HospitalInspections.org

Based on interview and record review, the hospital failed to implement its policies and procedures for the reporting of a serious adverse event to the hospital quality department for "1 of 8 patient records reviewed (Patient #1)."

Failure to report a serious adverse event to the hospital quality department put patients at risk when the quality department is not involved in the investigation and implementation of corrective action.

Findings included:

1. Document review of the hospital's policy titled "Core: Event Reporting System," approved 06/20, showed that staff were to report deaths, serious physical and psychological events to the hospital quality department for review and investigation.

2. Review of Patient #1's medical record showed that:

Patient #1 was admitted to the hospital on 05/29/20 for long-terrn acute care after having surgery for a subarachnoid hemorrhage (brain bleed). The patient was ventilator dependent. The patient was confused but was able to follow simple commands off and on. The patient was unable to move or turn without the assistance of staff.

a. On admit on 05/29/20 the skin assessment showed the patient did not have any pressure ulcers.

b. On 06/29/20 at 8:00 PM, the attending nurse documented the patient had a pressure ulcer to their right buttock. The attending nurse notified the hospital wound care team. No other skin care assessments were documented between 05/29/20 and 06/29/20 when the pressure ulcer was discovered.

c. On 06/30/20 at 5:51 PM, the wound care nurse determined the pressure ulcer was unstagable with black eschar (necrotic tissue) with no tunneling or undermining. The skin around the pressure injury was dark red/purple color and was non-blanchable (skin did not return to pink color when touched).

3. On 10/26/20 at 10:30 AM, Investigator #1 and #2 interviewed the Wound Care Coordinator (Staff #4). Staff #4 stated that she performed a root cause analysis of the pressure ulcer but did not report this to the hospital quality department.

4. On 10/27/20 at 11:30 AM, Investigator #1 and #2 interviewed the Director of Quality Management (Staff #5). Staff #5 verified the above information.

Based on interview and document review, the hospital staff failed to implement its policy and procedure for skin assessments by nursing staff for 1 of 8 patient records reviewed (Patient #1).

Failure to complete a head to toe skin assessment each shift puts patients at risk for poor health outcomes.

Findings included:

1. Document review of the hospital's policy titled, "Assessment and Re-Assessment, " last reviewed 06/20 showed that licensed nursing staff were to perform a complete head to toe skin assessment every 12 hours.

2. Review of Patient #1's medical record showed that the patient was admitted to the hospital on 05/29/20 for long-terrn acute care after having surgery for a subarachnoid hemorrhage (brain bleed). The patient was ventilator dependent. The patient was confused and unable to move or turn without the assistance of staff.

a. On admit on 05/29/20 the skin assessment showed the patient did not have any pressure ulcers.

b. On 06/29/20 at 8:00 PM, the attending nurse documented the patient had a pressure ulcer to their right buttock. The attending nurse notified the hospital wound care team. No other skin care assessments were documented between 05/29/20 and 06/29/20 when the pressure ulcer was discovered.

c. On 06/30/20 at 5:51 PM, the wound care nurse determined the pressure ulcer was unstagable with black eschar (necrotic tissue) with no tunneling or undermining. The skin around the pressure injury was dark red/purple color and was non-blanchable (skin did not return to pink color when touched).

3. On 10/27/20 at 9:00 AM, Investigator #1 interviewed a licensed nurse (Staff #1). Staff #1 stated that skin checks were to be done every 12 hours and more often as indicated by patient condition. If a pressure ulcer or other skin issue was identified this was to be reported to the hospital wound care nurse so that the most appropriate treatment was implemented.

4. On 10/27/20 at 10:15 AM, Investigator #1 interviewed the Director of Nursing Services (Staff #3). Staff #3 verified the above information.