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Based on interview and record review, the facility failed to follow policy and procedures to ensure 1 of 31 reviewed patients (Patient 21) received comprehensive skin assessments to identify early changes in skin integrity and implement interventions to prevent development of a stage III pressure ulcer. (A pressure ulcer refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure ulcer develops when one or more layers of skin and tissue are damaged from continuous pressure to the area. The depth of skin and tissue damage determines the stage of the pressure ulcer, which is on a scale of stage I to stage IV, with stage I the most superficial, and stage IV the deepest ulcer, including damaged skin and muscle down to the level of bone. A stage III ulcer has full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer.)

Nursing staff failed to notify physicians of the need to remove a medical device to inspect all areas of Patient 21's skin. This failure contributed to the delay in recognition of Patient 21's stage III pressure ulcer.

The failure to thoroughly assess Patient 21's skin and implement interventions to prevent development of a stage III pressure ulcer resulted in identification of a stage III pressure ulcer on day 18 post-admission on the back of Patient 21's head underneath a cervical collar. (C-collar, a medical device used to support and immobilize a person's neck after a traumatic head or neck injury. C-collars can be rigid or made of softer materials.) The development of the stage III pressure ulcer resulted in Patient 21 requiring antibiotic treatment and had the potential to progress to a stage IV pressure ulcer which can progress to blood or bone infection.

Findings:

During a review of Patient 21's history and physical (H&P), the H&P indicated Patient 21 had been hospitalized at another hospital after Patient 21 fell and broke a spinal bone in the neck area and had a severe cut to the scalp. The H&P indicated Patient 21 required intensive care following surgery to correct the damage from the fall, including use of a c-collar to stabilize the neck at the first hospital. The H&P indicated Patient 21 was transferred to the current facility on 6/18/24 for continued medical care and had the c-collar in use at the time of transfer to the facility.

During a review of the physician's order dated 6/18/24 for Patient 21, the physician order indicated, "Keep aspen cervical collar (a rigid type of c-collar) on at all times, every shift."

During a review of Patient 21's nursing admission note dated 6/19/24, the wound assessment section did not indicate there was any wound or skin irritation on the back of Patient 21's head.

During a review of Patient 21's nursing skin assessments dated 6/20/24, 6/21/24, 6/22/24, 6/23/24, 6/24/24, 6/25/24, 6/27/24, 6/28/24, 6/29/24, 6/30/24, 7/1/24, 7/2/24, 7/4/24, the skin assessments did not indicate the back of Patient 21's head had any skin irritation or wound.

During a review of Patient 21's wound nurse skin assessments dated 6/19/24, 6/23/24, and 6/30/24, the assessments did not indicate there was any wound or skin irritation on the back of Patient 21's head.

During an interview on 8/27/24 at 10:20 a.m., with the Wound Nurse 1 (WN 1), WN 1 stated wound nurses conducted a comprehensive and thorough head-to-toe skin assessment for new admissions, on a weekly basis and/or as needed.

During a review of Patient 21's facility nurse progress notes titled, "Weekly Wound Assessment," dated 7/6/24, the Assessment indicated a pressure injury was present on Patient's 21's occiput (the back of the skull near the neck junction). The Assessment indicated the wound was 3 centimeters (cm) long and four cm wide with depth not able to be determined. The Assessment indicated the wound bed had black eschar (dead tissue which may appear scab-like) and the wound had thin, yellowish-red drainage. The Assessment indicated the wound was related to the c-collar and was acquired after admission. The Assessment indicated, "Comments: New wound to occiput reported by primary nurse. Unable to assess full extent of wound at this time due to patient's matted hair."

During a review of the Change of Condition (COC) note, for Patient 21, dated 7/6/24, the COC indicated Patient 1 was identified to have a Stage III pressure injury on the back of Patient 21's head, 18 days after Patient 21's admission.
During a review of the Change of Condition (COC) note, for Patient 21, dated 7/6/24, and the addendum dated 7/7/24, the COC indicated Patient 1, "needed to have more hair cut, or removed to fully re-evaluate her scalp area ....Client's scalp was checked, more matted hair was cut, and wound was evaluated further to make sure, infection doctor was notified as well .... antibiotics ordered for patient."

