HospitalInspections.org

Based on document review, staff interview, and in one (1) of eight (8) medical records reviewed, the facility failed to ensure that staff reported hospital acquired pressure injuries as incidents per policy, and the facility failed to identify this and develop corrective action. (Patient #2).

Findings include:

Review of the facility's policy and procedure (P&P) "Reporting of Adverse Events," last revised January 2024, states: "any stage 3 or 4 or unstageable pressure ulcer acquired after admission/ presentation to the health care facility is classified as a Never Event."

The policy also states, as part of the adverse event procedure, "staff must also enter the event in the Patient Safety Intelligence (PSI) database ...The Patient Safety Risk Management staff read all reported PSI events and ensure that they are processed appropriately or reported to the appropriate State or Federal agency in accordance with New York State occurrence and incident reporting laws and Joint Commission Sentinel Event Standards."

Review of the facility's Incident Reports, from November 2023 to 1/11/2024 revealed that an incident was not reported for the development of two hospital acquired pressure injuries in Patient #2.


Review of Medical record for Patient #2 identified: patient was admitted to medical step-down unit on 11/03/2023 with a diagnosis of hypoxic respiratory failure, sepsis, and pneumonia. The registered nurse's (RN's) initial assessment revealed that the patient had a Stage 2 pressure injury on the mid-upper sacrum present on admission.
On 11/07/2023, Patient #2 was transferred to a general medical-surgical unit. On 11/14/2023, Staff G, Wound Care Nurse Practitioner (NP), documented, Patient #2 developed a deep tissue pressure injury (DTPI) of her left ischium. On 11/21/2023, documentation by Staff G, stated that Patient #2 developed an additional DTPI of her right iliac crest, and that the sacral and left ischium DTPIs had advanced to unstageable by 11/21/2023.

Review of the facility's Incident Reports revealed that an incident was not entered for the pressure injuries developed on 11/14/2023 or 11/21/2023.
Per interview on 1/12/2024 at 10:15AM, Staff E, RN, stated that they sometimes report hospital acquired pressure injuries as a PSI.

Per interview on 1/16/20204 at 11:00AM with Staff U, Nurse Manager of Unit 5600, stated, staff have daily huddles where they discuss patients at risk for pressure injury. Staff U also stated, they have a monthly staff meeting, and provided the document, "Unit 5600-5700 Staff Meeting Agenda/Minutes," dated 12/14/2023. The document stated: "Last month (November 2023) a patient had a worsening of a community-acquired pressure injury." However, the hospital acquired pressure injuries developed on 11/14/2023 and 11/21/2023 were not discussed. Staff U confirmed that this was not addressed during the staff meeting. Staff U stated that she became aware of Patient #2's pressure injury on 11/21/2023, one week after the first hospital acquired pressure injury was identified. When asked why an incident was not entered for this patient, Staff U stated there may have been some confusion because the patient was also admitted with an existing pressure injury, which they do not typically report.

Per interview on 1/16/2024 at 11:35AM, Staff B, Nurse Manager of Nursing Quality, confirmed that an incident report should have been completed for Patient #2's hospital acquired pressure injury. Staff B provided documentation of an email sent by Staff G, wound care NP on 11/14/2023, stating that Patient #2 had a hospital acquired pressure injury. Staff B also stated that incidents regarding nursing care issues will be referred to the nursing quality team for an Apparent Cause Analysis (ACA) investigation. Staff B provided documentation of an ACA report for Patient #2, dated 1/11/2024. When asked why Patient #2's ACA was not conducted until two months later when the surveyors were on site, Staff B stated they did not have an answer.