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Based on document review and interview, the Registered Nurse (RN) failed to ensure a patient was moved from the Emergency Department (ED) cart to an inpatient bed once admitted in one (1) instance, failed to ensure a patient was turned every two (2) hours (Q2h) in seventy (70) instances, and failed to ensure a risk report was completed/evaluated for a patient who had developed new wounds during the patient's length of stay. (Patient # 10)

The cumulative effects of these systemic problems resulted in the facility's inability to provide nursing care in a safe manner.

Based on document review and interview, the Registered Nurse (RN) failed to ensure a patient was moved from the Emergency Department (ED) cart to an inpatient bed once admitted in one (1) instance, failed to ensure a patient was turned every two (2) hours (Q2h) in seventy (70) instances, and failed to ensure a risk report was completed/evaluated for a patient who had developed new wounds during the patient's length of stay. (Patient # 10) .

Findings include:

1. The hospital policy titled, Skin and Tissue Inspection, Assessment and Management Procedure, PolicyStat ID 12484038, indicated to turn and reposition the patient at least every two (2) hours, and complete a risk control report and forward to Risk Management when patients are admitted with pressure injuries/wounds and/or patients develop pressure injuries/wounds during their length of stay. This policy was last revised in 10/2022.

2. The facility policy titled, Event Reporting of Patient/Visitor Incidents, PolicyStat ID 11064742, indicated to maintain a safe environment issues and events representing risks to the institiution are to be reported. The reports will be reviewed each business day. This policy was last revised in 10/2020.

3. Review of patient # 10's medical record indicated the following:
a. Emergency Department (ED) note dated 11/11/2023, indicated patient arrived with right lower leg wound.
b. The patient arrived at the ED on 11/11/2023 and remained on the cart until moved to the inpatient unit on 11/14/2023. Patient # 10's MR lacked documentation related to the patient being moved from an ED cart/gurney to an inpatient bed while waiting for an inpatient room. The MR lacked documentation the patient was turned/repositioned Q2h's on the following dates/times: 11/12/2023 at 0000, 0200, 0400, 0600, 0800, 1000, 1200, 1400, 1600, 1800, 2000, 2200; 11/13/2023 at 0000, 0200, 0400, 0600, 0800, 1000, 1200, 1400, 1600, 1800, 2000, 2200; 11/18/2023 at 0200, 0400, 0600; 11/21/2023 0800, 1000, 1200, 1400; 11/21/2023 2000, 2200; 11/22/2023 0000, 0200, 0400, 0600, 0800, 1000, 1200, 1400, 1600, 1800, 2000, 2200; 11/23/2023 0000, 0200, 0400, 0600; 11/24/2023 2000, 2200; 11/25/2023 0000, 0200, 0400, 0600; 11/27/2023 1400, 1600, 1800, 2000, 2200; and 11/28/2023 0000, 0200, 0400, 0600, 0800, 1000, 1200, 1400, 1600, 1800.
c. Wound Care note dated 11/14/2023 indicated the patient had a venous ulcer on his/her right medial lower leg, pressure ulcer left buttock, pressure ulcer sacrum, pressure ulcer left lower posterior leg calf proximal/distal, pressure ulcer right lateral lower leg calf proximal, and pressure ulcer right lower leg distal.

4. In interview on 01/10/2024 at approximately 12:30 pm with staff member S # 3 (ED RN), confirmed once we know the patient has been admitted we move them from the ED cart to a inpatient hospital bed. Everything should be documented.

5. In interview on 01/11/2024 at approximately 9:00 am with administrative staff member A # 1 (Assistant Vice President Patient Care Services), confirmed the ED did not have a policy related to boarding inpatients and/or moving the patient from the cart to an inpatient bed.

6. In interview on 01/11/2024 with administrative staff member A # 2 (Director of Critical Care), confirmed the patient should have been moved from the ED cart to an inpatient bed and turned Q2h's while an inpatient. He/she also confirmed there should have been a risk report completed related to the patients new wounds.

7. In interview on 01/11/2024 at approximately 1:45 pm with staff member S # 4 (Wound Care Registered Nurse), confirmed he/she evaluated the patient on 11/14/2023 and the patient had eight (8) wounds and an area of hyperpigmentation.

8. In interview on 01/11/2024 at approximately 2:15 pm with administrative staff member A # 4 (Regulatory Specialist), confirmed he/she had not received/reviewed any risk reports for the patient related to wounds.

Based on document review and interview the Registered Dietitian failed to ensure a nutritional supplement was ordered for one (1) of ten (10) medical records (MR's) reviewed. (Patient # 10)

Findings include:

1. The facility policy titled, Skin and Tissue Inspection, Assessment and Management Procedure, PolicyStat ID 12484038, indicated nutritional support interventions should be implemented as recommended by the dietary consult. This policy was last revised in 10/2022.

2. Review of patient # 10's MR indicated the following:
a. Medical Nutrition - Inpatient Follow-up Assessment note, dated 11/22/2023 by P # 1 (Registered Dietitian), indicated to continue current diet order per physician and initiate orders for vanilla Boost Plus one (1) times daily. Patient # 10 was considered High nutritional risk.
b. The MR lacked the order to initiate vanilla Boost Plus.

3. In interview on 1/11/2024 at approximately 2:30 pm with administrative staff member A # 1 (Assistant Vice President Patient Care Services-AVP SLPCS), confirmed the MR lacked the order from the RD.