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A. Based on document review and interview, it was determined that for 4 of 10 patients' (Pt. #1, Pt. #2, Pt. #3, and Pt. #4) clinical records reviewed for assessments, the Hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient by failing to conduct a daily Braden pressure ulcer risk assessment.

Findings include:

1. On 6/29/2022, the Hospital's policy titled, "Skin and Wound Care Program Overview" (dated 6/2020) was reviewed and included, "... 1. Pressure Ulcer Risk Assessment. A. Braden Scale completed by... nurse upon admission then daily..."

2. On 6/29/2022, Pt. #1's clinical record was reviewed. Pt. #1 was admitted to the Hospital from 3/2/2022 through 4/6/2022 due to acute respiratory failure. The clinical record indicated that Pt. #1's Braden score on 3/2/2022 was 12 (high risk for developing pressure ulcer). The clinical record lacked documentation that the Braden ulcer risk assessments were completed on 3/4/2022; 3/7/2022; 3/10/2022; 3/19/2022; 3/22/2022; 3/27/2022; and 4/5/2022.

3. On 6/30/2022, Pt. #2's clinical record was reviewed. Pt. #2 was admitted on 6/9/2022 with a diagnosis of respiratory failure. Pt. #2 was admitted with pressure ulcers to the right and left hip, right medial knee, left lateral knee, left ankle, right heel, and left and right Achilles. Pt. #2's clinical record lacked documentation of a Braden scale assessment on 6/23/2022 and 6/24/2022.

4. On 6/30/2022, Pt. #3's clinical record was reviewed. Pt. #3 was admitted on 6/22/2022, with a diagnosis of sepsis (life-threatening infection). Pt. #3 was admitted with pressure ulcer to the sacrum, coccyx, left hip, right hip and the left heel. Pt. #3's clinical record lacked documentation of a Braden scale assessment on 6/23/2022 and 6/24/2022.

5. On 6/30/2022, Pt. #4's clinical record was reviewed. Pt. #4 was admitted on 4/6/2022, with a diagnosis of protein-calorie malnutrition. Pt. #4 was admitted with pressure ulcers to the right and left heels, right medial ankle, left great toe, left upper back, right and left ischial tuberosity (back side of pelvic bone), and sacrococcygeal (tailbone area). Pt. #4's clinical record lacked documentation of a Braden scale assessment on 6/23/2022 and 6/24/2022.

6. On 6/29/2022 at approximately 11:30 AM and on 6/30/2022 at approximately 1:30 PM, findings were discussed with E #1 (Director of Quality Management). E #1 stated that the Braden assessments should have been completed daily. E #1 could not provide documentation that the Braden assessments were completed.

B. Based on document review and interview, it was determined that for 4 of 10 patients' (Pt. #1, Pt. #3. Pt. #4, and Pt. #6) clinical records reviewed for nursing care, the Hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient by failing to ensure that patients were turned and repositioned every two hours.

1. On 6/29/2022, the Hospital's policy titled, "Clinical Guidelines for Pressure Injury" (dated 6/2022) was reviewed and included, "... Policy... 2. All patients are considered at risk for pressure injuries... 5. Standard interventions for all patients... c. Repositioning... (minimum every two hours)..."

2. On 6/29/2022, Pt. #1's clinical record was reviewed. Pt. #1 was admitted to the Hospital from 3/2/2022 through 4/6/2022 due to acute respiratory failure. The clinical record lacked documentation that Pt. #1 was turned and repositioned on 3/10/2022 from 7:42 AM through 5:15 PM (approximately 9 hours and 33 minutes).

3. On 6/30/2022, Pt. #3's clinical record was reviewed. Pt. #3 was admitted on 6/22/2022, with a diagnosis of sepsis. Pt. #3 was admitted with pressure ulcers to the sacrum, coccyx, left hip, right hip and the left heel. Pt. #3's Braden scale skin assessment dated 6/22/2022, showed that Pt. #3 was at high risk for skin breakdown. The turning and repositioning documentation showed that on 6/24/2022 and 6/26/2022, Pt. #3 remained on the right side from 8:00 AM - 12:00 PM (4 hours), without being turned or repositioned.

