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Based on interviews and document review, the hospital failed to provide evidence that the nursing staff provided the care and treatment ordered by the physician for one patient's (P)1 wounds. The nursing staff failed to provide the standard of care for wound prevention and care and failed to follow the hospital policy. As a result of these deficiences, P1's coccyx wound was not part of the discharge planning process and did not have an initial referral for ongoing care. The Home Health Agency (HHA) initial assessment documented the coccyx wound to have worsened.

Findings include:

1) P1 was an 82 year old female admitted to the hospital on 09/13/2022 for sepsis, urinary tract infection, severe dehydration, vomiting and small bowel obstruction. During her hospitalization she was treated for a coccyx wound and Left (L) lower leg wounds. On 09/28/2022, P1 was discharged back to the care home.

2) Reviewed the facility policy number 500-110-02, titled "Prevention and Treatment of Pressure Injury," revised 11/2019. The policy included: "Patients admitted to the facility will be assessed using a pressure injury risk assessment tool; and prevention and/or interventions will be initiated by the registered nurse. ..."
"DTI (Deep Tissue Injury): Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister." "Pressure injuries should be assessed daily (at minimum) and with each dressing change. Documented assessments by the primary nurse should include a description of the exact appearance of the wound, interventions/treatments and weekly measurements of the wound injury. ..." "Positioning a. ...Turn patient every 2 hours ..."

3) Review of Medical Records included, but not limited to the following entries, related to P1's wounds:
09/14/2022 00:40 AM, RN note: Patient arrived from ED. ...Two RN skin check done...Noted with scattered scabs to BLE (bilateral lower legs), mepilex (absorbent dressing) applied to coccyx. Reposition q (every) 2 hours. ..."
09/16/2022 04:30 PM, Wound Nurse (WN) note: "Referral received. Patient seen for a hospital acquired suspected deep tissue injury (DTI) to her coccyx and multiple shallow wounds to her left lower leg. ...There is a diffuse area of purple discolored skin over her coccyx. There is a small open area on the right side of the discoloration. The tissue in that wound is dusky medially and red laterally. There is no bogginess, fluctuance, or induration. Blanchable redness to the peri wound skin. No inflammation. No obvious odor. See measurements and photograph in the Flowsheet... The wound was cleansed with soap and water then covered with a large mepilex dressing. ...Wound care recommendations: Cleanse the coccyx wound with saline then cover with a large mepilex sacrum dressing every 3 days. Continue to always turn and reposition Q2 H (every two hours) and float heels. ...Cleanse the left lower leg wounds with soap and water then apply venelex (ointment) and cover with adaptic and roll gauze daily. ..."
09/16/2022 04:32 PM, Verified Telephone Order entered by WN "Cleanse the coccyx wound with saline then cover with a large mepilex sacrum dressing every 3 days." The order was authorized by physician (MD)2 on 09/17/2022 at 08:49 AM.

4) Order Review:
9/16 02:41 PM, Physician (MD)2 order: Wound Nurse consult. "Reason for consult: suspected pressure wound, DTI coccyx." 9/16 04:37 PM, MD2 order: "Turn patient every 2 hours" 9/16 04:37 PM, MD2 order: "Perform dressing change: cleanse the coccyx wound with saline then cover with a large mepilex sacrum dressing every 3 days." 9/16 04:37 PM, MD2 order: "Cleanse the left lower leg wounds with soap and water then apply venelex and cover with adaptic dry dressing daily"

5) The flowsheet for the coccyx wound was initiated by the WN 09/16/2022. Per MD2's order, the coccyx wound should have been cleaned and dressing changed with documentation of wound assessment every three (3) days, 09/19/2022, 09/22/2022, 09/25/2022 and 09/28/2022 (date of discharge). Registered Nurse (RN) documentation included the following entries: 09/19/2022, RN1 note: "...Continue to turn and reposition every two hours. Wound care completed ...see flowsheet." The wound flowsheet included: "..sanguineous (initial discharge after open wound where the skin is broken), scant 1-25% dressing saturation."
09/22/2022, RN2 note: "...Mepilex to coccyx remains clean, dry and intact....assist with repositioning..." There was no documentation the dressing was changed, wound cleaned, or description of the wound. There was no documentation on the wound flowsheet. 09/25/2022 07:45 AM, RN2 note: "...Dressing to left lower ext (extremity) remains clean dry and intact. ..." There was no documentation of coccyx wound cleaned, dressing change or status of wounds. There was no documentation on the wound flowsheet . 09/28/2022, RN3 note: No documentation of coccyx wound cleaned, dressing change or status of wounds. There was no documentation on the wound flowsheet.

