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Based on observation, interview, and record review, the facility failed to develop and update a baseline care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for three (3) of 35 sampled patients (Patients 1, 2, 3) in accordance with the facility's policy and procedure regarding developing, implementing, and updating care plans. Patients 1 and 3 did not have an updated care plan regarding identified pressure injuries (injuries to skin and underlying tissue resulting from prolonged pressure on the skin), and Patients 1, 3 and 5 did not have care plans specific to Hemodialysis (HD- a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) care.

This deficient practice had the potential to result in delay of the provision of necessary care and services due to absence of an individualized care plan that contains information needed to properly care for the affected patients as well as in identifying the patients' needs and risks.

Findings:

1a. During a review of Patient 1's History and Physical (H&P), dated 12/29/2023, at 4:20 P.M., the H&P indicated, Patient 1's admitting diagnosis was left Subdural Hematoma (LSDH- a type of brain bleeding requiring surgeon evaluation).

During further review of Patient 1's medical records (MR) titled "Skin Assessment," dated 3/8/2023, the MR indicated Patient 1 developed a pressure injury Stage II (skin breakdown extending to the layers of the skin) to sacrum (The back wall of the pelvis located just above the tailbone), and the left buttock.

During a concurrent interview and record review on 8/1/2023, at 11:30 A.M., with Associate Administrator (AA1), Patient 1's wound documentation titled "Tissue Analytic (TA)," dated 3/8/2023, at 7:51 A.M., was reviewed. The TA indicated new pressure injury Stage II was discovered to sacrum and to the left buttock. The AA1 said upon new skin injury discovery, the Primary Registered Nurse (RN) was expected to perform basic skin assessment, identify new skin injury, photograph the injury, document findings in TA and update the plan of care specific to skin injury identified.

During a concurrent interview and record review on 8/1/2023, at 11:35 A.M., with Associate Administrator (AA1), Patient 1's medical records titled "Care Plan" (CP), initiated on 12/29/2023, was reviewed. The CP indicated, Preventive Skin Integrity Management Care Plan was initiated upon Patient 1's admission. The Skin Integrity Management CP specific to skin injury to sacrum, left buttock was initiated on 3/18/2023, at 10:55 P.M.. The AA1 stated the Primary RN should initiate a care plan specific to skin injury upon discovery as per facility's policy but the Primary RN did not.

During an interview on 8/2/2023, at 9:00 A.M., with Quality and Outcomes Specialist (QOS 1), the QOS 1 stated, all patients should have the Interprofessional Care Plan (IPOC) developed by the health care team. The QOS 1 stated an individualized care plan is developed based upon actual or potential problems and assessed needs, and typically includes problem identified, interventions, and outcomes, and should be reviewed at least every 24 hours and updated as patient progress indicates. The QOS 1 said a care plan serves as a guide for nursing staff to stay focused on problems, interventions, and progress of identified problems because it is beneficial for patients in meeting their expected outcomes.

During a review of the facility's Policy and Procedure (P&P) titled "Skin Care and Tissue Injury Management," dated 2/2023, the P&P indicated "Beginning upon admission, individualized Skin Integrity Management Care plan will be developed, initiated, implemented, reassessed, and updated by Primary Registered Nurse (RN) to promote optimal healing environment for patients identified with tissue injuries."

During a review of the facility's policy and procedure (P&P), titled "Interprofessional Plan of Care (IPOC) Guidelines for Completion and Use," dated 7/12/2022, the P&P indicated all members of the interprofessional team involved in the care of the patient are responsible to develop a care plan based on individualized patient needs. The P&P further indicated, the IPOC must include expected patient outcomes and goals, problems, interventions, and educational interventions and must be reviewed at least every 24 hours and updated as patient progress indicates.

1b. During a review of Patient 3's admission record titled "History and Physical (H&P)," dated 7/5/2023, the H&P indicated Patient 3 was admitted with altered mental status for severe sepsis with septic shock. The H&P further indicated Patient 3's past medical history included, but not limited to diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired) Type 2, end stage renal disease (ESRD- a medical condition in which a person's kidneys cease functioning on a permanent basis), on hemodialysis (HD- a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly).

During a review of Patient 3's medical records (MR) titled "Skin Assessment," dated 7/6/2023, the MR indicated Patient 3 was admitted with a pressure injury Stage II (skin breakdown extending to the layers of the skin) to coccyx (tailbone).

