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Based on record review and interview, facility staff failed to document wound measurements and ongoing wound documentation per facility policy for 2 of 2 patients (#1, #8) with new or worsening pressure injuries; failed to order a wound care consult per facility policy for 2 of 2 patients (#1, #8); and failed to follow wound consult recommendations for 2 of 2 patients (#1, #8) out of a total universe of 10 patients at risk for impaired skin integrity.

Findings include:

Facility staff failed to document wound measurements and ongoing wound documentation, failed to order wound care consults upon recognition of new or worsening pressure injuries, and failed to follow wound consult recommendations and orders for patients with new or worsening skin breakdown. See tag A395.

These deficient practices have the potential to affect all patients who present with or develop pressure injuries while admitted to the facility and has resulted in worsening pressure ulcers for 2 of 10 at risk patients (Patients #1 and #8).

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Based on record review and interview, the facility failed to document wound measurements and ongoing wound documentation per facility policy for 2 of 2 patients (#1, #8) with new or worsening pressure injuries; failed to order a wound care consult per facility policy for 2 of 2 patients (#1, #8); and failed to follow wound consult recommendations for 2 of 2 patients (#1, #8) out of a total universe of 10 patients at risk for impaired skin integrity. Patient #1 had two admissions with a pressure injury documented as present on admission which worsened while in the care of this facility. Patient #8 was admitted with no documented pre-existing skin breakdown and developed a pressure injury while in the care of this facility.

Findings include

Review of the facility policy titled, "Pressure Injury Assessment and Treatment Policy; Document ID: KT2N6QC5SZE5-3-2207" last reviewed/revised 1/16/20 revealed, " ...3.3. Management ...e. Consult wound care specialist/provider to provide dressing recommendations/orders ...3.4. Dressing Selection: ...b. Stage 2, 3, and 4 pressure injury: Consult wound care specialist/provider for further management/care instructions ...3.6. Document ...a. Initial wound documentation to include location, wound history, stage of injury, measurement, odor, drainage, wound bed appearance, presence of undermining or tunneling, condition of wound edge (curled or rolled), condition of peri-wound skin, signs/symptoms of infection and pain. b. Ongoing wound documentation to include location, stage of injury, wound bed, drainage, odor, peri-wound skin and pain. c. Wound measurements are completed upon admission, weekly and/or with significant improvement or decline ...e. Interventions ..."


Patient #1
Review of Patient #1's electronic medical record on 6/30/2020 at 2:20 PM revealed an admission on 2/28/2020 for a small bowel obstruction. The "Emergency Department report" revealed "SKIN: diffuse bruising. Scratches appreciated on the left side of her neck and forearm." Record review revealed nursing documentation under "Integumentary Incision/Wound/Skin" of a "pressure ulcer" location described as "Coccyx midline third" and description "without edema tissue color erythema (superficial reddening of the skin)." It is documented as "Present on Admission" and a hydrocolloid dressing (dressing that provides a moist and insulating healing environment which protects uninfected wounds while allowing the body's own enzymes to help heal wounds) was applied. There are no wound measurements or notification of the presence of the pressure ulcer to the physician per facility policy "Pressure Injury and Assessment and Treatment Policy".

Braden score (an assessment tool that predicts the risk for developing a hospital or facility acquired pressure ulcer/injury and assigns a score based on assessment of skin moisture, activity, mobility, nutrition, friction and shear defines low risk as a score of 15-18, moderate risk 13-14 and high risk 10-12 with corresponding interventions for each level to prevent and treat skin breakdown.) was 11 on admission indicating "high risk".

Review of Patient #1's 3/31/2020 History and Physical revealed admission for small bowel obstruction and a "present on admission" sacrococcygeal deep ulcer. The record revealed that a wound care consult was made on admission and Wound Care Nurse H saw the patient on 4/1/2020. The consult note revealed measurements and, under impression, "unstageable pressure injury" (obscured full-thickness skin and tissue loss) to the sacrum. Under "Plan", "continue offloading area turning patient side to side every two hours at a minimum. Review of the medical record under "Integumentary Incision/wound care" revealed the first documented dressing change on 4/6/2020 at 8:32 AM, 5 days after the wound care consult ordering "dressing changes every 3 days am as needed."

