HospitalInspections.org

Based on observations, staff interviews, and document review of electronic medical records and faciity wound care policies, the facility failed to ensure consistent implementation of the nursing care plan intervention related to pressure wound dressing changes for two (Patient #1 and Patient #3) of 6 sampled patients who were reviewed for wound management. Failure to ensure that wound dressing changes occurred as ordered could lead to the deterioration of a patient's wound, prolonged hospitalization and infections.

The findings include:

1) Patient #1 was admitted to the facility from a nursing home on 01/10/21 and discharged on 01/19/21 with altered mental status (AMS), morbid obesity, congestive heart failure, chronic renal failure, status post prolonged hospital stay at another acute care facility, respiratory failure, fever, and hypoxia. Patient #1 had a re-admission to the facility documented on 01/28/21 for an abnormal hemoglobin that required transfusions on 1/29/21, 2/3/21, and 2/15/21.

A review of the medical record documentation of admission assessment/ shift assessment notes, dated 01/11/2021 at 8:00 AM included skin alteration existed with an abrasion to lower back. Red/ moist/ smooth/ shallow wound base was visible as documented. Open area was marked as 'Yes'. Partial thickness with no measurement recorded. Pressure injury immobility related to sacrum present on admission, wound base visible skin was not intact and graded as a Stage II pressure injury. [Document on Page 9 submitted.] No wound management documented with this assessment and a photograph was included in the medical record.

Interviews were conducted with the wound management team Employee C, Registered Nurse (RN) and Employee D, RN on 04/14/2021 at 9:14 AM. Both staff members stated that the nurse on the unit performed the wound care dressing changes for each patient. The wound care team rounded on patients as needed.

Interviews were conducted with Employee C, RN Wound Care, and Employee D, RN Wound Care on 04/14/2021 at 10:51 AM. Employee D, RN Wound care stated that the wound care team saw a new consult usually by the next day and based on the wound care nurse protocols implemented interventions that the physician would order, and the floor nursing staff would perform the wound care dressing changes as ordered.

The following Admission/Assessment notes were reviewed as dated:

1/11/2021 at 1:15 PM-Wound Management Program (WMP) notes documented, "Patient off floor at time of rounding on 5 C. Will follow up for consult at a later date." 1/12/2021 at 8:00 AM documented existing wound as yes. [Page 25 submitted]

1/12/2021 at 1:26 PM [Page 26 submitted] a note Entered by Employee D, RN Wound Management Program notes-Patient resting supine in bed. Consulted primary nurse. Images observed to chart. Will place temporary wound care orders. Alginate to all sites for now. Additional supplies provided and left at bedside. WMP nurse to follow up at a later time. [Page 27 added note] Continue supportive and preventative care.

1/12/2021 at 1:55 PM [Page 27 submitted] Frequency documented as every two days Melgisorb Ag (Dressing) apply to coccyx and left back. Cover with DSD (dry sterile dressing). Additional instructions: Cleanse open wounds to coccyx region and left lower back wounds with normal saline, pat dry with gauze apply Melgisorb Ag to open wounds cover with dry sterile dressing. Change every 2 days and as needed (PRN) spoilage. (Wound Care Nurse) Protective Barrier cream two times a day (BID) and with every incontinence episode. Keep clean and dry.

1/12/21 at 8:14 PM [Page 29 submitted]-documented skin alteration exist. Documented existing wound [Page 30]. [Facility printer for documents printed on 4/15/2021 was off date and confirmed printing the documentation for the surveyor date printed as 1/22/2021 at 12:17 AM by the Director of Informatics by review and interview on 4/15/2021 at 8:25 AM.]

1/13/2021 at 8:00 AM assessment Page 33- Skin alteration present/exists. Page 34 existing wound documented as "yes."

1/13/2021 at 2:04 PM [Page 37 submitted]- Wound Management Program Notes- at 2:06 PM by Employee D, RN Patient is off the floor for hemodialysis treatment. WMP nurse to follow up at a later time. Continue wound care orders as per Meditech. Continue supportive and preventative care.

1/13/2021 at 7:00 PM-Skin alteration present/exist was documented by shift nurse. [Page 38 and Page 39 submitted] Documented existing wound. [No wound dressing change note.]

1/14/2021 at 1:00 AM-[page 41] documented on assessment skin alteration present/exists. Abrasion thighs bilateral active with tissue type worst was Pink/red/erythema/intact. Skin intact, blanchable documented no for open areas. Superficial for the skin abrasions medial thigh.