During a concurrent interview and record review on 8/1/2023, at 11:35 A.M., with Associate Administrator (AA1), Patient 3's medical records titled "Care Plan" (CP), initiated on 7/5/2023, was reviewed. The CP indicated, Preventive Skin Integrity Management Care Plan was initiated upon Patient 3's admission on 7/5/2023. The Skin Integrity Management CP specific to skin injury to coccyx was not initiated during Patient 3's hospital admission. The AA1 stated, the Primary RN should initiate a care plan specific to skin injury upon admission as per facility's policy and the Primary RN did not.

During an interview on 8/2/2023, at 9:00 A.M., with Quality and Outcomes Specialist (QOS 1), the QOS 1 stated, all patients should have the Interprofessional Care Plan (IPOC) developed by the health care team. The QOS 1 said an individualized care plan is developed based upon actual or potential problems, and should be reviewed at least every 24 hours, and updated as patient progress shows. The QOS 1 stated IPOC serves as a guide for nursing staff to stay focused on problems, interventions, and progress of identified concerns because it is beneficial for patients in meeting their expected outcomes during their hospital stay.

During a review of the facility's Policy and Procedure (P&P) titled "Skin Care and Tissue Injury Management," dated 2/2023, the P&P indicated, "Beginning upon admission, individualized Skin Integrity Management Care plan will be developed, initiated, implemented, reassessed, and updated by Primary Registered Nurse (RN) to promote optimal healing environment for patients identified with tissue injuries."

During a review of the facility's policy and procedure (P&P) titled "Interprofessional Plan of Care (IPOC) Guidelines for Completion and Use," dated 7/12/2022, the P&P indicated all members of the interprofessional team involved in the care of the patient are responsible to develop a care plan based on individualized patient needs. The P&P further indicated the IPOC must include expected patient outcomes and goals, problems, interventions, and educational interventions and must be reviewed at least every 24 hours and updated as patient progress indicates.

2a. During a review of Patient 1's admission records, dated 12/29/2023, the admission record indicated Patient 1 was admitted with diagnosis of left Subdural Hematoma (SDH- a type of brain bleeding that requires a surgery to remove the blood).

During further review of Patient 1's physician progress notes (PPN) titled "Neurology IP Progress Note," dated 3/16/2023, at 9:14 A.M., the PPN indicated Patient 1's hospital course was complicated by the following medical issues, including, but not limited to persistent prolonged encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), bacteremia (the presence of bacteria in the blood), acute kidney injury (a sudden episode of kidney failure or kidney damage affecting its function to filter waste and water from the blood) leading to chronic kidney disease (gradual loss of kidney function) and long-term dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly).

During a concurrent interview and record review on 8/2/2023, at 9:00 A.M., with Informatics Clinical Specialist (ICS 1), Patient 1's care plan (CP) record was reviewed. The CP record indicated there was no care plan initiated for fluid management and electrolyte imbalance. The ICS explained "Fluid volume excess" CP was available for nursing staff to initiate for patients receiving dialysis treatment, but no care plan was initiated during Patient 1's hospital stay. The ICS stated a care plan is developed to monitor patient progress, interventions, and plays an important role in patient education and per facility's policy, nurses should develop an individualized care plan based on individualized patient's problems.

During an interview on 8/2/2023, at 10:30 A.M., with associate administrator for nursing education (AA1), the AA 1 stated nursing staff should develop an individualized plan of care based on actual patient problems/needs because an individualized care plan is beneficial to all aspect of patient care and is an important indicator of treatment progress toward meeting patient goals and outcomes.

During an interview on 8/2/2023, at 9:00 A.M., with Quality and Outcomes Specialist (QOS 1), the QOS 1 stated all patients should have the Interprofessional Care Plan (IPOC) developed by the health care team. The QOS 1 said an individualized care plan based upon actual or potential problems should be developed, initiated, and reviewed at least every 24 hours and updated as patient progress indicates. The QOS 1 stated a care plan serves as a guide for nursing staff to stay focused on problems, interventions, and progress of identified problems because it is beneficial for patients in meeting their expected outcomes.

During a review of the facility's policy and procedure (P&P) titled "Interprofessional Plan of Care (IPOC) Guidelines for Completion and Use," dated 7/12/2022, the P&P indicated all members of the interprofessional team involved in the care of the patient are responsible to develop a care plan based on individualized patient needs. The P&P further indicated the IPOC must include expected patient outcomes and goals, problems, interventions, and educational interventions and must be reviewed at least every 24 hours and updated as patient progress indicates.