Review of Patient #1's "Activities of Daily Living - Activity - ADLs - Patient Position and repositioned" revealed the following documentation; 4/2 at 7:02 AM through 4/3 at 7:10 AM every 2 hour patient position "bed" and two instances at 7:26 AM indicating position as left side and 4:24 PM indicating position as right side. No other specifics as to position are documented. On 4/8 every 2 hour documentation revealed 3:17 PM "chair" until 9:53 PM without documentation as to repositioning, 4/9 8:00 AM every 2 hour until 1:00 PM "chair" without documentation as to repositioning, 4/9 at 8:18 PM "bed" every 2 hour until 9:24 AM without documentation as to repositioning, 4/11 8:10 PM every 2 hour until 4/12 at 9:40 AM "bed" without documentation as to repositioning, 4/13 at 4:00 PM "chair" every 2 hour until 7:54 on 4/14 without documentation as to repositioning, 4/15 at 8:30 PM "bed" every 2 hour until 4/16 at 3:30 PM without documentation as to repositioning, 4/17 at 3: PM "bed" every 2 hour until 7:52 AM 4/18 with three instances of position as "bed, supine", 4/22 at 5:38 AM "bed" every 2 hour until 5:16 PM with two instances of position as "bed, supine", on 4/47 at 6:39 PM "bed" documented every 2 hours until 4/28 at 3:00 AM with no documentation as to repositioning.

The 4/7 Wound Care note revealed, "Staff were reminded to reposition patient side to side and keep off of back as much as possible ..." The 4/17 Wound Care note documents "Stage 4 pressure ulcer."

For the 10 day hospitalization there was no nursing documentation of reassessment of the coccyx or change of the hydrocolloid dressing. Per interview with Wound Nurse H on 7/2/2020 at 3:50 PM the hydrocolloid dressing that was used can be "kept in place for 3-7 days unless drainage or integrity is compromised." When asked about Wound Care consult on this patient H stated, "according to policy we should have been involved." Patient #1 was discharged to a skilled nursing facility on 3/9/2020.

Patient #8
Review of Patient #8's electronic medical record conducted on 7/1/20 at 8:35 AM with Informatics RN (Registered Nurse) J revealed Patient #8 was admitted as an inpatient to the facility on 5/23/20 at 11:19 AM via the Emergency Department with a chief complaint of "GI (gastrointestinal) Bleed."

Review of the document titled, "History and Physical" completed on 5/23/20 at 9:52 AM revealed " ...multiple comorbid conditions including coronary artery disease status post CABG (coronary artery bypass graft), atrial fibrillation on chronic anticoagulation ...status post pacemaker placement, CKD stage III (Stage 3 chronic kidney disease), hypertension (high blood pressure), hyperlipidemia (high cholesterol), hypothyroidism (under-active thyroid) ...peripheral vascular disease." Further review of the "History and Physical" revealed Patient #8 had presented to an outside hospital with "worsening exertional dyspnea (shortness of breath with activity)" and was subsequently transferred to this facility for the need for a higher level of care.

"Physical Exam" in the "History and Physical" revealed, " ...SKIN: No rash." "Assessment/Plan" revealed, " ...Pressure ulcer prevention ..."

Review of the nursing flowsheet documentation titled, "Integumentary Assessment" revealed on 5/23/20 at 11:25 AM, "Skin Integrity General" was documented as "Intact" and "Braden Score" was documented as "18" (Low risk). Review of subsequent Braden scores revealed #8 continued to score in the "Low Risk Braden 15-18" category each shift from 5/23/20 at 11:25 AM to 5/28/20 at 2:49 AM.

On 5/24/20 at 2:07 PM, 26 hours and 42 minutes after the initial admission assessment, "Incision/Wound/Skin" flowsheet revealed, "Buttock Midline ...Skin Abnormality Type: Erythema ...Skin Abnormality Color: Pink, Red ...Pressure Point: Bony Prominence ...below coccyx, reddened ...Incision, Wound Dressing: Other: barrier cream ...Incision, Wound Assessment Activity: New wound assessment ...Incision, Wound Distribution: Localized." Review of subsequent shift reassessments revealed no change in wound assessment documentation from 5/24/20 at 2:07 PM until 5/28/20 at 2:49 AM.

