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Based on clinical record review, review of facility policies and procedures, and staff interview, it was determined the facility failed to follow the established policy in that the facility failed to investigate and provide a resolution to a grievance for 1 of 10 complaints reviewed. This failed process prevented the facility from acting in a prompt manner, for complaint resolution after a complaint had been voiced. Findings follow

A. Review of the Policy titled, "Complaint and Grievance Process," revised 2000, showed the following:
1) The patient/family/patient representative may initiate the formal grievance process verbally or in writing.
2) The patient advocate will document the patient grievance and initiate the grievance resolution.
3) A record of the grievance, investigation and follow-up action will be documented and located in the Grievance database.
B. Review of Grievance database showed Patient #1 filed a grievance on 10/18/21. There was no evidence the grievance was investigated or evidence of the resolution of the grievance.
C. An interview was conducted on 6/29/22 at 12:30 PM, with the Vice President of Patient Care Services who verbalized the "complaint was sent prior to the new system and was lost in the system."

Based on policy and procedure review, clinical record review, and interviews, it was determined that the facility failed to develop, update, implement, and individualize an interdisciplinary integumentary plan of care for 3 (#1, #2, and #4) of 10(#1-10) patients. Failure to develop an individualized interdisciplinary integumentary plan of care did not assure the skin policies, protocol, and orders were followed to prevent further skin breakdown. The failed practices did not assure patients were protected from potential injury; the nursing staff could determine when a wound had improved, remained the same or declined; the nursing staff could readily identify which interventions were linked to which problem; and integumentary goals were measurable to determine if the problem continued or was resolved. The failed practice affected Patient #1, #2, and #4 and had the likelihood to affect all patients admitted to the facility.
See Tag A0396.

Based on policy and procedure review, clinical record review, and interviews, it was determined that the facility failed to develop, update, implement, and individualize an interdisciplinary integumentary plan of care for 3 (#1-#2 and #4) of 10 (#1-10) patients. Failure to develop an individualized interdisciplinary integumentary plan of care did not assure the skin policies, protocol, and orders were followed to prevent further skin breakdown. The failed practices did not assure patients were protected from potential injury; the nursing staff could determine when a wound had improved, remained the same or declined; the nursing staff could readily identify which interventions were linked to which problem; and integumentary goals were measurable to determine if the problem continued or was resolved. The failed practice affected Patients #1, #2, and #4 and had the likelihood to affect all patients admitted to the facility.

A. Review of policy titled, "Skin integrity, Care of the Patient with or at Risk for Impairment," dated 02/1994 showed the following:
1) Skin assessments were to be conducted on admission and each shift.
2) Pressure ulcers were to be staged and measured in the admission assessment and repeated weekly.
3) Patients with intact skin and Braden score of 16 or less or have high risk diagnosis (Rheumatoid arthritis, para/quadriplegia, Chronic diabetes, End Stage Renal Disease) were to have preventative measures (pressure redistribution mattress, turning every two hours and protective barrier) implemented.
4) Pressure ulcers were to be documented in the wound assessment section of the patients' chart.
5) Pressure ulcers would be photographed on admission, upon detection and weekly by the Wound Ostomy Continence Nurse (WOCN).

B. Review of policy titled, "Core Nursing standards of Practice," dated 01/2022 showed the following:
1) Two licensed clinicians would perform skin assessments on admission, upon discovery, and upon transfers from another unit/department. The Registered Nurse (RN) would perform skin assessment with each shift.
2) Upon discovery of a suspected pressure injury/wound injury, a wound consult be requested.
3) Photograph all wounds/pressure injuries on admission, discovery, weekly, prior to discharge, and/or change in wound status.
4) The RN would develop and implement a plan to provide safe, effective, and efficient patient-centered care.
5) Interprofessional teams were to be consulted according to the patient condition and health needs.

