My parent-in-law, a non-ambulatory (bed-bound) elderly patient, was admitted to the Geraldton regional hospital for inpatient management of a urinary tract infection (UTI) and COVID-19 pneumonia in which I felt they received excellent treatment, however during their five-day hospitalization, they developed an unstageable pressure injury (decubitus ulcer or bedsore) on their heel, consistent with a hospital-acquired pressure injury (HAPI) secondary to prolonged immobility, inadequate repositioning, and potential deficits in skin integrity monitoring protocols.
This injury was neither identified, documented in the medical record, nor communicated during discharge handoff. Upon transfer back to their long-term residential care facility, the receiving nurse noted the presence of the pressure injury during initial assessment however the transferring staff from the regional hospital explicitly stated that the patient had no existing pressure injuries at the time of discharge.
However, I believe the clinical severity and progression of the unstageable lesion-obscured by a Bulla or eschar—strongly indicate that it was iatrogenically acquired during the hospital stay and as I understand such injuries typically evolve over several days under conditions of sustained pressure and shear forces in vulnerable, immobile patients.
It is obvious to me that this injury should have been picked up prior to discharge however, in my opinion it is clear to me that procedures are not being followed. I apologize to all the hardworking staff and know you strive to provide outstanding care for your patients and community... But I feel that maintaining silence fails to ensure improvement.
Staff skills
Treatment
Responses
See more responses from Cameron Ross