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Based on interview, record and policy review the facility failed to evaluate the nursing care (pressure injury) of each patient and on an ongoing basis and in accordance with accepted standards of nursing practice and hospital policy of 1 (SP#1) out of 3 sample patients (SP).



Findings include:

1. Review of SP#1 Emergency Department Note Physician Final Report dated 12/14/2018 at 8:34PM revealed patient with slurred speech and very agitated. Stroke call made. Physical Examination, Skin: Warm, dry.


Review of SP#1 Flowsheet Date Range: 12/14/2018 - 12/16/2018 revealed 12/14/2018 at 11:58AM noted Skin temperature: Warm, Skin description: Dry; 12/15/2018 at 12:30AM noted scar present on sacral area; no skin breakdown noted.

On 12/15/2018 at 11:19PM noted Incision/Wound Activity (Sacrum): present on admission.

Review of SP#1 Photographic Wound Documentation dated 12/15/2018 revealed Type of Wound: Stage I, Location: Sacrum, Pressure Injury present on admission from the community: Yes, Tunneling: No, Undermining: No, Drainage-type: None, Drainage-amount: None, Odor: No, Surrounding Skin: Normal

Review of Pressure Ulcer Prevention of Deep Tissue Injury, Stage 1 revealed the only intervention for a Stage 1 Pressure Ulcer is to apply protective cream to skin, no dressing required.


Review of SP#1 Photographic Wound Documentation dated 12/17/2018 revealed Type of Wound: Other - Healed ulcer, Location: Sacral, Pressure Injury present on admission from the community: Yes, Tunneling: No, Undermining: No, Drainage-type: None, Drainage-amount: None, Odor: No, Surrounding Skin: Normal

Review of SP#1 Nursing Skin Assessment dated 12/17/2018 at 7:00AM revealed Skin Integrity: Intact, Braden Score: 16

Review of SP#1 Nursing Skin Assessment dated 12/17/2018 at 7:00PM revealed Skin Integrity: Intact, Braden Score: 16

Review of SP#1 Nursing Narrative Note dated 12/22/2018 at 7:58PM revealed upon assessment, open area noted to sacral area. Picture taken. Continuing repositioning patient.

Review of SP#1 Nursing Narrative Notes dated 12/23/2018 at 5:35AM revealed during change of shift, noted open area to sacrum with AM Registered Nurse. Pictures taken, area cleaned with normal saline, and dressing placed according to wound care treatment. Medical Doctor called to make aware. Wound care consult placed. Will continue to reposition patient every 2 hours.

Review of SP#1 Nursing Narrative Notes dated 12/24/2018 at 2:13PM revealed wound care consulted for a sacral wound. Pictures from admission and every few days and today's assessment indicate the deep tissue injury was present on admission and is now evolving. Today wound is presenting as a stage 3. MediHoney ointment daily, covered with mepilex ordered by wound care.

Review of SP#1 Wound Care Progress Notes dated 12/24/2018 at 3:11PM revealed Factors for Pressure Ulcer Risk: Total Braden: 12 (12/24/2018). Assessed patient for deep tissue injury evolving to stage 3 pressure injury on sacrum area size 4cmX3.5cmX.2cm, wound bed 20% yellow slough, wound bed 80% dark maroon, scant amount of serous drainage.


Review of SP#1 Nursing Narrative Note dated 01/06/2019 at 5:38PM revealed wound care provided to stage 3 sacrum pressure ulcer per wound care instructions. Wound is noted to have eschar. Wound also has foul smell. Wound care consult ordered. Physician notified.

Review of SP#1 Surgery Consult dated 01/07/2019 at 12:50PM revealed during this admission general surgery has been consulted for chronic unstageable sacral decubitus. Patient is bedbound in a debilitated state. Upon assessment, patient has an unstageable sacral decubitus ulcer with extensive necrosis and foul odor. At this time recommend surgical intervention for debridement of sacral ulcer to promote wound healing and granulation.

Review of SP#1 Operative Report dated 01/08/2019 at 8:22AM revealed Indication for Surgery: infected sacral decubitus stage IV decubiti,

Review of SP#1 Operative Report dated 01/10/2019 at 5:01PM revealed Indication for Surgery: infected sacral decubitus stage IV decubiti. Debridement of sacral decubitus and excision of coccyx, Findings: Unviable tissues fascia and bone exposed, Specimen: Sacral ulcer coccyx, Packing: Dry packing, Complications: None.

Interview with Risk Manager A on 02/20/2019 at 2:40 PM revealed that an intake nurse does the assessment to identify any skin issues. If a stage 1 pressure ulcer is present, nursing treats according to what the stage 1 pressure ulcer protocols are.

