assessment" dated 10/25/21 at 1:57 a.m. revealed:
Skin alteration: Pressure injury; immobility related Left Heel
Pressure injury present on admission: yes
Pressure injury; immobility related Sacrum
Pressure injury present on admission: yes
Dressing dry and intact

A wound care consultation was completed on 10/25/21 at 11:13 a.m.
Physician orders were entered on 10/25/21 at 11:21 a.m. for:
- Dressing change to left heel wound daily.
- Sacral wound to be cleansed and an application of barrier cream applied twice daily and as needed.

A review of the clinical documentation revealed that P#1's left heel dressing was changed: 10/26/21 at 4:00 p.m., 10/27/21 at 8:30 p.m. and 10/28/21 at 10:00 a.m.
Continued review of the clinical documentation revealed that P#1 was bathed 10/25/21 at 7:30 a.m., 10/26/21 at 4:36 p.m., 10/27/21 at 7:00 a.m., and 10/28/21 at 1:10 p.m.
P#1 went to surgery for a feeding tube placement on 10/28/21.

A physician order was entered on 10/29/21 to change the left heel dressing every three days.
Review of the clinical documentation revealed that P#1's left heel dressing was changed 10/29/21, 11/1/21, and 11/4/21.

A physician ordered was entered 11/4/21 at 5:30 a.m. to begin sacral wound dressing changes daily.

A review of "Clinical Documentation Record" dated 11/4/21 at 2:12 p.m., wound care center notes, revealed that P#1 had been on the joint and spine unit and was now in the Intensive Care Unit secondary to seizures. P#1 was on a waffle overlay and was being turned and positioned. Despite this, the sacral wound was worsening. The wound measured 9 cm x 7 cm x 1.5 cm depth. Eschar (dead tissue that falls off health skin) tissue had broken down. There was 30 percent eschar and slough. Dakins was to be requested. P#1's right heel skin was intact. The left heel was continuing to close and measured 1 cm x1 cm x no depth.

A review of "Clinical Documentation Record" dated 11/4/21 at 4:00 p.m. for a shift assessment revealed that a wound care nurse was at bedside. Documentation revealed that right and left heel were stage 3 pressure injuries. The sacral wound was a stage 4.

A review of "Clinical Documentation Record" dated 11/4/21 at 4:23 p.m., revealed wound/dressing care orders. P#1's sacral wound was to be cleansed with normal saline and covered with Dakins moistened Kerlix and covered with gauze. Dressings were to be changed daily. Foam wedges, posey heel guards, and waffle overlay were to be utilized.
P#1's buttocks were to be cleaned with foam cleanser and covered with Calzamine barrier paste. Foam dressing was not to be used. P#1 was to be repositioned every one to two hours.

A review of the clinical documentation revealed that P#1's sacral dressing was changed 11/4/21, 11/6/21, and 11/7/21.

A review of the 'Admission/shift assessment dated 11/11/21 at 8:00 a.m. revealed that P#1 had right, and left heel injuries related to immobility and a sacral injury related to immobility. All had been present on admission. P#1 was discharged home with home health services on 11/11/21 at 10:10 a.m. via ambulance in stable medical condition.


A review of P#2's MR revealed that P#2 was a 75-year-old who was admitted to the facility on 07/12/23 at 10:18 a.m. via the emergency department for evaluation of gangrene. P#2 had a history of diabetes and kidney failure.

A review of the "Operative Note" dated 7/13/23 at 6:10 p.m. revealed that P#2 had a pre-operative diagnosis of
1. Left and right foot osteomyelitis
2. Left and right foot wounds with necrosis of bone
3. Left and right foot diabetic wounds
P#2 had amputation of the great toe on the left foot and sesamoidectomy (removal of bone in the toe) on the right side. Bilateral adjacent tissue transfer was completed.

A review of 'flowsheet' revealed a pressure injury to right heel was observed on 7/19/23 at 5:15 p.m. and a heel offloading boot was present.

A review of 'flowsheet' note by physical therapy on 7/20/23 at 3:09 p.m. revealed that P#2 was found supine in bed with loose stool present on perineal area and linen. Documentation revealed that P#2 was observed to have an open wound to the right buttock area on 7/20/23 at 3:09 p.m. An order for a wound care consultation was entered 7/20/23 at 2:36 p.m. A wound care consult was not completed until 7/25/23 at 4:35 p.m.

