HospitalInspections.org

Based on hospital policy review, medical record review, interview and observation, the facility failed to follow dressing change orders and provide comprehensive wound assessments for 1 patient (Pt #1) out of 2 patients reviewed.

The findings include:

Review of the hospital policy, "Pressure Injury Assessment, Prevention, and Treatment," dated 7/3/2024, revealed "...Registered Nurse [RN] should perform a systematic skin assessment within 4 hours of admission and the primary RN or LPN [Licensed Practical Nurse] will complete a skin assessment each shift. Assessment includes removal of clothes, stockings, shoes, orthotic devices, and bandages to evaluate for existing skin breakdowns or wounds...stage 3...provider orders required for treatment options..."

Review of the hospital policy, "Wound and Skin Care Treatment Guidelines," dated 11/2/2024, revealed "...treatment of stages 3 and 4 pressure injuries [require a provider order]...Key Point: Routine dressing changes per nursing staff..."

Medical record review revealed Pt #1 was admitted 6/23/2025 from the Emergency Department with complaints of falling and confusion. Diagnoses included Urinary Tract Infection, history of Kidney Disease with Kidney Transplant, Diabetes, and Cirrhosis (scarring of the liver), Depression and Failure to Thrive.

Medical record review revealed Pt #1 had multiple hospitalizations from October 2024-June 2025. During June 2025, Pt #1 experienced multiple falls at home resulting in skin tears and wounds on both arms and hands. It is unknown when he obtained a pressure injury prior to the most recent admission.

Medical record review of a Nurses Notes dated 6/24/2025 at 12:42 AM, revealed the initial nursing assessment of wounds, "Sacral wound noted-foam dressing in place. Dressing clean, dry and intact. LUE [left upper extremity] and RUE [right upper extremity] skin tears noted. Dressings clean, dry and intact. Generalized bruising is noted. Wound care consult added..."

Medical record review of nursing assessments for the 6 days from 6/24/2025-6/30/2025, revealed documentation for Pt #1's dressings and wounds as follows:
6/24/2025 at 8:11 AM: assessment of all dressings - did not
include wound assessments
6/24/2025 at 9:41 PM: assessment of all dressings - did not
include wound assessments
6/25/2025 at 8:05 AM: assessment of all dressings - did not
include the wound assessments
6/26/2025 at 8:29 PM: assessment of all dressings - did not
include wound assessments
6/26/2025 at 8:51 AM: assessment of all dressings - did not
include wound assessments
6/26/2025 at 9:17 PM: assessment of all dressings - did not
include wound assessments
6/27/2025 at 8:14 AM: no assessment of dressings or
wounds
6/27/2025 at 9:12 PM: assessment of all dressing - did not
include wound assessments
6/28/2025 at 8:40 AM: no assessment of dressings or wounds
6/28/2025 at 8:42 PM: no assessment of dressings or wounds
6/29/2025 at 8:00 AM: assessment of bilateral upper
extremities dressings only- did not
include wound assessments
6/29/2025 at 8:36 PM: no assessment of dressings or wounds
6/30/2025 at 8:35 AM: assessment of all dressings - did not
include wound assessments

Medical record review of the Wound Care Nurse (WCN) Assessment and orders for Pt #1 dated 6/24/2025 at 3:46 PM, revealed "...stage 3 pressure injury...full thickness [all layers of the skin] on coccyx [tailbone]...slough [dead tissue which is yellow/tan] and exudate [fluid that seeps from a wound]...serous drainage [blood tinged]...dressing changed...wound present for approximately 2 weeks, closed then reopened..." Assessment of the left wrist showed a "partial thickness [superficial layer of skin] wound with scant serosanguinous [clear watery] drainage...100% pink tissue...left posterior hand [top of hand]...partial thickness wound...excoriation marks [of raw skin]...100% red tissue...right wrist...partial thickness wounds...serous drainage...x2 ulcerations...100% pink..."

Review of the WCN orders (from pre-approved protocols) for dressing changes were placed 6/24/2025 at 6:45 PM and 6:50 PM, as follows:
Coccyx: "Clean every 24 hours with normal saline, pat dry, place [silver impregnated-gelling dressing] to wound and cover with a foam dressing, change PRN [as needed] or if nonintact."
Bilateral hands (both hands) and left lower arm: "cleanse with normal saline, pat dry, apply xeroform gauze [Vaseline impregnated gauze for an occlusive seal and to provide moisture] to wound bed and cover every 48 hours."

Medical record review of Nurses Notes dated 6/24/2025-6/30/3035, of dressing changes revealed the following:
6/24/2025: The WCN completed all dressings changes.
6/25/2025: No dressing changes documented
6/26/2025: Completed at 5:35 AM, without specific dressings
documented
6/27/2028: No dressing changes documented.
6/28/2025: No dressing changes documented.
6/29/2025: Completed at 4:40 AM - without specific dressings
documented
6/30/3035: No dressing changes documented

Interview on 7/9/2025 at 9:22 AM, with the Wound Care Nurse, revealed when seeing a patient for the first time, a full skin assessment is done and "if they have dressings" she changes the dressing and assesses the wound and makes treatment recommendations, "...the type of dressing change depends on the type of wound." Interview revealed she did not remember Pt #1 but reviewed her documentation and confirmed the orders for the dressings were appropriate for the type of wounds Pt #1 presented with on admission.

Interview on 7/9/2025 at 3:05 PM, with LPN #1 (Licensed Practical Nurse) revealed she remembered frequently caring for Pt #1 and stated he had wounds on his arms but she did not remember a coccyx wound. She stated, "...the daughter-in-law was adamant she would do those dressing changes on the arms...I was told that in report also...I went in one time and she was changing them..." Interview confirmed LPN #1 did not chart when the family did the arm dressings. LPN #1 revealed when she assessed patients she did not pull off dressings to look at wounds. LPN #1 revealed she was unsure if she should even document the description of a wound when she changes dressings.

Interview on 7/9/2025 at 3:12 PM, with the RN Educator revealed, "...if a family changes dressings, the nurse should document this...If a patient is a high risk for skin problems, there should be [an assessment] done at each shift change...the off going nurse and the oncoming nurse assess the skin at each shift change together..." Interview revealed the Nurse Educator did not address the lack of assessments for Pt #1 and did not address the lack of wound care on 4 out of 7 days for the stage 3 pressure ulcer.

In summary, the nursing staff failed to follow the hospital's policy and complete a comprehensive assessment of Pt #1's wounds within 4 hours of admission and subsequently every 24 hours. Patient #1's nurses failed to perform all dressing changes as ordered and did not provide a comprehensive wound assessment of the patient's stage 3 pressure ulcer from 6/25/2025 to 6/30/2025, day of dismissal.