During a review of the facility's policy and procedure (P&P) titled "Interprofessional Plan of Care (IPOC) Guidelines for Completion and Use," dated 7/12/2022, the P&P indicated all members of the interprofessional team involved in the care of the patient are responsible to develop a care plan based on individualized patient needs. The P&P further indicated, he IPOC must include expected patient outcomes and goals, problems, interventions, and educational interventions and must be reviewed at least every 24 hours and updated as patient progress indicates.

2b. During a review of Patient 2's admission record titled "History and Physical (H&P)," dated 7/2/2023, the H&P indicated Patient 2 was admitted to the facility for a surgical evaluation of aortic stenosis (AS- a type of heart valve is narrowed and does not open properly) of transcatheter aortic valve replacement (TAVR- an artificial valve, surgically implanted). Patient 2's H&P also indicated Patient 2's past medical history included, but was not limited to End Stage Renal Disease (ESRD), on hemodialysis (HD) and an order for strict intake and output (the importance of recording and monitoring fluids consumed or given intravenously [through the vein] or fluids removed) for fluid management on admission.

During a review of Patient 2's medical records (MR) titled "Hemodialysis (HD) Treatment Notes," dated 7/20/2023, the MR indicated Patient 2 was receiving HD treatments to filter blood, correct electrolyte imbalance and assist in fluid management.

During a concurrent interview and record review on 8/2/2023, at 9:00 A.M., with Informatics Clinical Specialist (ICS 1), Patient 2's care plan record was reviewed. The record indicated there was no care plan initiated for fluid management and electrolyte imbalance. The ICS explained "Fluid volume excess" care plan was available for nursing staff to initiate for patients receiving dialysis treatment, but no care plan was initiated during Patient 2's hospital stay. The ICS stated, a care plan is developed to monitor patient progress, interventions, and plays an important part in patient education and per facility's policy, nurses should develop an individualized care plan based on identified patient needs.

During an interview on 8/2/2023, at 9:00 A.M., with Quality and Outcomes Specialist (QOS 1), the QOS 1 stated all patients should have the Interprofessional Care Plan (IPOC) developed by the health care team as per facility's policy. The QOS 1 said an individualized care plan is developed based upon actual or potential problems and assessed needs, and typically includes problem identified, interventions, and outcomes and should be reviewed at least every 24 hours and updated as patient progress indicates. The QOS 1 stated a care plan serves as a guide for nursing staff to stay focused on problems, interventions, and track progress of identified problems because it is beneficial for patients in meeting their expected outcomes.

During a review of the facility's policy and procedure (P&P) titled "Interprofessional Plan of Care (IPOC) Guidelines for Completion and Use," dated 7/12/2022, the P&P indicated all members of the interprofessional team involved in the care of the patient are responsible to develop a care plan based on individualized patient needs. The P&P further indicated the IPOC must include expected patient outcomes and goals, problems, interventions, and educational interventions and must be reviewed at least every 24 hours and updated as patient progress indicates.

2c. During a review of Patient 3's admission record titled "History and Physical (H&P)," dated 7/5/2023, the H&P indicated Patient 3 was admitted with altered mental status (a disruption in how brain works that causes a change in behavior) for severe sepsis (occurs when one or more of your body's organs is damaged from this inflammatory response) with septic shock (a condition sometimes occurring in severe sepsis, in which the blood pressure fails and the organs of the body fail to receive sufficient oxygen). The H&P further indicated, Patient 3's past medical included, but not limited to diabetes Type 2 and end stage renal disease (ESRD), on hemodialysis (HD).

During a review of Patient 3's hemodialysis (HD) medical records (MR), dated 7/5/2023, the HDMR indicated Patient 3 underwent first HD treatment for clearance and fluid removal on 7/5/2023.

During a review of Patient 3's medical records titled "Care Plans" (CP), dated 7/3/2023-8/2/2023, the CP records indicated no CP pertinent to fluid management and electrolyte imbalance was initiated by nursing upon admission and during Patient 3's hospital stay.

During a concurrent interview and record review on 8/2/2023, at 9:00 A.M., with Informatics Clinical Specialist (ICS 1), Patient 3's care plan record was reviewed. The record indicated, there was no care plan initiated for fluid management and electrolyte imbalance. The ICS explained "Fluid volume excess" nursing care plan was available for nursing staff to initiate for patients receiving dialysis treatment, but no care plan was initiated during Patient 2's hospital stay. The ICS stated a care plan is developed to monitor patient progress, interventions, and plays an important part in patient education and per facility ' s policy nurses should develop an individualized care plan based on individualized patient's problems.

