HospitalInspections.org

Based on record review and interview, facility staff failed to document two nurse skin checks at admission and failed to reposition patients per policy to prevent skin breakdown in 1 of 10 medical records reviewed (Patient #1).

Findings include:

A review of facility policy #14493095, "(Facility System Name) Pressure Injury Prevention Bundle (Hospital Names) Best Practice Guidelines", last revised 5/9/2023 revealed, "...Skin Assessment:...Head to toe minimum q (every) 24 hours, 2nd nurse skin check on admission, OR (Operating Room) cases lasting > 4 hours, Unit to unit transfers...Keep Turning:...Reposition q 2 hours while in bed, Reposition q 1 hour while sitting in chair, Offload heels...Keep Turning: Change position frequently with early ambulation: Turn all patients with limited mobility/no mobility at least every 2 hours..."

A review of Patient #1's medical record revealed Patient #1 was admitted to the facility on 3/22/2024 with complaints of weakness, fatigue, poor oral intake and dizziness. Patient #1 was found to be in mixed obstructive/cardiogenic shock (shock caused by the obstruction of blood flow and dysfunction of the heart) and required transfer to Other Hospital O for a higher level of care which occurred within the first 4 hours of Patient #1's admission. Patient #1 was then transferred back to this facility on 3/25/2024 for continued hospitalization until discharge on 4/2/2024.

An interview was conducted with Patient #1's adult child on 5/23/2024 at 11:19 who stated that Patient #1 had multiple pressure ulcers on his/her coccyx which were discovered sometime after returning home on 4/2/2024. Patient #1's adult child also stated the discharge paperwork did not include information for the presence or treatment of Patient #1's pressure ulcers. Patient #1's adult child also stated nobody verbally advised them of Patient #1's pressure ulcers upon discharge.

A review of Patient #1's medical record "Integumentary" daily nursing assessment revealed no skin integrity issues were documented upon admission to the facility on 3/22/2024 (facility charts by exception--assessments documented only if not within normal limits). There was no documentation of a second nurse skin check.

A skin check with 2nd nurse participation was documented upon arrival to Other Hospital O on 3/22/2024 at 1:00 AM without mention of any wounds or concerns.

A review of "Integumentary" admission and daily nursing assessment revealed no documented skin check with second nurse participation was completed upon re-admission to this facility on 3/25/2024. Daily skin assessments from 3/25/2024 through 4/1/2024 do not include any documentation of skin breakdown, bedsores or wounds.

Skin assessment dated 4/2/2024 at 8:49 AM revealed, "...Skin location: Coccyx, Skin location orientation: Mid, Skin Integrity: Abrasion, Skin Color: Erythemia (redness of the skin which occurs with skin injury)...Type of Wound: Pressure ulcer...Pressure Injury Properties: Date first assessed/Time first assessed: 4/2/2024 8:54 AM...Dressing Status: Clean, Dry, Intact, Dressing changed: New, Staging: Stage I, State of Healing: Early...Wound Assessment: Fragile...Dressing: Foam...10:15 PM: Skin Location: Coccyx...Skin Integrity: Abrasion, Skin Color: Erythemia, Skin Condition/Temp: Warm..."

A review of "Braden Scale - For Predicting Pressure Sore Risk" scoring tool revealed Risk Factors include Sensory Perception, Moisture, Activity, Mobility, Nutrition and Friction and Shear. Total scores indicate risk as follows: "Severe Risk: Total score < 9; High Risk: Total score 10-12; Moderate Risk: Total score 13-14; Mild Risk: Total score 15-18." Risk Factor for Mobility reveals, "Mobility: Ability to change and control body position. Score/Description: 1. Completely Immobile - Does not make even slight changes in body or extremity position without assistance. 2. Very Limited - Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. 3. Slightly Limited - Makes frequent though slight changes in body or extremity position independently. 4. No limitations - Makes major and frequent changes in position without assistance..."

Nursing documentation of Patient #1 Braden assessment scores as follows:
3/25/2024 - 3 assessments recorded. Overall scores of 17, 19 and 16 (mild risk). Mobility scores of 3, 3, and 3 (slightly limited).
3/26/2024 - 2 assessments recorded. Overall scores of 16 and 15 (mild risk). Mobility scores of 2 and 2 (Very Limited ...unable to make frequent or significant changes independently).
3/27/2024 - 2 assessments recorded. Overall scores of 15 and 15 (mild risk). Mobility scores of 2 and 2 (Very limited).
3/28/2024 - 2 assessments recorded. Overall scores of 15 (mild risk) and 12 (high risk). Mobility scores of 2 and 2 (Very limited).
3/29/2024 - 2 assessments recorded. Overall scores of 12 (high risk) and 15 (mild risk). Mobility scores of 2 (very limited) and 3 (slightly limited).
3/30/2034 - 2 assessments recorded. Overall scores of 15 (high risk) and 14 (moderate risk). Mobility scores of 3 and 3 (slightly limited).
3/31/2024 - 2 assessments recorded. Overall scores of 16 (mild risk) and 12 (high risk). Mobility scores of 3 and 3 (slightly limited).
4/1/2024 - 2 assessments recorded. Overall scores of 12 (high risk) and 16 (mild risk). Mobility scores of 3 and 3 (slightly limited).

