HospitalInspections.org

Based on review of medical records, facility policies and procedures, and staff interviews, it was determined that nursing staff failed to complete dressing changes as ordered, complete skin assessments every shift and failed to turn/reposition one patient (P) (P#2) of four patients (P#1, P#2, P#3 and P#4) reviewed.


Findings include:


Review of medical record revealed that P#2 was admitted to the ICU (Intensive Care Unit) on 11/20/24 at 3:01 p.m.


Review of the initial skin assessment done by ED Registered Nurse (RN) revealed that P#2 had redness on the sacral area (regions of the back and buttocks). Skin protectant and bordered foam dressing was applied by the ED Nurse.


A review of History and physical (H&P) done on 11/20/24 at 4:58 p.m. by the hospitalist revealed P#2 was lethargic (a state of weariness that involves diminished energy) with diminished cognition (decline in mental abilities).


A review of the note completed by a wound care nurse on 1/8/25 at 2:22 p.m. referenced P#2's sacral wound and evaluation of the wound as follows:
" 50 % red lower border and 50% upper border loosening black soft slough .
Peri -wound scaly skin. No odor. DTPI (deep Tissue Pressure Injury) in evolution is currently unstageable. Foley, HOB up. Continued review revealed that the plan was to add hydrogel gauze; continue to follow for wound teaching if appropriate.


A review of P#2's medical record revealed a wound care note completed by Wound Care Nurse (WCN) GG on 1/13/25 at 1:00 p.m. that included:
Sacral wound W/A thick area of necrosis superiorly, otherwise wound is full thickness pink. Area cleansed, sharp debridement of the necrosis, no bleeding. Applied alginate, will change daily.


Review of nursing flow sheet revealed that P#2's initial skin assessment was done in ED on 11/20/24 by ED nurse RN KK, as redness on sacral area, skin protectant and bordered foam dressing was applied but failed to reveal any pictures of the reddened sacral area.

Continued review of medical record failed to reveal daily dressing change of sacral wound as per ordered by WCN GG in ICU until 1/20/25 when first dressing was changed.

Continued review of the record revealed that sacral wound dressing changes were ordered by WCN GG on 1/13/25. Sacral wound dressing changes were not documented until 1/20/25 .


Review of the medical record revealed missed skin assessments in November 2024 through January 2025 were as follows:
November 2024
11/23/24 night shift
11/24/24 day and night shift
11/25/24 day and night shift
11/26/24 day and night shift
11/28/24 day shift
11/29/24 day and night shift.

December 2024
12/4/24 day shift
12/6/24 night shift
12/7/24 day shift
12/8/24 day shift
12/9/24 night shift
12/10/24 night shift
12/11/24 night shift
12/12/24 night shift
12/14/24 night shift
12/20/24 night shift
12/21/24 night shift
12/22/24 night shift
12/23/24 night shift
12/25/24 night shift
12/26/24 night shift
12/28/24 night shift
12/31/24 night shift.

January 2025
1/1/25 night shift
1/2/25 night shift
1/5/25 night shift
1/6/25 night shift
1/7/25 night shift
1/8/25 night shift
1/11/25 night shift
1/12/25 night shift
1/13/25 night shift
1/14/25 night shift
1/16/25 night shift
1/17/25 night shift
1/19/25 night shift
1/20/25 night shift
1/22/25 day shift
1/23/25 night shift
1/24/25 night shift
1/26/25 night shift
1/28/25 day and night shift
1/30/25 night shift
1/31/24 night shift.

A continued review of the medical record review failed to indicate that P#2 was turned and repositioned every two hours per protocol.


November 2024 through January 2025 revealed missed opportunities of turning and repositioning as follows:
11/25/24 (10:00 a.m. 12:00 p.m. 2:00 p.m. 4:00 p.m. 6:00 p.m.)
11/26/24 (12:00 a.m. 2:00 a.m. 4:00 a.m. 6:00 a.m. 8:00 a.m. 10:00 a.m. 4:00 p.m. and 6:00 p.m.)
11/27/24 (8:00 a.m. 10:00 a.m.)
11/28/24 (4:00 a.m. 6:00 a.m.)
11/29/24 (2:00 p.m. 6:00 p.m. 8:00 p.m. 10:00 p.m.)
11/30/24 (12:00 a.m. 4:00 a.m. 6:00 a.m. 8:00 a.m. 10:00 a.m. 4:00 p.m. and 6:00 p.m.)
12/02/24 (8:00 a.m. 10:00 a.m. 12:00 p.m. 2:00 p.m. 4:00 p.m. and 6:00 p.m.)
12/3/24 (4:00 a.m. 6:00 a.m. 4:00 p.m. and 6:00 p.m.)
12/4/24 (8:00 p.m. 10:00 p.m.)
12/5/24 (12:00 a.m. 2:00 a.m. and 4:00 a.m.)
12/6/24 (10:00 a.m. 12:00 p.m. 2:00 p.m. 4:00 p.m. and 6:00 p.m.)
1/8/25 (12:00 a.m. 2:00 a.m. and 4:00 a.m.)


