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Based on observation, interview, and record review, the hospital failed to provide an organized nursing service. (3) Three out of (5) five patients', the hospital identified as having developed pressure injuries or bruising while at the hospital, were missing daily wound and skin assessment documentation. The nursing staff were not educated on the Allevyn pressure relieving dressings. These practices place patients at risk of not receiving treatment to prevent worsening wounds, increased pain, infection, and possibly death. (Patients #21, 22, and #23)

Findings:

1.) Patient #21 had an Allevyn dressing applied to his coccyx. The nursing staff failed to assess and document the underlying skin, four days later a wound was discovered, it had progressed to a stage II with a reddened, open skin wound.

2.) Patient #22 was discharged to a nursing facility with multiple new bruises to the back of the head, back, and left knee. The hospital did not document these bruises; the patient had to return to the hospital's ED (emergency department) to get a head CT (computerized tomography) to rule out a brain bleed.

3.) Patient #23 developed a new wound on 1/16/23, the staff nurse documented skin assessment reflected an inner left buttocks pressure injury, the assessment did not include the length or width, preventing the hospital from closely monitoring the wound and for five days the staff nurses did not assess or document the wound.

Cross Refer to A0395

Based on observation, interview, and record review, the hospital nursing staff failed to evaluate, assess and document patient's skin. (3) Three out of (5) five patients', the hospital identified as having developed pressure injuries or bruising while at the hospital, were missing daily wound and skin assessment documentation. The nursing staff were not educated on the Allevyn pressure relieving dressings. These practices place patients at risk of not receiving treatment to prevent worsening wounds, increased pain, infection, and possibly death. (Patients #21, 22, and #23)

Findings include:

Review of the facility provided policy Admission and Identification of Patient Needs, Assessment of Patients and Care Planning 6011-005 (undated) reflected,
"POLICY: ASSESSMENTS / REASSESSMENTS
...Information obtained during initial screens or assessments may indicate the need for further assessment or reassessment. At a minimum, the need for collecting this information shall be determined by the care, treatment, and services sought, the patient's presenting condition(s), and whether the patient agrees to the recommended care, treatment, or service.
Initial Screens / Assessments
Appropriate to the care, treatment, or service provided in a care setting, the patient - at a minimum - shall receive an initial assessment that includes the following:
o Physical, psychological, and social status
o Nutrition and hydration status
o Functional status
o Screen and/or assessment to determine care needs related to pain"

Patient #21
Review of Patient #21's medical records review revealed, an 81-year-old-male admitted on 12/24/22, for a cerebral hemorrhage. There is no contradicting order to repositioning the patient.

The skin assessment dated 12/24/22 reflected a Braden scale of 12 (High Risk) Interventions included if wound present, notify provider for wound care consult. The patient did not have any wounds documented until 1/6/23, when a Stage 2, pressure injury is noted to the right perinium, and described as a nickel size, open blister; there is no indication the physician was notified, an Allevyn dressing was applied. The skin assessment reflected, "Offer toileting & checking for incontinence every 2 hours; Provide skin care & barrier cream as needed; inspect skin & bony prominences; lf non-ambulatory, turn every 2 hours." There is no further documentation of the Perineal blister.

On 1/7/23, 1/8/13, and 1/9/23, the staff nurse documented a pressure wound to the coccyx , UTA (unable to assess).
On 1/10/23 at 6:00 am, the coccyx pressure ulcer was documented as Pink, Painful and at 12:32 pm, the pressure ulcer was not measured but was documented as Red, Fragile, Bleeding.
On 1/11/23 at 1:28 pm Patient #21's skin was documented as, "wound to the Coccyx, extending to the Buttocks, Red, Light purple; Painful, 8 cm length, 7 cm width, 0.1 cm deep. Wound surface area 56 cm."

During an interview on 03/06/23, at 2:30 pm in the conference room, Staff#2, Administrative Director of Critical Care stated, "Patient #21 had an Allevyn dressing to keep him from developing a pressure injury."