C. During an interview on 6/28/22 at 2:10 PM, the Vice President of Patient Care Services confirmed the findings in A-B.

D. Review of Patient # 1's Clinical record on 6/28/22, showed the following:
1) Patient #1 was admitted on 9/23/21, with the following diagnosis: Altered Mental Status, Sepsis, Anemia, Congestive Heart Failure, Bacteremia, Seizure disorder, History of Cerebral Vascular Accident, Diabetes Mellitus, Bilateral Below Knee Amputation, End Stage Renal Disease and Braden score of 10.
2) There was no evidence Patient #1 had a skin assessment on admission, every shift and on discovery per established policy. For example:
a) Emergency room note dated 9/23/21, at 9:30 PM, RN event note showed a "Skin tear (red and tender) on left lower butt cheek."
b) On 9/23/21, at 2:00 AM, the RN assessment showed a Stage II left lower buttock pressure ulcer dry, pink with attached edges.
c) On 9/25/21, at 8:19 AM, the RN assessment showed a Stage II left lower buttock pressure ulcer dry, pink with attached edges.
d) On 9/27/21, at 3:29 PM, the WONC consult note showed a Stage II left lower buttock pressure ulcer dry, pink with attached edges.
g) On 10/01/21, at 11:30 AM, the WONC consult note showed an unstageable sacral pressure ulcer with eschar.
3) There was no evidence of measurements of the wound with changes or upon discovery per established policy on 9/27/21, at 3:59 PM and 1/05/21, at 2:10 PM.
4) There was no evidence Patient #1 was repositioned every two hours per the established policy. For example:
a) On 9/26/21, the patient was turned at 10:59 AM. There was no evidence the patient was turned until 9/26/21, at 2:16 PM.
b) On 9/29/21, the patient was turned at 9:09 AM. There was no evidence the patient was turned until 9/29/21, at 3:10 PM.
c) On 9/30/21, the patient was turned at 11:17 PM. There was no evidence the patient was turned until 10/1/21, at 3:07 AM.
d) On 10/4/21, the patient was turned at 7:52 PM. There was no evidence the patient was turned until 10/5/21, at 7:52 AM.
e) On 10/5/21, the patient was turned at 10:58 AM. There was no evidence the patient was turned until 10/5/21, at 6:31 PM.
5)There was no evidence of an individualized care plan for the patient's skin breakdown/wound.
6) During an interview on 6/29/22, at 10:00 AM, the Clinical Informatics Nurse confirmed the findings in D.

E. Review of Patient # 2's Clinical record on 6/28/22, showed the following.:
1) Patient #2 was admitted on 11/23/21, with the following diagnosis: Cerebral Vascular Accident, hypotension, and Braden score of 10.
2) There was no evidence of a skin assessment each shift per established policy. For example:
a) On 5/11/22, at 9:18 AM, the WONC note showed a right lateral malleolus Stage 2 pressure injury with pink, dry and decolorated wound edges "scab."
b) On 6/01/22, at 3:53 PM, the WONC note showed a right lateral malleolus Stage 2 pressure injury with dry "scab."
c) On 6/22/22, at 2:05 PM, the WONC note showed a right lateral malleolus pressure injury with unstageable with yellowish/brown slough.
3) There was no evidence Patient #2 was repositioned every two hours per the established policy. For example:
a) On 4/21/22, the patient was turned at 5:17 AM. There was no evidence the patient was turned until 4/21/22, at 9:40 AM.
b) On 6/06/22, the patient was turned at 11:58 AM. There was no evidence the patient was turned until 6/06/22, at 7:04 PM.
c) On 6/25/22, the patient was turned at 8:13 PM. There was no evidence the patient was turned until 6/26/22, at 5:01 AM.
3) There was no evidence Patient #2 was assessed for the need of a low air loss mattress on admission per the established policy.
4) There was no evidence of an individualized care plan for the patient's skin breakdown/wound.
5) There was no evidence of photographs of the wound per established policy, for example, on 11/23/21, 5/11/22, and 6/22/22.
6) During an interview on 6/29/22 at 10:00 AM, the Clinical Informatics Nurse confirmed the findings in E.

F. Review of Patient # 4's Clinical record on 6/28/22, showed the following:
1) Patient #4 was admitted on 9/22/21, with the following diagnosis: Hypertension, Alcohol Abuse, Anemia, Sepsis, and Morbid Obesity.
2) There was no evidence, Patient #4 was assessed for the need of a low air loss mattress per the established policy on admission due to the diagnosis of anemia and morbid obesity.
3) There was no evidence of an individualized care plan for the patient's skin breakdown/wound.
4) During an interview on 6/29/22 at 11:15 AM, the Clinical Informatics Nurse confirmed the findings in F.

G. During an interview on 6/29/22 at 9:30 AM, Surveyor asked the WOCN the following questions with WOCN answers:
1) When asked, what hat is the process to get an automatic order for Wound consult to see a patient, WOCN stated, "the only time we receive the order to see patients is when an order is put in and when the nurse documents on the wound section of the assessment, we get notified."
2) When asked, what happens when a patient meets the qualifications based on the Braden score of 3) When consulted for wound care, do you do a full head to toe assessment, WOCN stated, "we only look at the wound consulted for and do not look at other areas, especially since we have such limited time to see all of the patients."
4) When asked to explain the standards for the Skin Integrity policy, WOCN stated "I do not know them."
5) When asked to explain the requirements for wound documentation, WOCN stated, "Measurement and photographs are taken and scanned to the electronic health record."

H. During an interview on 6/29/22 at 9:30 AM, Surveyor asked 4W Nurse Manager (NM) the following questions with NM answers:
1) When asked to explain the standards for the Skin Integrity policy regarding qualifications for implementation of preventive care, NM stated, "The patient has to have a Braden of 2) When asked, what chronic health diagnosis would trigger the Staff RN to initiate the preventive care, NM stated, "I do not know of any of them that would qualify."
3) When asked to explain the standards for the Skin Integrity/Wounds documentation, NM stated, "the Staff RN would document the findings on the assessment and wound section describing any findings."
4) When asked to explain the standards for photographing and measurement of wounds, NM stated the following,
a) "The Staff RN does not do that and only WONC is responsible for those to be documented",
b) "Each unit is not equipped to photograph wounds" and,
c) "New policy has just been implemented and we do not have all of the policy and procedures posted for the staff."