Interview with Wound Care Nurse on 02/21/2019 at 12:08AM revealed that the nurse completes the skin assessment and if wound care consult is needed one is ordered. For Stage 1 and Stage 2 pressure ulcers the nurse follows the protocol in the computer system. This protocol does not include a wound care consult for Stage 1 and Stage 2 pressure ulcers. Wound care is only consulted for Stage 3 and above pressure ulcers. There is a protocol for a specialty bed and it can be ordered by the judgement of the nurse. There is an algorithm in the policy for Therapeutic Surface for Stage 1, a low air-loss bed. The nurse can automatically order a bed but it would not require a wound care consult/assessment. If the pressure ulcer develops into a Stage 3 or above, a wound care consult is required.

Review of Policy Number: BHM BCH-GPR 83; Type: Departmental; Policy Title: Wound Management Guidelines; Revision Date: 2016/12/02; Procedures to Ensure Compliance: 1. Skin Assessment - a. The Registered Nurse (RN) will assess patient's skin for alteration in skin integrity upon admission and every shift thereafter. 2. Patient found to have alteration in skin integrity - a. The RN will document findings in the patient's record. B. If the wound is a pressure injury, notify the attending physician. If present on admission or hospital acquired pressure injury. C. Photographic documentation must be done on admission, discovery during hospitalization, every Wednesday, change in condition of wound, and upon discharge. 4. Pressure Injury Identification - a. Stage one Pressure injury: Intact skin with a localized area of non-blancheable erythema, which may appear differently in darkly pigmented skin. Presence of blancheable erythema or changes in sensation, temperature, or firmness may precede visual changes. 7. Wound Management - c. Basic wound care interventions must be done by the primary nurse using the standing wound care order sets to prevent further alteration in skin integrity. D. These order sets can be initiated by the nurse until patient is seen by the wound care nurse.
Review of Addendum 1 " Therapeutic Surface/ Specialty Bed Algorithm" Development of pressure injury on regular bed and Braden Scale score of 18 or less, "yes" to a Low Air-loss Bed choose which ever is available for your unit.

2.Review of sample patient (SP) #3 Physician Order dated 02/19/2019 revealed to clean wound with normal saline, apply silvadene daily and cover with mepilex. Stop date: 03/21/2019.

Observation of wound care with Staff F revealed the nurse performed a dressing change on SP#3 on 02/20/2019 at 12:40 PM. Staff F changed gloves without performing hand hygiene. Staff F opened a new bottle of normal saline labeled with SP#3 information and dated the bottle. Staff F cleansed the stage 2 pressure ulcer and dried the area in a circular motion with sterile gauze. Staff F applied silvadene cream with a gloved finger. The Nurse Manager reminded Staff F that that pictures had to be taken of the wound. Staff F removed the silvadene with sterile gauze, removed gloves, took pictures and donned another pair of gloves without performing hand hygiene. Staff F reapplied silvadene cream with gloved finger and covered area with mepilex dressing. Dressing dated 02/20/2019 timed 12:57 PM, and initialed.

Interview with Nurse Educator 2 Clarke on 02/20/2019 at 1:03PM, the nurse educator stated when cream is needed for the dressing change, a cotton-tip applicator should be used to apply cream to the wound. Hand hygiene is required when entering and exiting the room.

Interview with Director Infection Prevention on 02/21/2019 at 11:10AM revealed that staff may use foam sanitizer in between glove changes. Handwashing is required when the patient is positive for clostridium difficile or when the hands are visibly soiled. Once hands are not visibly soiled, there is no specific amount of time a staff can utilize the foam sanitizer before washing hands.

Review of Mosby's Skills: Dressing -Dry and Moist-to-Dry revealed Procedure 9. Cleanse the wound. 10. If ordered, apply antiseptic ointment with a cotton-tipped applicator or gauze over the incision. 11. Remove gloves and perform hand hygiene. Don clean gloves. 12. Apply the dressing.

Review of Policy Number: BHM-581.01; Type: Administrative; Policy Title: Hand Hygiene; Responsible Department: Infection Prevention and Control; Review Date: 2017/08/16; Revision Date: 2018/06/08; Definitions: Hand hygiene is a general term that applies to plain hand washing, antiseptic hand wash, or antiseptic hand rub. Procedures to Ensure Compliance: Hand Hygiene must be performed before and after patient contact including donning and doffing of gloves as well as after having contact with anything in patient's environment such as equipment and furniture. Wearing gloves does not replace the need for hand hygiene.