A review of a "Therapy Note" dated 7/25/23 at 4:35 p.m. revealed that a WCON consult was completed due to a new skin breakdown to P#1's sacrum. The wound was first assessed on 7/20/23 at 4:45 p.m. The sacral wound was not present on hospital admission.
The pressure wound was categorized as a stage III that measured seven centimeters (cm) in length, 4.5 cm in width, and 0.2 cm in depth. The recommendation was to apply Venelex (an ointment that provided a protective cover for pressure wounds) and cover with dressing every eight hours. Staff was to continue to turn and reposition P#2.

A follow-up wound care visit was scheduled for 8/2/23 for P#2's left buttocks.

A review of 'Intentional Rounding' revealed that P#2 was positioned every two hours and was capable of turning self during the hospitalization. A review of the 'Braden Scale' revealed that it was calculated every shift during the hospitalization.

A review of the "Discharge Summary" revealed that P#2 was discharged on 7/25/23 in fair condition to a skilled nursing facility. Discharge diagnosis included chronic toe ulcer, type 2 diabetes, and stage 5 kidney disease with chronic dialysis. The discharge diagnosis failed to include P#2's sacral ulcer.

A review of the facility's 'Skin Breakdown Prevention Procedures', last revised 1/27/20 revealed that the purpose of the procedures were to establish guidelines for prevention of skin breakdown, promotion of healthy intact skin throughout the hospitalization, promptly identification of patients at high risk of development of skin breakdown. The risk for the development of pressure ulcer/pressure injuries was assessed on admission to the nursing unit and at least every 12 hours. Continued review revealed that patients were assessed by a RN using the Braden Score and reassessed every 12 hours or whenever the patients condition changes or deteriorates. The skin and bony prominences were inspected every shift. All skin changes and description including actions taken was documented. The appropriate plan of care for any pressure wounds was implemented. The Wound care services was consulted for any break in skin and/or suspected deep tissue injuries related to pressure.

A review of the facility's "Nursing Patient Assessment/Reassessment" Policy, policy #12930386, last revised 1/16/23 revealed that the purpose of the policy was to establish guidance for assessing and reassessing patients. Each patient was entitled to have a qualified individual from the appropriate discipline assess and provide treatment throughout the continuum of care given by the organization.

An interview took place in the conference room on 8/8/23 at 11:25 a.m. with Registered Nurse (RN) AA, who is also the certified wound ostomy continence nurse. RN AA stated that she usually consulted a patient when she receives the order from the nurse, and the consultation involved a generalized wound assessment. RN AA stated that when a patient is incontinent, she usually recommends a moisture control /barrier with frequent turning and repositioning. RN AA also stated that administration of pain medication is dependent on the patient and the pain assessment. RN AA stated that a stage four pressure ulcer that was frequently soiled would require packing and covering it with an antimicrobial to protect it.

An interview took place in the conference room on 8/8/23 at 1:30 p.m. with Registered Nurse BB, who is also a charge nurse for one of the Medical-Surgical units. RN BB stated that if a patient presented with a wound on admission, they would assess the wound and notify the doctor, and put in a wound consult for the wound care nurse to see the patient. RN BB stated that once the patient is seen by the wound care nurse, the nurses would perform the wound dressing as per the wound care nurse's orders. RN BB stated that nurses could apply dry dressings for protection without an order for protection while awaiting the wound care orders.

An interview took place in the conference room on 8/9/23 at 10:25 a.m. with RN DD, who is also a charge nurse for one of the Medical-Surgical units. RN DD stated that according to her documentation on P#1's chart, she did not change the wound before she discharged P#1 because it had been done prior and based on her assessment, the dressing was clean. RN DD also stated that the wound dressings are guided by the wound care nurse's orders. RN DD further stated that P#1 was put on a waffle mattress; however, an air mattress could have been better.

A telephone interview took place on 8/10/23 at 3:00 p.m. with MD EE, who is also a Hospitalist in the facility. MD EE stated that P#1 was admitted for breakthrough seizures and was malnourished on admission. MD EE stated that P#1 presented with wound ulcers and was seen by the wound care nurse. MD EE stated that P#1 dislodged her previous PEG tube, and because it took three months before another PEG tube was inserted, it made P#1 more malnourished, which affected the wound healing process. MD EE stated that there was a request for air mattress by the case manager, but it seemed there was a delay with the approval from Medicare. However, a request for an air mattress for use at home was made for P#1 on discharge. MD EE also stated that she believed the pain medication prescribed for P#1 while on admission was adequate as the nurses would have reported to the medical team that it was not effective. MD EE further stated that due to P#1's safety, they had to tread with caution in the administration of pain medications.