DPH pressure ulcer

[zumbaspinRN]

I did an admission on a patient that was partially ambulatory, admitted to med surg unit for uti from rehab. i work nights and she came to the floor at 0530 am. i checked for skin issues and pressure ulcers and i really did not see anything on her coccyx or heels; i got a call from the manager stating the patient had a unstaggeable heal on her left heel discovered around 1030 am and that it needed topical debridement and all the pressure ulcers protocols were then strictly enforced such as the speciality mattress, wound nurse, dressing etc. now the issue is they said i did not document any skin issues on my assessment and this would have to be reported to the DPH. i had told her i dont recall seeing anything but now they have emailed me again (my manager) requesting to sit down and look over the documentation. they said maybe there was an error or something in my documentation. also she forwarded me the other emails to the heads of the hospital "How can this be? Unstageable PUs that are not present on admissions are SREs, reportable to DPH." I am very nervous about this. I recently just got a position from working part time 24 hours to full time 36 hours at the hospital and they have yet to give me a start date. They just told me I got the position days before this incident happened. I am worried I am going to get fired and not get this position anymore. what do i do? i looked back at my nurses notes and i did not mention anything about wounds. i was thinking of just stating yes i overlooked it and did not document. ugh. one of my co workers said the ER did not see it either so just stick to what you did not see. i am so scared. please help

[vintagemother, BSN, CNA, LVN, RN]

Did you look at her feet? I do look at the soles if the feet and in between the toes when you do the admission assessment? I do. (But I like feet so it doesn't bother me) lol!

[jadelpn, LPN, EMT-B]

This is an unfortunate position to be in, to say the least. If you have malpractice insurance (and if you do not, going forward you should) Call and ask their advice.

You can't make stuff up. But I would think this is on the staff of the unit the patient went to if this occured after you saw the patient. With all that being said, I would not ever add things to the chart so that the facility is paid and impedes on the ethical nature of your practice.

In other words, cover your butt and not theirs. And that they would ask you to change documentation is not ethical, not legal, and if questioned by a licensing/reimbursement whomever higher up--it would be squarely on you, as a facility is NOT going to admit they asked you to document falsely.

Going forward, follow your company policy on wound documentation--most places it is document, measure and any other skin breakdown documentation, advise MD, order for treatment of MD's choice--and a skin care plan. If you document skin intact, the the skin is intact. If the patient is non-ambulatory, be sure you change the patient's position and DOCUMENT it. If you have a patient who has been on the floor or some other situation where the risk is high, use the barrier cream, use the heel protectors, do what you can and DOCUMENT it--so that prevention is occuring with you. When the patient is transferred to a unit, it is up to the admitting nurse to do an inital assessment, documenting skin...and on it goes. From the time of your initial assessment to the transfer time to the other unit can skin breakdown occur to that level? Perhaps. However, going forward make sure you are continually assessing those patients who can not move on their own.

I get that jobs are hard to find. I get that full time is ideal for many of us. But if you are in a position where you are made to lie on documentation, that would not be worth it to me. And I will say that it is a good probability if you are caught, you are on your own--

[Maddy's Minion]

Just a little clarification - was the patient admitted from ER or transferred to your unit from rehab? Does your hospital have an allowed time to complete an admission assessment on your unit, say 24 hours? It's impossible for a necrotic unstageable pressure ulcer to occur from the time the patient was admitted to your unit to the time found by another nurse on the next shift (5 hours?). I wouldn't document anything you didn't see at the time you completed the admission assessment but if you are allowed a time period to complete it, I don't see a problem with adding an addendum that stated something like, ...after completing a second skin assessment, an unstageable pressure ulcer was found..., etc. It all depends on the time you're allowed to complete your admission assessments. Honesty is always the best policy when documenting, the problems happen when a nurse tries to cover up a mistake.

[dudette10, MSN, RN]

I thought that wounds documented as "prior to admission" within 24 hours of admission were not reportable. The ulcer was found 5 hours after admission. Sounds like someone needs to read up on the regulations.

And anyone with half a brain would know that the ulcer was not caused in 5 hours.

[zumbaspinRN]

The patient was admitted from rehab to the ED then to the unit. I have learned to come that the ED did not document anything or see anything either. The higher ups say its a serious reportable event to the dph. I don't know what to do. Last I heard was an email from the manager saying she would like me to come in and talk about it with her but I can't access my work email so I told her to call me or email my personal email

so we could set up a time to come in (I also gave her the times I could come in and speak to her) so no reply yet. Do I just wait for further questioning or do I call and ask?

[toomuchbaloney]

You should wait. Do not reach out to them. You didn't necessarily do anything wrong.You should NOT change your documentation because that would be better for them. Review your facility policy on skin assessment during admission. Do notify your malpractice insurer.Good luck!

[jadelpn, LPN, EMT-B]

Pressure Ulcers: What Clinicians Need to Know

Interesting article, and noted in same--Deep tissue injury may APPEAR one way, and seemingly "overnight" become something else entirely.