HospitalInspections.org

Based on record reviews and interviews, the facility failed to ensure that nursing services were provided to meet the needs of patients, for 1 of 1 patients (#1) admitted to the facility who developed a pressure ulcer in house. The facility failed to ensure that nursing staffs followed facility policy in the treatment and documentation of patient #1's pressure ulcer.

Findings included:

Record review of the medical record for Patient #1 revealed that he was an 84 year old male, admitted on 5/26/18, with diagnosis of CHF, CAD CABG, DM II, failure to thrive, and pneumonia. Further review revealed he was bedridden and required complete assistance with his activities of daily living.

Record review of the nursing admission assessment, dated 5/26/18 at 13:30 revealed inpart the following information:
- Skin Problems: NO

Review of the wound care nursing notes dated 5/29/18 (Untimed) revealed a photograph of patient #1's sacral/ buttock area (No measurement tool present in photograph) which showed the presence of a pressure ulcer, size and stage unable to determine due to the lack of meaurement tool.

Record review of the wound care assessment, dated 5/31/18 at 14:09 revealed the following"
- #1 buttocks bilateral
-Wound location comment
"Patient in the reclinerat this time. Viewed photos in the chart. discussed with nurse. From photos, partial thickness openings noted which are non-complex with erythema. Recomendations given for TRIAD twice daily, and repositioning every 2 hours. Bedside nurse to perform BID. Triad left at bedside."

Record review of the wound care assessment, dated 6/01/18 at 08:00 revealed the following,
- #1 buttocks bilateral
-Wound location comment
"From photos in the chart, partial thickness openings noted which are non-complex with erythema. Recomendations given for TRIAD twice daily, and repositioning every 2 hours. Bedside nurse to perform BID. Triad left at bedside."

Wound comment: TRIAD reapplied, with cardiac rehab.

Further review of the wound care assessment notes for the duration of patient #1's hospital stay, revealed no further photographic documentation of patient #1's pressure ulcer.

Record review of the facility policy entitled, Pressure Injury Prevention and Management Protocol, revised 6/2017 revealed in part the following information:
7.) All patients admitted with or developing a pressure injury should have the wound measured using photography and a recognized available measurement system such as EZ graph and/or wound rulers. Measurements shoud be completed on admission, weekly, and on discharge. This documentation is part of the medical record.

In an interview conducted on 10/10/18 at 11:30 am, the facility Regional Quality Director confirmed the above findings.