During an interview on 8/2/2023, at 10:30 A.M., with associate administrator of nursing education (AA1), the AA1 stated nursing staff should develop an individualized plan of care based on actual patient problems, because an individualized care plan is beneficial to all aspect of patient care and is an important indicator of treatment progress toward meeting patient goals and outcomes.

During an interview on 8/2/2023, at 9:00 A.M., with Quality and Outcomes Specialist (QOS 1), the QOS 1 stated, all patients should have the Interprofessional Care Plan (IPOC) developed by the health care team to plan and provide patient care. The QOS 1 said an individualized care plan is developed based upon actual or potential problems and assessed needs, and typically includes problems identified, interventions, and outcomes, and should be reviewed at least every 24 hours and updated as patient progress indicates. The QOS 1 stated a care plan serves as a guide for nursing staff to stay focused on problems, interventions, and progress of identified problems because it is beneficial for patients in meeting their expected outcomes.

During a review of the facility's policy and procedure (P&P) titled "Interprofessional Plan of Care (IPOC) Guidelines for Completion and Use," dated 7/12/2022, the P&P indicated all members of the interprofessional team involved in the care of the patient are responsible to develop a care plan based on individualized patient needs. The P&P further indicated, he IPOC must include expected patient outcomes and goals, problems, interventions, and educational interventions and must be reviewed at least every 24 hours and updated as patient progress indicates.

Based on interview and record review, the facility failed to adhere to the facility's wound care management protocol for one of 30 sampled patients (Patient 1) who had skin integrity issue as evidenced by:

1. Failure to ensure timely follow-up with and notification of PT/WT (a team comprised of Physical Therapists specializing in wound care and treatment) for evaluation and treatment of an identified deep tissue injury (DTI-persistent non-blanchable, deep red, purple or maroon areas of intact skin) for Patient 1

2. Failure to document assessment and re-assessment of Patient 1's pressure injury condition between 3/10/2023 to 3/18/2023

3. Failure to notify or provide an update to Patient 1's primary decision maker regarding Patient 1's wound care progression.

These deficient practices resulted in Patient 1 not obtaining timely and appropriate wound care evaluation and treatment, which can negatively affect Patient 1's health outcomes and well-being.

Findings:

During a review of Patient 1's History and Physical (H&P), dated 12/29/2023, at 4:20 P.M., the H&P indicated, Patient 1's admitting diagnosis was left Subdural Hematoma (SDH- a type of brain bleeding that requires a surgery to remove the blood).

During further review of Patient 1's History and Physical (H&P), dated 12/29/2023, at 4:20 P.M., the H&P indicated Patient 1 was alert and oriented x 3 (person, time, and place), had right arm weakness, unsteady walking, and had no skin injuries identified on admission.

During a review of Patient 1's Medical Records (MR) titled "Physician's Progress Note," dated 12/20/2023, the MAR indicated Patient 1 had a surgical procedure to remove accumulation of blood in Patient 1's brain.

During a review of Patient 1's Daily Nursing Skin Assessment (DNSA) record, dated 12/29/2023, the DNS record indicated, Patient 1 did not have skin injuries when Patient 1 was initially admitted to the facility.

During a review of Patient 1's Daily Nursing Skin Assessment (DNSA) record titled "Braden Score Assessment (A skin assessment to identify patients at risk for developing pressure injury)," dated 12/29/2023, the DNSA record indicated, Patient 1's Braden Score was 20 (the Braden Score less than 18 indicates patient is at risk for alteration in skin integrity), indicating the patient is at low risk, with no need for treatment at this time.

During further review of Patient 1's Medical Record (MR) titled "Mental Status Assessment," dated 1/8/2023, the MR indicated Patient was alert and disoriented, and was not able to follow commands and required nursing assistance with all activities of daily living (ADLs-fundamental activities required to independently care for one-self).

During a review of Patient 1's Daily Nursing Skin Assessment (DNSA) record titled "Braden Score Assessment (A skin assessment to identify patients at risk for developing pressure injury)," dated 1/9/2023, the DNSA record indicated Patient 1's Braden Score was 11, indicating a decline, and placing Patient 1 at a higher risk for developing a skin injury.

During a review of Patient 1's Daily Nursing Assessment (DNA) record titled "Skin Assessment," dated 3/8/2023, the DNA indicated Patient 1 developed a pressure injury Stage II (skin breakdown extending to the layers of the skin) to sacrum (The back wall of the pelvis located just above the tailbone), the left buttock.

