HospitalInspections.org

Based on review of medical records, policy and procedure, and interviews with staff, it was determined the facility failed to ensure patients were provided a safe environment to prevent the development of pressure injuries, and failed to follow policies and orders to ensure wounds did not deteriorate.

Refer to Tag A 144 for findings.

Based on review of medical records (MR), policies and procedures, and interviews with staff, it was determined the facility failed to ensure a safe environment was provided to prevent the development of pressure injuries. The facility failed to ensure staff:

1. Provided skin assessments on persons at risk for developing pressure ulcers.

2. Implemented measures to prevent pressure ulcers.

3. Assessed and accurately staged wounds.

4. Performed wound care as ordered.

This deficient practice affected 3 of 3 records of patients with wounds including Patient Identifier (PI) # 5, PI # 6, and PI # 7.

Findings include:

Facility policy: Patient's Rights and Responsibilities Policy
Policy number: None listed
Date revised: 2/1/15

...Policy:

Recognizing and respecting patient's rights encourages them to become more informed and involved in their care...

Recognizing patient's rights directly affects the provision of care. Care should be provided in a way that respects and fosters the patient's dignity...

You have the right to:

Be treated in a dignified and respectful manner...

An environment that is safe...

Facility Policy: NU (Nursing Unit) Pressure Injury/Prevention Management Policy
Revised: 9/20/21

...2. Policy

...A. Upon admission, patients will receive a comprehensive assessment to determine their risk for breakdown. An individualized prevention and treatment plan with interventions for patients at risk or with pressure injuries will be initiated based on physical assessment findings, Braden score and identified specific needs.
B. The Daily Skin Assessment form (GRMC (Gadsden Regional Medical Center) # 82) should be completed on all critical care patients on admission and transfer. ICU (Intensive Care Unit) patients should have the Daily Skin Assessment form completed each shift. The RN (Med Surg and ICU) caring for the patient each shift should complete the appropriate skin assessment/Braden Scale computerized flowsheet for their area.
C. Documentation of pressure injuries and wounds should be done utilizing the Electronic Health Record (EHR). The pressure injuries documentation includes a description and photograph of wounds/injuries with proper identification. Wound staging should be completed by the physician and/or Wound Care nurse.
D. Pressure injuries should be color photographed by the assessing RN upon discovery or on admission, as needed, and at discharge...

3. Interventions Based on Braden Assessment Score...

Low to High Risk (17 or less per Braden Scale assessment); Initiate routine skin care orders...

G. Reposition at a minimum of every 2 hours, off-loading pressure points (heels, occiput, toes, sacrum, buttocks, over bony prominences...) ...
H. Utilize pressure relieving devices including Air Mattress, Elbow/Heel protectors...
K. Inspect skin each shift for signs and symptoms of breakdown; note any changes from admission or previous shift assessment in the nurses' notes on appropriate form/flowsheet.

Facility Policy: NU Dressing Changes per Aseptic Technique Policy
Policy Number: None
Revised Date: 1/9/19

Purpose:

...to provide instructions to be followed when changing dressings using aseptic technique.

Policy:

A. Dressings should be changed ...for non-surgical wound and skin breakdown.

...C. The physician should be notified of abnormal conditions of the wound such as bleeding or signs of infection...

Procedure:

...D. Charting:

1. Condition of the wound (inspect for redness, excessive pain, ecchymosis, edema, drainage, approximation and odor.)

2. Patient's tolerance to procedure.

3. Medication used.

4. Time and date of dressing change (Note in patient's chart and on dressing.)

1. PI # 5 was first admitted on 8/15/21 with diagnoses including Covid 19, Encephalopathy, and ESRD (End Stage Renal Disease).

Review of the Nursing documentation dated 8/17/21 at 12:05 AM revealed the nurse documented no pressure ulcer on admission, Braden Score of 17.

Review of the Plan of Care/Order Sets revealed an Impaired Skin Integrity POC (Plan of Care) was suggested in the EHR on 8/17/21 at 12:29 AM but was not accepted and initiated until 8/23/21.

