HospitalInspections.org

Based on record review and interview, inpatient nursing staff failed to document wound measurements and ongoing wound documentation per facility policy for 4 of 5 patients with new or present on admission pressure injuries (Patients #3, 4, 5, 6); failed to document a wound care consult order per facility policy for 2 of 5 patients upon initial identification of a pressure injury (Patients #4, 6); and failed to follow wound care orders for 3 of 5 patients with wound care-related orders (Patients #4, 5, 6) out of a total universe of 9 patients at risk for impaired skin integrity.

Findings include:

Review of facility policy #KT2N6QC5SZE5-3-2207 titled, "Pressure Injury Assessment and Treatment Policy" last revised 9/8/2020 revealed, "...3.2. Assessment...c. Describe location, stage of injury, measurement, odor, drainage, wound bed appearance, presence of undermining, tunneling, condition of wound edge (curled or rolled) and peri-wound skin, signs/symptoms of infection, pain. d. Measure wound in centimeters upon admission, weekly and as needed for significant improvement/decline...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, resence 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..."

Review of the computer-based training (CBT) module completed by all inpatient adult unit Registered Nurses (RNs) between 07/28/2020 and 09/01/2020 revealed, "...Consult to Wound Team...ALL stage 2, 3, 4, & unstageable pressure injury wounds and deep tissue injuries MUST include a consult to the wound care specialist(s)...Documentation of Consult...All consults to the wound team need to have an order this includes a verbal consult. Orders...All provider and wound consult recommendations and strategies ordered for wound care need to be followed...If this is not documented then it is viewed as not following orders. Interventions...DOCUMENT all interventions to reflect care that was provided. If it is not documented it is viewed as NOT done...Wound Measurements...Frequency of wound measurements (in centimeters) completed: Upon admission...Weekly...With any significant improvement or decline...Policy Attestation...I am acknowledging that I have reviewed, understand, and will follow the policies outlined within this CBT for wound and skin care management..."

Patient #3:

Patient #3's electronic medical record was reviewed on 10/07/2020 at 11:20 AM with Staff B who confirmed the following per interview:

Patient #3 was admitted on 10/06/2020 with a chief complaint of altered mental status. Review of the "History and Physical Reports" from 10/06/2020 at 9:59 PM revealed, "...Extremities: Bilateral venous stasis ulcers on lower legs...Skin: No new onset concerning skin lesions. Back: Patient has small ulcer on the back and sacral area..." Patient #3 was a current inpatient at the time of record review.

Review of the initial skin assessment documented in the nursing flowsheet titled, "Integumentary...Incision/Wound/Skin" on 10/06/2020 at 5:17 PM revealed no documentation of presence or assessment of a back or sacral wound.

On 10/07/2020 at 12:55 AM, the "Integumentary...Incision/Wound/Skin" flowsheet revealed, "...Coccyx Midline...Skin Abnormality Type: Pressure Ulcer...Incision, Wound Pressure Ulcer Stage: Stage 2...Incision, Wound Assessment Activity: New wound assessment..." There were no wound measurements documented per facility policy.

At 10:05 AM, 9 hours and 10 minutes after the initial pressure ulcer documentation, "Incision, Wound Pressure Ulcer Stage: Stage 3." There were no measurements or additional wound characteristics documented per facility policy.

Based on the lack of documented wound measurements or associated wound characteristics, it is unclear if Patient #3's wound worsened and progressed to a Stage 3 pressure ulcer, or if nursing documented inaccurate wound staging.

During an interview on 10/07/2020 at 2:00 PM with Staff C, when asked if wound care staff had indicated staging of Patient #3's wound, C stated, "There is no note entered yet."

Patient #4:

Patient #4's electronic medical record was reviewed on 10/07/2020 at 11:36 AM with Staff B who confirmed the following per interview:

Patient #4 was admitted on 10/01/2020 with a chief complaint of right lower limb ischemia. Review of the "Hosp (Hospital) History and Physical" created on 10/01/2020 and signed 10/02/2020 at 9:34 AM revealed, "...Assessment and Plan...Ulcer of right foot with fat layer exposed...Soft tissue infection of foot...We will go ahead and involve...wound care for evaluation of the patient's wounds on [his/her] right foot as well as what [he/she] tells me is a sacral ulcer on [his/her] buttock..." Patient #4 was a current inpatient at the time of record review.

On 10/01/2020 at 2:55 PM, the initial skin assessment documented in the nursing flowsheet titled, "Integumentary... Incision/Wound/Skin" revealed, "...Sacrum Other: 2 Areas...Skin Abnormality Type: Pressure Ulcer...Incision, Wound Pressure Ulcer Stage: Stage 2...Pressure Ulcer Present on Admission: Yes..." There were no initial wound measurements documented per facility policy. Further review of Patient #4's medical record revealed no measurements were documented in subsequent sacral wound assessments.

The last documentation of wound staging was documented on 10/03/2020 at 8:00 AM and revealed, "...Incision, Wound, Pressure Ulcer Stage: Stage 2." Further review of subsequent sacral wound assessments revealed no documentation of wound stage.

There was no order for a wound care team consult found in Patient #4's medical record per facility policy.

On 10/01/2020 at 5:17 PM, "Orders" revealed, "Dressing Change...Coccyx/sacral every other day dressing change...Change every other day and PRN (as needed) if rolled, soiled, or saturated..."

Review of the nursing flowsheet titled, "Integumentary...Incision/Wound Care" revealed no documentation of a dressing change to the sacral pressure ulcer until 10/06/2020 at 9:30 PM, 5 days after the order was entered.

