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Based on interview and record review, the wound care nurse failed to document a comprehensive assessment and wound measurements for 1 (#11) of 1 patients who developed a pressure ulcer at the facility out of a total of three patients with ulcers reviewed, resulting in the potential for unsatisfactory outcomes. Findings include:

Failure to evaluate skin pressure injury --See A-395

Based on interview and record review, the facility failed to evaluate the nursing care of a pressure sore for 1 (#11) of 1 patient who developed pressure sores at the facility out of a total of three pressure ulcer patients reviewed, resulting in unsatisfactory outcomes. Findings include:

On 2/13/24 at approximately 1100, interview with Intensive Care Unit (ICU) Nurse Manager C revealed that the ICU beds had pressure relieving mattresses, patients were assessed and turned frequently. She further explained that the nurses were able to treat stage I and stage II pressure ulcers, but they did not stage or do the exact measurements of the wounds. The wound nurse was to be consulted for wounds more than a stage II and she did the wound measurements and advised of additional interventions.

On 2/13/24 at approximately 1430, review of patient #11's medical record with staff members A and B revealed that the patient was a 53-year-old male admitted to the facility on 5/1/23 with shortness of breath and chest pressure. He coded just after admission and was transferred to the ICU. The patient was bedbound and on a ventilator. The flow sheets documented that on 5/9/23, the patient developed a stage II coccyx pressure injury (sore) that was not present on admission. (Stage II = partial thickness loss of dermis presenting as a shallow open ulcer with red or pink wound bed, without slough or bruising) Measures to keep the area clean and dry, including dressings were documented through 5/19/23. On 5/20/23, the nurse documented serosanguineous drainage and a dressing change. The nurses started to apply a silicone dressing on 5/22/23. A wound consult was requested on 5/30/23.

Review of the Wound Nurse Consult dated 5/30/23 revealed that it did not document an assessment of the pressure sore appearance, odor, or size (i.e. length, width, depth). On 2/24/24 at 1000, interview with Wound Nurse L verified that she did not document an assessment of the pressure wound and did not recall the patient, although she recommended and documented for the nurses to use Triad Cream on 5/30/23. The patient was transferred to a Long-Term-Acute-Care (LTAC) facility on 6/1/23.

Review of the facility policy titled "Pressure Injuries: Prevention and Care, #2 PC 5202, dated 8/10/2021" documented, "Documentation in EMR I-View: Wound location, Length, width, and depth in centimeters, Wound bed description, including color, presence of slough or eschar, and pressure injury stage/type, Undermining/tunneling, Drainage and odor, Surrounding tissue color and condition, Status..." A comprehensive assessment and evaluation of patient #11's pressure injury had not been done.

A review of the receiving facility's wound care assessment dated 6/2/23 at 1102 documented, a wound on the "sacrum, unstageable, necrotic tissue, 6 centimeters (cm) x 5 cm x 0 cm (length by width by depth), yellow slough, necrotic tissue amount was 75% to 100% wound covered..."