An observation of Patient #21's, facility provided photographed Coccyx wound, dated 1/11/23 revealed multiple opened areas to both buttock cheeks, reddened, with areas of sloughing skin to the coccyx. The wounds extended to both buttocks cheeks, and two tails extending up to the lower back around the sacrum."

Review of the training documentation, provided on 11/2022, reflected there were no instructions on how often to change the Allevyn dressing and if the dressing could be removed and reapplied to enable the nurse to check the wound. Staff #12, Quality Director confirmed the nurses were not provided additional instructions on how and when to use the Allevyn Life Sacrum dressing.


Patient #22
Review of Patient #22's medical record review revealed, an 80-year-old-female admitted on 12/2/22. Patient #22's integumentary assessment, completed by a staff RN, dated 12/20/22 reflected, Skin integrity bruising; flaky. The note had no additional description or location of the bruise.

During an interview on 03/06/23, at 2:30 pm in the conference room, Staff #2, Administrative Director of Critical Care, confirmed Patient #22's skin assessment showed a bruise on admission and that the document did not reflect where, what size, number of bruises, or what color (To indicate the age of the bruise). There was no documented skin assessment on the day of discharge.

Review of the ED Nurses note dated, 12/27/22, reflected, "Pt presented to ED from group home c/o left knee pain. Pt was recently discharge from hospital today and staff at group home states...non-ambulatory and new bruises to her body. Pt is noted to have multiple healing bruises to the back of her head, right wrist, left elbow, forearm, and hand."


Patient #23
Review of Patient #23's medical records revealed, a 50-year-old-male admitted on 1/10/23, for Metastatic malignant melanoma.

The skin assessment, completed by a staff nurse, dated 1/10/23 reflected, a wound to the head and an incision to the hand; there are no other wounds noted.

On 1/16/23, the skin assessment, completed by a staff nurse, reflects at 11:00 am, an inner left buttocks pressure injury, 16 cm surface measurement and a 1.6 cm (centimeter) volume; staged as a DTI (deep tissue injury.) The assessment did not include the length or width.

Review of the physician's orders did not reflect a notification to the physician or an order for the treatment of the wound.

Review of the facility provided, patient's photographed wound, dated 1/16/23 revealed, a DTI wound with a dark purple area surrounded by old sloughing skin.

Review of Patient #23's medical records skin assessments, completed by the staff nurses, reflected on 1/16/23 an Allevyn dressing was applied to his coccyx.

The coccyx wound was documented as unable to assess on 1/18/23, 1/21/23, 1/22/23, 1/25/23, 1/26/23.

The last full assessment, completed by a staff nurse, on 1/24/23 reflected, "yellow, red, pink, light purple, dark purple, 3.5 cm wound length, 1.5 cm width, 0.1 cm depth, 5.25 cm surface measurement and 0.52 cm wound volume."

During an interview on 03/06/23, at 12:30 pm in the conference room, Staff#3, wound care nurse stated, "We only see patients that are referred to us. Sometimes staff will ask me for advice on treating a wound, I will tell them what to use; I don't follow up on those patients. We get a physician's order for treatments. We are not involved in the wound care training of the nurses"

When asked if there is a procedure or protocol for the treatments of wounds, Staff #12, Quality Director stated, "No, we realized we don't have a criterion. We provided the nurses training, back in November. Patient #21, had the Allevyn dressing, it can be removed and reapplied to check the skin."

Review of the facility provided nurse training from November 2022, reflected there was information on the placement and uses of the Allevyn dressing; the manufacturer's information showed the dressing is used to prevent and treat pressure injuries. The training did not include information on how often to change the dressing and that the dressing could be removed and reapplied to check the skin integrity. Staff #2, Critical Care Nurse confirmed the findings.

Staff #2, Director of Critical care confirmed Patient #23's skin assessments was not complete and stated, "They are just documenting unable to assess, we need to do more training."

During an interview on 03/06/23 at 1:00 pm in the conference room, Staff #12, Quality Director stated, "The Directors and Managers bring in new products all the time. We realized there is no tied intervention to the patient's Braden (a tool to determine a patient's risk level of developing skin breakdowns) score.