HospitalInspections.org

Based on document review and interview, the Nurse Executive failed to ensure the nursing staff followed policies and procedures for pressure ulcer prevention, for a referral to wound care team for a patient braden score of "13" (high risk), and for event reports, related to completion of an event report for 1 of 6 closed medical records reviewed. (Patient # 8)

Findings include:

1. Review of hospital policy titled: "PRESSURE ULCERS-PREVENTION PROTOCOL UTILIZATION GUIDELINES FOR SKIN RISK ASSESSMENT", indicated under GUIDELINES, 4., "A Wound Ostomy Continence Nurse [WOCN] consultation will be initiated for scores of (High Risk) 13 or less". This policy was last reviewed 12/2015.

2. Review of hospital policy titled: "Processing of the Risk Management Event Report (ERS)", indicated under PROCEDURE:, 1. "Event Reports are completed in the Electronic Reporting System (ERS) by the associate that discovers or witnesses the event within 24 hours and ideally prior to the end of their shift". This policy was last reviewed 12/2015.

3. Review of hospital "E-learning" for Event Reporting System for employee staff, indicated on page 6 and page 26, indicated the following:
a. "ERS has ten (10) main event types:", point 8, "Pressure Ulcers (all stages)"
b. "Section 4/Wound Events", "will include selecting all applicable indicators.", "If an acquired pressure ulcer event occurs, the user will be prompted to stage the pressure ulcer when discovered."

4. Review of closed medical record (MR) for Patient # 8, indicated the following:
a. Patient # 8 admitted on 3/11/2018, with a braden score of "13" (high risk).
b. Patient # 8 skin assessment upon physical exam, during H&P (history & physical) by MD # 34 (Internist), indicated under "Integumentary: warm, dry, and pink, with no rash, purpura, or petechia".
c. Patient # 8 seen by wound care staff nurse-Charge Nurse (N # 20), on 3/21/2018 for (HAPU) hospital acquired pressure ulcers ("bilateral buttock, gluteal fold" and "left heel").

5. In interview with administrative staff member A # 4 (Manager Inpatient Wound Care), on 9/25/2018, at approximately 4:15 pm, and on 9/26/2018, at approximately 9:35 am, indicated the following:
a. That the wound care team did not receive a referral or order for wound care consult for Patient # 8 at time of admission; with a "verbal" referral received 3/20/2018; after the patient had already developed HAPU's (hospital acquired pressure ulcer).
b. The patient was seen by wound care staff on 3/21/2018, and noted to have more than one HAPU's.
c. Did not receive a copy of any event report in regards to a hospital acquired pressure ulcer for Patient # 8; also does not know if risk management received a event report for this patient's HAPU.
d. Nursing staff on unit, should have generated an event report for HAPU.

6. In interview with administrative staff member A # 1 (Chief Nursing Officer), on 9/26/2018, at approximately 12:05 pm, and at approximately 3:35 pm, the following was confirmed:
a. Not sure why a nurse or nurses did not complete a referral for Patient # 8, to wound care team for a low braden score, for evaluation and treatment.
b. Not sure why the EMR (electronic medical record) documentation (braden score of 13) did not "trigger" a referral to wound care staff for consultation.
c. Nursing staff receive education/training for completing event reports on initial hire and for annual reeducation.
d. Not sure why a event report was not completed for a patient who had HAPU's.

7. In interview with A # 3 (Director Risk Management), on 9/25/2018, at approximately 4:45 pm, confirmed that there were no event reports for 6 closed medical records reviewed for March through June 2018, for pressure ulcers; which included Patient # 8.

8. No other documentation was provided prior to exit.