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Based on document review and interview, facility failed to ensure patient's Power of Attorney (POA) was updated/involved in patient plan of care with patient's medication change/administered, per facility policy and standards of practice for 1 of 10 patients (Patient # 8).

Findings Include:

1. Review of hospital policy titled "Patient Rights and Responsibilities", PolicyStat ID 13517670, last approved 04/2023: indicated under Procedure: You have the right to receive information about your health status, course of treatment, prospects for recovery and outcomes of care, including unanticipated outcomes, in terms you can understand, tailored to the patient's age and language; have your family and/or agent, when appropriate, be informed of your care, including unanticipated outcomes, in order to participate in current and future decisions affecting your care and to participate in the development and implementation of your plan of care. During hospitalization information concerning your condition, medication, treatment, and discharge plans may be shared with your personal friends and family through your designated spokesperson. Your designated spokesperson will be responsible to update friends and family members as desired to protect your privacy. If you have a Power of Attorney, that person will be the designated spokesperson, if appropriate.

2. Review of patient 8's MR indicated a designated POA based on patient's medical diagnosis and inability to make medical decisions regarding his/her care. MR for patient 8 indicated at approximately 9:30 pm, 10/05/24, the following medications were administered to patient: Ativan, 0.5 mg, IM and Haldol 2.5 mg, IM, as ordered, to calm patient. MR lacked documentation of P8's POA notification for change in medication ordered/administered.

3. Incident Report Log dated 10/05/24 at approximately 9:30 pm, indicated N2 (Registered Nurse [RN]) received a telephone order from MD5 (Nurse Practitioner [NP]) to administer a one time injection of Ativan, 0.5 mg, IM (intramuscularly) and Haldol 2.5 mg, IM, to calm patient 8.

4. In Interview on 10/21/24 at approximately 10:05 am to 10:12 am, N2 confirmed an order was received/administered to patient 8 intramuscularly of Ativan and Haldol to help patient calm down. N2 did not recall if patient's POA was notified.

Based on document review and interview facility staff failed to measure wounds after wounds/skin breakdown noted on admission; failed to evaluate patient's nutritional needs after patient refused to eat or drink; failed to documented Intake/Output; failed to complete admission lab draw; and failed to develop a nursing care plan to evaluate/address patient's nutritional needs after patient refused to eat or drink for 1 in 10 patients. (Patient #8)

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 facility staff failed to measure wounds after wounds/skin breakdown noted on admission; failed to evaluate patient's nutritional needs after patient refused to eat or drink; failed to documented Intake/Output; and failed to complete admission lab draw, for 1 of 10 patient medical records reviewed. (Patient 8)


Findings include:
1. Facility policy titled, Wound Care and Treatment, PolicyStat ID: 12385988, last revised 09/2022, indicated under Policy: A. Wounds will be measured on admission (length, height, width). 1. Additional measurements may be made by the Wound Care Nurse or designee. This includes pressure-related and non-pressure related wounds. C. A Wound Care Nurse, through a contracted service or on-staff, shall provide all needed wound care services including treatment and documentation of progress or regress. E. The registered dietitian will provide a nutritional screening and interventions deemed necessary to promote healing.

2. Facility policy titled, Skin-Pressure Ulcer Assessment and Prevention, PolicyStat ID: 12197143, last revised 1/2020, indicated under Procedure: Initial Assessment: Upon admission, all patients will be assessed for the risk of skin impairment using the Braden Pressure Ulcer Risk Assessment, which is part of the Nursing Admission Database form. The Braden Pressure Ulcer Risk Assessment is a scored scale that predicts a hospitalized patient's risk for skin impairment. Scoring: Moderate risk: 13 - 14. For any patient scoring as a moderate or high risk, the nurse will initiate the Nursing Care Plan - Impaired Skin Integrity. The nurse will identify all factors that contribute to the patient's risk for impaired skin integrity, including: decreased sensory perception, decreased mobility, decreased activity, poor nutrition , mechanical factors (i.e., shearing forces, pressure, restraints), altered circulation, sensation, incontinence. The nurse will identify all applicable nursing interventions to assist in achieving the expected outcomes and goals, including but not limited to :recording intake to ensure adequate nutrition and hydration, referring to dietitian for a nutritional assessment, implementing low air loss mattress in bed. All Patients: Patients with Moderate Risk and/or a Stage I Pressure Ulcer will receive all interventions listed above, in addition to: the patient will be turned and repositioned (or cued to do so) at a minimum of every two hours, avoiding positioning patient on the affected side, if possible. Notify the dietitian to evaluate the patient's nutritional intake and review corresponding labs.