During an interview on 8/29/24 at 2:30 p.m., with Patient 21's primary physician (MD), MD stated Patient 21 was transferred to their facility from another hospital. MD stated the c-collar order was initially written by a surgeon from the previous hospital and had been continued by MD's associate upon admission to the facility. MD stated MD had not been asked by any nurses during Patient 21's daily rounds about clarification of the c-collar "on at all times" order. MD stated if the c-collar was to be removed for a skin assessment or cleaning of the area, and multiple staff members would be needed to stabilize Patient 21's neck during the procedure. MD stated assessment of the entire body was necessary to ensure all irregularities were identified and treated. MD stated if Patient 21 had not received treatment for the stage III ulcer, the ulcer could have gotten worse and progressed to a stage IV.

During an interview on 8/29/24 at 3:35 p.m. with the Nurse Educator (NE), the NE stated the admitting nurse was to complete a patient's general skin assessment, followed by a more comprehensive skin assessment by the wound nurse. The wound nurse was responsible to identify patients at risk of pressure injury, presence of any pressure injury/ulcer and stage of any ulcers present. The NE stated the written physician order, "do not remove c-collar," should have been clarified: there was significant risk for Patient 21 to develop a wound under the c-collar pressure points. NE stated nursing staff had not reported the increased risk of pressure ulcer development from Patient 21's constant wearing of the c-collar to a physician.

During a telephone interview on 8/30/24 at 10:51 a.m., with Patient 21, Patient 21 stated the c-collar was placed four to six weeks before the pressure ulcer was found. Patient 21 stated her hair had been long and matted in the back when she was transferred to the facility. Patient 21 stated when a family member (FM) assisted a nurse to remove the tangled hair, FM and the nurse discovered a wound underneath the c-collar. Patient 21 stated no one had removed the c-collar to check under the c-collar before that time. Patient 21 stated her hair was cut twice so the pressure ulcer could be seen clearly. Patient 21 stated antibiotic therapy was needed to prevent infection of the pressure wound.

During a review of the facility's policy, "Core: Wound Care Team Assessment," dated 6/2021, the policy indicated, "The policy of Kindred Hospital is to ensure the Wound Care Team is accountable for every patient having a thorough skin and wound assessment on admission and appropriate intervals thereafter."

During a review of the facility's policy, "Core: Skin & Wound Care Program Overview," with a release date 06/2023, the policy indicated the hospital is to ensure the "Pressure ulcer risk assessment" was completed by admitting nurse upon admission, then daily; and the wound care nurse upon admission, then with each subsequent wound assessment. The policy indicated, "Practice Standards/Procedures: Wound care approaches and products should be evidence-based and consistent with the Agency for Healthcare Research and Quality (AHRQ), Wound Ostomy and Continence Nurses Society (WOCN), and Centers for Disease Control (CDC) Guidelines, National Pressure Injury Advisory Panel (NPIAP), and within individual state practice acts."

During a review of the National Pressure Injury Advisory Panel (NPIAP) book titled," Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline 2019," third edition, 2019, the book indicated, "Device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. Non-medical devices (e.g., bed clutter, furniture and equipment) can also result in pressure injuries when they (usually inadvertently) remain in contact with skin and tissues. The resultant pressure injury generally closely conforms to the pattern or shape of the device.1 Potential sources of device related pressure injuries include ...cervical collars."

During a review of the NPIAP article, "Pressure Injury Prevention Points," dated 2016, the article indicated, "Inspect all of the skin upon admission as soon as possible (but within 8 hours). Inspect the skin at least daily for signs of pressure injury, especially nonblanchable erythema (area of redness that does not disappear under applied pressure). Assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters, elbows and beneath medical devices."

During a review of the AHRQ article, "Preventing Pressure Ulcers in Hospitals," reviewed February 2024, the article indicated, Comprehensive skin assessment is a process by which the entire skin of every individual is examined for any abnormalities. It requires looking and touching the skin from head to toe, with a particular emphasis over bony prominences ... As the first step in pressure ulcer prevention, comprehensive skin assessment has a number of important goals and functions. These include: Identify any pressure ulcers that may be present."