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Based on observation, record review and staff interview the facility failed to ensure nursing followed policy for pressure ulcer risk and followed practioner orders with regard to wound care (A-395), failed to ensure nursing care plans addressed the patient's needs with regard to skin integrity (A-396), and failed to ensure medications were administered to the patient (A-405). The cummulative effect of these systemic practices resulted in the inability of the facility to provide safe, effective nursing care.

Based on record review and staff interview the facility failed to ensure nursing followed hospital policy with regard to repositioning patients (Patient #'s 2 and 5) at risk for skin breakdown and failed to ensure nursing obtained and/or followed practitioner orders for wound care (Patient #'s 2 and 6) and orders for dietary intake (Patient #9). The total sample size was ten and the current census at the time of the survey was 101.

Findings include:

Review of Policy No.-511-Pressure Ulcer Prevention with a revision date of 12/2017, directs the nurse to assess the patient for pressure ulcer risk every shift utilizing the Braden Scale. Based on the assessment the nurse obtains a score which determines the patient's risk. If a patient scores 18 or below they are at risk for pressure ulcer. Mild risk 15-18, moderate risk 13-14, high risk 10-12. Interventions are then put in place based on the patient's score from the assessment. The first intervention listed under the section for Activity/Mobility was Turn and position Q2h or more frequently-30 degree side-lying.

The policy directed that assessment of patients for pressure ulcer risk utilizing the Braden Scale was to be done at the time of admission to the hospital or assignment of observation status and once between the hours of 7:00 AM and 7:00 PM and once between 7:01 PM and 6:59 AM. The policy directed nurses to consult nutrition services and offer ordered supplement frequently and teach family the purpose of the supplement. Feed the patient and record accurate intake of oral fluids and feedings.


1. The medical record review for Patient #2 was completed on 2/19/2020. Patient #2 was admitted to the hospital on 12/20/19 with diagnoses that included dehydration and schizophrenia and discharged to a skilled nursing facility on 1/06/2020. At the time of admission a Braden score of "12" was assigned to the patient indicating Patient #2 was at high risk for a pressure ulcer. During the seventeen day hospital stay the patient's Braden score ranged from 12 (high risk for pressure ulcer) on admission to 17. A score of 18 or below indicates the patient is at risk for pressure ulcer.

Review of the nursing documentation revealed no position changes from 12/24/19 at 8:00 AM through 12/26/19 at 8:00 AM, from 12/26/19 at 6:30 PM through 12/28/19 at 3:00 PM, from 12/30/19 at 8:00 AM through 12/31/19 at 4:00 AM, from 1/01/2020 at 00:30 to 1/02/2020 at 12:30 PM and from 1/04/2020 at 9:30 AM through 1/06/2020 at 8:00 AM.

Interview with Staff B on 2/19/2020 at 11:20 AM confirmed these findings and stated nursing should have changed the patient's position every two hours based on her risk for pressure ulcers.

In addition, Patient #2 had a second admission arriving from the nursing home on 1/08/20. The nursing assessment on admission revealed a right buttock blister and a left buttock unstageable wound. Nursing documentation reveals the two wounds were assessed at least twice daily (from 01/08/2020 to 01/13/2020) and varying techniques were documented regarding the cleansing, care and covering of the wounds. In several instances, the nurse documented, "dressings changed according to orders". No practitioner orders for wound care were found in the medical record until 01/13/2020 when the Nurse Practitioner saw the patient and wrote them.

This finding was confirmed with Staff B on 2/19/2020 at 3:20 PM.

2. The medical record review for Patient #5 was completed on 2/19/2020. Patient #5 was admitted to the hospital on 2/15/2020 with altered mental status, a left above the knee amputation and a right below the knee amputation and a finding of "healing scar tissue" from a pressure injury on her sacrum. During Patient #5's three day admission the score for activity/mobility started out as a "3" and dropped to a "1" on 2/17/2020. The patient's total Braden score ranged from a "16" at the time of admission and dropped to a "12" on 2/17/2020.

Review of the nursing documentation revealed no position changes throughout the patient's admission until discharge on 2/18/2020 at 7:30 PM.

