HospitalInspections.org

Based on review of medical records (MR), hospital policies and procedure, home health agency MR, and interviews, it was determined the facility failed to ensure staff:

1. Documented complete wound care orders.

2. Performed wound care as ordered.

3. Performed wound assessments per the hospital policy.

4. Documented the position of the patient every two hours accurately and/or as ordered by the physician.

These deficient practices did affect two of three MRs reviewed with wounds, including Patient Identifier (PI) # 1 and PI # 3, and had the potential to affect all patients served by the hospital with wounds.

Findings include:

Hospital Policy: Pressure Ulcer Treatment/Alteration of Skin Integrity Treatment

Policy Number: Not documented

Scope: Nursing Services

Reviewed Date: 1/24

...Policy: Patients will be assessed on admission, by an RN (Registered Nurse), and daily, by a licensed nurse ... the nurse will implement appropriate wound management strategies ...and document in the patient's MR at a minimum and as applicable:

The stage of the wound ... Location ... Describe tissue type and/or wound bed (granulation, necrotic, eschar, slough, and/or epithelial), Size including length, width, and depth in centimeters (cm) (every 7 days), Presence and location of tunneling and/or undermining, describe exudate/drainage (odor, color, type, and/or character), describe surrounding tissue ...

Procedure: An RN will perform assessment of the patient on admission to inspect for breaks in the integrity of the skin. A licensed nurse will reassess daily...

All assessments, interventions, and consults will be documented in the patient's MR ...

Hospital Policy: Patient Assessment

Policy Number: Not documented

Scope: Nursing Services

Reviewed Date: 12/23

...Policy: ...Significant changes in assessment are reported to the attending physician (i.e... wounds...).

1. PI # 1 was admitted to the hospital on 3/3/24 with diagnoses including Acute Urinary Tract Infection, Altered Mental Status, and Acute Kidney Injury.

Review of the nursing note dated 3/4/24 at 8:00 AM revealed the patient had a stage 2 pressure ulcer on the buttocks. There was no documentation of the exact location of the ulcer, the wound bed, the size, the presence of tunneling and/or undermining, exudate/drainage, and the surrounding tissue. There was no documentation the physician was notified of the stage 2 pressure ulcer to the buttocks.

Review of the 15 nursing shift assessments dated 3/5/24 until discharge on 3/12/24 revealed no documentation of the stage 2 pressure ulcer documented on 3/4/24.

Review of the PT (Physical Therapy) Initial Evaluation dated 3/11/24 revealed the patient was maximum assistance for bed mobility, including turning and changing position.

Review of the Patient Activity (every two hour turning and repositioning) entries dated 3/11/24 to 3/12/24 revealed 21 of 31 entries failed to document the position of the patient, and 10 of the 31 entries revealed documentation the patient could turn her/himself.

Review of the MR revealed PI # 1 was discharge home with home health on 3/12/24.

Review of the home health agency admission note dated 3/13/24 revealed the patient was maximal assistance for bed mobility, had a stage 2 pressure ulcer to the sacrum measuring 3 cm (centimeters) in length, 0.5 cm in width, and 0.1 cm in depth, maceration (A softening and breaking down of skin resulting from prolonged exposure to moisture) to the groin with peeling skin, and a rash to the groin and between the thighs.

An interview was conducted on 7/10/24 at 9:36 AM with Employee Identifier (EI) # 9, Physical Therapist (PT) who performed the PT evaluation. EI # 9 verbalized when maximum assistance with bed mobility is documented, it means the patient is unable to do anything on their own, even if asked to roll to side, the patient is unable to do so. EI # 9 also verbalized PI # 1 had difficulty following commands and could not turn at all. EI # 9 further verbalized PI # 1's eyes would be open, but he/she couldn't give a verbal reply and most of the time when shown a command, such as raising an arm, the patient did not follow the command.

An interview was conducted on 7/10/24 at 10:34 AM with EI # 6, Licensed Practical Nurse (LPN), who performed PI # 1's discharge on 3/12/24. EI # 6 verbalized when a patient had been in the hospital several days and no report (from other nurses/staff) was received the patient had a wound, "I don't necessarily check" the patient's skin for a wound when performing a skin assessment. EI # 6 verbalized, "...I don't go looking for something that wasn't reported to me. Also, if the patient is not complaining of discomfort, I don't look..."

