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Based on record review and interview, the facility failed to ensure the right of each patient to receive a grievance resolution / decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion, citing

1 of 3 patient's (Patient #1's) family did not receive a resolution to their 9/05/2023 unresolved compliant.

Findings

Patient #1's record documented, "9/05/2023 11:40 AM...family complaints regarding wound care...would like to meet with family...attempted to stop by room at 10:30 AM and 11:30 AM, but patient is off the unit for a procedure and family is out of the room. Will attempt again tomorrow...9/7: Patient transformed to another unit...manager spoke with patient's husband at bedside..."

During an interview and record review on 10/25/2023 ending at 4:03 PM, Personnel #3 was asked again for complaint/grievances. Personnel #3 stated we have nothing official.

Based on interview and record review the hospital failed to ensure ongoing evaluation and treatment of 1 of 3 (Patient #1) patient's wound. Patient #1 was admitted to the hospital with a bottom wound (Staged at Stage 3 progressing to Stage 4 before discharge).

~ The prevention measures (every 2-3 hour turns for pressure relief/Skin IQ bed), and wound care (48 hours). Wound Care assessments were not documented per orders and were not completed in a like manor.

~ There was no common location to document wound care for the bottom wound including the medications and antimicrobial solution. It appeared the staff used the 3 wound entries (Ischial Tuberosity, Gluteal, and Sacral) interchangeably.

~ The staff did not enter an event/incident report for the wound.

Findings

Patient #1's record reflected:
The patient had been hospitalized since March 2023 in various facilities. The patient arrived from an LTAC (long term acute care) for an evaluation of fever. The patient was a 71 year-old in septic shock, pulmonary embolism, and hypotension. Norepineprine and heparin were ordered in the emergency room. The medical history included right chest wall dialysis permcath, colostomy, tracheostomy, and NG (naso-gastric feeding) tube, obese, diabetes, hypertension, cirrhosis, wound complications, chronic kidney disease, hypothyroid disease, atrial fibrillation, anemia, congestive heart failure, deep vein thrombosis, bladder cancer, and multiple extensive wounds. The patient's prognosis was poor. Family refused attempts for palliative care.

The patient came with a high buttock wound that was staged by the wound care nurse (Personnel #7) and wound care physician (Personnel #8) as a Stage III on 8/17/2023. The wound was put in the record as Ischial Tuberosity and a separate Gluteal wound.

The staff did not place an event/incident report for the wound per policy.

The wound was documented as suspected Stage IV decubitus ulcer on 8/26/2023 by the Hospitalist (Personnel #9. On 8/28/2023, the wound was re-staged to a Stage IV by the wound care nurse (Personnel #1). Later in the record, an additional described Sacral wound was placed and then removed. The pictures showed the largest part of the wound was on the right side of the bottom.

The Skin Treatment Pathway was started on admission. The pathway required, "Limit the time the patient is seated without pressure relief...shift position hourly for weak and immobile patients...Wound care every other day (48 hours) and as needed when soiled or dislodged...Turn and reposition every 2-3 hours...Stage 3 & 4...Fill with Aliginate and cover with silicone foam. Notify the provider and enter Wound Ostomy Nurse Eval/treat for worsening or not improving..."

The 8/17/2023 10:55 Wound Care order: every other day until specified...Sacrum...cleanse with antimicrobial solution...Fill/cover with non-adherent Ag 4 ¼ inch Silvercel...Cover with silicone foam bordered sacrum 9 x 10...additional PRN dressing...

Taking into account the electronic record's 3 different named wounds for the same area on the bottom, wound care was not documented after 8/17/2023 until 8/21/2023 (missing 8/18 and 19). Wound care was not documented after 8/22/2023 until 8/28/2023 (missing 8/23, 24, 25, 26, &27).

Wound Care Nurse Evaluation dates with Measurements:

Pressure injury Ischial Tuberosity Left posterior
8/16/2023 Stage 3 Length 3.5 cm x Width 2.8cm; depth 0.2 cm; wound surface area 9.8 cm^2; volume 1.96 cm^3
8/21/2023 Stage unstageable Length 2 cm x Width 1 cm; depth 0.1 cm; wound surface area 2 cm^2; volume 0.2 cm^3 Wound healing 90%
8/28/2023 No assessment or measurements documented
9/01/2023 No assessment or measurements documented
9/04/2023 Stage 3 No measurements documented
9/11/2023 No assessment or measurements documented
9/18/2023 No assessment or measurements documented
9/25/2023 Stage 3 Length 2 cm x Width 3 cm; depth 0.1 cm; wound surface area 6 cm^2; volume 0.6 cm^3 Wound healing 69%