Interview with Staff B on 2/19/2020 at 11:20 AM confirmed this finding and stated nursing should have changed the patient's position every two hours based on her risk for a sacral pressure ulcer.




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3. Review of the medical record for Patient #6 was admitted to the intensive care unit on or about 11:23 PM on 02/14/2020 with diagnoses which included gastrointestinal bleed, lactic acidosis, and anemia. The nurse assessed the patient on 02/15/2020 shortly after midnight with a right heel pressure injury with black and brown eschar and no wound drainage. The wound care nurse was consulted on 02/17/2020 for the patient's right heel and sacral wounds and ordered nursing to cleanse the right heel with normal sterile saline, apply silver gel to the right heel and cover with Allevyn daily; the order for the sacral wound ordered nursing to cleanse the sacral wound with normal sterile saline and apply Allevyn daily to the sacral wound. Additionally, the medical record revealed the nurse assessed the patient on 02/02/16/2020 at 8:00 PM and noted the wound was a pressure injury and the wound base was pink with no drainage, the dressing was dry intact.

The medical record revealed there was no wound assessment per the facility policy of every 12 hours until 02/18/2020 at 7:00 AM or an elapsed time of 36 hours.

Review of the nursing medication and treatment administration records revealed the facility was unable to provide documentation the treatments were completed on 02/17/2020 and 02/18/2020 per the wound nurse's orders.

Interview with Staff C on 02/19/2020 at 11:10 AM confirmed the facility was unable to provide documentation Patient #6's wound treatments were completed per the wound nurse's orders. Interview with Staff B on 02/20/2020 at 8:23 AM confirmed the facility was unable to provide documentation the patient was assessed every 12 hours per facility policy and procedure.

4. Review of the medical record for Patient #9 was admitted to the facility on 02/16/2020 at 8:48 AM with diagnoses which included history of nausea and vomiting and abdominal pain for approximately one week, history of chronic anemia, type II diabetes mellitus, and chronic obstructive pulmonary disease (COPD) and congestive heart failure. The patient was admitted to the hospital with a left buttocks pressure wound. The registered dietician was consulted. The dietary consult noted the patient with low blood serum albumin of 2.9 mg/dL (normal is 3.4 to 5.0 mg/dL; albumin is an indicator of nutritional deficiency). The nutritional diagnosis was documented as increased protein needs related to impaired skin integrity as evidenced by deep tissue injury to the left buttock. The nutritional recommendations directed that if the patient's oral intake of food was 50% or less of the meal tray to consider supplemental Boost Glucose (14 gm protein per 8 ounces).

Review of the nursing documentation for oral intake documented Patient #9 ate 100% of lunch on 02/17/2020, refused dinner on 02/17/2020, refused breakfast on 02/18/2020 and only consumed 25% of the lunch tray on 02/18/2020 and consumed 75% of breakfast on 02/19/20, however there was no documentation regarding lunch prior to discharge from the facility on 02/19/2020 at 3:09 PM.

The medical record failed to document if the patient was offered the high protein supplement per dietician's recommendation for poor oral intakes.

This finding was confirmed with Staff C on 02/20/2020 at 10:13 AM.

Based on record review and staff interview the facility failed to ensure nursing care plans addressed the patient's current needs with regard to skin integrity. This affected four of five (Patient #'s 2, 5, 6 and 9) patients reviewed for pressure ulcer risk. The sample size was ten patients and the current census at the time of the survey was 101.

Findings include:

Review of the facility's Plan of Care policy, CP-137 directed that long and short term goals are framed within the following categories for example, skin integrity, infection prevention, restraints, fall risk, mobility, comfort, pain, barriers to discharge. The goals are reviewed and revised based on the patient's ongoing assessment, response to interventions, progress toward goals or outcome achievement. The expectation is that the registered nurse create short term goals within hours of admission and are updated by the nurse based on the patient's on going assessment, response to interventions; and is continually assessed to identify current priority problems that can prevent a patient from being discharged.