On 5/28/20 at 2:49 AM, "Braden Score" was documented as "12" (High risk). "Incision/Wound/Skin" flowsheet revealed, "Buttock Midline ...Skin Abnormality Type: Other: small open ...Skin Abnormality Color: Pink, Red ...Pressure Point: Bony Prominence ...Incision, Wound Dressing: Other: barrier cream ...Wound Exudate Amount: None ...Incision, Wound Assessment Activity: Reassessment."

The first documentation of a pressure injury was on 5/28/20 at 7:39 AM. "Incision/Wound/Skin" flowsheet revealed, "Buttock Midline ...Skin Abnormality Type: Pressure Ulcer ...Skin Abnormality Color: Pink ...Pressure Point: Bony Prominence ...Pressure Ulcer Present on Admission: No ...Incision, Wound Dressing: (blank) ...Wound Exudate Amount: None ...Incision, Wound Assessment Activity: Reassessment." There was no evidence found that wound staging, measurements, or additional wound characteristics were documented as per facility policy. There was no evidence found that a consult to wound care was initiated per facility policy.

At 4:00 PM, " ...Incision, Wound Dressing: Other: Aquacel ...Incision, Wound Dressing Assessment: Clean, Dry, Intact." Review of subsequent shift reassessments revealed no change in wound assessment documentation from 5/28/20 at 4:00 PM until 6/1/20 at 8:20 AM. "Braden Score" was documented as "15" (Low risk). #8 continued to score in the "Low Risk Braden 15-18" category each shift from 5/28/20 at 7:39 AM until 5/30/20 at 9:00 AM.

On 5/30/20 at 9:00 AM, "Braden Score" was documented as "13" (Moderate risk). Review of subsequent Braden scores revealed #8 continued to score in the "Moderate Risk Braden 13-14" category each shift from 5/30/20 at 9:00 AM to 6/6/20 at 9:12 AM.

The first documentation of wound measurements and other characteristics was on 6/1/20 at 8:20 AM, 4 days and 41 minutes after the pressure ulcer was first documented. "Incision/Wound/Skin" flowsheet revealed, "Buttock Midline ...Skin Abnormality Type: Pressure Ulcer ...Skin Abnormality Color: Pink, Red ...Pressure Point: Bony Prominence ...Pressure Ulcer Present on Admission: No ...Incision, Wound Dressing: Other: Aquacel ...Incision, Wound Dressing Assessment: Loose ...Incision, Wound Dressing Activity: Assess, Changed ...Incision, Wound Length: 0.5 ...Incision, Wound Width: 0.4 ...Wound Edge: Approximated ...Wound Exudate Type: Serosanguineous ...Wound Exudate Amount: Small ...Wound Exudate Odor: None ...Incision, Wound Assessment Activity: Reassessment." There was no evidence found that wound staging was documented per facility policy. There was no evidence found that subsequent wound measurements were documented by nursing staff in the "Integumentary Incision/Wound/Skin" flowsheet between 6/1/20 at 8:20 AM and the final documented assessment on 6/8/20 at 8:02 AM.

On 6/3/20 at 4:56 PM, "Incision, Wound Pressure Ulcer Stage" in the "Incision/Wound/Skin" flowsheet was documented as "Stage 2." Further review of the flowsheet revealed no change in wound staging from 6/3/20 at 4:56 PM to the final documented assessment on 6/8/20 at 8:02 AM.

At 4:58 PM, "Orders" revealed, "Air Mattress ...dolphin mattress."

At 4:59 PM, "Orders" revealed, "Dressing Care ...Thick barrier paste to sacral pressure injury twice daily and as needed. No briefs."

