HospitalInspections.org

Based on interview and record review the hospital failed to ensure 1 (Patient #1) of 2 patient's wound records were current, accurate and complete.

Findings included:

Patient #1 was a 38-year-old male with a medical history of untreated HIV/AIDS, profound anemia, liver mass, weakness, abdominal distension, diarrhea, and respiratory distress. He was previously intubated. A brain biopsy indicated the patient had Diffuse Large B-cell Lymphoma. Patient #1 was stabilized and transferred from a local acute hospital for weaning of tracheostomy and continuation of care.

Wound Care Consultation. Bilateral Buttocks. Patient #1 was being seen for full thickness ulceration categorized as stage 3 pressure ulcer. A sacral pressure injury was present.

A review of Patient #1's Pressure Ulcer/Injury Data Collection Tool dated 4/3/19 reflected a "3" appeared to be handwritten over a "2" under, "Stage at Time Identified" for the left and right buttock wounds. The wound progress notes dated 4/03/19 indicated the left and right buttock wounds were stage 2 pressure injuries.

During an interview on 4/18/19 at 1:50 PM with Personnel #1, she reviewed Patient #1's Pressure Ulcer/Injury Data Collection Tool dated 4/3/19 with the surveyor. She agreed a "3" appeared to be written over a "2" under, "Stage at Time Identified" for the left and right buttock wounds. The wound progress notes dated 4/03/19 indicated the left and right buttock wounds were stage 2 pressure injuries. Personnel #1 said when she first saw this, she had questioned the wound care nurse (WCN) Personnel #3, and asked her if the wounds were a stage 3 or stage 2. Personnel #3 indicated the wounds were a stage 3, and said she would create a late entry with the corrections. She never created the late entry.

During an interview on 4/18/19 at 2:11 PM with Personnel #3, she said Patient #1 was admitted with stage 3 pressure injuries on his bilateral buttocks. She mistakenly wrote stage 2, then wrote a 3 over the 2 on the above forms dated 4/03/19. She had talked with Personnel #1 about the mistake and intended on writing a late entry, but forgot. Personnel #3 said every Monday measurements and pictures were taken of the patient's wounds.

During an interview on 4/22/19 at 10:10 AM with Physician #4 she said Patient #1 was admitted with stage 3 pressure ulcers on his bilateral buttocks, and an unstageable pressure injury on his coccyx. The bilateral buttock pressure ulcers had opened temporarily due to moisture and friction. However, they had healed.

On 4/22/19 at 2:00 PM Personnel #1 presented documentation with a right buttock picture labeled "R. Coccyx, stage 3", and dated 4/08/19. There were no measurements on the original documentation. She said it was mistakenly labeled and should be labeled as the right buttocks. On the paper was handwritten "R Buttocks Stg 3 4.0 X 1.0 X 0.1". Personnel #1 confirmed.

Personnel #1 then presented documentation and a picture of the patient's left buttocks and gluteal area. It was dated 4/08/19 and labeled left gluteal. There were no measurements on the original documentation. On the documentation was hand written "L Buttocks. 3.0 X 1.0 X 0.1". Personnel #1 confirmed.

Personnel #1 presented documentation with a picture of the patient's bilateral buttocks. It was dated 4/15/19 and labeled right buttock. On the same paper was handwritten "4/15/19 Left Buttocks closed". Personnel #1 confirmed the handwritten documentation had just been added before showing the surveyor.

During an interview on 4/22/19 at 2:40 PM with Personnel #5 he was informed about the mislabeling and incomplete wound care entries. He indicated before the medical records were closed out, the medical records would be completed.