1. The medical record review for Patient #2 was completed on 2/19/2020. Patient #2 was admitted to the hospital on 12/20/19 with diagnoses that included dehydration and schizophrenia. At the time of admission a Braden score of "12" was assigned to the patient indicating she was at high risk for a pressure ulcer. During the seventeen day hospital stay the patient's Braden score ranged from 12 (high risk for pressure ulcer) on admission to 17. A score of 18 or below indicates the patient is at risk for pressure ulcer.

The nursing care plan during the patient's admission from 12/20/19 to 1/06/2020 never addressed the patient's skin.

2. The medical record review for Patient #5 was completed on 2/19/2020. Patient #5 was admitted to the hospital on 2/15/20 with diagnoses that included a left above the knee amputation, a right below the knee amputation and healing scar tissue noted from an old pressure injury on the sacrum. The patient's Braden score ranged from a 12 to a 16 during the patient's three day stay.

The nursing care plan never addressed the patient's skin during her admission from 2/15/2020 to 2/18/2020.

These findings were confirmed with Staff A and C on 2/20/2020 at 10:00 AM.


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3. Review of the medical record for Patient #6 revealed the patient was admitted to the facility on 02/14/2020 with diagnoses which included gastrointestinal bleed, lactic acidosis, and anemia. The wound care nurse was consulted on 02/17/2020 for the patient's right heel and sacral wounds and provided orders for wound management on 02/17/2020.

Review of the medical record lacked evidence of a plan of care that addressed Patient #6's wounds and skin integrity goals.

Interview with Staff C on 02/19/2020 at 2:20 PM confirmed the facility was unable to provide a skin plan of care for Patient #6.

4. Review of the medical record for patient # 9 revealed the patient was admitted to the facility on 02/16/2020 with diagnoses which included abdominal pain, schizoaffective disorder, non insulin diabetes mellitus, chronic obstructive pulmonary disease (COPD), and history of hypertension. The medical record documented on 02/01/2020 at 4:45 PM the patient had a left buttock pressure injury, measurements were recorded and an Allevyn dressing placed over the buttocks wound. Additionally, the nursing documentation dated 02/16/2020 at 8:00 PM revealed the patient had bilateral reddened and boggy heels and that the heels were elevated.

Review of the medical record lacked evidence of a plan of care that addressed Patient #9's wounds and skin integrity goals.

Based on observation and staff interview the facility failed to ensure that prescription medications were administered and not left on the patient's bedside table. This finding affected two of two patients observed in the intensive care unit. (Patient #10 and # 9) The facility census was 101.

Findings include:

1. Tour of the facility's intensive care unit (ICU) was completed on 02/18/2020. During an interview at 1:32 PM with the family of Patient #10 a clear plastic medication administration cup was observed on the patient's bedside table. The family of Patient #10 verbalized that they had spent the night with the patient and the day nurse had entered the room this morning at about 8:00 AM and left the medications in a cup and instructed the patient to take the medications. The cup contained one bright red capsule and one white tablet, both unidentifiable medications. Patient #10's family verbalized there were originally more pills in the cup but the patient had tried to consume them but then vomited.

Review of the Medication Administration record revealed the nurse had signed medications as administered for Patient #10 on 02/18/2020 between 8:20 and 8:24 AM. Review of the medical record for Patient #10 revealed the patient has had some difficulty swallowing and when he eats meat he frequently vomits.

Interview with Staff B on 02/18/2020 at 1:38 PM revealed the facility's policy is that medications are never left at the bedside stating that it is unacceptable.

2. Interview on 02/18/2020 at 1:47 PM with ICU Patient #9 revealed the patient was sitting up in bed and had the noon day meal on the over-bed table. The tray was observed to have a clear medication administration cup on the meal tray. The medication cup contained a light pinkish colored medication tablet in it. Patient #9 verbalized the nurse had brought in and left the medication at the bedside for the patient to consume.

Interview with Staff E on 02/18/2020 at 1:56 PM confirmed medications had been left at the bedside, removed them and destroyed the medications. Staff E verbalized the expectation of the facility was that medications were never left at the bedside.