A review of facility's policy titled "Prevention and Treatment of Skin Breakdown," review date 12/12/2023, revealed following:

Purpose:
To provide guidelines for the prevention and treatment of pressure ulcers as well as other wound types and to reduce the risk for all patients at risk for skin breakdown.
Policy:
[The facility]will provide consistent care for prevention and treatment of skin breakdown. The registered nurse will assess each patient for potential for skin breakdown on admission, each shift and as needed for a change in the patient's condition.
o The Braden Risk Assessment Scale provides general guidelines for patient evaluation.
o Assess the patient for additional risk factors for development of pressure ulcers. Including
> 65 years of age, albumin < 3.5, low H&H levels, hyperglycemia, morbid obesity, and
hemodynamic instability.
o Patient and family will be informed about the importance of proper skin care, repositioning and the causes and risk factors for pressure ulcer development and ways to minimize risks.
Procedure:
Assessment:
1. A Registered Nurse (RN) will assess all inpatients on admission for individual risk of skin breakdown using the Braden Risk Assessment Scale. Assistive/adaptive devices and dressings will be removed prior to initial assessment.
2. Assess for intrinsic and extrinsic risk factors.
3. If admitted with a pressure ulcer or other wound type, the RN will select the appropriate wound type protocol and document a description of the ulcer. The description of the ulcer may include location, odor, color, drainage, and pain. Based on admissions nurse findings, a protocol can be selected from the wound assessment or physical assessment. The wound type protocols are Yellow, Red, Black, General Skin Breakdown and Treatments, Staff can order a Wound Ostomy Continence Nurse (WOCN) screen as needed.
B. Reassessment:
1. Nursing will reassess patient's risk for skin breakdown using the Braden Risk Assessment Scale every shift. The condition of the skin will be documented in physical assessment or under wound assessment.
2. If skin integrity is compromised, document a thorough description of the ulcer in the nurse's notes. The description of the ulcer should include location, odor, color, drainage and pain. Measurements will be recorded by WOC department.
a. The nurse will notify the WOCN regarding any hospital acquired skin breakdown. The nurse will notify the primary physician and the family of changes in skin integrity.
b. Nurses will order a Nutritional Screen upon admission or when there is a change in condition.
c. The director, charge nurse, or primary nurse will complete a patient safety report.
C. Prevention of Skin Breakdown: For patients in need of a specialty surface the charge nurse, administrative supervisor or WOCN will order the appropriate support surface.
a. Foam, wedges and pillows can be used to reposition patients who are unable to self-position.
b. Consult the WOCN department for the selection of appropriate pressure redistribution devices for chairs, wheelchairs, and beds.
1. Interventions used based on Braden risk assessment score and nursing judgment.
a. Assess the patient's ability to reposition themselves, both from a physical and a mental standpoint.
b. Turn and reposition at least every 2 hours and document in real time Use as many turning surfaces as possible.
c. Position patients to redistribute pressure on bony prominences, i.e., sacrum, elbows, heels. Redistribute pressure under heels off-loading with pillows, pressure redistribution boots, and other off-loading devices.


An interview was conducted with Registered Nurse/ ICU Charge Nurse (RN) EE on 4/24/25 at 10:05 a.m. in the facility's conference room. RN EE revealed that she did recall P#2 because she took care of P#2 few times. RN EE further stated that pictures of P#2's sacral wound were taken but camera was not uploading to the EMR (Electronic Medical Record), for which facility's IT (information Technology) department was contacted several times and it took at least three weeks to get that working. RN EE also stated that the photos were in the camera. RN EE also acknowledged that dressing change of sacral wound, skin assessment and repositioning every two hours for P#2 were missed during his (P#2) hospital stay.


An interview was conducted with the Director of Risk Management (DRM) DD on 4/24/25 at 11:13 a.m. in the facility's conference room. DRM DD reviewed P#2's EMR. DRM DD acknowledged that photos were not taken at the time of initial skin assessment of P#2. DRM DD acknowledged that skin assessment, dressing changes and repositioning was not documented as ordered.


An interview was conducted with the Wound Care Nurse (WCN) GG on 4/24/25 at 1:11 p.m. in the facility's conference room. WCN GG explained that staff can request a wound care consult anytime without doctor's order. WCN GG further stated that there were two wound care and colostomy nurses for the hospital. A wound care consult for P#2 was received on 1/8/25.P#2 was seen by a wound care nurse, who assessed the sacral wound and wrote that the deep tissue pressure injury was unstageable. WCN GG continued to state that in her experience, once the skin starts to break down, it would not stop. WCN GG also stated that she followed up with P#2 on 1/13/25, did a debridement of narcotic (dead) tissue from the sacral wound and wrote the order for daily dressing changes.


An interview was conducted with the Chief Nursing Officer (CNO) CC on 4/24/25 at 2:17 p.m. in the facility's conference room. CNO CC explained that typically nurse to patient ratio in the ICU was one nurse to two or three patients. The charge would also take two patients. CNO CC acknowledged the gaps in the flow sheet documentation of the daily skin assessment, dressing changes for sacral area and repositioning.


An interview was conducted with Registered Nurse (RN) II on 4/24/25 at 3:33 p.m. in the facility's conference room. RN II revealed that he did skin assessments and wound checks once a shift, but he (RN II) may not have documented on P#2.