HospitalInspections.org

Based on policy and procedure review, clinical record review, and interviews, it was determined that the facility failed to develop, update, implement, and/or individualize an interdisciplinary integumentary plan of care for 2 (#6 and #8) of 10 (#1-#10) patients in that the facility failed to provide a Wound Care Nurse consultation per established policy. The failed practice did not assure the skin care policies were followed to prevent further skin breakdown. The failed practice affected Patients #6 and #8 and had the likelihood to affect all patients admitted to the facility. Findings follow:

A. Review of policy titled, "Skin Integrity, Care of the Patient with or at Risk for Impairment: dated 02/1994 along with Appendix A Central AR - HAPI Prevention Interventions" showed to consult a wound nurse for a Braden Score less than 14 or less.
B. In an interview on 02/12/24 at 11:45 PM, the Director of Quality stated the process for the audit tool was to identify patients with a Braden Score of less than 15 without a wound consultation ordered. If the wound consultation was not ordered within 24 hours of the change in the Braden Score, the audit tool was shared with the nurse manager of the hospital department. The nurse manager then spoke with the registered nurse that omitted the order to hold them accountable.
C. In an interview on 02/12/24 at 12:45 PM, the Director of Quality stated that 24 out of 54 patients with a Braden Score of less than 15 did not receive a wound consultation within 24-hours. Of the 24 patients, there were four patients that had more than three missed opportunities to obtain an order within 24 hours.
D. Review of clinical records showed that Patient #6 and #8 with a Braden score less than 15 did not have wound consultations ordered within 24 hours of admission.
1. Review of the Integumentary Assessment on 01/30/24 at 11:00 PM, for Patient #6, showed a Braden score of 13 without a wound consult ordered within 24 hours per policy.
2. Review of the Integumentary Assessment on 01/30/24 at 1:40 PM, for Patient #8, showed a Braden score of 13 without a wound consult ordered within 24 hours per policy.
3. During an interview on 02/12/24 at 12:55 PM, the Wound Ostomy, and Continence Nurse (WOCN) confirmed knowledge of the Low Braden Score Daily Audit. WOCN confirmed that a Braden score of 15 or less should have had a wound consult order initiated by the registered nurse. WOCN confirmed that the patients that have had a wound/pressure ulcer were followed throughout the patient's hospital stay.