HospitalInspections.org

Based on record review and interview, the Hospital failed to identify opportunities for improvement and changes that will lead to improvement through data collected for 1 Patient (#1) out of a total sample of 12 Patients; Patient #1 developed an unstageable pressure injury while in the Hospital.

Refer to A-0283.

Based on record review and interview, the Hospital failed to identify opportunities for improvement and changes that will lead to improvement through data collected for 1 Patient (#1) out of a total sample of 12 Patients; Patient #1 developed an unstageable pressure injury while in the Hospital.

Findings include:

Review of the Hospital Quality and Safety Plan, effective 2023-2024 and updated December 2022, indicated the following:
-The Hospital Quality Committee of the Board of Directors (QCBD) actively looks for errors and safety hazards.
-Review of events that meet certain criteria will be accomplished in part through the mechanism of root cause analysis (RCA), a systemic approach of individual or pattern problem identification, followed by the institution of appropriate measures to improve patient care, safety, and patient satisfaction and reduce the likelihood of recurrence.
-The QCBD is responsible in assuring all actions are completed in a timely manner and sustained to ensure nor recurrence of the event reported.

The Hospital Policy titled "Nurse Initiated Pressure Injury/ Wound Care Order Protocol", dated 6/1/2021, indicated the following:
-The Nurse will initiate wound treatment orders for any in-patient identified with a pressure injury or wounds as per the nurse-initiated pressure injury / wound care order set.
-The Wound Care Nurse (WOCN) assesses and makes recommendations to the Patient's plan of care, interventions, performs outcome evaluations, and collaborates with other members of the interdisciplinary team.

Patient #1 was admitted to the Hospital on 3/12/22 with diagnoses including sepsis, urinary tract infection, pneumonia, and pressure ulcers.

Review of Patient #1's medical record indicated Patient #1 was admitted to the Hospital on 3/12/22 and was assessed to have a Braden Score of 10 (high risk for skin breakdown), and a quarter-sized Stage 2 pressure ulcer to the left buttock on 3/13/22 at 4:30 A.M. A foam dressing was placed to cover the wound by the Registered Nurse (RN), however, the medical record failed to indicate any orders for the treatment of Patient #1's Stage 2 pressure ulcer were initiated in the Electronic Medical Record (EMR). Further, Patient #1's medical record failed to indicate an order for a WOCN consult was ever placed for Patient #1 after assessment of the Patient's Stage 2 pressure ulcer on 3/13/22. Review of Patient #1's physical assessments from 3/13/22 to 3/24/22 indicated the Patient continued to have a Stage 2 pressure sore but failed to indicate consistent dressing changes for the Patient. A Physician documented on 3/25/22 at 12:05 A.M. Patient #1 now had an unstageable pressure ulcer at his/her coccyx; an order for a WOCN consult was placed in Patient #1's medical record at this time. On 3/26/22 the Physician documented Patient #1 had a concerning sacral ulcer and a wound care consult had been placed a few days prior, however, it did not seem the WOCN had seen the Patient. On 3/27/22 at 9:39 A.M., Patient #1 was assessed by a General Surgeon for the treatment of his/her unstageable pressure ulcer; the General Surgeon consult indicated Patient #1 had an unstageable sacral decubitus (pressure ulcer), the Patient was soiled with urine and stool and unchanged due to lack of appropriate nursing care and recommended more appropriate fecal and urine management given excessive saturation of the Patient's wound. Patient #1's nursing assessment from 3/27/22 at 4:06 P.M. indicated the Patient's wound had black eschar (dead tissue) in the wound bed. On 3/28/22 at 10:17 A.M., the WOCN assessed Patient #1 (25 days after the discovery of the Stage 2 pressure ulcer). Patient #1's WOCN consult dated 3/28/22 indicated Patient #1's sacrococcygeal pressure ulcer was unstageable, was covered in 100% black eschar, and now measured at 9cm (centimeters) x 6cm with an unmeasurable depth due to the eschar covering the wound; the WOCN entered an order on 3/28/22 into Patient #1's EMR for Santyl (enzymatic debriding agent) and a daily wound dressing for the sacrococcygeal wound (this was the first order for wound care of Patient #1's pressure ulcer since it had been identified on 3/13/22).

Review of Documentation provided by the Hospital indicated the Director of Nursing and Nurse Manager for the unit Patient #1 was admitted to reviewed Patient #1's medical record after receiving a complaint from the Patient's family in April 2022. The documentation further indicated the complaint was also reviewed by the Chief Medical Officer, Chief Nursing Officer, Director of Quality and Risk, Risk Manager, and the Patient Advocate and the investigation was completed on June 8, 2022. The Hospital investigation failed to indicate why wound care orders were not placed for Patient #1 after discovery of his/her stage 2 pressure ulcer, nor why a wound consult was not placed at that time. Further, the investigation failed to address the concerns of lack of appropriate nursing care documented by the General Surgeon on 3/27/22 nor the first assessment conducted by the WOCN on 3/28/22 (25 days from the initial identification of the pressure ulcer and 3 days after the initial order was placed for a WOCN consult.)