Review of the Frequent Documentation notes and ADL (Activities of Daily Living) notes from 8/16/21 to 8/23/21 revealed PI # 5 position was changed as follows:

On 8/17/21 at 1:00 AM, it was documented PI # 5 was on the right side.
On 8/18/21 at 9:00 AM, it was documented the patient was on the back, which was 32 hours in the same position.
On 8/21/21 at 2:00 AM, it was documented the patient was turned to left side.
On 8/21/21 at 9:00 PM, it was documented the patient was repositioned, which was 19 hours on left side.
On 8/22/21 at 9:00 PM, it was documented the patient was turned to the back.
On 8/23/21 at 8:00 AM to 4:00 PM, it was documented PI # 5 was in Fowlers position.
On 8/24/21 at 8:00 AM, it was documented the patient was repositioned, which was 35 hours on the back or Fowlers position. This was the only documented position change on 8/24/21.
On 8/25/21 at 12:00 PM, it was documented the patient was in Fowlers position, at 10:00 PM it was documented the patient was in Fowlers position.
On 8/26/21 at 9:00 PM, it was documented the patient was in Fowlers position, at 11:00 PM it was documented the patient was in Fowlers position.
On 8/28/21 at 9:00 AM, it was documented the patient was on the right side, which was the only documented change of position Fowlers position for 121 hours.
On 8/28/21 at 7:00 PM, it was documented the patient was repositioned, which was 10 hours on the right side.
On 8/29/21 at 9:15 AM, it was documented the patient was in Fowlers position, at 8:00 PM turned to the back, which was 10 hours 45 minutes in the Fowlers position.
On 8/30/21 at 10:00 AM, it was documented the patient was on the left side, which was 14 hours on the back or Fowlers position.

Review of the Physician Orders dated 8/22/21 at 6:25 PM revealed an order to consult wound care nurse for skin breakdown on sacrum.

Review of the Wound Care Documents dated 8/23/21 at 11:42 AM revealed photos were taken of the buttocks and sacrum, and coccyx and described by EI # 4, Wound Nurse, as "pressure related wound to sacrum and coccyx, entire wound bed maroon to purple with two sheering areas noted to right buttock. Recommend pressure reducing waffle mattress, clean with wound cleanser, pat dry, apply Triad hydrophilic wound paste every shift and PRN (as needed), turn patient every 2 hours to reduce pressure to sacrum and buttocks". There were no measurements documented of the wound.

Review of the Physician Order dated 8/23/21 at 1:36 PM revealed "Sacrum and buttocks: Clean wound with cleanser, pat dry apply Triad hydrophilic wound paste every shift and PRN".

Review of the Physician Orders dated 8/23/21 at 6:04 PM revealed "apply Mepilex heel foam dressing. Offload heals with pillows or pressure reduction boots..."

Review of the Wound Care Documents dated 8/31/21 at 5:30 PM revealed photos were taken of the wound area and EI # 4 documented "...sacral and buttocks sheering, now with worsening sheared areas and incontinence associated dermatitis with suspected deep tissue injury to bilateral buttocks ... wound beds red and pink with deep purple discoloration to center of (right) buttocks wound, no drainage, periwound area with erythema. ..." There was no documentation of the wound measurements.

Wound care and assessment was provided by the wound care nurse on 8/23/21 and 8/31/21. There was no other documentation of wound assessment or wound care provided through discharge on 9/9/21 to a skilled nursing facility (SNF).

Review of the SNF Admission Skin Assessment completed by the LPN (Licensed Practical Nurse) on 9/9/21 revealed PI # 5 "...opened areas to coccyx, yellow/gray...tissue, old drsg (dressing) (with) stool and foul smelling drainage...".

Review of the SNF RN (Registered Nurse) Wound Assessment Report dated 9/10/21 revealed the nurse documented PI # 5 "admitted with Stage 4 pressure injury to Coccyx, area appears to have been 2 areas merged together with islands of intact skin, covering areas of the left buttocks, coccyx, and right buttocks. Entire area 10 cm (centimeters) x 10 cm x 1 cm depth. 40 % yellow sough, 40 % black/tan necrotic tissue to center of wound bed and 20 % granulation tissue to wound bed edges. Small serosanguineous drainage. Slight foul odor. Surrounding tissue red and yeast noted..."

In an interview conducted on 10/8/21 at 11:20 AM, Employee Identifier (EI) # 1, Chief Quality Officer (CQO) confirmed PI # 5 was not turned every 2 hours per facility policy and the wound care and assessment was not performed as ordered.

