HospitalInspections.org

Based on document review and interview, it was determined that for 2 of 10 clinical records (Pt. #1 and Pt. #9) reviewed for pressure ulcer prevention and care, the hospital failed to ensure that the wound care nurse was notified for a consult and failure to ensure that turning and repositioning was done every 2 hours to prevent pressure ulcers, as required.

Findings include:

1. On 5/16/2025, the hospital's procedure titled, "Skin Bundle" (dated 3/2024) was reviewed and indicated, " ...Keep turning - Reposition patient at least every two hours when in bed."

2. On 05/16/2025, the hospital's policy titled, "Patient Assessment and Reassessment" (undated) was reviewed and required, "Skin Risk Assessment ... within 4 hours upon admission... Braden Skin Risk Score for 18 or less - Initiate Skin Bundle ... Wound Care Specialist for accurate documentation and appropriate referral ..."

3. On 5/16/2025, Pt. #1's clinical record (dated 9/24/2024 through 10/16/2024) was reviewed and indicated:

Pt. #1's outpatient clinical record (dated 9/24/2024) noted that Pt. #1 was admitted for outpatient surgery for [Right video assisted thorascopic surgery, right lower lobectomy, lymph node dissection with bronchoscopy]. Pt. #1 was transferred to ICU (intensive care unit) on 9/24/2024 following Pt. #1's outpatient surgery.

Pt. #1's ICU skin assessment (dated 9/24/2024 at 2:38 PM) noted, "bruising upper arms, wound buttocks -blanchable erythema (a reddened area of skin that turns white when pressure is applied and then immediately returns to its normal color when pressure is released. This indicates healthy blood flow and tissue viability). Braden score 14 - (risk assessment - total score determines the patient's risk level - very high risk - total score of 9 or less, high risk -total score of 10-12, moderate risk -total score 13-14 and mild risk - total score 15-18). Foam dressing applied."

Wound documentation dated 10/11/2024 written by E #1 -Wound Nurse notes, "Left sacrum stage 2 pressure injury, 1.5 cm x 1 cm x 0.05 cm."

Pt. #1's nursing flowsheets (dated 9/24/2024 through 10/16/2024) were reviewed and lacked documentation of repositioning Pt. #1 on the following dates and times:

- 9/25/24 from 8:00 PM to 8:00 AM (12 hours instead of every 2 hours)
- 9/26/24 from 8:00 PM to 8:30 AM (12 hours and 30 minutes instead of every 2 hours)
- 9/27/24 from 8:30 AM to 8:00 PM (11 hours and 30 minutes instead of every 2 hours)
- 9/27/24 from 10:00 PM to 8:00 AM (10 hours instead of every 2 hours)
- 9/28/24 from 8:00 PM to 8:00 AM (12 hours instead of every 2 hours)
- 9/29/24 from 8:00 AM to 8:00 PM (12 hours instead of every 2 hours)
- 9/30/24 from 8:00 AM to 8:00 PM (12 hours instead of every 2 hours)
- 10/1/24 from 6:00 AM to 10:26 AM (4 hours and 26 minutes instead of every 2 hours)
- 10/2/24 from 10:26 AM to 6:15 AM on 10/3/24 (approximately 20 hours instead of every 2 hours)
- 10/4/24 from 8:00 AM to 8:30 PM (12 hours and 30 minutes instead of every 2 hours)
- 10/5/24 from 12:00 PM to 8:00 PM (8 hours instead of every 2 hours)
- 10/5/24 from 8:00 PM to 5:00 AM on 10/6/24 (9 hours instead of every 2 hours)
- 10/7/24 from 2:00 AM to 6:00 AM (4 hours instead of every 2 hours)
- 10/8/24 from 12:00 AM to 4:00 AM (4 hours instead of every 2 hours)
- 10/9/24 from 4:00 AM to 8:00 PM (16 hours instead of every 2 hours)
-10/10/24 from 8:00 AM to 8:00 PM (12 hours instead of every 2 hours)
- 10/11/24 from 8:00 AM to 8:00 PM (12 hours instead of every 2 hours)
- 10/12/24 from 9:00 AM to 8:00 PM (11 hours instead of every 2 hours)
- 10/13/24 f:rom 8:00 AM to 8:00 PM (12 hours instead of every 2 hours)
- 10/15/24 from 6:45 AM to 8:00 PM (approximately 13 hours instead of every 2 hours)
- 10/16/24 from 8:00 AM to 8:00 PM (12 hours instead of every 2 hours)
- 10/17/24 from 8:00 AM to 8:00 PM (12 hours instead of every 2 hours)

4. On 05/17/2025, Pt. #9's clinical record was reviewed. Pt. #9 was admitted to the hospital on 05/12/2025, with a diagnosis of generalized weakness. The initial nursing assessment on 05/12/2025 at 1348 (1:48 PM) included a skin/wound assessment, with a Braden Score of 17. A pressure injury was identified on the sacrum described as: "Skin/Sacrum: Redness/Purple, Non-Blanching." The clinical record lacked documentation that the wound care nurse was notified for a consult.

Pt. #9's nursing flowsheets (dated 05/15/2025 through 05/17/2025) were reviewed and lacked documentation of repositioning Pt. #9 on the following dates and times:

- 05/15/2025 from 12:00 AM to 3:15 PM (15 hours and 15 minutes)
- 05/16/2025 from 12:15 AM to 1:30 PM (13 hours and 15 minutes)
- 05/16/2025 from 8:00 PM to 05/17/2025 at 4:00 AM (15 hours and 30 minutes)

5. On 05/16/2025 at approximately 12:20 PM, an interview was conducted with the ICU Manager (E #4). E #4 stated that all patients in the ICU will have an initial nursing assessment that includes two staff to assess the skin to identify if any existing wounds or skin alterations. If the patient has impaired skin integrity or pre-existing wounds, the nurse will initiate the skin bundle, which includes adding a special mattress, heel protectors, moisture prevention, turning every 2 hours, consulting the wound care nurse and notifying the physician.

6. On 5/16/2025 at 1:00 PM, an interview was conducted with the Wound Nurse (E #1). E #1 stated that patients should be turned every 2 hours. E #1 stated that E #1 assessed Pt. #1's pressure ulcer. E #1 stated that developed a pressure ulcer while in the hospital.

7. On 5/16/2025 at 2:20 PM, an interview was conducted with the ICU Registered Nurse (E #6). E #6 stated that patients should be turned every two hours.