At 5:00 PM, "Hospital Wound Consult" revealed, "Chief Complaint: The patient is referred to the Wound Service for evaluation and treatment of pressure injury. Pt reports pain with the area especially at night ...Current Treatment: sacral pressure injury stage II (2) ...Examination: ...Type: pressure ...Location: sacral ...Measurement cm (centimeters): 1x1," indicating an increase in size from the prior measurement documented by unit nursing staff on 6/1/20 at 8:20 AM. Further review of the "Hospital Wound Consult" revealed, " ...Undermining cm: none ...Tunneling cm: none ...Bed Appearance: partial thickness, pink, clean ...Edges: intact ...Drainage Type: none ...Drainage Amount: none ...Odor: none ...Edema: none ...Procedures/Treatment: Prior dressing removed and wound cleansed with normal saline. Periwound skin prepped with No Sting Barrier Film. Impression: stable stage 2 pressure injury. Plan: Dolphin mattress ...Thick barrier paste to sacral pressure injury twice daily and as needed. Wound ostomy will follow up in one weeks (sic) ..."

There was no evidence found that the specialty dolphin mattress was initiated until 6/4/20 at 8:00 PM, 27 hours after the order was placed. No further documentation of the presence of the specialty mattress was found in Patient #8's medical record.

Further review of the "Incision/Wound/Skin" flowsheet revealed documentation of the application of thick barrier paste on 6/3/20 at 11:10 PM and 6/4/20 at 8:00 PM. The next documentation of barrier cream application was on 6/5/20 at 11:00 AM. There was no evidence found in the documentation that barrier cream was applied twice on 6/4/20 as ordered.

There was no evidence found in the documentation that barrier cream was applied to Patient #8's pressure injury on 6/6/20, 6/7/20, or the date of discharge, 6/8/20.

On 6/6/20 at 9:12 AM, "Braden Score" was documented as "11" (High Risk). Review of subsequent Braden scores revealed #8 continued to score at "11" each shift from 6/6/20 at 9:12 AM until the last documented assessment on 6/8/20 at 8:02 AM.

On 6/6/20, Patient #8 was transferred to palliative care unit and comfort care measures were initiated. Patient #8 expired on 6/8/20 at 11:20 AM.

During an interview with Wound/Ostomy NP (Nurse Practitioner) H on 7/1/20 at 10:19 AM, when asked who was responsible for documenting staging and measurements of wounds, NP H stated, "Wound care works in collaboration with the nursing staff. Nursing should be documenting all that upon recognition of a pressure injury and weekly or if they are doing the dressing changes." When asked how wound care staff are notified of a consult, NP H stated, "We might get a phone call and are asked to see a patient. There isn't necessarily always a consult order entered. Or they can enter it under nurse to nurse communication." When asked if there was an expectation for nursing to document that wound care was consulted, NP H stated, "Not if we just get a phone call. Sometimes we'll put the order in, but if we are only seeing the patient once, then we might not put in an order for a consult." When asked about the expectation for documenting interventions such as specialty mattresses, dressings, or other pressure-relieving interventions, NP H stated, "Staff are advised to document any and all interventions."

Based on record review and interview the facility failed to provide necessary medical information to the post-acute skilled care facility regarding the follow up care and treatment of an identified pressure ulcer.

Findings

Record review of Patient #1's 2/28/2020 -3/9/2020 admission revealed documentation of a coccyx pressure ulcer. Review of the "Discharge Summary", the "Discharge/Transfer Information" and the "Patient Discharge Instructions" from the medical record, all dated 3/9/2020, found no mention of the pressure ulcer, no instructions for dressing changes or follow-up care specific to the pressure ulcer. Review of facility policy KT2N6QC5SZE5-3-1833 last reviewed 8/26/2019 titled, "Discharge Hospital Patients Process" revealed under 3.2 c ...For patients discharged to another facility where skilled nursing care will be provided, instruction will be provided using the Facility Transfer Nursing Report ..."

In interview with Staff C on 7/2/2020 at 9:00 AM she confirmed that there was no documentation of written instructions for pressure ulcer care at discharge to a skilled nursing facility. She stated that "nursing calls the skilled facility prior to discharge and would give skin condition as part of their verbal report but that hand off of information does not get documented in the medical record but I would think that the pressure ulcer was mentioned."