PI # 5 was re-admitted to Gadsden Regional Hospital on 9/16/21 with diagnosis of Abdominal Pain.

Review of the Physician Order dated 9/17/21 at 10:46 PM revealed Consult to Wound Care Nurse for pressure ulcer on admission and turn every 2 hours.

Review of the MR from 9/16/21 through discharge on9/20/21revealed no documentation the Wound Care Consult was performed as ordered.

Review of the Braden Assessment score was 13 on 9/17/21 at 10:40 PM, indicating the patient was at risk for developing pressure ulcers.

Review of the Nursing Note dated 9/18/21 at 4:55 AM revealed "large decubitus to sacral and buttocks area. Mepilex will not be sufficient for coverage. Cleaned area and applied Zinc barrier cream, patient turned to left side and wedge placed behind (him/her), pillow between legs at the knees..."

There was no other documentation of wound assessment, of wound care provided, or documentation the patient was turned every 2 hours.

PI # 5 was discharged to a SNF on 9/20/21.

Review of the SNF Wound Assessment Report dated 9/21/21 revealed "...Right Coccyx stage 4 pressure injury. Area is 11 cm x 6 cm x 1.5 cm depth. 30 % granulation tissue, 30 % black/tan eschar, and 40 % adherent slough to wound bed. Small amount of serosanguineous drainage. Surrounding tissue pink and blanchable..."

In an interview conducted on 10/8/21 at 11:20 AM, EI # 1 confirmed PI # 5 was not turned every 2 hours, the wound care consult was not completed, and there was no documentation of wound measurements or wound care other than on 9/18/21.

PI # 5 was re-admitted to Gadsden Regional Hospital on 9/24/21 with diagnosis of Hematuria.

Review of the Integumentary documentation dated 9/25/21 at 12:13 AM revealed the Braden Score was 13, indicating the patient was at risk for developing pressure injuries.

Review of the Surgical Documentation dated 9/29/21 at 6:15 PM revealed an Incision and Drainage was performed on the Sacral Decubitus Ulcer.

Review of the Wound Care Documents dated 9/27/21 at 3:59 PM revealed the Wound Care Nurse documented "Wound care consult completed...Pt (patient) known to wound care from previous admission with sacral wound on 8/31/21. Worsening of sacral and buttocks wound noted this admission...Noted right sacral area extending to right buttocks with unstageable pressure injury...Noted left buttocks with Stage 2 pressure injury, L (Length) 3 cm x W (Width) 2 cm x D (Depth) 0.1 cm..." There was no documentation of the depth of the wound.

Review of the Wound Care Documents dated 9/30/21 at 12:15 PM revealed the Wound Care Nurse documented "Wound Care follow up post surgical debridement...on 9/29/21 to sacral and right buttocks unstageable pressure injury, now Stage 3, L 10.3 cm x W 6 cm with varying depths greatest D 3.2 (cm) with undermining from 1 o'clock to 5 o'clock with greatest D 4.2 cm...Wound full thickness with subcutaneous fat visible wound bed with (approximately) 25 % red tissue..."

In an interview conducted on 10/6/21 at 12:15 PM, EI # 4 was asked what was the stage of the wound on 9/30/21. EI # 4 responded "Stage 3, full thickness, through fat and into muscle. It probably should be a Stage 4. The doctor looked at it and said it was a Stage 3. Said it probably could be pushed to a Stage 4 but we are calling it a Stage 3."

On 10/6/21 at 12:45 PM an observation of PI # 5 wound was conducted with 2 surveyors, EI # 1, and EI # 5, Director. The dressing was removed from the buttocks and coccyx area revealing a large Stage 4 pressure injury to sacral area extending to right buttocks. Measurements obtained by EI # 4 were L 9.4 cm x W 5.4 cm x D 3.2 cm, undermining 5.3 cm. Area to left buttocks 2.1 cm x 1.0 cm.

Review of the Surgical Documentation dated 10/5/21 at 3:26 PM revealed a Laparoscopic Colon Resection was performed under General Anesthesia for a Diverting Colostomy.