During a concurrent interview and record review on 8/1/2023, at 11:30 A.M., with Associate Administrator 1 (AA1), Patient 1's wound documentation record titled "Tissue Analytic (TA)," dated 3/8/2023, at 7:51 A.M., was reviewed. The TA indicated new pressure injury Stage II was discovered to sacrum (The back wall of the pelvis located just above the tailbone), the left buttock. The AA1 stated, the Primary Registered Nurse (RN) should perform basic skin assessment, identify new skin injuries, photograph the injury, document findings in TA.

The AA1 also said the Primary RN was expected to provide care and treatment to patients with identified wounds as pressure injury Stage I (pressure-related alteration of intact skin with non-blanchable redness) and Stage II as per facility's standardized orders. The AA1 stated the Primary RN was expected to notify patient or primary decision maker and the provider of all new and declining tissue injuries and document status updates in Clinician Communication and TA. The AA1 said the Primary RN I was not considered a wound care specialist and when in doubt, the Primary RN can contact the Wound Care Nurse Specialist or ask the provider for a Wound Care Evaluation and Treatment order for a PT specialist to evaluate the skin injury.

During a concurrent interview and record review on 8/1/2023, at 11:35 A.M., with Associate Administrator (AA1), Patient 1's Nursing Documentation Records titled "Clinician Communication (CC)" Note, dated 3/8/2023, at 7:51 A.M. was reviewed. The CC Note indicated the Primary Registered Nurse (RN) notified primary decision maker and the provider of a new tissue injury, identified as Stage II pressure injury to sacrum, left buttock. The CC Note further indicated the provider wanted to order Wound Team Evaluation and Treatment (WTE&T) to be done by a Physical Therapy Wound Team (PT/WT). The AA1 said PT/WT is a team of professionals specializing in treatment of wounds and pressure injuries. The AA1 further stated, typically there was no need to obtain an order for WTE&T for pressure injuries identified as Stages I and II. However, Primary RN may request PTW&T evaluation by a specialist PT/WT from the provider based on professional judgement.

During a review of Patient 1's Physician's Orders Record, dated 3/8/2023, the Physician's Orders Record indicated there was no documentation of a new order for Wound Team Evaluation and Treatment.

During a review of Patient 1's Wound Documentation Record titled "Tissue Analytic (TA)," dated 3/10/2023, at 3:33 P.M., the TA indicated new Pressure Injury-Deep Tissue to sacrum, coccyx area was identified by RN Coordinator/Wound Management Program and notified the unit manager of the need for a physician's order for Wound Team Evaluation and Treatment.

During an interview on 8/1/2023, at 11:35 A.M., with Associate Administrator (AA1), the AA1 stated the RN Coordinator/Wound Management Program has the responsibility and accountability for development and implementation of all clinical aspects of the skin injury prevention programs and serves as an expert clinician for nursing staff in assisting them to identify skin injuries requiring involvement and evaluation by the Physical Therapy Wound Team (PT/WT) specializing in wound care.

During a review of Patient 1's Nursing Documentation Record titled "Clinician Communication (CC)" Note, dated 3/10/2023, at 4:00 P.M., the CC Note indicated the Primary Registered Nurse (RN) notified the provider of a declining skin injury to sacrum, coccyx ( tail bone) area, identified as Pressure Injury-Deep Tissue with epidermal ( the surface layer of skin) lifting, and need for Wound Team Evaluation and Treatment (WTE&T) order. The CC Note further indicated there was no documentation of Primary RN notification to primary decision maker of a declining tissue injury.

During a concurrent interview and record review on 8/1/2023, at 11:35 A.M., with Associate Administrator (AA1), Patient 1's Physician Orders, dated 3/10/2023, were reviewed. The order review indicated there was no documentation of a new order for Wound Team Evaluation and Treatment (WTE&T). The AA1 stated, the physician must place an order for WTE&T upon newly identified skin injuries requiring evaluation by PT/WT as per facility's policy and procedure.

During a review of Patient 1's Nursing Documentation Record (NDR), titled "Clinician Communication" Note, dated 3/10/2023-3/18/2023, the NDR indicated, there was no further follow up documentation of Primary RN communication with primary care physician to request a Wound Team Evaluation and Treatment (WTE&T) order.

During a review of Patient 1's Wound Documentation Record, titled "Tissue Analytic (TA)," dated 3/10/2023-3/18/2023, the TA indicated, there was no documentation of assessment and re-assessment of Pressure Injury-Deep Tissue to sacrum, coccyx area from 3/10/2023-3/18/2023.

