HospitalInspections.org

Based on policy review, medical record review and interview, the hospital failed to ensure pressure injuries were routinely assessed for 1 of 4 (Patient #1) sampled patients with pressure injuries.

The findings included:

1. Review of the facility's "Wound Assessment..." policy documented, "...All patients admitted will have a skin assessment within 8 hours of admission and skin will be assessed every shift...Deep Tissue Pressure Injury (DTPI)...This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury......"

Review of the facility's "Wound Photography" policy documented, "...at discharge, all abnormal, non-intact, non-healthy skin will be photographed (within 1 day before discharge) by the Charge Nurse/House Supervisor or Wound Nurse..."

2. Medical record review revealed Patient #1 was admitted to the facility on 12/17/18 with diagnoses to include Traumatic Respiratory Failure after a motor vehicle accident and Quadriplegia. Patient #1 was discharged from the hospital to a rehabilitation facility on 1/8/19.

The admission history and physical dated 12/17/18 documented, "...Plan...wound care consults..."

An admission wound assessment progress note dated 12/17/18, revealed a sacral pressure injury present on admission that measured 4centimeters (cm) in length, 3cm in width, skin intact, no depth. Periwound skin color was dark red or purple and non-blanchable. Wound management was a zinc based barrier cream. A photograph dated 12/17/18 was labeled as suspected deep tissue injury/deep tissue injury ("sDTI/DTI").

A physician order dated 12/17/18 revealed to apply zinc/menthol ointment to skin two times daily (BID) and as needed (PRN) to the gluteals/peri area.

Weekly wound assessment progress notes dated 12/26/18 and 1/2/19 revealed a sacral pressure injury present on admission that measured 3cm in length, 3cm in width, skin intact, no depth. Periwound skin color was dark red or purple and non-blanchable. Wound management was a zinc based barrier cream. A photograph dated 12/26/18 was labeled as "sDTI/DTI".

Patient #1 was discharged to a rehabilitation facility on 1/8/19.

There was no documentation the sacral pressure injury was assessed between 1/2/19 and 1/8/19.

The discharge summary dated 1/8/19 revealed no documentation of a pressure injury.

The receiving facility's medical record review revealed Patient #1 was admitted on 1/8/19 for rehabilitation.

Review of a wound care initial assessment at the receiving hospital dated 1/9/19 revealed Patient #1 had a stage 3 pressure injury to the sacrum that measured 9cm length, 6cm width, and 1cm depth. The wound description documented, ..."edges separated, granulated, necrotic tissue, slough..." A photograph of the wound dated 1/9/19 verified the description of the sacral pressure injury.

During an interview in the conference room on 3/6/19 at 12:15 PM, the Wound Care Nurse (WCN) was asked about Patient #1's deep tissue injury. The WCN stated, "According to NPUAP [National Pressure Ulcer Advisory Panel], a DTI can start to open but still be dark around the open area and is still classified as a DTI if it was flat, and can use Calmoseptine or a skin prep around the area with a foam dressing on it. The WCN was asked what treatment was provided for the open area found on 1/2/19 on Patient #1. The WCN stated, "Normally, we use Calmoseptine until they open and have significant depth where we need to change the course of treatment...We see complex wounds daily and others non-complex and DTI's we see weekly..."

There was no documentation of any treatment changes for Patient #1 from admission to discharge.

Interview in the conference room on 3/6/19 at 3:30 PM, the Director of Quality Management (DQM) was asked about Patient #1's pressure injury. The DQM stated Patient #1's father came back on January 24, 2019 and showed her and the Chief Executive Officer (CEO) a picture of the wound.
The DQM confirmed they should have looked at the pressure injury and documented the appearance on the day Patient #1 was discharged.