Review of the Wound Care Documents dated 10/6/21 and documented at 6:15 PM revealed the Wound Care Nurse documented "Wound care follow up post surgical debridement on 9/29/21 to sacral and right buttocks unstageable pressure injury, now Stage 4, L 9.4 cm x W 5.4 cm with varying depths greatest D 3.2 (cm) with undermining from 1 o'clock to 5 o'clock with greatest D 5.3 cm. Wound full thickness with muscle and subcutaneous fat visible wound bed mixed with tan and black fibrous slough to more proximal wound bed, light serosanguineous drainage, slight malodorous, which improved with wound cleansing..."

An interview was conducted on 10/6/21 at 11:20 AM with EI # 1 who confirmed facility policy was not followed for skin assessments, turning, and wound care.

2. PI # 6 was admitted on 9/12/21 with diagnoses including Covid 19 Pneumonia and Hypoxia.

Review of the Braden Assessment dated 9/12/21 at 9:00 PM revealed a score of 12 indicating the patient was at risk for developing pressure ulcers.

Review of the Physician Orders dated 9/13/21 at 2:18 PM revealed orders to turn patient every 2 hours and Skin Bundle Assessment BID (twice a day).

Review of the Frequent Documentation, Patient Position revealed the patient's position was changed as follows:

On 9/13/21 at 12:00 AM, the patient position was "Head of Bed (HOB) elevated". The next documented change was on 9/16/21 at 8:00 PM, which was 92 hours. There was no documentation the patient was turned side to side.

On 9/17/21 at 2:00 AM the nurse documented the patient was repositioned. The next documented patient position was on 9/18/21 at 1:00 AM, which was 23 hours later.

On 9/18/21 at 5:00 AM the nurse documented the patient was repositioned. The next documented patient position change was at 8:00 PM, which was 15 hours later.

Review of the Integumentary assessment dated 9/27/21 at 10:00 AM revealed the nurse documented a Midline Coccyx skin tear.

Review of the Integumentary assessment dated 9/28/21 8:00 AM revealed the nurse documented a Midline Coccyx pressure ulcer and foam dressing changed.

Review of the Physician Order dated 9/28/21 at 6:57 PM revealed "Coccyx: Recommend clean with wound cleanser, pat dry and cover with Exufiber dressing and foam as long as drainage is present. Change daily and PRN...".

Review of the Wound Care Nursing documentation dated 9/28/21 at 7:37 PM revealed "Wound care consult completed...Coccyx: Stage II pressure injury noted to coccyx, wound bed pink, open, non-draining area (L 3.7 cm x W 1 cm x 0.3 cm) surrounded by suspected deep tissue injury (L 8 cm x W 8 cm x D 0 cm) wound bed deep brown with serous drainage noted...".

Further review of the Integumentary assessments revealed the dressing was not changed again until 10/3/21 at 7:00 PM, which was 5 days later.

An interview was conducted on 10/7/21 at 3:00 PM with EI # 1, who confirmed PI # 6 did not have a wound prior to admission, was not turned every 2 hours per facility policy, and wound care was not performed as ordered.

3. PI # 7 was admitted on 9/27/21 with diagnoses including Covid 19 and Hypoxia.

Review of the Physician Orders dated 9/27/21 at 9:59 PM revealed an order to consult the Wound Care Nurse.

Review of the of the Physician Orders dated 9/28/21 at 12:32 PM revealed an orders to turn patient every 2 hours.

Review of the Wound Care Documents dated 9/28/21 at 6:34 PM revealed "Wound care consult completed...Suspected deep tissue injury to right ear (L 0.5 cm x W 0.5 cm x D 0 cm) wound bed dark blue, skin intact, peri-wound area with slight redness...Suspected deep tissue injury noted to left buttock (L 6.2 cm x W 4.9 cm x d 0 cm) wound bed patchy purple and red center with red-pink edges, no open or draining area noted, periwound area pink...".

Review of the Frequent Documentation, Patient Positioning, revealed the following documentation:

On 9/28/21 at 6:00 PM the patient was on the left side. The next documented position change was on 9/29/21 at 11:00 PM when PI # 7 was turned to the right side, which was 15 hours later. The next position change was on 9/29/21 at 5:00 PM, which was 6 hours later.

Further review of the Frequent Documentation, Patient Positioning, revealed on 10/2/21 at 10:00 AM PI # 7 was supine position. The position was not changed until 7:00 PM to the prone position.

An interview was conducted on 10/7/21 at 3:14 PM with EI # 1 who confirmed PI # 7 was not turned every 2 hours as ordered.



