HospitalInspections.org

Based on medical record review, staff interviews, and facility policy and procedures, it was determined that the facility failed to follow MD (Medical Doctor) orders to turn and reposition two patients (P) (P#1 and P#4) of five patients (P#1, P#2, P#3, P#4, P#5) reviewed.


Findings include:


A review of the document "EHC Nurse-Driven Skin Care Decision Tree" revealed that Patients were AT RISK if their Braden Score was 18 or less.
Implement all appropriate interventions and products:
- Repositioning
- Pressure Protection
- Moisture Management


A review of the facility's policy titled "Wound Care Management for WOC Nursing ," effective date 10/18/24, revealed that the policy's purpose was to provide evidenced-based topical wound care therapy included in the patient's individualized plan of care.
PROTOCOL Desired Outcomes:
1. Develop individualized dressing selection recommendations that follow the principles of evidence-based topical therapy by providing passive and active support of wound healing (McNichol et al., 2021).
2. Address systemic factors that affect wound healing including adequate nutrition, hydration, pressure redistribution, and preventing infection.
3. Patient/ family demonstrate understanding of skin breakdown causes and techniques for prevention of further skin breakdown by discharge.


Review of policy titled "Nurse-Driven Skin Care Prevention and Management," effective 02/28/2024, revealed that its' purpose was to document and track pressure injuries that are present on admission to hospital. To prevent and manage skin breakdown and injuries. To promote and maintain general skin health, patient/family/care partner verbalizes understanding of skin breakdown causes and preventative skin care measures by discharge. To provide a systematic, and ongoing assessment tool to identify patients with altered skin integrity and those at risk for development of skin impairments. To provide nursing personnel guidelines for planning and evaluating appropriate interventions for patients with or at risk for skin breakdown.
Procedure:
1. Nursing team members are responsible for completing "It Takes Two" Screening within the
first 8 hours of admission and transfer. Refer to It Takes Two Screening Policy.
2. RN/LPN/LVN are responsible for completing an Integumentary assessment within 8 hours
of admission and repeated every shift. Document assessment in EeMR.
3. RN/LPN/LVN are responsible for assessing patients' risk for the development of pressure
injuries, a Braden Scale risk assessment is completed within 8 hours of admission and
repeated every shift. A patient is at risk if the Braden score is 18 or less.
4. RN/LPN/LVN are responsible for documenting all wounds present on admission (POA) per
EHC operational definition (see definition below).
a. EeMR documentation and photography should be done promptly on admission and
transfer as soon as possible within the first 8 hours to capture an accurate assessment
on admission and transfer.
b. If POA status is clinically undetermined, document as such in EeMR.
c. Continue to document suspected differential wound assessment and/or the possibility
the wound condition is POA as the condition evolves, regardless of timeframe.
Nursing team members are responsible for photographing of wounds using hospital-issued
handheld devices should be taken at the determined standard intervals:
a. All admissions and transfers, within the first 8 hours of admission or transfers during the
It Takes Two procedure.
b. Every 7-10 days; tasked every Wednesday known as "Wound Wednesday" unless a
photo has been taken and recorded in EeMR within the last 72 hours or not clinically
indicated.
c. Upon discharge at last dressing change or within 72 hours of discharge unless not
clinically indicated.
d. Wound photos can be rescheduled if not clinically indicated on Wednesday. Acceptable
contraindications include:
i. Approximated/closed surgical incision
ii. Difficult or non-removable dressing change not due
iii. Informed by provider or WOC nurse to reschedule
iv. Palliative/hospice care
Patient/care partner refusal
vi. Patient is too unstable
vii. Patient is unavailable due to long procedure
viii. Uncontrolled pain or discomfort
e. Clearly communicate outstanding photo needs during beside shift reports or nurse to nurse
patient handoffs.
f. Wounds in scope for photography: pressure injury; venous ulcer; arterial ulcer, diabetic/neuropathic ulcer; open incision; skin tear; burn; traumatic wound; radiation wound; soft tissue necrosis; moisture associated skin damage; medical adhesive related skin Injury; blister; mass/tumor; skin graft; or other skin abnormalities based on clinical judgment.
A WOC nurse should be consulted for all patients admitted with unstageable, deep tissue injuries, stage 3 or 4 pressure injuries, full thickness wounds, and all suspected hospital acquired pressure injuries. Patients were turned and repositioned every 2- 4 hour and as needed. At risk patients with a Braden of 18 or less were required more frequent turning.


1. A review of P#1's medical record revealed an MD order on 9/11/24 at 6:00 p.m., to reposition every two hours.

Flowsheet assessments from 9/12/24 at 12:15 after midnight until P#1's discharge on 10/10/24 at 6:11 p.m. failed to reveal that P#1 was consistently turned every two hours per doctor's orders. Each week revealed more than two-hour time lapses to turn and reposition P#1.


2. A review of medical records for P#4 revealed that P#4 was admitted to the facility on 7/2/24 at 7:03 p.m. with the diagnosis of Acute Respiratory Failure with Hypoxia (when there isn't enough oxygen in the body's tissues).