6) The MD order was to reposition P1 every two hours. The expectation of the nursing staff was to document on the flow sheet every two hours the patient's position. Review of the flowsheet documentation revealed several gaps in repositioning, that included but not limited to the following:
On 09/17/2022, P1 was documented to be supine (lying on back) from 07:30 AM until 03:20 PM, when she was repositioned to her right (R) side.
On 09/21/2022, P1 was positioned on her L side from 05:00 PM until 10:00 PM when she was turned to her R side.

7) On 11/17/2022 at 10:15 AM, during an interview with the WN, she said the hospital had two wound care specialists. She said due to large number of referrals for consult and wound care, they need to prioritize, and after the initial assessment, some patients follow up and wound care will be the responsibility of the nurses on the unit. The WN said if the nursing staff feel WN should see the wound again, they put in another referral. She said if the patient has a mepilex dressing, it is the expectation the dressing is "peeled back to assess the wound every shift and then reattached." She went on to say documentation of the assessment should include "description of wound characteristics, appearance, and if any odor or drainage." The WN said wounds "should be measured every Friday, to see if its getting larger or deeper." Inquired how post discharge wound care is coordinated, and she said through the Case Manager. The WN said positioning is usually done by the aides, but it is a team effort and should be documented in the flow chart. She said they usually alternate more side to side, and are flat mostly just for eating to keep pressure off the coccyx."

On 11/17/2022 at 03:38 PM, during a second interview with the WN, completed a review of nursing documentation for wound care and positioning. The WN validated there was lack of documentation that the wound was cleaned and dressing changed, lack of documentation the dressing was peeled back and wound assessed every shift and lack of documentation of positioning every two hours.

8) Early identification, proper and accurate documentation and aggressive treatment are extremely important for a patient with a DTI. The wound was identified early and assessed by the WN. Orders were obtained for treatment, but nursing staff did not document ongoing treatment or assessments. The wound was measured by the WN on 09/16/2022, and should have been remeasured on Friday 09/23/2022. There was no documentation of a second measurement at the hospital. Available wound measurements in centimeters (cm), length x width x depth were as follows:
09/16/2022 measurement by WN: 3.5 cm x 4.5 cm x undetermined depth
10/01/2022 measurement by HHA RN on first visit: 6 cm x 5 cm x 0.5 cm
10/16/2022 measurement by WN on readmission: 6 cm x 4.9 cm x 2.2 cm. ...Bone palpable but covered with tissue. ..."

Based on interviews and document review, the facility failed to reevaluate and identify one patient (P)1's discharge needs of a sample of four patients. P1 had a deep tissue injury (DTI-tissue pressure injuries are persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues) on her coccyx and multiple shallow wounds to her left (L) lower leg that required treatment and dressings. Wound care was not identified as a need post discharge during the discharge planning process. As result of this deficiency, there was no Home Health Agency (HHA) referral for wound care, and no education to the Care Home Manager (CHM) at the Care Home (CH). P1 was readmitted to the hospital on 10/18/2022 for a Stage 4 Pressure Ulcer (the most severe of pressure ulcer, with full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures). .

1) P1 was an 82 year old female with a past medical history (hx) included Diabetes type II, Chronic Kidney disease, Hypertension, Stroke with residual right sided weakness, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Paraplegia due to polio, and dementia. She had a past surgical hx of excision soft tissue mass of left (L) foot, L foot amputation transmetatarsal (surgical removal of a part of the foot), debridement of L wound foot and insertion of wound vacuum device in 06/2022.

P1 lived in a care home (CH) and developed nausea/vomiting for about a week, when she was taken to the Emergency Department (ED) on 09/13/2022. P1 was diagnosed with sepsis, urinary tract infection, severe dehydration, vomiting and small bowel obstruction, and admitted for further care. P1 had a laporascopic cholesystectomy (minimally invasive surgical procedure for removal of gallbladder) on 09/15/2022 with the placement of a biliary tube (to help the flow of bile). During her hospitalization she was treated for a coccyx DTI and leg wounds. On 09/28/2022, P1 was discharged back to the care home with a referral to HHA for care of the biliary tube.