The Hospital failed to provide a RCA or evidence of corrective action for the development of a decompensating pressure ulcer for Patient #1.

During an interview with the WOCN on 2/16/23 at 10:00 A.M., she said the first time she assessed Patient #1 was on 3/28/22; Patient #1 had greater than 50% necrotic tissue in his/her wound. She said when a RN or physician put an order in the EMR for a WOCN consult, the order notifies her to assess a Patient for a wound. She said if a pressure ulcer is identified generally an order for a WOCN consult should be ordered at that time. She said she had not been notified to see Patient #1 until 3/28/22. She said nurses are educated when she puts treatments and recommendations in place for Patients. She said no education on the WOCN consult process/ wound management process was provided after Patient #1 developed an unstageable pressure ulcer to his/her sacrococcygeal area.

The Hospital failed to identify opportunities for improvement and changes that will lead to improvement through data collected following the development of an unstageable sacrococcygeal for Patient #1.

Based on record review and interviews, the Hospital failed to ensure licensed nursing staff provided wound care according to the Hospital's policies and procedures for 2 Patients (#1 and #4), who developed decompensating pressure ulcers, out of a total sample of 12 Patients.

Refer to A-0398.

Based on record review and interviews, the Hospital failed to ensure licensed nursing staff provided wound care according to the Hospital's policies and procedures for 2 Patients (#1 and #4), who developed decompensating pressure ulcers, out of a total sample of 12 Patients.

Findings include:

The Hospital Policy titled "Pressure Injury Prevention and Management", revised 11/26/2019, indicated the following:
-Proper management of moisture including incontinence care.
-All preexisting and hospital acquired pressure injuries are reported to the Physician
-A wound care nurse or designee sees Stage 2, 3, 4, unstageable, or deep tissue pressure injuries and an individualized plan of care will be developed for the Patient.

The Hospital Policy titled "Nurse Initiated Pressure Injury/ Wound Care Order Protocol", dated 6/1/2021, indicated the following:
-The Nurse will initiate wound treatment orders for any in-patient identified with a pressure injury or wounds as per the nurse-initiated pressure injury / wound care order set.
-The Wound Care Nurse (WOCN) assesses and makes recommendations to the Patient's plan of care, interventions, performs outcome evaluations, and collaborates with other members of the interdisciplinary team.

1. Patient #1 was admitted to the Hospital on 3/12/22 with diagnoses including sepsis, urinary tract infection, pneumonia, and pressure ulcers.

Review of Patient #1's medical record indicated Patient #1 was admitted to the Hospital on 3/12/22 and was assessed to have a Braden Score of 10 (high risk for skin breakdown), and a quarter-sized Stage 2 pressure ulcer to the left buttock on 3/13/22 at 4:30 A.M. A foam dressing was placed to cover the wound by the Registered Nurse (RN), however, the medical record failed to indicate any orders for the treatment of Patient #1's Stage 2 pressure ulcer were initiated in the Electronic Medical Record (EMR). Further, Patient #1's medical record failed to indicate an order for a WOCN consult was ever placed for Patient #1 after assessment of the Patient's Stage 2 pressure ulcer on 3/13/22. Review of Patient #1's physical assessments from 3/13/22 to 3/24/22 indicated the Patient continued to have a Stage 2 pressure sore but failed to indicate consistent dressing changes for the Patient. A Physician documented on 3/25/22 at 12:05 A.M. Patient #1 now had an unstageable pressure ulcer at his/her coccyx; an order for a WOCN consult was placed in Patient #1's medical record at this time. On 3/26/22 the Physician documented Patient #1 had a concerning sacral ulcer and a wound care consult had been placed a few days prior, however, it did not seem the WOCN had seen the Patient. On 3/27/22 at 9:39 A.M., Patient #1 was assessed by a General Surgeon for the treatment of his/her unstageable pressure ulcer; the General Surgeon consult indicated Patient #1 had an unstageable sacral decubitus (pressure ulcer), the Patient was soiled with urine and stool and unchanged due to lack of appropriate nursing care and recommended more appropriate fecal and urine management given excessive saturation of the Patient's wound. Patient #1's nursing assessment from 3/27/22 at 4:06 P.M. indicated the Patient's wound had black eschar (dead tissue) in the wound bed. On 3/28/22 at 10:17 A.M., the WOCN assessed Patient #1 (25 days after the discovery of the Stage 2 pressure ulcer). Patient #1's WOCN consult dated 3/28/22 indicated Patient #1's sacrococcygeal pressure ulcer was unstageable, was covered in 100% black eschar, and now measured at 9cm (centimeters) x 6cm with an unmeasurable depth due to the eschar covering the wound; the WOCN entered an order on 3/28/22 into Patient #1's EMR for Santyl (enzymatic debriding agent) and a daily wound dressing for the sacrococcygeal wound (this was the first order for wound care of Patient #1's pressure ulcer since it had been identified on 3/13/22).

