HospitalInspections.org

Based on policy review, medical record review, and interview, nursing services failed to provide accurate assessments to identify and prevent the occurrence of healthcare associated adverse events and other pressure injuries for 1 of 1 (Patient #1) sampled patient with wounds.

The findings included:

Review of the "Pediatric Pressure Injury Prevention, Assessment, and Management" policy revealed, "... Assess and document integrity of skin and dressings daily and PRN (as needed). This includes removing equipment (for example BP (blood pressure) cuff, SCD's (sequential compression device), respiratory equipment, pulse oximeter probe, etc.) and assessing underlying skin ...Documentation of skin assessments, dressings, and Brayden/ Brayden Q scale are documented in the electronic medical record. Skin assessment documentation includes a description of any integrity variations after visually inspecting the entire body surface..."

Medical record review for Patient #1 revealed the patient arrived at Hospital #1's Emergency Department on 12/26/2020 with a chief complaint of fever, labored breathing, increased secretions, low oxygen saturation, and lethargy.

Patient #1 was admitted as an inpatient on 12/26/2020 with diagnoses that included Acute Respiratory Failure, Fever, Seizures, and Sialorrhea (excessive saliva/secretions from the mouth).

Past medical history includes: Hypoxic-Ischemic Encephalopathy (HIE), Profound Neurocognitive Disability, Seizure Disorder, Supraventricular tachycardia (SVT), Epilepsy, Sialorrhea, Sleep Disorder Breathing, Respiratory Failure, Chronic Aspiration, Dysphagia (difficulty swallowing) requiring a Gastro-Jejunal tube (GJ tube) to Left Upper Quadrant. A submandibular gland excision and parotid duct ligation was completed on 1/11/2021.

Review of a Nursing Addendum note dated 1/8/2021 for Patient #1 revealed Registered Nurse (RN) #1 documented, "...approximately 9:40 beside nurse, (RN #2) received a call from foster mom. Foster mom was irate and yelling through the phone. RN #1 (Charge RN) overheard the yelling and came to the bedside nurses (RN #2) side. Foster mom stated she received a text message photo of the patient's stomach this morning that displayed a new wound. The text photo was sent by the DCS (Department Children Services) sitter at the bedside. DCS sitter did not mention the wound to the bedside RN. Bedside RN told foster mom she was unaware of the wound but would immediately assess the patient...bedside RN and Charge RN assessed the patient's abdomen and discovered a small healing abrasion to the patients right abdominal quadrant. RN explained to the foster mom the wound was from an unknown origin and not passed along on report. Charge RN explained the wound could potentially be from a respiratory lead sticker..."

Review of the Physician's Clinical Document note dated 1/8/2021 for Patient #1 revealed the physician documented, "... wound care consulted due to small healing scab on abdomen appears to be from a sticker from CP (cardiac pacer) monitor. Informed by bedside nurse and charge nurse that foster mom very upset about this. Foster mom has threatened staff today and stated she would come take patient AMA (Against Medical Advice). Social worker and nursing had been in contact with DCS and risk management throughout the day...Foster mom to bring up any problems she has with patients care with DCS who will contact hospital. Foster mom does not have medical decision-making for the patient. All consents must go through DCS. I have called to update (Named foster mom) this afternoon on (Named Patient #1's) course, updated her on improvement in her respiratory status and plan to have scab evaluated wound care..."

Review of orders revealed a Wound Nurse consult was ordered on 1/8/2021. An order was placed for Melipex border on 1/8/2021 per the wound nurse.

Review of the wound care evaluation note dated 1/8/2021 for Patient #1 revealed the wound care nurse documented, "...the patient has a partial thickness wound to her right abdomen of unknown origin...anterior quadrant with partial thickness to the wound. The wound measures 1.8 centimeters (cm) by 1.5 centimeters. The wound is 50% (percent) open with a pale wound bed and 50 % with a thin scab layer. Scant blanchable erythematous wound edge. No drainage appreciated. The wound was cleaned with sterile saline. A Mepilex Border dressing applied..."

Review of the admission skin assessment on 12/26/2020 revealed no documentation of a wounds.

Review of the skin assessment sheets dated 12/26/2020 through 1/7/2021 revealed documentation of skin assessments daily. There was no documentation of a wound. The wound to the abdomen was documented the first time on 1/8/2021.

Review of the Discharge Orders dated 1/18/20201 revealed Patient #1 was discharged in stable condition. Discharge orders included to apply Mepilex Dressing on abdomen and change every 3 days or if soiled until healed.

In an interview on 1/19/2021 at 10:10 AM, the Director of Risk Management verified the wound had not been assessed or documented until 1/8/2021. She stated wound care was consulted that day. The Director of Risk Management stated, "...we were unable to determine the origin of the wound...It looked like it could have been made by a monitor pad..." The Director of Risk Management stated the hospital did not have a policy related to timeframes for changing monitor pads.

In a telephone interview on 1/20/2021 at 3:50 PM, Patient #1's foster mother stated, "...the hospital does not know how to take care of (Named Pt #1). They didn't even know about the wound on her abdomen. I called and spoke to the nurse when the sitter from DCS sent me a text of the wound. I asked her (Nurse #2) how that happened. The nurse told me she didn't know and that no one had reported it. It seems like every time she (Patient #1) goes to that hospital she gets hurt somehow.

The facility failed to ensure nursing staff performed and documented accurate skin and medical device assessments, to prevent skin breakdown for Patient #1.