HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the nursing staff notified the family or the next of kin of the Stage 3 PI size progression for one of four sampled patients (Patient 1) as per the hospital's P&P. This failure posed an increased risk of substandard health outcome for the patient.

Findings:

Review of the hospital's P&P titled Core: Interdisciplinary Assessment and Re-Assessment dated June 2023 showed notification responsibilities when an assessment reveals a change or suspected change in condition. The nurse assigned to the patient or supervising care of the patient is responsible for notification of and communication to the patient's primary physician or designee using appropriate channels and chain of command for assuring that there is physician response. Notify the nursing supervisor of patient change in condition. Others are notified as appropriate (Nurse Manager, Chief Clinical Officer...) and per facility designation, including notification of patient's family or significant other. Document change of condition, notification and interventions in the medical record.

Medical record review for Patient 1 was initiated on 8/14/25.

Patient 1 was admitted to the hospital on 4/29/25 and was transferred to the SNF, subacute unit on 5/30/25.

Review of the WCN Notes for Patient 1's community acquired Stage 3 PI on the sacrococcygeal showed the following:

- On 4/30/25 at 1504 hours, the PI wound measured 2 cm (length) by 2 cm (width) by 0.2 cm (depth). Necrotic tissue was not visible. The skin color surrounding the wound was dark red or purple and/or non blanchable.

- On 5/21/25 at 1637 hours, the PI wound measured 3.5 cm by 4.2 cm by 0.2 cm. There was 25% necrotic tissue. The skin color surrounding the wound was black or hyperpigmented.

- On 5/28/25 at 1002 hours, the PI wound measured 4 cm by 5.5 cm by 0.2 cm. There was 40% necrotic tissue. The skin color surrounding the wound was pink or normal for ethnic group.

Review of Patient 1's sacrococcygeal PI photos showed the image on 4/30/25 at 1822 hours, 5/21/25 at 1943 hours, and 5/28/25 at 1739 hours, with the progression of the PI size.

On 8/14/25 at 1428 hours, an interview and concurrent record review of Patient 1's Education Plan for Wound Management was conducted with RN 3. RN 3 stated on 5/14/25, the WCN was unable to contact the patient's family or next of kin to educate about Patient 1's Stage 3 PI; and on 5/21/25, there was no documented evidence the WCN educated the family or next of kin of Patient 1's Stage 3 PI. RN 3 stated the WCN should notify the family and the physician when there was a change in the condition of the wound. RN 3 verified there was a change in the size of the sacrococcygeal PI.

The findings were shared with the COO/CCO and the Director of Quality Management.