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Based on interview and record review, the facility failed to ensure that nursing personnel adhere to the facility's policy on the submission of a risk report when injuries to the skin were identified after admission for 1 (P-1) of 3 patients reviewed, resulting the potential for unidentified injuries and the increased potential for adverse outcomes for all patients. Findings include:

P-1 had an initial nursing assessment initiated on 6/28/24 at 2048. A 4-eyed (2 registered nurse) skin assessment was documented as within defined limits (WDL), without wounds.

Pressure injuries and skin injuries/wounds identified and documented after admission included:

Wound: Right Breast - first noted by nursing recorded on 7/3/24. Documentation by wound care nurse on 7/17/24, revealed right breast assessed with full thickness wound of uncertain etiology, and on 7/22/24 (day of transfer) right breast wound of uncertain etiology appears slightly improved, still with slough and eschar that is becoming soft and moist. No risk report found for this skin wound/injury.

Pressure injury: Right heel first noted by nursing 7/6/24. Review of assessment by wound care nurse on 7/22/24, revealed right heel deep tissue injury had evolved into an open wound, partial thickness. A risk report was submitted for this wound.

Pressure injury: Face (upper) first noted by nursing on 7/10/24. Documentation by wound care nurse on 7/10/24, revealed: "Forehead with linear area of intact purple discoloration, suspect deep tissue injury related to medical device". No risk report found for this pressure injury.

Wound: Skin around perineal area with full thickness damage noted on 7/17/24. Wound care nurse documentation of 7/17/24, revealed: "likely due to exposure to incontinence and previous use of adhesive rectal pouch". No risk report found for this injury.

On 1/13/25 at approximately 1500, interview with wound care nurse Staff N revealed it is the responsibly of the wound care nurses to complete risk reports for hospital acquired pressure injuries. A risk report was completed for the right heal deep pressure injury that evolved to an open wound. When queried if a risk report was submitted for breast wound of unknown etiology, facial wound (suspect deep tissue injury related to medical device), and perianal skin injury, likely do to incontinence and previous use of rectal pouch, Staff N stated, "no"

On 1/14/25 at 0900, interview with RN Staff P revealed she reported skin breakdown to right breast and forehead wound to provider at time of assessment, and that she did not complete a risk report.

On 1/14/25 at 1005, interview with clinical risk specialist Staff S revealed anything of concern or out of the ordinary should prompt a risk report. Staff S was asked if she would expect an event report to be complete for an injury of unknown etiology (right breast for P-1) or a facial injury possibly caused by a medical device, and she responded, yes, and that any employee could initiate a risk report.

On 1/14/25 at approximately 1030, interview with CNO Staff B revealed, she expects the nursing staff to follow policy and procedures of the facility.

On 1/14/25 record review of policy, "Inpatient Skin, Wound and Pressure Injury" dated 7/21/24, revealed: Wound: A wound is a disruption of the normal structure and function of the skin and soft tissue ...Pressure injury: Localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical / other device ...Stage 3 Pressure Injury (Full-thickness skin loss): Full-thickness loss of skin, in which fat tissue is visible in the ulcer. Granulation tissue ...are often present. Slough and or eschar may be visible ...".

On 1/14/25 record review of policy, "Risk Identification Through Safety Event Reporting", dated 10/6/24, revealed "Purpose-The safety event reporting system ... is available to all ...Health team members to report patient and visitor safety events, adverse events for any patient ... utilize ...data for the purpose of reducing morbidity and mortality, preventing adverse events for any patient ...and safety. This is done through the identification, investigation, trending, statistical analysis, and reporting of risks/ potential risks to patients, visitors, and the organization overall ... Patient Safety Event: Event, incident, or condition that could have resulted or did result in harm to a patient ...It is the responsibility of every ...team member to identify and report any concerns that have caused, or have potential to cause, harm to patients ...A safety event report will be initiated for the following circumstances: Any variation in the care of the patient, an adverse event for any patient ....adverse patient outcomes, accidents involving patients or visitors, or situations with potential for patient or visitor injury."