An interview was conducted on 7/10/24 at 2:05 PM with EI # 1, Quality and Risk Director, and EI # 2, Chief Nursing Officer, who confirmed the hospital staff failed to perform wound assessments per the hospital policy and documented the patient's position accurately. EI # 1 and EI # 2 confirmed there was no documentation the physician was notified and/or aware of the stage 2 pressure ulcer to the buttocks.

2. PI # 3 was admitted to the hospital on 7/3/24 with diagnoses including Pressure Injury of Sacral Region of back Stage IV (four) and Paraplegia.

Review of the Provider orders dated 7/3/24 at 4:17 PM revealed an order to turn the patient from side to side every two hours.

Review of the Patient Activity entries dated 7/3/24 to 7/8/24 revealed 107 of 113 entries failed to document the position of the patient in the bed and 20 of the 113 entries revealed documentation the patient could turn him/herself.

Review of the Provider orders dated 7/4/24 at 2:24 PM revealed an order to perform a wet to dry dressing change with Dakin's solution (mixture of sodium hypochlorite and boric acid diluted in water), gauze, and tape twice daily. There was no documentation of the wound location for the dressing change.

Review of the Provider orders dated 7/4/24 at 4:49 PM revealed an order to perform a wet to dry dressing change with Dakin's solution, gauze, and tape every 12 hours. There was no documentation of the wound location for the dressing change.

Review of the nursing notes dated 7/5/24 revealed no documentation wound care was performed per the provider order.

Review of the five nursing notes dated 7/6/24 to 7/8/24 revealed the patient had a sacral wound with tunneling of 2 to 3 cm. There was no documentation of the location of the tunneling to the wound.

Review of the nursing notes dated 7/7/24 revealed wound care was provided at 4:00 AM and 9:00 AM, which was 5 hours apart instead of the 12 hours per the provider order. There was no documentation wound care was provided again on 7/7/24.

Review of the Provider orders dated 7/8/24 at 12:58 PM revealed an order to clean and pack wound with Dakin's solution, cover with gauze, and reinforce with paper tape and abdominal pad twice a day and as needed when soiled. There was no documentation of the wound location for the dressing change.

An observation was conducted on 7/8/24 at 5:00 PM with EI # 3, LPN, and EI # 4, Registered Nurse, to observe wound care provided to PI # 3.

Prior to performing the wound care, EI # 3 and EI # 4 turned the patient to the right side using the bed sheet and EI # 4 continued to hold the patient on the right side along with adjusting the position of the patient due to the patient's inability to perform any action to facilitate turning or repositioning self.

During the wound care, the following four wounds were observed along with red blanchable areas surrounding each wound.

a. Wound one was to the sacral area, with a necrotic wound bed. The wound measured 9.5 cm in length, 7 cm in width, and 1.75 cm in depth with tunneling at approximately the 7 o'clock position of 2.25 cm and at the approximately 11 o'clock position of 1.5 cm. The wound was provided per orders.

b. Wound two was a stage 2 pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) to the left buttock measuring approximately (surveyor observation) 6 cm in length, 2 cm in width, and 0.1 cm in depth. The wound was covered with an abdominal dressing and tape. The staff failed to clean and pack the wound with Dakin's solution and cover the wound with gauze.

c. Wound three was a deep tissue injury (DTI, persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues.) with a black center to the left gluteal fold. The wound measured (performed by EI # 3) 1.75 cm in length, 2 cm in width, and 0 cm in depth, a moisture barrier cream was applied to the wound. There was no documentation of a provider order for a moisture barrier.

d. Wound four was a DTI to the right gluteal fold with a dark red/maroon center. The wound measured (performed by EI # 3) 0.25 cm in length, 0.5 cm in width, and 0 cm in depth, a moisture barrier cream was applied to the wound. There was no documentation of a provider order for a moisture barrier.

Review of the nursing note dated 7/8/24 at 5:00 PM revealed the nurse failed to document the sacral wound tunneling at the approximately 11 o'clock position. There was no documentation of wound two, wound three, and wound four.

Further review of the nursing note dated 7/8/24 at 5:00 PM revealed the nurse documented education was provided to the patient on turning every two hours. There was no education on turning every two hours provided to the patient during the observation.

Interviews were conducted on 7/10/24 with three staff members, two nurses and one patient care technician, who had cared for PI # 3 during the hospital stay. The three staff members verbalized PI # 3 had not been able to turn and reposition self in the bed from the time of admission through 7/10/24.

An interview was conducted on 7/10/24 at 1:49 PM with EI # 1 and EI # 2 who confirmed the hospital staff failed to document complete wound care orders, perform wound care as ordered, and failed to perform wound assessments per the hospital policy.