Braden scale documentation indicates risk for pressure injuries for patient #1 of "high risk" at times with bed mobility assessed 7 times over a 1 week period as "very limited" (inability to make significant changes in position independently).

A review of Physical Therapy Scoring tool revealed, "...Scoring 1 - Total/Assist of 2 (or unable); 2 - A lot (modA (moderate assist) or maxA (maximum assist)); 3 - A little (minA (minimum assist)); 4 - None (no physical assist, ind (independent) or SBA (stand by assist))..."

A review of Physical Therapy Note dated 3/25/2024 at 2:17 PM revealed, "...How much help from another person do you currently need...1. Turning from your back to your side while in a flat bed without using bedrails? 3; 2. Moving from lying on your back to sitting on the side of a flat bed without using bedrails? 3; 3. Moving to and from a bed to a chair (including a wheelchair)? 2; 4. Standing up from a chair using your arms (e.g., wheelchair, or bedside chair)? 2; 5. To walk in hospital room? 1; 6. Climbing 3-5 steps with a railing? 1..."

A review of repositioning schedule revealed no documentation was found that indicated Patient #1 was repositioned by staff or that staff assisted repositioning every two hours. Inconsistent documentation of Patient #1 "self" repositioning found.

An interview was conducted with Registered Nurse (RN) J on 5/28/2024 at 2:15 PM. When asked how a patient's skin is assessed on admission or transfer, RN J stated that 2 nurses check skin and both sign off on the nursing assessment. When asked how often patient's skin is assessed, RN J stated, "I assess my patient's skin every day and I update the patient and family on wound care and the plan for healing." When asked how repositioning is documented in a patient's record, RN J stated that there is a "turning schedule" that should be documented on every 2 hours.

An interview was conducted with Wound Care Nurse (RN) K on 5/28/2024 at 2:28 PM. When asked which patients are seen by Wound Care, RN K stated that he/she gets notified to consult on a patient and that there would be no consult conducted unless it was requested and ordered by a physician. RN K stated that they often write wound care orders for patients in-house, and then the physicians will copy and paste these orders into the discharge summary and discharge instructions at discharge. There is no evidence this occurred in this case, as the Discharge Summary does not contain information or instructions regarding wound care. When asked if repositioning should be always be documented in the repositioning schedule, RN K stated, "Yes."

Based on record review and interview the facility staff failed to provide necessary information at discharge to the patient and patient's family regarding the follow up care and treatment of an identified pressure ulcer, a referral for physical/occupational therapy, and the need for supplemental oxygen in 1 of 10 medical records reviewed (Patient #1).

Findings include:

A review of Patient #1's medical record revealed Patient #1 was admitted to the facility on 3/22/2024 with complaints of weakness, fatigue, poor oral intake and dizziness. Patient #1 was found to be in mixed obstructive/cardiogenic shock (shock caused by the obstruction of blood flow and dysfunction of the heart) and required transfer to Other Hospital O for a higher level of care which occurred within the first 4 hours of Patient #1's admission. Patient #1 was then transferred back to this facility on 3/25/2024 for continued hospitalization until discharge on 4/2/2024.


Note that due to a cyberattack on this facility and others in the hospital system nation-wide on 5/8/2024, the facility is unable at this time to provide copies of Patient #1's "After Visit Summary", a document provided to all patients upon discharge outlining all discharge instructions including, but not limited to those for medications, follow up appointments, scheduled therapy, wound/dressing care and illness information.

Oxygen needs at Discharge

An interview was conducted with Complainant A on 5/23/2024 at 11:19 AM. Complainant A stated Patient #1 never used oxygen during the day, but required the use of oxygen at night when going to bed.

A review of Patient #1's medical record "Internal Medicine...History and Physical" dated 3/25/2024 at 1:22 A.M. revealed, "...Assessment and Plan...Supplemental O2 (oxygen) to maintain SPO2 (saturation of peripheral oxygen - amount of oxygen in blood) 88-92%..."

A review of Patient #1's medical record "Internal Medicine Discharge Summary" dated 4/2/2024 at 11:15 PM revealed "...On 3-4 L (liters) O2 (oxygen) NC (nasal canula) at baseline..." No documentation of need for oxygen upon discharge.