39098

Based on review of medical records, facility policies and procedures, RN (Registered Nurse) Wound Care Nurse Position Description, observations, and interviews, it was determined the facility failed to perform skin assessments on patients at risk for developing pressure ulcers, failed to assess, measure, and accurately stage wounds, and perform wound care as ordered. The facility also failed to adhere to their own staff qualifications for wound care nurse.

This deficient practice affected 3 of 3 records reviewed of patients with wounds, including Patient Identifiers (PI) # 5, PI # 6, and PI # 7.

Please refer to tag A 392.

Based on Medical Record (MR) review, Facility Policies, RN (Registered Nurse) Wound Care Nurse Position Description, observations, and interviews it was determined the facility failed to:

1. Provide skin assessments on persons at risk for developing pressure ulcers.

2. Failed to implement measures to prevent pressure ulcers.

3. Failed to assess and accurately stage wounds.

4. Failed to perform wound care as ordered.

5. Ensure wound care nurse was a Certified Wound Care Nurse.

This deficient practice affected 3 of 3 records of patients with wounds including Patient Identifier (PI) # 5, PI # 6, and PI # 7.

Findings include:

Facility Policy: NU (Nursing Unit) Pressure Injury/Prevention Management Policy
Revised: 9/20/21

...2. Policy

...A. Upon admission, patients will receive a comprehensive assessment to determine their risk for breakdown. An individualized prevention and treatment plan with interventions for patients at risk or with pressure injuries will be initiated based on physical assessment findings, Braden score and identified specific needs.
B. The Daily Skin Assessment form (GRMC (Gadsden Regional Medical Center) # 82) should be completed on all critical care patients on admission and transfer. ICU (Intensive Care Unit) patients should have the Daily Skin Assessment form completed each shift. The RN (Med Surg and ICU) caring for the patient each shift should complete the appropriate skin assessment/Braden Scale computerized flowsheet for their area.
C. Documentation of pressure injuries and wounds should be done utilizing the Electronic Health Record (EHR). The pressure injuries documentation includes a description and photograph of wounds/injuries with proper identification. Wound staging should be completed by the physician and/or Wound Care nurse.
D. Pressure injuries should be color photographed by the assessing RN upon discovery or on admission, as needed, and at discharge...

3. Interventions Based on Braden Assessment Score...

Low to High Risk (17 or less per Braden Scale assessment); Initiate routine skin care orders...

G. Reposition at a minimum of every 2 hours, off-loading pressure points (heels, occiput, toes, sacrum, buttocks, over bony prominences...) ...
H. Utilize pressure relieving devices including Air Mattress, Elbow/Heel protectors...
K. Inspect skin each shift for signs and symptoms of breakdown; note any changes from admission or previous shift assessment in the nurses' notes on appropriate form/flowsheet.

Facility Policy: NU Dressing Changes per Aseptic Technique Policy
Policy Number: None
Revised Date: 1/9/19

Purpose:

...to provide instructions to be followed when changing dressings using aseptic technique.

Policy:

A. Dressings should be changed ...for non-surgical wound and skin breakdown.

...C. The physician should be notified of abnormal conditions of the wound such as bleeding or signs of infection...

Procedure:

...D. Charting:

1. Condition of the wound (inspect for redness, excessive pain, ecchymosis, edema, drainage, approximation and odor.)

2. Patient's tolerance to procedure.

3. Medication used.

4. Time and date of dressing change (Note in patient's chart and on dressing.)

Position Title: RN Wound Care
Job Number: 60001
Date of Last Revision: February 2019

Position Purpose:

...The RN Wound Care Nurse is responsible for assessment and wound care and providing education and guidance for staff in the care of the patient with wounds. Assist with education and care of ostomy patients.

Position Qualifications

Education Required: Associate Degree/ BSN (Bachelor of Science in Nursing) preferred. Certified Wound Care Nurse.

General Duties

...Wound Care Specific:

Assist in developing, maintaining data collection and evaluation of QA/PI (Quality Assessment/ Performance Improvement) related to skin care of ostomy care.

Assesses learning needs of staff and provides education on an ongoing basis.

Teaches skin care and ostomy care to new nurses.

Serves as a resource person to others by the sharing of knowledge.

Reviews and revises policies related to skin care and ostomy care, as needed.

...Coordinates with Infection Prevention Coordinator to identify potential infection prevention issues; assist in education of staff...