Pressure Injury Gluteal Right; Left
8/17/2023 Stage 3 Length 9 cm x Width 8 cm; depth 0.2 cm; wound surface 72 cm^2 Volume 14.4 cm^3
8/21/2023 Stage 3 Length 7 cm x Width 4 cm; depth 0.1 cm; wound surface 28 cm^2 Volume 2.8 cm^3 Wound healing 81%
8/28/2023 Stage 4 Length 9 cm X Width 5.2 cm; depth 3 cm; wound surface 46.8 cm^2 Volume 140.4cm^3 Wound Healing -875
9/01/2023 Stage 4 Length 8.3 cm X Width 3.3 cm; depth 3 cm; wound surface 27.39 cm^2 Volume 82.17 cm^3 Wound Healing -471
9/04/2023 Stage 4 Length 8.5 cm X Width 3.5 cm; depth 3.5 cm; wound surface 29.75 cm^2 Volume 104.125 cm^3 Wound Healing -632
9/11/2023 Stage 4 Length 8 cm X Width 16 cm; depth 2.2 cm; wound surface 128 cm^2 Volume 281.6 cm^3 Wound Healing -1856
9/18/2023 Stage 4 Length 15 cm X Width 15 cm; depth 4 cm; wound surface 225 cm^2 Volume 900 cm^3 Wound Healing -6150
9/25/2023 Stage 4 Length 10.7 cm X Width 13 cm; depth 4 cm; wound surface 139 cm^2 Volume 556.4 cm^3 Wound Healing -3764

9/19/2023 Sacral wound was entered into the record, and then discontinued.

Patient #1 was discharged on 9/28/2023. There were no wound care nurse assessments from 9/26/2023 to 9/28/2023.

On 8/17/2023 there was 8 hours documented on the right side and an additional 6 hours on the right side without documented change to left, or supine positioning. On 8/18/2023 6 hrs on the left side without documented change. 8/19/2023 4 hours without documented change and an an additional 4 hours without documented change.

8/16/2023 2300 positioned to the left;
8/17/2023 01 right; remained on right all the way until 09 left; (8 hrs on right); right 11; left 13; right at 15; left 17; right 19; right 2100 (4 hrs on right); 2300 left;

8/18/2023 right 01; left 03; patient preferring to be on left 05; 07 left (6 hrs on left); supine 09; right 11; supine 13; right 15; left 17; right 19; left 21; right 23;

8/19/2023 left 01; right 03; 05 said turn (4 hrs on right) ; left at 07; right 09; supine 11; 13 supine changing colostomy dressing; 15 left ; right 17; left 19; turn 21 (4 hrs); right 23.

The patient's weight was documented as under 300 pounds.

The facility's "Wound Prevention and Management" policy required, "Enter an event report for all skin injuries present on admission...Complete a head-to-toe skin assessment...prior to discharge...Notify physician for all pressure injury findings and worsening wounds...Specialty Bed...Patient less than 300 pounds with Braden 18 or less and/or moisture related skin issues: Skin IQ Mattress..."

Skin IQ - Microclimate management mattress cover | Arjo Skin IQ® is a waterproof, vapor permeable, single patient use coverlet for use in combination with a pressure redistribution surface to help prevent pressure injuries. This powered coverlet uses Negative Airflow Technology® (NAT) to continually draw away excess moisture and help to control temperature at the skin/surface interface (microclimate), providing a simple yet sophisticated solution to enhance the performance of a support surface with microclimate managing properties.

During an interview and record review in the conference room on 10/25/2023 ending at 4:03 PM, Personnel #3, and #4 were present. Personnel #4 navigated the records. They confirmed the findings. Personnel #4 was asked the Braden score. Personnel #4 stated 13.

Personnel #2 came in and was asked if specialty beds were used for turns. Personnel #2 stated no, I spoke with Personnel #6, Nurse Manager. She said we do not use any beds that turn except Pulmonary.

Personnel #5, Assistant Manager Wound Care was brought in. Personnel #5 was asked if she found more documentation for turns. Personnel #5 stated no, there was a lot of inconsistency in the turns. Personnel #5 was asked if she found additional dates of wound care documentation. Personnel #5 stated no. Personnel #5 was asked about the staging. Personnel #5 stated the initial staging should have been unstageable instead of Stage 3. Personnel #5 explained reasoning as to how the trained wound care nurse and physician could have initially staged the wound wrong. Personnel #5 was asked if she realized it was the same nurse for both the initial and re-staging of the wound. Personnel #5 sated yes.

Personnel #5 was asked about the lack of a measurement reference in the pictures. Personnel #5 stated they don't require that. Personnel #5 was asked about the measurements recorded by the wound care nurse showed the wound getting larger. Personnel #5 agreed and gave explanation as to how measurements should be performed. Personnel #5 was asked about the 3 wound entries (Ischial Tuberosity, Gluteal, and Sacral) being used interchangeably. Personnel #5 agreed and stated she/patient had a lot of wounds. Nursing can get confused with a lot of wounds. We have been looking at a new Wound photograph system that would measure and have a measuring reference in the pictures.