During an interview with RN #1 on 2/15/23 at 11:00 A.M., she said if a patient is admitted with a wound or develops a wound, she would put something in place for the wound initially and put an order in the EMR for a WOCN consult to alert the WOCN to assess a Patient's wound. She said the order for a WOCN consult transmits to the WOCN and that is how the WOCN is notified a Patient needs to be assessed for a wound.

During an interview with the WOCN on 2/16/23 at 10:00 A.M., she said the first time she assessed Patient #1 was on 3/28/22; Patient #1 had greater than 50% necrotic tissue in his/her wound. She said when a RN or physician put an order in the EMR for a WOCN consult, the order notifies her to assess a Patient for a wound. She said if a pressure ulcer is identified generally an order for a WOCN consult should be ordered at that time. She said she had not been notified to see Patient #1 until 3/28/22.

The Hospital failed to ensure licensed nursing staff provided wound care according to the Hospital's policies and procedures and Patient #1 developed an unstageable pressure



40928


2. Patient #4 was admitted to the Hospital on 4/16/22 with shortness of breath (SOB), sepsis and acute hypoxemic respiratory failure and was assessed to have a Braden score of 12 (a high risk for developing a pressure injury). Patient #4's physical assessment dated 4/16/22 indicated he/she had erythemic (red) skin, flaky skin on the face and dusky legs bilaterally.

Review of Patient #4's medical record indicated Patient #4 was assessed on 4/17/22 to have a Stage 3 Pressure Injury (full thickness skin loss in which fat is visible in the ulcer and granulation tissue and rolled edges are often present) on his/her nasal bridge from a BiPap device (a machine to help push air into lungs); dressing placed to relieve pressure. Nursing documentation for Patient #4 on 4/17/22 failed to indicate a physician was made aware of this new pressure injury nor that orders for a wound consult or wound treatment were ordered for the Patient. On 4/21/22 Patient #4 was assessed to have an unstageable (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) pressure ulcer to his/her medial upper nose. On 4/24/22 Patient #4 was assessed to have black eschar (dead tissue) and bleeding at the unstageable pressure ulcer on his/her nasal medial upper nose. An order was entered in Patient #4's Electronic Medical Record (EMR) on 4/25/22 (7 days after the pressure injury on his/her nose was identified and documented for the first time) for a wound/skin consult.

Further review of Patient #4's medical record indicated the Wound Ostomy Certified Nurse (WOCN) assessed Patient #4 on 4/25/22. The WOCN documentation from 4/25/22 indicated Patient #4 was assessed by the WOCN in the ICU (Intensive Care Unit) for "wound on nose"; the WOCN documentation indicated Patient #4 had a 2cm (centimeter) x 1.2cm unstageable pressure ulcer with unmeasurable depth on the bridge of his/her nose. The WOCN entered orders in Patient #4's EMR for Treatment: cleanse with Vashe (a cleanser), patted dry, applied Vashe moistened Aquacel AG (an antimicrobial dressing) cut to fir the wound bed, followed by thin Duoderm (a moisture retentive wound dressing) on 4/25/22 (7 days after the identification of the Patient's pressure ulcer and 4 days after the wound deteriorated to an unstageable pressure ulcer with necrosis).

-A wound care note dated 4/25/22: Patient seen in bed at upon entering the room with primary nurse, patient appeared lethargic lying supine. Assessment: 2x 1.2x unable to determine depth unstageable Pressure injury on bridge of nose with raised red scab, proximal edges with tiny redness non-blanchable noted, wound caused by BiPap per RN, surrounding skin clean, dry and intact. Please re-consult for wound care or notify MD if skin or wound deteriorates or other issues. Will monitor.

During an interview on 2/15/23 at 11:01 A.M., Nurse #1 said that if a patient is observed with skin that is reddened but intact, the nurse will place a foam dressing for protection. Nurse #1 said that for any skin issues more than reddened, intact skin, the nurse should place an order for a wound consult by the wound nurse. Nurse #1 said nurses can put the order in electronically and it transmits to the wound nurse.

During an interview on 2/16/23 at 10:00 A.M., the WOCN said she could not remember any specifics regarding Patient #4. The WOCN said the expectation is that an order will be placed for a wound care consult if a patient is admitted with a wound or develops a wound during their hospitalization. The WOCN said she is alerted to any orders placed for a wound care consult and tries to respond as soon as she is aware. She said that if an order for a consult is not placed than she has no way of knowing who has a wound. The WOCN acknowledged Patient #4 was documented as having an open area to his/her nose on 4/17/22 and no orders for a wound consult or treatment were placed until 4/25/22, when the wound was documented as being unstageable. The WOCN said that for patients with medical devices, including a BiPap, there is a risk for breakdown from the device and that nursing could implement a protective dressing.

The Hospital failed to ensure licensed nursing staff provided wound care according to the Hospital's policies and procedures and Patient #4 developed an unstageable pressure.