HospitalInspections.org

Based on record review and interview the facility failed to analyze and implement preventative actions in a timely manner when it did not identify and analyze a hospital acquired pressure injury for 1 of 1 patients (Patient #1) in a sample 11 records reviewed.

Findings include:

The facility failed to address a serious safety event when reported in 1 of 3 patients with pressure ulcers in a sample of 11 records reviewed. See Tag A-0286

Based on record review and interview the facility failed to ensure that patient safety events/complaints are thoroughly investigated and action plans are developed and implemented to mitigate risk in 1 of 1 (Patient #1) safety events reviewed in a total sample of 5 patient complaints/grievances reviewed.

Findings include:

Review of the facility policy titled, "Patient Safety Event Reporting (System)" #11291767 dated 3/2022 revealed, "Definitions:...Adverse Event: a patient safety event is any unusual event that is inconsistent with the normal, routine operation of the organization or any unexpected outcome that has caused some harm, or has the potential to cause some injury to a person..." Under "Policy: A. A SafetyZone event report should be completed by the person who has the best knowledge of the event. This may be the person involved or the person who first discovered or became aware of the event...2. Events will be categorized by a severity index that identifies the seriousness of the event. A. Death B. Severe Harm - bodily or psychological injury that interferes substantially with functional ability or quality of life C. Moderate Harm: bodily or psychological injury adversely affecting functional ability or quality of life but not at the level of severe harm...

B. If the event is categorized as severity level A, B, C resulting in patient harm or death, it is considered a severe adverse event or possible sentinel event. 1. The Director/Manager or designee of the department involved takes immediate action to mitigate harm and prevent recurrence. ...confirm that no one is in "immediate" danger, focus on the involved patient, assess the safety of other patients, as appropriate. 2. The Clinical Risk Management and Patient Safety Partner is to be contacted immediately...

Review of the Safety/Adverse Event log revealed after receiving a Grievance from Pt. #1 on 11/18/2022 a safety event was entered by the facility.

Pt. (patient) #1 was a 26 year old who sustained a complete C-5 (cervical) fracture on 7/17/2022 after a diving accident. He was transported to the facility and neurosurgery consulted. He was intubated (tube inserted to assist breathing) and had surgery on 7/18/2022 to stabilize the fracture. He was considered to have complete quadraplegia (paralysis that affects all a person's limbs and body from the neck down). He was placed on a every 2 hour repositioning schedule. His inpatient stay was complicated by contracting c-diff (a bacterium that causes diarrhea) and experiencing a pressure ulcer to his coccyx (tailbone). He remained hospitalized at this facility until 8/12/2022 when he was considered to be stable and was transferred to Mayo Rochester inpatient rehab.

Review of the medical record revealed:
7/19/2022 - 7/31/2022: "Nursing Flowsheet" assessment for "Integumentary (skin): "warm, dry, intact"
7/28/2022 - pt. contracts c-diff - experiencing frequent loose stools
8/1/2022 at 8:00 AM: "Nursing Flowsheet: Integumentary: barrier cream to peri (perineal) area"
8/2/2022 at 8:00 AM: "Nursing Flowsheet: Integumentary: excoriated (skin damage from mechanical injury is typically superficial or partial thickness) diaper area"
8/3/2022 at 8:00 AM: "Nursing Flowsheet: Integumentary: excoriated diaper area"
8/4/2022 at 8:00 AM: "Nursing Flowsheet: Integumentary: red, excoriated diaper area"
8/6/2022 at 8:00 AM: "Nursing Flowsheet: Integumentary: diaper area open, bleeding"
8/7/2022 at 4:00 PM: picture of sacral wound taken placed under media tab in medical record, wound entered in care plan; pink, fragile, barrier cream, stoma powder (protective creams) applied
8/9/2022 - pt. transferred to IMCU (Intermediate Care Unit)
8/11/2022 at 8:45 AM: "Nursing Flowsheet: Integumentary: redness. Care Plan Progress Note: Outcome: NOC (night shift) rating 4 (mildly compromised) Most recent Braden Scale Score = 12 (high risk)...impaired skin integrity due to wound - list location: buttocks (partial thickness).
8/12/2022 at 9:00 AM - pt. is discharged from IMCU to (Name of receiving hospital) for inpatient rehab.