1/14/2021 at 8:01 AM-[Page 43]- Admission/shift assessment indicated skin alterations present lower back, thighs bilateral and a pressure injury related to sacrum active and present on admission to the facility. Dressing was documented intact. Date of last dressing change was documented 1/11/2021 at 5:00 PM which indicated a time frame greater than every 2 days for this dressing change and Meditech orders to be followed.

1/14/2021 at 2:26 PM [Page 47]-Wound Management program notes indicated by Employee D, RN "Patient resting in bed upon arrival. Noted Bariatric (low air loss) LAL surface. WMP role explained. Patient immediately refused stating "that is old. But what you can do is see about my IV burning in my arm." Patient holding arm in the air at the time. Primary nurse consulted and made aware. WMP nurse will follow up at a later time. Continue wound care. [No documented wound care was provided.]

1/14/2021 at 7:10 PM [Page 50] Admission/shift assessment reviewed-skin alteration present exists. This nurse documented a "No" under existing wound demonstrated inconsistent documentation from the above skin alteration present and existed.

1/15/2021 at 8:00 Am [Page 54] indicated wound present. No documented wound interventions evident.

1/15/2021 at 20:00 hours- [Page 58] indicated patient had a present/existing skin condition and indicated "wound present.'[Page 59] No wound/dressing change documented.

The pattern of repeated skin assessment continued on [Page 69] skin alterations exists, wound present on page 70 dated 01/16/2021 at 9:05 PM. [No identified wound dressing changed provided as dated 1/16/21.]

01/17/2021 at 7:20 AM [Page 73] documented admission/shift assessment pressure injury immobility related to sacrum. Present on admission. Dressing intact and date of last dressing change was documented 1/16/2021 at 5:00 PM. Mepilex dressing, no area calculated. [Page 74] documented wound present. Total dependence documented on 1/17/20201 at 6:05 PM. At 7:55 PM documented on [Page 80] skin alteration present/exists and wound existing.

1/18/2021 at 11:59 AM [Page 84] Nutritional Assessment documented under intake: Physical Assessment: Per RN shift assessment 1/17/2021. Pressure-related wound to sacrum. No stage documented. Wound management has been unable to assess wound yet this admission.

1/18/2021 at 1:01 PM [Page 86] skin alteration present/exists and wound [Page 87] documented skin breakdown education and wound care. On 01/18/2021 at 8:15 PM documented Existing wound. [Page 90 & Page 93]

1/19/2021 at 5:17 PM [Page 98] Dressing to coccyx clean dry and intact. Left below knee amputation, right foot partial amputation.

A review of Patient #1's medical record for admission assessment, dated 01/28/2021 at 11:53 PM was conducted and it was documented 'Skin alteration: Pressure injury immobility related to posterior back middle. Open area Yes. Skin intact no.' No measurement for advanced wound. Sacral wound documented. An interview with the Director of Informatics was conducted on 04/14/21 at 1:45 PM. She confirmed that wounds identified on admission should have documented measurements.

An initial wound care management consult was triggered by the physician order and included a documented wound care note entered by Employee C, RN (Wound Care Nurse) dated 02/03/21 at 4:46 PM. The documented note included a Stage 3 pressure injury with Deep Tissue Injury (DTI) component. Measured at 16.5 cm X 14.0 cm X 0.5 cm depth. Stage 3 pressure injury to coccyx with congestion to base, dry wounding, DTI component with deep purple and maroon skin discoloration, highly likely to evolve. Wounding dry to touch. The WMP recommendations included to change every three days hydrocolloid dressing change to sacrococcygeal; change from foam dressing as needed for soilage. Every 3 days preventative dressing to back DTI's; barrier cream to gluteal folds and perineum.

A review of the medical record was conducted with the Director of Informatics on 04/14/2021 at 1:22 PM revealed that dressing changes performed by nursing could not be provided for at least six days of Patient #1 admission to the facility. The facility could not provide that the intervention ordered was actually completed for Patient #1 as ordered. On 2/3/21, the sacral wound was assessed as a stage 2 pressure injury. Dressing changes were not documented as completed for 2/4/21, 2/7/21, 2/10/21, 2/13/21, 2/16/21, 2/19/21. On 2/19/21, Patient #1 expired.


2) A review of the medical record for Patient #3 was conducted and documented that Patient #3 was admitted to the facility on 03/26/21 at 11:30 AM for a complaint of altered mental status and Urinary Tract Infection (UTI). Patient #3 had a documented medical history that placed the 77-year-old patient at risk for the development of wounds which required a thorough assessment for wound development. Risk factors included UTI, Diabetes, deep vein thrombosis and arthritis per past medical history.

