HospitalInspections.org

Based on document review and interview, it was determined that the facility Staff failed to notify the Physician and provide nursing care to prevent pressure injuries for one (1) of three (3) Patients (P), P # 3.

The findings include:

On January 24, 2024, at approximately 12:00 p.m., clinical record review revealed the following:

P # 3 was admitted to the facility on December 15, 2022.
The History and Physical (H&P) dated December 15, 2022 reads in part "[P # 3] who presented with chief complaint of left leg pain and swelling since yesterday. According to patient had breast biopsy done yesterday, did well, while was stepping inside house fell and hit leg to the ground. [P # 3] was able to get with help of family got into the chair. While getting out of the chair patient fell again and started having severe pain swelling of the left leg which was rated as 7-8 over 10 pain gets worse whenever [P # 3] tries to move leg or anything touches."

Review of Flowsheet data from December 15 - 27, 2022 revealed "skin intact".
On December 28, 2022 at 10:39 a.m. documentation reads in part
"Wound buttocks right stage 2 -pink, slight bleeding.
Date first assessed 12/28/2022.
Primary wound type: Pressure inj.
Location: Buttocks.
Wound location orientation: right.
Wound description: stage 2-pink, slight bleeding."

On December 29, 2022 at 1:05 p.m. - "pressure stated 2, clean, dry and intact dressing.
On January 1, 2023 at 5:19 a.m. - new dressing applied. soap and water. moist to dry dakins.
On January 1, 2023 at 10:08 a.m. - "clean, intact, dry, not cleansed. ace wrap, abd pad, negative pressure wound therapy. small drainage purulent, serosanguinous.
On January 5, 2023 at 6:44 a.m. - clean, dry and intact, no drainage."

There was a lack of documented pressure injury evaluation on December 30, 31, 2022 and January 2, 3 and 4, 2023.

On January 24, 2024, a review of the nursing unit schedule revealed adequate staff.

An interview with Staff Member (SM) # 1 revealed "During this time period [December 2022 to April 2023], there were no staffing issues at the facility. Staffing is based on census."

A review of Physician progress notes to include plastic surgery notes revealed no documentation of a pressure injury.

The discharge summary dated January 6, 2023 reads in part
"Discharge diagnosis: Large hematoma of left leg
Leg wound status postdebridement and wound vac placement
Mechanical fall
Coagulopathy secondary to anticoagulation/xarelto (blood thinner medication)
HTN (hypertension)
AKI on CKDIIIb (acute kidney injury on chronic kidney disease Stage 3B)
Hypothyroid symptoms
Dementia"

There was a lack of documented Physician notification of the pressure injury during P #3's hospitalization from December 28, 2022 through January 6, 2023

On January 24, 2023, a review of the facility policy titled "Pressure injury/ulcer prevention" reads in part "Nurse will perform a comprehensive skin assessment as part of the head to toe assessment each shift.
Interventions to manage pressure when patient is in bed may include but not limited to: pressure redistribution surface as indicated.
Maintain or enhance level of activity.
Off load heels.
Reposition approximately every two hours.
Use 30 degree side lying position.
Pad between skin to skin or skin to equipment contact.

Hospital acquired pressure injury (HAPI)
If HAPI is identified the nurse will notify the attending physician and notify the patient or NOK/POA (next of kin/power of attorney) as appropriate."

On January 24, 2024, a review of the grievances and complaints revealed a grievance was filed and investigated concerning P # 3; there was no deviation from the facility policy and procedure.

On January 24, 2024 at 12:30 p.m., an interview with SM # 1 revealed "all mattresses are low air loss mattresses which are pressure relieving mattresses."

On January 24, 2024 at 2:00 p.m., the findings were discussed with SM # 1, # 2, # 3 and # 4 during the exit interview.