3. Review of patient 8's MR lacked documentation of: wound measurements on admission to bruise on back of left hand and wrist, scabbed wounds to lower left leg, bruise to upper right thigh, pressure injury to left inner great toe, wound to left outer ankle, skin tear to right inner upper thigh, bruise to right lower/outer forearm; low air loss mattress placement on patient's bed; patient turned/repositioned or cued to turn every 2 hours; consult for wound care nurse; completed admitting lab draw, per provider order; and/or referral to dietician for nutritional screening and interventions necessary to promote healing per policy.

4. In interview on 10/17/24 at approximately 9:26 am to 9:48 am, N5 (Registered Nurse [RN]) confirmed no wound measurements were taken of P8's skin abnormalities on admission.

5. In interview on 10/21/24 at approximately 10:05 am to 10:12 am, N2 (RN) indicated he/she was assigned P8 on 3-nights (10/05/24 - 10/07/24) and that patient was not on a low air loss mattress.

6. In interview on 10/17/24 at approximately 10:03 am to 10:40 am, A1 (Quality, Risk & Compliance) confirmed no measurements/photos were taken of P8's skin abnormalities, per policy, on 10/04/24. A1 confirmed wound care nurse consult was not initiated, per policy, as facility no longer had a wound care nurse. A1 confirmed a Nursing Plan of Care for Skin Integrity was not initiated on P8 based on patient's skin condition or Braden scoring, per policy.

Based on document review and interview facility staff failed to develop a nursing care plan to evaluate/address patient's nutritional needs after patient refused to eat or drink for 1 in 10 patients (Patient #8).

1. Facility policy titled, Skin-Pressure Ulcer Assessment and Prevention, PolicyStat ID: 12197143, last revised 1/2020, indicated under Procedure: Initial Assessment: Upon admission, all patients will be assessed for the risk of skin impairment using the Braden Pressure Ulcer Risk Assessment, which is part of the Nursing Admission Database form. The Braden Pressure Ulcer Risk Assessment is a scored scale that predicts a hospitalized patient's risk for skin impairment. Scoring: Moderate risk: 13 - 14. For any patient scoring as a moderate or high risk, the nurse will initiate the Nursing Care Plan - Impaired Skin Integrity. The nurse will identify all factors that contribute to the patient's risk for impaired skin integrity, including: decreased sensory perception, decreased mobility, decreased activity, poor nutrition , mechanical factors (i.e., shearing forces, pressure, restraints), altered circulation, sensation, incontinence. The nurse will identify all applicable nursing interventions to assist in achieving the expected outcomes and goals, including but not limited to :recording intake to ensure adequate nutrition and hydration, referring to dietitian for a nutritional assessment, implementing low air loss mattress in bed. All Patients: Patients with Moderate Risk and/or a Stage I Pressure Ulcer will receive all interventions listed above, in addition to: the patient will be turned and repositioned (or cued to do so) at a minimum of every two hours, avoiding positioning patient on the affected side, if possible. Notify the dietitian to evaluate the patient's nutritional intake and review corresponding labs.

2. P8's MR indicated on admission assessment a bruise on back of left hand and wrist, scabbed wounds to lower left leg, bruise to upper right thigh, pressure injury to left inner great toe, wound to left outer ankle, skin tear to right inner upper thigh, bruise to right lower/outer forearm. MR indicated on assessment a Moderate Braden Score of 13 (where 15 = low). MR lacked Nursing Care Plan for Impaired Skin Integrity and Insufficient Nutrition.

3. In interview on 10/17/24 at approximately 9:26 am to 9:48 am, N5 (Registered Nurse [RN]) confirmed no Nursing Care Plan for P8 was initiated for Impaired Skin Integrity or Insufficient Nutrition.

4. In interview on 10/17/24 at approximately 10:03 am to 10:40 am, A1 (Quality, Risk & Compliance) confirmed a Nursing Plan of Care for Skin Integrity was not initiated on P8 based on patient's skin condition or Braden scoring, per policy.