Review of the medical records for Pt. #1 from the receiving facility revealed a Wound-Ostomy nurse Progress Note on the day of admission, 8/12/2022 at 3:35 PM that revealed, "Pre Existing Unstageable Pressure Injury: Coccyx: ...upon admission, patient presents with an unstageable pressure injury over his coccyx...the wound bed is obscured by gray and black eschar (dead tissue found in a full-thickness wound). There are small areas of white and red tissue around the nonviable tissue, small amounts of serosanguineous (contains or relates to both blood and the liquid part of blood (serum)) drainage...is boggy to palpation and a dusky purple in color..." Wound-Ostomy Progress Note on 8/17/2022 at 12:03 PM at receiving facility, "...provided sharp debridement to wound...a full thickness wound bed was exposed, the wound now presents as a Stage 4 pressure injury...

Review of Pt. #1's medical record while hospitalized at this facility revealed Rehab Physician P's daily "Progress Notes". The notes revealed documentation under "Skin" as "normal" each day until 8/8/2022. The "Progress Note" by Rehab Physician P on 8/8/2022 at 11:49 AM revealed, "Wound: reviewed on media tab. Full thickness distal sacral/near coccyx breakdown...Sacral decubitus (pressure) ulcer Stage II (when a pressure ulcer reaches the second stage, the sore has broken through the top layer of the skin and part of the layer below, typically results in a shallow, open wound) - reviewed pressure relief with pt and family, continue q (every) 2 hour position change...when sidelying to spread buttock cheeks a part (sic) when in bed."

Rehab Physician P's Progress Notes from 8/9/2022 - 8/11/2022 reveal the same verbiage as in the 8/8/2022 note staging the wound as a "2".

In an interview on 11/29/2022 at 12:30 PM with Rehab Physician P, Rehab Physician P acknowledged that she was the Physical Medicine & Rehab doctor for Pt. #1. Rehab Physician P stated that she received a call from (Receiving hospital) "about 5 days to a week" after Pt. #1 was transferred there, "They gave me an update on how he was doing and then told me that the pressure ulcer that I had called a Stage 2 was debrided and was actually a Stage 4." When asked if she shared that information with anyone Rehab Physician P stated that she had not but "probably should have". Rehab Physician P stated that she had only looked at the photo that the nurse had taken on 8/7/2022 and never actually looked at the wound in person stating, "I rely on the nurses to keep me updated if something has changed."

When shared that the initial wound assessment at (receiving hospital) revealed the wound as unstageable (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed), Rehab Physician P stated that (receiving hospital) had called her the week after Pt. #1 was admitted there and had given her an update on status and told her that after several debridements (the removal of necrotic tissue from a wound) the wound had been classified as a 4 (stage 4 pressure ulcer extends into the tissues below the fatty tissue, such as the muscles, ligaments, tendons and bone). Rehab Physician P then stated, "I probably should have shared that with someone here."

Physician P did not report an adverse safety event related to pressure injuries upon receipt of that information in 08/2022. The facility did not provide prevention education to staff until 11/16/2022.

Review of the Safety/Adverse Events log and follow up for the event entered on 11/18/2022 (complaint submitted by Patient #1) did not reveal any action taken as of the onsite complaint survey on 11/28/2022.

In an interview with Pt. #1 on 11/21/2022 at 10:05 AM Pt. #1 stated that he filed a complaint with the facility and did receive a voice mail that he had not returned. "I have been told that I need to have plastic surgery to repair the pressure ulcer, an injury that I think should have been prevented." Review of the medical record from (receiving hospital) confirmed that a consult to plastic surgery had been made for closure of the pressure ulcer.

In an interview with VP (Vice President) L on 11/28/2022 at 5:15 PM when asked about the investigative notes for the Safety Event entered on 11/18/2022 VP L stated, "I'm sure we aren't finished with the investigation."

In an email from VP L on 11/30/2022 at 4:29 PM when asked about the severity rating for the Adverse Event VP L responded, "We are not complete (sic) with the review yet. Currently in safety zone our choice is complaint or grievance and we called this a grievance, there is no harm choice for this.."

When emailed the "Patient Safety Event Reporting (System)" policy defining the actions for an Adverse Event and requesting the severity rating no reply was received.