1. PI # 5 was first admitted on 8/15/21 with diagnoses including Covid 19, Encephalopathy, and ESRD (End Stage Renal Disease).

Review of the Nursing documentation dated 8/17/21 at 12:05 AM revealed the nurse documented no pressure ulcer on admission, Braden Score of 17.

Review of the Plan of Care/Order Sets revealed an Impaired Skin Integrity POC (Plan of Care) was suggested in the EHR on 8/17/21 at 12:29 AM but was not accepted and initiated until 8/23/21.

Review of the Frequent Documentation notes and ADL (Activities of Daily Living) notes from 8/16/21 to 8/23/21 revealed PI # 5 position was changed as follows:

On 8/17/21 at 1:00 AM, it was documented PI # 5 was on the right side.
On 8/18/21 at 9:00 AM, it was documented the patient was on the back, which was 32 hours in the same position.
On 8/21/21 at 2:00 AM, it was documented the patient was turned to left side.
On 8/21/21 at 9:00 PM, it was documented the patient was repositioned, which was 19 hours on left side.
On 8/22/21 at 9:00 PM, it was documented the patient was turned to the back.
On 8/23/21 at 8:00 AM to 4:00 PM, it was documented PI # 5 was in Fowlers position.
On 8/24/21 at 8:00 AM, it was documented the patient was repositioned, which was 35 hours on the back or Fowlers position. This was the only documented position change on 8/24/21.
On 8/25/21 at 12:00 PM, it was documented the patient was in Fowlers position, at 10:00 PM it was documented the patient was in Fowlers position.
On 8/26/21 at 9:00 PM, it was documented the patient was in Fowlers position, at 11:00 PM it was documented the patient was in Fowlers position.
On 8/28/21 at 9:00 AM, it was documented the patient was on the right side, which was the only documented change of position Fowlers position for 121 hours.
On 8/28/21 at 7:00 PM, it was documented the patient was repositioned, which was 10 hours on the right side.
On 8/29/21 at 9:15 AM, it was documented the patient was in Fowlers position, at 8:00 PM turned to the back, which was 10 hours 45 minutes in the Fowlers position.
On 8/30/21 at 10:00 AM, it was documented the patient was on the left side, which was 14 hours on the back or Fowlers position.

Review of the Physician Orders dated 8/22/21 at 6:25 PM revealed an order to consult wound care nurse for skin breakdown on sacrum.

Review of the Wound Care Documents dated 8/23/21 at 11:42 AM revealed photos were taken of the buttocks and sacrum, and coccyx and described by EI # 4, Wound Nurse, as "pressure related wound to sacrum and coccyx, entire wound bed maroon to purple with two sheering areas noted to right buttock. Recommend pressure reducing waffle mattress, clean with wound cleanser, pat dry, apply Triad hydrophilic wound paste every shift and PRN (as needed), turn patient every 2 hours to reduce pressure to sacrum and buttocks". There were no measurements documented of the wound.

Review of the Physician Order dated 8/23/21 at 1:36 PM revealed "Sacrum and buttocks: Clean wound with cleanser, pat dry apply Triad hydrophilic wound paste every shift and PRN".

Review of the Physician Orders dated 8/23/21 at 6:04 PM revealed "apply Mepilex heel foam dressing. Offload heals with pillows or pressure reduction boots..."

Review of the Wound Care Documents dated 8/31/21 at 5:30 PM revealed photos were taken of the wound area and EI # 4 documented "...sacral and buttocks sheering, now with worsening sheared areas and incontinence associated dermatitis with suspected deep tissue injury to bilateral buttocks ... wound beds red and pink with deep purple discoloration to center of (right) buttocks wound, no drainage, periwound area with erythema. ..." There was no documentation of the wound measurements.

Wound care and assessment was provided by the wound care nurse on 8/23/21 and 8/31/21. There was no other documentation of wound assessment or wound care provided through discharge on 9/9/21 to a skilled nursing facility (SNF).

Review of the SNF Admission Skin Assessment completed by the LPN (Licensed Practical Nurse) on 9/9/21 revealed PI # 5 "...opened areas to coccyx, yellow/gray...tissue, old drsg (dressing) (with) stool and foul smelling drainage...".