4. On 6/30/3022, Pt. #4's clinical record was reviewed. Pt. #4 was admitted on 4/6/2022, with a diagnosis of protein-calorie malnutrition. Pt. #4 was admitted with pressure ulcers to the right and left heels, right medial ankle, left great toe, left upper back, right and left ischial tuberosity (back side of pelvic bone), and sacrococcygeal (tailbone area). Pt. #4's Braden scale skin assessment dated 6/7/2022, showed that Pt. #4 was at high risk for skin breakdown. The turning and repositioning documentation dated 6/7/2022, showed that Pt. #4 was not turned and repositioned between 3:53 AM and 8:00 AM (4 hours and 7 minutes). The turning and repositioning documentation dated 6/16/2022, showed that Pt. #4 was not turned and repositioned between 5:07 AM and 10:00 AM (4 hours and 53 minutes).

5. On 6/30/2022, Pt. #6's clinical record was reviewed. Pt. #6 was admitted on 6/9/2022, with a diagnosis of sepsis. Pt. #6 was admitted with pressure ulcers to the right buttocks and sacrococcygeal. Pt. #6's Braden scale skin assessment dated 6/11/2022 and 6/20/2022, showed that Pt. #6 was at moderate and low risk for skin breakdown with slightly impaired mobility. The turning and repositioning documentation dated 6/11/2022 showed that Pt. #6 remained on the right side between 12:00 PM - 4:00 PM (4 hours). On 6/13/2022, Pt. #6 was not turned or repositioned between 5:44 AM - 8:00 PM (14 hours and 16 minutes). On 6/20/2022, Pt. #6 was not turned or repositioned between 4:00 PM - 8:00 PM (4 hours).

6. On /29/2022 at approximately 11:15 AM and on 6/30/2022 at approximately 10:00 AM, findings were discussed with E #1 (Director of Quality). E #1 stated that all patients should be turned and repositioned every two hours. E #1 could not provide documentation that the patients were turned and repositioned.

C. Based on document review and interview, it was determined that for 1 of 10 patients' (Pt. #1) clinical records reviewed for physician's orders, the Hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient by failing to ensure that the physician's order was followed.

Findings include:

1. On 6/29/2022, the Hospital's job description for registered nurses (undated) was reviewed and included, "... Essential Functions... Receives physician's orders... and documents completion..."

2. On 6/29/2022, Pt. #1's clinical record was reviewed. Pt. #1's clinical record included a physician's order, dated 3/17/2022, to use Dakin's solution (topical antiseptic) in cleansing the sacral wound every 12 hours. The clinical record lacked documentation that the order was followed on 3/20/2022, AM shift (7 AM through 7:00 PM); 3/21/2022 AM shift; and 3/27/2022 AM shift.

3. On 6/29/2022, findings were discussed with E #1 (Director of Quality). E #1 stated that the physician's order should be followed. E #1 could not provide documentation that the order was followed.

D. Based on document review and interview, it was determined that for 1 of 10 patients' (Pt. #1) clinical records reviewed, the Hospital failed to ensure that the registered nurse supervised and evaluated the nursing care for each patient by failing to ensure interventions were performed in preventing pressure injuries.

Findings include:

1. On 6/29/2022, the Hospital's policy titled, 'Clinical Guidelines for Pressure Injury" (dated 6/2022) was reviewed and included, "... This policy and procedures establish guidelines for the RN's role in preventing... pressure injuries based on Braden Risk Score...1. The skin... assessment is conducted per the RN...b. Each shift... 4.... h... Manage causative factors including but not limited to... ii. incontinence... 5. Standard interventions for all patients... c. Repositioning... (minimum every two hours)..."

2. On 6/29/2022, the incident report for Pt. #1 was reviewed. The incident report dated 3/21/2022 indicated that Pt. #1 developed new pressure ulcer (Stage 3/deep pressure sore on right ischium/hip).

3. On 6/29/2022, Pt. #1's clinical record was reviewed. Pt. #1 was admitted to the Hospital from 3/2/2022 through 4/6/2022 due to acute respiratory failure. The clinical record indicated that Pt. #1's Braden score on 3/2/2022 was 12 (high risk for developing pressure ulcer). The clinical record lacked documentation that Pt. #1 was repositioned on 3/20/2022 from 2:01 AM through 6:07 AM (four hours and six minutes). There was also no documentation that Pt. #1 was cleaned during the night shift on 3/20/2022 from 12:00 AM through 7:00 AM. Pt. #1 was incontinent of bowels and had three stools during the night shift.

4. On 6/30/2022 at approximately 12:22 PM, an interview was conducted with MD #2 (Wound Physician). MD #2 stated that Pt. #1's risks for developing pressure ulcer was very high. Regarding strategies to prevent development of pressure sores, MD #2 stated that turning and repositioning every two hours and keeping the patient clean are part of the interventions.