HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the RN supervised and evaluated the care of each patient. This deficient practice was evidenced by:
1. Failure to ensure wound care RN notified the physician after assessing a patient with deteriorating wound prior to patient discharge for 1 (#1) of 3 (#1-#3) patients sampled with wounds.
2. Failure to ensure the RN documented Braden score every shift, per hospital policy, for 1 (#3) of 3 (#1-#3) sampled patients with wounds.
Findings:

Review of the hospital policy titled "Wound Care: Assessment, Staging and Treatment of Pressure Injury" with an original creation date 03/1989 and next review date 05/2025 revealed, in part: "Policy: 1. Assess and document Braden score, skin integrity, and actual/suspected skin breakdown: b. Every shift and with acute changes by primary nurse. Document in EMR: 1. Skin assessment and Braden score with initial assessment and then every shift or for acute changes in condition or Braden Assessment."

1. Review of Patient #1's medical record revealed an admit date 11/22/2024. Patient #1 had the diagnoses of peripheral vascular disease, stroke, end stage renal disease, and coronary vascular disease.

Review of Patient #1's nurses' notes revealed Patient #1 had wounds to buttocks. Further review of assessments of wounds revealed, in part:
12/12/2024, AM assessment: Drainage amount: small. Wound odor: none.
12/12/2024, PM assessment: Drainage amount: small. Wound odor: mild.
12/13/2024, AM assessment: Drainage amount: small. Wound odor: mild.
12/13/2024, PM assessment: Drainage amount: small. Wound odor: foul.
12/14/2024, AM assessment: Drainage amount: small. Wound odor: mild.
12/14/2024, PM assessment: Drainage amount: scant. Wound odor: foul.
12/15/2024, AM assessment: Wound bed progress: deteriorating. Drainage amount: moderate. Wound odor: foul.
12/15/2024, PM assessment: Wound bed progress: deteriorating. Drainage amount: moderate. Wound odor: foul.

Review of Patient #1's physician "Progress Notes" dated 12/15/2024 revealed, in part: "Nurses at bedside concerned that sacral wounds seem deeper. Wound care re-consulted."

Review of Patient #1's wound care "Progress Notes" dated 12/16/2024 by S4RN, Wound Care, revealed, in part: "Assessed in room with S6RN, Wound Care. Sacrum extending to bilateral buttocks unstageable. Mild odor noted. As per (S5MD) recommendation will continue enzymatic debridement."

Review of Patient #1's medical record revealed, in part, S5MD recommended enzymatic debridement on 12/10/2024. Further review of Patient #1's medical record revealed no evidence RN wound care nurses contacted the physician after assessing the patient's wounds on 12/16/2024.

Review of Patient #1's medical record revealed the patient discharged from the hospital 12/16/2024.

In an interview on 02/11/2025 at 10:13 AM, S4RN, Wound Care confirmed Patient #1's physician was not notified of buttock wound with odor after assessing the patient on 12/16/2024. S4RN, Wound Care confirmed S5MD's recommendations from 12/10/204 were used to treat Patient #1's sacrum to bilateral buttocks wound on 12/16/2024.

In an interview on 02/11/2025 at 11:23 AM, S2Dir. PSQ confirmed Patient #1's buttocks wound deteriorated from 12/12/2024 to 12/16/2024. S2Dir. PSQ confirmed there was no evidence wound care RNs notified the physician after assessing Patient #1 on 12/16/2024. S2Dir. PSQ confirmed Patient #1 was discharged from the hospital on 12/16/2024.

2. Review of Patient #3's medical record revealed an admit date 12/05/2024. Patient #3 had the diagnoses of chronic stage IV ulcers of the sacrum and both hips, chronic sacral and left ischial osteomyelitis, and quadriplegia.

Review of Patient #3's medical record revealed, in part, no evidence Braden score documented for PM shift on 12/09/2024.

In an interview on 02/10/2025 at 2:18 PM, S2Dir. PSQ confirmed Patient #3 did not have Braden score documented for PM shift on 12/09/2024. S2Dir. PSQ confirmed hospital policy required RN to document Braden score every shift.