An interview was conducted with Employee A, RN on 04/13/2021 at 1:26 PM. She stated that she was covering for the nurse who cared for Patient #3 at the time but would attempt to provide information related to a wound identified for Patient #3. She confirmed that Patient #3 had a pressure wound, orders were present; however, she was not sure how to look up the past wound documentation when asked.

An interview was conducted with Employee B, RN on 4/13/21 at 1:45 PM about the wound care for Patient #3. She was not able to identify a wound dressing change that was referred to by staff as dressing changed on 4/12/2021 at midnight. Employee B, RN printed the orders for the wound intervention documented as Cleanse with Normal Saline, 4 X 4. The wound care note was obtained provided by and revealed that the wound care was ordered on 03/29/2021 at 5:23 PM by the wound management team (Employee C, RN and Employee D, RN). The wound care plan included a documented frequency to be completed every 2 days and as needed. Apply Melgisorb Ag to right buttock, sacrum, and cover with Optifoam.

A review of the admission assessment/ shift assessment that indicated the presence of a wound on Patient #3 was documented by Employee F, RN on 3/28/21 at 3:53 PM. The note reviewed read, "Sacral wounds cleaned and dressings clean/dry/intact."

A review of the medical record for Patient #3 was conducted for the wound dressing change referenced in the medical record note printed on 04/14/21 at 12:05 PM. The note included "Pressure injury immobility related Sacrum." This wound was documented as an active wound with dressing documented dry and intact. Date of the last dressing change was documented as 04/12/21 at midnight. This documented wound care dressing change could not be provided as requested by the surveyor.

A review of the medical record for Patient #3 documented on 04/06/21 at 12:30 PM by Employee D, RN Wound Care, "Triggered by follow up for wound care visit. Patient Care Technician at bedside for assistance with turning and repositioning. Patient resting in Accumax surface. Wound care nurse role was explained, and patient was agreeable to visit. The assessment indicated generalized poor skin turgor and tensile strength. Sacrococcygeal: Fissure noted. Measured 2.0 cm X 0.4 cm. Moist, mild erythema and a bit blanchable. Melgisorb ag applied and sacral dressing applied.

A review of the medical record admission assessment/ shift assessment form included an entered wound care note dated 4/14/21 documented by Employee C, RN and included Sacrococcygeal: Fissure noted. The wound measured 2.0 cm X 0.4 cm, moist and mild erythema bit blanchable. Melgisorb ag applied and sacral dressing applied. Closed scarring to sacrum. Presents as pinhole sized scar/hole. Fissure to perineum 3.8 cm long, superficial wounding, moist and small amount of serosanguinous drainage noted.

The facility could not provide the referred to 04/12/21 midnight dressing change documented after multiple times requested and multiple reviews conducted by the (Assistant Director of Nursing) ADON and the Director of Informatics who was interviewed on 4/15/2021 at 8:25 AM. They confirmed that the facility did not provide a completed and documented plan of care with interventions for Patient #3's wound management.

On 4/15/21 at 8:25 AM, an interview was conducted with the ADON, Director of Nursing (DON), and the Director of Informatics confirmed the facility could not provide documented evidence that all wound team/ physician ordered wound interventions occurred as ordered for Patient #1 and Patient #3 two out of six patients reviewed for the presence of wound care needs being met.

An interview was conducted with the ADON on 4/15/2021 at 8:41 AM. She stated that she agreed that the facility failed to demonstrate by medical records reviewed for Patient #3 that nursing staff followed the plan of care for wound treatments.

A policy review conducted of policy identification number 7206786 included that it applied to medical personnel involved in the photographing of pressure-related skin breakdown for the medical record at the facility. Purpose to provide visual record to document within the patient's chart the initial condition/ impairment of the patient's skin and healing progression for inpatients at the facility.

A policy review was conducted of policy identification number 7295250 which included the interdisciplinary policy that the facility staff would assess, plan and implement, and evaluate the care of those patients at risk for skin breakdown or admitted with skin impairment. At line 7, it was documented that subsequent wound measurements of pressure ulcers should be obtained weekly as part of the nursing assessment.

A policy review was conducted of policy stat identification number 7206771 "Wound Care Program" and indicated at line 3 that "Ordered dressing changes will be the responsibility of the staff nurse unless specified otherwise by a physician order for the wound nurse only to perform dressing changes."