2) Reviewed the facility policy number 300-108-03, titled "Discharge Planning," revised date 07/2020. The policy included: "A discharge plan for post-hospital ...follow-up care is addressed by the interdisciplinary team. When appropriate, documentation in the medical record reflects a discharge planning assessment of the patient's discharge needs, and disposition. The patient and his or her designated caregiver should be engaged in the discharge planning process." The purpose included: "2.1 To outline a process for Health System, especially the Care Management Department, to identify patients, with potential discharge planning needs, conduct discharge planning planning assessments, facilitate safe transitions in care, prevent avoidable hospital days and ensure compliance with discharge planning standards as defined by regulatory and accrediting bodies. ...2.3 The plan is monitored, reevaluated and revised as necessary throughout the patient's hospital stay. The plan and revisions are documented in the medical record."

3) Review of Discharge Planning notes revealed the following: 09/14/2022: Discharge Planning/Admission Form completed. 09/16/2022: "Chart reviewed for discharge planning." 09/26/2022: "Chart reviewed for discharge planning. Discussed with MD2. Anticipate discharge tomorrow. ...DC (discharge) Plan: Home; return to 24/7 caregiver and hospice services." 09/28/2022: "Chart reviewed for discharge planning. Discussed with MD2. Patient discharging today. ...Spouse requesting HHA referral. ..."
09/28/2022: Referral made and confirmed with HHA.
There was no documentation in Discharge planning notes that P1 was being treated for a coccyx and leg wounds or that she would need ongoing wound care at discharge.

4) Record review included, but not limited to the following documentation related to P1's wounds:
09/16/2022 04:30 PM, Wound Nurse (WN) note: "Referral received. Patient seen for a hospital acquired suspected deep tissue injury to her coccyx and multiple shallow wounds to her left lower leg. ...There is a diffuse area of purple discolored skin over her coccyx. There is a small open area on the right side of the discoloration. The tissue in that wound is dusky medially and red laterally. There is no bogginess, fluctuance, or induration. Blanchable redness to the peri wound skin. No inflammation. No obvious odor. See measurements and photograph in the Flowsheet... The wound was cleansed with soap and water then covered with a large mepilex (absorbent) dressing. ...Wound care recommendations: Cleanse the coccyx wound with saline then cover with a large mepilex dressing every 3 days. Continue to always turn and reposition Q2 H (every two hours) ...Cleanse the left lower leg wounds with soap and water then apply venelex (ointment) and cover with adaptic and roll gauze daily. ..."

09/16/2022 04:32 PM, Verified Telephone Order entered by WN "Cleanse the coccyx wound with saline then cover with a large mepilex sacrum dressing every 3 days." The order was authorized by physician (MD)2 on 09/17/2022 at 08:49 AM.

5) Cross Reference Tag 813 Discharge Planning-Transmission Information
The facility failed to provide necessary verbal and written discharge instructions and medical information pertaining to P1's current skin condition and treatment of a coccyx and leg wounds to the CHM when P1 was discharged.

Based on interviews and document review, at the time of discharge, the facility failed to provide the Care Home Manager (CHM) the necessary information about one patient's (P)1 skin condition, and did not provide verbal/written discharge instructions for the ongoing treatment of her coccyx and leg wounds. In addition, the facility failed to obtain a physicians order and referral with the necessary medical information to the Home Health Agency (HHA) for the referral for wound care post discharge. As a result of this deficiency, the CHM did not have the education needed to provide care to P1. P1 was readmitted to the hospital on 10/18/2022 for a Stage 4 Pressure Ulcer (the most severe of pressure ulcer, with full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures).

Findings include:

1) P1 was an 82 year old female with a past history included Diabetes type II, Chronic Kidney disease, Hypertension, Stroke with residual right sided weakness, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Paraplegia due to polio, and dementia. She lived in a care home (CH) and had nausea/vomiting for about a week when she was taken to the Emergency Department on 09/13/2022. P1 was diagnosed with Sepsis, Urinary Tract Infection, severe dehydration, vomiting and small bowel obstruction, and admitted for further care. P1 was discharged 9/28/2022 back to the Care Home with referral for Home Health Agency (HHA) referral.

2) Cross reference Tag 802: Discharge Planning- Pt Re-Evaluation
The facility failed to identify during the discharge planning process P1 had wounds that required ongoing treatment post discharge. The Case Manager (CM) was not aware that P1 was being treated for a deep tissue injury (DTI) on her coccyx and had wounds on her Left lower leg that required cleaning and dressing changes. The facility did not obtain an order for a referral for wound care to the Home Health Agency (HHA) prior to discharge.