Patient #5:

Patient #5's electronic medical record was reviewed on 10/07/2020 at 12:17 PM with Staff B who confirmed the following per interview:

Patient #5 was admitted to the facility on 10/01/2020 with a chief complaint of shortness of breath and weakness. Review of the "History and Physical Reports" from 10/01/2020 at 2:18 PM revealed, "...Physical Exam...Skin: normal color no rash no ulcerations, normal turgor..." Patient #5 was a current inpatient at the time of record review.

On 10/01/2020 at 5:47 PM, the initial skin assessment documented in the nursing flowsheet titled, "Integumentary Assessment" revealed, "...Skin Integrity General...Intact."

The first documentation of a pressure injury was on 10/05/2020 at 7:30 AM, nearly 4 days after admission. The "Integumentary...Incision/Wound/Skin" flowsheet revealed, "Sacrum...Skin Abnormality Type: Pressure Ulcer Stage 2...Pressure Ulcer Present on Admission: Yes...Incision, Wound Assessment Activity: New wound assessment...[spouse] states that patient had this wund (sic) at home and [he/she] was putting lotion on it every day." There were no inital wound measurements documented per facility policy. Further review of Patient #5's medical record revealed no measurements were documented in subsequent sacral wound assessments, and no change in wound staging was noted.

On 10/06/2020 at 11:26 AM, "Orders" revealed, "Air Mattress...dolphin." There was no documentation found in Patient #5's medical record that the specialty mattress had been initiated at the time of record review.

Patient #6:

Patient #6's electronic medical record was reviewed on 10/07/2020 at 12:36 PM with Staff B who confirmed the following per interview:

Patient #6 was admitted to the facility on 09/27/2020 with a chief complaint of rectus sheath heamatoma (an accumulation of blood in the sheath of the abdominal muscle). Review of the "History and Physcial Reports" from 09/27/2020 at 5:18 AM revealed, "...Physical Exam...Skin: no rash identified...Assessment/Plan: ...Pressure ulcer prevention..."

Review of the inital skin assessment documented in "Integumentary Assessment" on 09/27/2020 at 4:42 AM revealed no documentation of skin integrity. The first documentation of skin integrity was on 09/28/2020 at 7:51 AM, 1 day after admission, and revealed, "...Skin Integrity General...Intact." Further review of the "Integumentary Assessment" flowsheets revealed no changes in skin integrity documentation until 10/05/2020 at 7:45 PM, 8 days after admission. "Skin Integrity General" revealed, "Localized abnormality."

Review of the nursing flowsheet titled, "Integumentary...Incision/Wound/Skin" on 09/30/2020 at 2:06 AM, nearly 3 days after admission, revealed, "...Coccyx...Skin Abnormality Type: Erythema...Incision, Wound Assessment Activity: Reassessment."

On 09/30/2020 at 1:03 PM, "Coccyx...Skin Abnormality Type: Blister..." There was no change in the documented "Skin Abnormality Type" on subsequent assessments until 10/01/2020 at 4:15 PM, which revealed, "Coccyx...Skin Abnormality Type: Blister popped and open."

The first documentation of a pressure injury was on 10/02/2020 at 5:10 PM, 5 days after admission and 2 days after the initial documentation of the blister. "Integumentary...Incision/Wound/Skin" revealed, "Coccyx...Skin Abnormality Type: Pressure Ulcer...assessed by WOCN (wound/ostomy care nurse) and classified it as a pressure ulcer...Incision, Wound Pressure Ulcer Stage: Stage 3...Pressure Ulcer Present on Admission: Yes...Incision, Wound Assessment Activity: Reassessment..." There were no initial wound measurements documented per facility policy. Further review of Patient #6's medical record revealed no measurements were documented by nursing in subsequent coccyx wound assessments.

There was no documented order for a wound care consult found in Patient #6's medical record per facility policy.

Review of "Physician Progress Note" on 10/02/2020 at 3:48 PM revealed, "Hospital Wound Consult...Chief Complaint...The patient is referred to the Wound Service by [physician name] for evaluation of ruptured blister to coccyx area. Per staff RN patient was admitted with blister to the area that has now ruptured...Examination...Type: pressure injury stage 2...Location: coccyx...Measurement cm (centimeters): 6x6x0.1cm...Plan..Will order dolphin mattress for pressure redistribution..."

On 10/02/2020 at 4:26 PM, "Orders" revealed, "Air Mattress." There was no documentation found in Patient #6's nursing flowsheets or assessments that the specialty mattress was initiated per facility policy.

The last documentation of wound staging was documented on 10/03/2020 at 4:57 PM and revealed, "...Incision, Wound, Pressure Ulcer Stage: Stage 3." Further review of subsequent coccyx wound assessments revealed no documentation of wound stage.

On 10/06/2020 at 12:23 PM, "Wound Progress Notes" revealed, "...Examination: Type: rupture blister, stage 2 pressure injury...Location: coccyx...Measurement cm: 5.6 x 6.0 x 0.1 cm...Impression: Healing stage 2 pressure injury... Continue Dolphin Mattress..." Further review of Patient #6's medcial record revealed no documentation was found regarding the presence of the specialty mattress within nursing flowsheets or assessment documentation per facility policy.

On 10/06/2020 at 3:45 PM, "Coccyx...Wound is reddened area only without noticable breakdown."

On 10/06/2020 at 6:30 PM, "Coccyx...Wound has first level of skin worn away. No tunneling noted. Area is red in the wound bed and purple around it."

In an interview with Staff B during record review regarding the discrepancies in Patient #6's medical record between nursing's documentation of the wound staging and that of wound care staff, Staff B stated, "I don't know. These are so subjective."

During an interview with Staff A, Staff B, and Staff C on 10/07/2020 at 9:46 AM, Staff A stated, "We are aware that we are not where we want to be yet with meeting goals regarding this documentation. We are communicating follow ups and the results of the audit summary to leaders and staff."