During further review of Patient 1's Daily Nursing Assessment (DNA) record titled "Braden Score Assessment (A skin assessment to identify patients at risk for developing pressure injury)," dated 3/10/2023, the DNA record indicated, Patient 1's Braden Score was 9, and significantly decreased since Patient 1's admission on 12/29/2023.

During a concurrent interview and record review on 8/2/2023, at 3:27 P.M., with Director of Wound Care Team (DWCT), the facility's policy and procedure (P&P) titled "Skin Care and Tissue Injury Management," dated 1/2023 was reviewed. The P&P indicated the Braden Score less than 18 indicated patient was at risk for alteration in skin integrity. The DWCT stated the Braden score of 9 was considered a high risk for skin tissue injury. DWCT said when a patient is identified as high risk for skin injury and develops an active tissue injury, such as Deep Tissue Injury, a comprehensive (full) wound assessment must be provided by a wound specialist -Physical Therapy Wound Team (PTWT) because patient may require adjustment of prevention strategies and treatment orders for a new tissue injury. The DWCT further said the Primary RN was not considered a specialist in deep tissue injuries and was required to obtain a PTE&T order when a deep tissue injury was identified.

During a review of Patient 1's Wound Documentation Record (WDR) titled "Tissue Analytic (TA)," dated 3/18/2023, at 6:54 P.M., the WDR indicated Primary RN noted declining deep tissue injury (DTI) and notified MD for an emergency Wound Care Evaluation and Treatment order.

During a review of Patient 1's Wound Documentation Record (WDR) titled "Tissue Analytic" (TA), dated 3/18/2023, at 9:32 P.M., the WDR indicated Patient 1's wound to sacrum declined, with local infection, dermis (second skin layer below epidermis, first skin layer) exposed, described as partial thickness skin breakdown, extending down to both buttocks and coccyx (tail bone).

During a review of Patient 1's Wound Documentation Record (WDR) titled "Tissue Analytic (TA), dated 3/20/2023, at 8:10 P.M., the WDR indicated Patient 1's pressure injury was unstageable (full thickness skin and tissue loss in which the extent of tissue damage within the injury cannot be confirmed because it is covered by dead tissue or scab).

During a concurrent interview and record review on 8/1/2023, at 11:35 A.M., with Associate Administrator (AA1), Patient 1's medical records titled "Care Plan (CP)," initiated on 12/29/2023, was reviewed. The CP indicated Preventive Skin Integrity Management Care Plan was initiated upon Patient 1's admission on 12/29/2023. The Skin Integrity Management CP specific to skin injury to sacrum, left buttock was not updated on 3/8/2023 when pressure injury Stage II was initially identified by the Primary RN. The Skin Integrity Management CP specific to Deep Tissue Pressure Injury (DTPI) to sacrum, left buttock was not updated on 3/10/2023 when discovered by the Primary RN. The AA1 stated the Primary RN should update CP specific to skin injury upon discovery as per facility's policy but the Primary RN did not.

During an interview, on 8/2/2023, at 9:00 A.M., with Quality and Outcomes Specialist (QOS 1), the QOS 1 stated, all patients should have the Interprofessional Care Plan (IPOC) developed by the health care team to plan and provide patient care. The QOS 1 said an individualized care plan is developed based upon actual or potential problems and assessed needs, and typically includes problem identified, interventions, and outcomes, and should be reviewed at least every 24 hours and updated as patient progress indicates. The QOS 1 stated a care plan serves as a guide for nursing staff to stay focused on problems, interventions, and progress of identified problems because it is beneficial for patients in meeting their expected outcomes.

During a review of the facility's Policy and Procedure (P&P) titled "Skin Care and Tissue Injury Management," dated 2/2023, the P&P indicated basic wound assessment is performed by non-specialist, any Registered Nurse (RN) and full wound assessment is provided by a Specialist; 22. Primary RN will notify patient or primary decision maker and provider of all new tissue injuries and provide status updates documented in Clinician Communication; 28. When basic wound assessment are not due, the primary RN will perform and document a shift assessment of each tissue/injury skin condition which includes: comparing visible wound beds (s) to previous Tissue analytics photo and assessment to identify unchanged, improving, or declining wound status; 29. The primary RN will notify provider of any skin injury/condition noted in decline, and update patient or primary decision maker, and report the issue through the hospital occurrence system. For new full thickness wound, the RN will obtain Wound Team Evaluation and Treatment orders.