-
pso.ahrq.gov/sites/default/files/wysiwyg/oig-list-long-term-care-hospitals-2019.pdf
January 01, 2019 - infection and subsequent partial dehiscence due to inadequate wound care
• Wound infection of below … 2 nasal pressure ulcer associated with face mask
• Deep tissue injuries related to ace wraps
• New stage … 2 sacral pressure ulcer
• Progression of stage 2 to stage 3 sacral pressure ulcer
• Sacral pressure … injury of sacral area
• Suspected deep tissue injury of the sacrum
• Worsening pressure ulcer of sacrum … Bleeding not directly associated with anticoagulants
• Gross hematuria due to trauma from urinary catheter
-
pso.ahrq.gov/sites/default/files/wysiwyg/adverse-events-rehab-hospitals.pdf
July 01, 2016 - and agitation secondary to benzodiazepine led
to patient pulling urinary catheter with resultant injury … brace
• Skin excoriation on buttocks
Fall associated with patient care
• Fall from bed with minor injuries … (elbow, knees, and small skin tear)
Device trauma or malfunction
• Clotted arteriovenous shunt (dialysis … access device)
• Trauma due to multiple failed Foley catheter insertions
Edema or volume overload
• … erythema on right thigh
Surgical Site Infection (SSI)
• Superficial infection that developed on existing wound
-
pso.ahrq.gov/sites/default/files/wysiwyg/working-with-pso-webinar-value-hospitals.pdf
January 01, 2020 - Late, Planned,
Unplanned
• Restraint Utilization
• Falls/Unassisted Falls
o By Diagnosis Group
• Injuries … Resulting from
Falls/Unassisted Falls
o By Diagnosis Group
• Pressure Injuries
• Venous Thromboembolism … Sharing
2019
• Our Recent TJC Survey Experience
• Eliminating CAUTI among patients with spinal cord injuries