3) Review of P1's medical records included the following: 09/13/2022 Physician (MD)1 Admission History and Physical: "Skin: Dry, no rash" 09/16/2022 04:32 PM, Verified Telephone Order entered by Wound Nurse (WN) "Cleanse the coccyx wound with saline then cover with a large mepilex sacrum dressing every 3 days." The order was authorized by MD2 on 09/17/2022 at 08:49 AM. 09/23/2022 at 11:53 AM, Discharge Summary by MD2. The discharge summary did not include any notation of P1's skin or documentation that she was being treated for and had an order for wound care to her coccyx and left lower leg. The discharge instructions included to stop taking the medications doxepin, Torsemide, Sodium Bicarbonate and Clopidogrel (plavix).

09/28/2022 01:34 PM Nursing note: "Discharge completed with pt's caregiver, via phone. Discussed dx (diagnosis) and medication summary with caregiver. All questions answered. ..."
09/28/2022 Review of "After care summary"/discharge instructions revealed no documentation of any wounds, or wound care instructions.

4) On 11/18/2022 at 09:59 AM, during interview with the Case Manager (CM), she said her first involvement with P1 was on 09/16/2022, and that the discharge plan was to return home (Care Home) with Home Health Services, which has been requested by P1's husband. The CM said a referral for HHA services was faxed to the agency on 09/28/2022. She said she determines patient discharge needs by reviewing the progress notes, physician notes, physical/occupational therapy notes and makes the appropriate referrals. The CM said she also talks "to the team" to identify patient needs. She said she did not recall if anyone had notified her that P1 had wounds. At that time, the CM reviewed her progress notes and confirmed there was no documentation of wound care needs, or a wound care referral post discharge.

5) On 11/17/2022 at 04:00 PM, during an interview with the CHM, she said when she spoke with the RN about P1's discharge and discharge instructions, it was never mentioned P1 had a "bed sore." The CHM said one of the first things she does when a patient returns from the hospital is check their skin. She said she always takes diapers off to check the skin. The CHM said when she opened P1's diaper, she "saw it (wound) right away." The CHM described the wound to be "bigger than a quarter in size, and deep." She said she called the HHA to make sure they knew about the wound and were going to include wound care in their services. The CHM said the "HHA came and took measurements of the wound." She said P1 is very compliant and follows instructions to reposition. The CHM said she also called the hospital Social Worker to let her know P1 had the coccyx wound.

The CHM said the other concern she had was when P1 arrived home, she was "all swollen." She said her eyes were so swollen she couldn't open them, and her arms and legs were swollen. The CHM said she called the hospital and spoke with a "guy nurse" and asked why P1 was "all swollen." She went on to say that P1's Torsemide (used to reduce extra fluid in the body) had been discontinued in the hospital, but the RN told her (CHM) to resume it. This was conflicting information from what was in the written discharge instructions given to her husband, when he picked P1 up at the hospital.

6) Review of HHA records revealed the following: Visit date 10/01/2022 diagnosis included: "Pressure-Induced Deep Tissue Damage of Sacral Region, Non-pressure Ulcer Left Ankle and foot." 10/01/2022 RN Oasis Admission included: "Client was sent home from hospital on metoprolol and albuterol. Caregiver did not stop giving medications that are ordered to stop including Plavix, Doxepin, NA BICARB and Torsemide. Will fax Dr to see if he wants these medications continued. ...Client acquired a deep tissue injury to her coccyx and has multiple venous stasis wounds to her left lower leg and foot." Assessment included: "Client has a hospital acquired deep tissue injury that is difficult to stay [sic] due to necrosis over the wound. ...wound has no s/s (signs/symptoms) of infection due to necrosis, hard to view whole wound. Wound is full of barrier cream and has no dressing today. ...Client has venous stasis wounds to the left lower leg and foot. ...Caregiver is cleaning them with soap and water and then letting dry and applying betadine to areas. ..." "Plan: 1. Educate caregiver on pressure ulcer prevention. 2. Wound care consult" "...Coccyx, Unstaged DTI Wound Onset date 09/26/2022. Measurements: 6 x 5 x 0.5 (centimeters length by width by depth), Wound care provided. Using clean technique, use normal saline to cleanse area and apply sacral boarder over wound."
Documentation of the coccyx wound revealed on 10/14/2022 the wound was declining, and on 10/17/2022, client was hospitalized for deterioration for wound. P1 was readmitted to the Hospital on 10/18/2022 for worsening of the coccyx wound.