HospitalInspections.org

Based on interview, review of medical record and other documents, it was determined in one (1) of eight (8) medical records; nursing staff did not implement the facility's policy for the management of patients with pressure ulcer.
Findings include:
Patient A is a 71-year-old female who was admitted on 6/29/14 after a cardiac arrest and fall at home. The patient suffered anoxic brain injury and was managed in the Critical Care Unit.
The initial nursing assessment of the patient on 6/30/14 at 6:00 PM described patient's skin as intact, cold, and mottled. She was identified as a high risk for the development of pressure ulcers evidenced by a Braden Risk Assessment (clinical tool used to assess risk of a patient/client developing a pressure ulcer) score of 12.
A stage II pressure ulcer (Partial thickness skin loss involving epidermis, dermis, or both) was identified on the patient's sacral spine on 7/17/14 that deteriorated to an unstagable pressure ulcer (Full thickness tissue loss where enough of the base of the wound is covered with slough or eschar) on 7/28/14. There was no evidence in the medical record of physician involvement in the assessment and management of the patient deteriorating pressure ulcer.
The facility's policy and procedure titled "Pressure Ulcer: Prevention, Assessment, and Management," last reviewed and revised April 2013 notes, "several aspects of pressure ulcer management are driven by physician or other members of the interdisciplinary team ... " The policy notes that nursing staff would consult with members of the interdisciplinary care team as needed for debridement of pressure ulcer of devitalized tissue; use of antimicrobials and systemic antibiotics as indicated ...
Consequently, the patient was discharged to a Skilled Nursing Facility on 8/6/14 with an unstagable sacral ulcer that had not been assessed by a physician to determine a treatment plan and the need for debridement of devitalized tissue.
At interview with Staff #1, Patient Care Services Manager, on 9/28/15 at 2:30 PM, she stated, the prevention and management of pressure ulcer is a team approach; however, the care of the patient with pressure ulcer is physician driven. She acknowledged there was no physician assessment and written order for the care of the patient's pressure ulcer.