Review of the SNF RN (Registered Nurse) Wound Assessment Report dated 9/10/21 revealed the nurse documented PI # 5 "admitted with Stage 4 pressure injury to Coccyx, area appears to have been 2 areas merged together with islands of intact skin, covering areas of the left buttocks, coccyx, and right buttocks. Entire area 10 cm (centimeters) x 10 cm x 1 cm depth. 40 % yellow sough, 40 % black/tan necrotic tissue to center of wound bed and 20 % granulation tissue to wound bed edges. Small serosanguineous drainage. Slight foul odor. Surrounding tissue red and yeast noted..."

In an interview conducted on 10/8/21 at 11:20 AM, Employee Identifier (EI) # 1, Chief Quality Officer (CQO) confirmed PI # 5 was not turned every 2 hours per facility policy and the wound care and assessment was not performed as ordered.

PI # 5 was re-admitted to Gadsden Regional Hospital on 9/16/21 with diagnosis of Abdominal Pain.

Review of the Physician Order dated 9/17/21 at 10:46 PM revealed Consult to Wound Care Nurse for pressure ulcer on admission and turn every 2 hours.

Review of the MR from 9/16/21 through discharge on9/20/21revealed no documentation the Wound Care Consult was performed as ordered.

Review of the Braden Assessment score was 13 on 9/17/21 at 10:40 PM, indicating the patient was at risk for developing pressure ulcers.

Review of the Nursing Note dated 9/18/21 at 4:55 AM revealed "large decubitus to sacral and buttocks area. Mepilex will not be sufficient for coverage. Cleaned area and applied Zinc barrier cream, patient turned to left side and wedge placed behind (him/her), pillow between legs at the knees..."

There was no other documentation of wound assessment, of wound care provided, or documentation the patient was turned every 2 hours.

PI # 5 was discharged to a SNF on 9/20/21.

Review of the SNF Wound Assessment Report dated 9/21/21 revealed "...Right Coccyx stage 4 pressure injury. Area is 11 cm x 6 cm x 1.5 cm depth. 30 % granulation tissue, 30 % black/tan eschar, and 40 % adherent slough to wound bed. Small amount of serosanguineous drainage. Surrounding tissue pink and blanchable..."

In an interview conducted on 10/8/21 at 11:20 AM, EI # 1 confirmed PI # 5 was not turned every 2 hours, the wound care consult was not completed, and there was no documentation of wound measurements or wound care other than on 9/18/21.

PI # 5 was re-admitted to Gadsden Regional Hospital on 9/24/21 with diagnosis of Hematuria.

Review of the Integumentary documentation dated 9/25/21 at 12:13 AM revealed the Braden Score was 13, indicating the patient was at risk for developing pressure injuries.

Review of the Wound Care Documents dated 9/27/21 at 3:59 PM revealed the Wound Care Nurse documented "Wound care consult completed...Pt (patient) known to wound care from previous admission with sacral wound on 8/31/21. Worsening of sacral and buttocks wound noted this admission...Noted right sacral area extending to right buttocks with unstageable pressure injury...Noted left buttocks with Stage 2 pressure injury, L (Length) 3 cm x W (Width) 2 cm x D (Depth) 0.1 cm..."

Review of the Surgical Documentation dated 9/29/21 at 6:15 PM revealed an Incision and Drainage was performed on the Sacral Decubitus Ulcer.

Review of the Wound Care Documents dated 9/30/21 at 12:15 PM revealed the Wound Care Nurse documented "Wound Care follow up post surgical debridement...on 9/29/21 to sacral and right buttocks unstageable pressure injury, now Stage 3, L 10.3 cm x W 6 cm with varying depths greatest D 3.2 (cm) with undermining from 1 o'clock to 5 o'clock with greatest D 4.2 cm...Wound full thickness with subcutaneous fat visible wound bed with (approximately) 25 % red tissue..."

In an interview conducted on 10/6/21 at 12:15 PM, EI # 4 was asked what was the stage of the wound on 9/30/21. EI # 4 responded "Stage 3, full thickness, through fat and into muscle. It probably should be a Stage 4. The doctor looked at it and said it was a Stage 3. Said it probably could be pushed to a Stage 4 but we are calling it a Stage 3."

Review of the Surgical Documentation dated 10/5/21 at 3:26 PM revealed a Laparoscopic Colon Resection was performed under General Anesthesia for a Diverting Colostomy.