A review of the History and Physical (H&P) on 7/2/24 at 8:08 p.m. revealed that P#4 had a heart transplant in November 2022 and had a past medical history of End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids) and was on Hemodialysis (a procedure that filters the blood of a person whose kidneys are no longer working properly).


Documentation under the nursing progress notes on 10/2/24 at 10:59 a.m. revealed that P#4 had a partial thickness/shallow wound on the right posterior thigh, which was not present on admission.


An electronic medical record review at the facility revealed that P#4 was not turned two-hourly as per the order.
Documentation for P#4 revealed the following:
On 7/2/24, last turned at 7:50 p.m. and was not turned again until 2:00 a.m.
On 7/3/24, last turned at 1:44 p.m. and was not turned again until 6:00 p.m.
On 7/12/24, last turned at 6:00 a.m. and was not turned again until noon.
On 7/13/24, last turned at 5:22 a.m. and was not turned again until 8:00 p.m.
On 7/14/24, last turned at 6:00 a.m. and was not turned again until 8:00 p.m.
On 7/15/24, last turned 6:00 a.m., and was not turned again until 8:00 p.m.
On 7/22/24, last turned at 6:00 a.m. and was not turned again until 8:00 p.m.
On 8/5/24, last turned 8:00 p.m., and was not turned again until 8:00 a.m. the next day.
On 8/7/24, last turned at 1:00 a.m. and was not turned again until 8:00 a.m.
On 8/13/24, last turned at 12:00 a.m. and was not turned again until 8:00 a.m.
On 9/13/24, last turned at 6:00 a.m. and was not turned again until 7:43 a.m.
On 9/17/24, last turned at 6:00 a.m. and was not turned again until 4:00 p.m.
On 9/19/24, last turned at 2:00 p.m. and was not turned again until 8:00 a.m.
On 9/26/24, was last turned at 8:00 p.m. and was not turned again until 10:00 a.m. the next day 9/27/24.


An interview took place in the facility's conference room on 10/29/2024 at 11:30 a.m., with Director, Wound Care Nurse (WCN) DD who stated that P#4 had an unstageable pressure injury (a full-thickness skin and tissue loss where the extent of damage is not clear because the base of the wound is covered with dead tissue) present on admission, which was adequately cared for and got better before P#4 left. WCN DD stated that the wound P#4 had on his right posterior thigh was an abrasion and not a pressure injury, which was also healed by the time patient was discharged.


An interview took place at the facility's conference room on 10/29/2024 at 12:20 p.m. with Wound Care Nurse (WCN) CC who stated that she saw P#4 back in August when patient needed a debridement (a medical procedure that removes dead, damaged, or infected tissue from a wound to help the healthy tissue heal) because the wound on the sacrum had a lot of necrotic (dead) tissue. WCN CC stated that she called P#4's family member to give an update regarding the debridement, and family member of P#4 only had a concern if the wound was infected, which was not.


An interview took place at the facility's conference room on 10/29/2024 at 12:35 p.m., with Registered Nurse (RN) FF who stated that she could not recall P#4. However, if a patient comes in with wounds present on admission, an assessment would be done with another nurse for verification purposes, pictures would be taken, and the wound care protocol would be followed.


An interview took place at the facility's conference room on 10/29/24 at 1:10 p.m. with Patient Care Technician (PCT) HH who stated that P#4 had wounds and was on a two-hourly turn. PCT HH stated that she rounded on all patients assigned to her at 10:00 a.m. where she would clean/groom patients. PCT HH stated that if she was with a patient, and she could not make it to another patient on time, she would call the nurse to help.


An interview was conducted with Registered Nurse (RN) II on 10/29/2024 at 2:01 p.m., RN II stated that she remembered P#1 and that patient was admitted to the unit in the late evening hour towards the end of her shift. She said P#1 had some pinkish excoriation to sacral area on the initial assessment. She stated she conducted P#1's assessment towards the end of her shift and remembered that P#1's family member was present at shift change on the day of P#1's admission. RN II stated that she spoke with P#1's family member and informed her that wound care would come to assess P#1's wound. She said that patients are repositioned and turned every two hours to prevent pressure ulcers and patients that can't call out for help were checked on the same schedule as other patients. RN II recalled that P#1's family was always at the patient's bedside.


An interview was conducted with Licensed Practical Nurse (LPN) KK on 10/29/2024 at 3:33 p.m. LPN KK stated that she remembered P#1 and that she required total care. LPN KK stated she was P#1's discharging nurse, and that P#1 was discharged to home hospice care. She said P#1 was medicated for pain prior to discharge. She said some of the supplies P#1 needed prior to the outside agency taking over were sent home with her. LPN KK stated that P#1's family was aware that P#1 had a sacral wound. LPN KK said that she provided P#1 with daily care and was turned every two hours and as needed per protocol. She said that if she noticed any change in any of her patients' condition, she'd notify her charge nurse of the changes.