Plan of Care note dated 4/2/2024 at 11:56 PM revealed, "(Patient #1) was discharged home with (Complainant A) @ 10:00 PM. (Patient #1's) original discharge at 8:00 PM was delayed due to a lack of an oxygen tank needed for discharge. (Patient #1's) family retrieved one and (Patient #1/Complainant A) were provided discharge teaching, and left using (Patient #1's) own wheelchair from home."

No documentation was found related to the patient's home oxygen orders at admission. No documentation of a change in oxygen needs was found. No order for a change in oxygen use was found in Patient #1's discharge summary. No documentation found of a discussion with Patient #1 or family member regarding need for an oxygen tank for use at discharge. Due to the cyberattack, unable to verify instructions received by Patient #1 in their After Visit Summary.

An interview was conducted with Case Management Manger M on 5/28/2024 at 3:09 PM. When asked how patients and family members get information regarding discharge plans, Manager M stated that every situation is unique. Patients may refuse to have family members included in discussions of plans, and if the patient does not have an activated POAH (power of attorney for healthcare) there may not be a need to discuss discharge plans with family members. Manager M stated that there must be an order to fax to oxygen supply agencies when a patient is going home on O2 (oxygen) or if they have home O2 and the required needs change.

Pressure Injury care and treatment after discharge

An interview was conducted with Patient #1's adult child on 5/23/2024 at 11:19 who stated that Patient #1 had multiple pressure ulcers on his/her coccyx which were discovered sometime after returning home on 4/2/2024. Patient #1's adult child also stated the discharge paperwork and verbal instructions did not include information for the presence or treatment of Patient #1's pressure ulcers.

Daily skin assessments for patient #1 from 3/25/2024 (admission) through 4/1/2024 do not include any documentation of skin breakdown, bedsores or wounds.

Skin assessment dated 4/2/2024 at 8:49 AM revealed, "...Skin location: Coccyx, Skin location orientation: Mid, Skin Integrity: Abrasion, Skin Color: Erythemia (redness of the skin which occurs with skin injury)...Type of Wound: Pressure ulcer...Pressure Injury Properties: Date first assessed/Time first assessed: 4/2/2024 8:54 AM...Dressing Status: Clean, Dry, Intact, Dressing changed: New, Staging: Stage I, State of Healing: Early...Wound Assessment: Fragile...Dressing: Foam...10:15 PM: Skin Location: Coccyx...Skin Integrity: Abrasion, Skin Color: Erythemia, Skin Condition/Temp: Warm..."

Patient #1 was discharged on 4/2/2024 (same day the pressure injury was first documented). Due to the inability to access Patient #1's After Visit Summary, there is no evidence that information was provided at discharge related to follow-up care for patient #1's stage 1 pressure injury to the coccyx.

Physical Therapy (PT)/Occupational Therapy (OT) needs at discharge

A review of Patient #1's medical record revealed History and Physical dated 3/25/2024 at 1:22 AM, "...PT/OT (Physical Therapy/Occupational Therapy) consults..."

Physical Therapy Evaluation dated 3/26/2024, "...Discharge Recommendations:...Recommend continued multidisciplinary therapy after hospital stay...Assessment: (Patient #1) is a 80 y.o. (year old) male/female admitted with acute B (bilateral) PE (pulmonary embolism) s/p (status post) systemic tPA (medication used to dissolve blood clots and restore blood flow) at (other hospital), now transferred back...Presents below functional baseline, limited by severe deconditioning, dyspnea with minimal activity, impaired endurance and balance...Will benefit from skilled PT intervention in order to progress mobility as tolerated...Plan: PT m-f (Monday-Friday)..."

Occupational Therapy note dated 3/28/2024 at 8:49 AM revealed, "...Discharge recommendations:...Recommend continued multidisciplinary therapy after hospital stay..."

Internal Medicine Progress Note dated 3/26/2024 at 12:16 PM revealed, "...Decreased Functional Mobility:...HHC (Home Health Care) and therapy referrals sent and pending..."

Internal Medicine Progress Note dated 4/1/2024 at 7:49 AM revealed, "...Plan...Family agreed to take the patient home with home PT/OT. Social worker working on arranging home health..."

Internal Medicine Discharge Summary dated 4/2/2024 at 11:15 PM revealed, "...Forward to PCP (Primary Care Physician): PCP to do:...Other Issues Requiring O/P F/U (Outpatient follow up): Charged with home health PT/OT due to continued functional impairment requiring assistance...Decreased Functional Mobility:...Due to the prolonged hospital stay (Patient #1) was able to continue to work with PT and OT and was able to achieve functional status that permitted him/her to go home with home health care, PT, OT..."

Due to the inability to access Patient #1's After Visit Summary, there is no evidence of orders sent to or received by PT, OT or home care agencies. There was no documentation in the social work note indicating that the referral for services had been made and identifying the agency that would provide services.