HospitalInspections.org

Based on document review and interview, nursing services failed to place a wound care consult for an at risk patient, for 1 of 10 MRs (Medical Record) reviewed. (Patient # 2).

Findings include:

1. Review of established policy titled: Pressure Injury Prevention Assessment and Treatment, Policy number: SMMC.PCS-P 1.0, indicated on page 3, under Protocol for Consulting Wound Care Nurse Team, 7.0, 3rd point, indicated Any patient with a Braden score <=14 will be seen by Wound Care Services (consult to be placed). Last effective date 3/2025.

2. Review of Patient # 2 MR, indicated, the following:
(a). Nurse flowsheet on 2/8/2025 for patient's admission reflected Braden score = 13 (moderate risk), and included, but not limited to: On 2/9/2025 - Braden score = 13. On 2/13/2025 - Braden score = 13.
(b). Wound care nurse note on 2/17/2025 - by N # 22 (RN {Registered Nurse} - Wound care nurse) reflected patient seen for impaired skin integrity related to pressure. Present on admission: No. Pressure injury location: Sacrum. Wound classification: full thickness. Stage: 3. Length = 5 cm (centimeter), width = 3 cm, depth = 0.2 cm.

3. In interview on 6/12/2025 at approximately 3:49 pm, with N # 22, confirmed that no wound consult prior to 2/15/2025, when patient # 2 had lower braden score.

4. In interview on 6/12/2025 at approximately 4:15 pm, with A # 3 (Chief Nursing Officer), confirmed that Policy for pressure injury prevention not followed for wound care consult for patient's braden score of 14 or below.