On 10/6/21 at 12:45 PM an observation of PI # 5 wound was conducted with 2 surveyors, EI # 1, and EI # 5, Director. The dressing was removed from the buttocks and coccyx area revealing a large Stage 4 pressure injury to sacral area extending to right buttocks. Measurements obtained by EI # 4 were L 9.4 cm x W 5.4 cm x D 3.2 cm, undermining 5.3 cm. Area to left buttocks 2.1 cm x 1.0 cm, there was no documentation of the depth.

Review of the Wound Care Documents dated 10/6/21 and documented at 6:15 PM revealed the Wound Care Nurse documented "Wound care follow up post surgical debridement on 9/29/21 to sacral and right buttocks unstageable pressure injury, now Stage 4, L 9.4 cm x W 5.4 cm with varying depths greatest D 3.2 (cm) with undermining from 1 o'clock to 5 o'clock with greatest D 5.3 cm. Wound full thickness with muscle and subcutaneous fat visible wound bed mixed with tan and black fibrous slough to more proximal wound bed, light serosanguineous drainage, slight malodorous, which improved with wound cleansing..."

An interview was conducted on 10/6/21 at 11:20 AM with EI # 1 who confirmed facility policy was not followed for skin assessments, turning, and wound care.

2. PI # 6 was admitted on 9/12/21 with diagnoses including Covid 19 Pneumonia and Hypoxia.

Review of the Braden Assessment dated 9/12/21 at 9:00 PM revealed a score of 12 indicating the patient was at risk for developing pressure ulcers.

Review of the Physician Orders dated 9/13/21 at 2:18 PM revealed orders to turn patient every 2 hours and Skin Bundle Assessment BID (twice a day).

Review of the Frequent Documentation, Patient Position revealed the patient's position was changed as follows:

On 9/13/21 at 12:00 AM, the patient position was "Head of Bed (HOB) elevated". The next documented change was on 9/16/21 at 8:00 PM, which was 92 hours. There was no documentation the patient was turned side to side.

On 9/17/21 at 2:00 AM the nurse documented the patient was repositioned. The next documented patient position was on 9/18/21 at 1:00 AM, which was 23 hours later.

On 9/18/21 at 5:00 AM the nurse documented the patient was repositioned. The next documented patient position change was at 8:00 PM, which was 15 hours later.

Review of the Integumentary assessment dated 9/27/21 at 10:00 AM revealed the nurse documented a Midline Coccyx skin tear.

Review of the Integumentary assessment dated 9/28/21 8:00 AM revealed the nurse documented a Midline Coccyx pressure ulcer and foam dressing changed.

Review of the Physician Order dated 9/28/21 at 6:57 PM revealed "Coccyx: Recommend clean with wound cleanser, pat dry and cover with Exufiber dressing and foam as long as drainage is present. Change daily and PRN...".

Review of the Wound Care Nursing documentation dated 9/28/21 at 7:37 PM revealed "Wound care consult completed...Coccyx: Stage II pressure injury noted to coccyx, wound bed pink, open, non-draining area (L 3.7 cm x W 1 cm x 0.3 cm) surrounded by suspected deep tissue injury (L 8 cm x W 8 cm x D 0 cm) wound bed deep brown with serous drainage noted...".

Further review of the Integumentary assessments revealed the dressing was not changed again until 10/3/21 at 7:00 PM, which was 5 days later.

An interview was conducted on 10/7/21 at 3:00 PM with EI # 1, who confirmed PI # 6 did not have a wound prior to admission, was not turned every 2 hours per facility policy, and wound care was not performed as ordered.

3. PI # 7 was admitted on 9/27/21 with diagnoses including Covid 19 and Hypoxia.

Review of the Physician Orders dated 9/27/21 at 9:59 PM revealed an order to consult the Wound Care Nurse.

Review of the of the Physician Orders dated 9/28/21 at 12:32 PM revealed an orders to turn patient every 2 hours.

Review of the Wound Care Documents dated 9/28/21 at 6:34 PM revealed "Wound care consult completed...Suspected deep tissue injury to right ear (L 0.5 cm x W 0.5 cm x D 0 cm) wound bed dark blue, skin intact, peri-wound area with slight redness...Suspected deep tissue injury noted to left buttock (L 6.2 cm x W 4.9 cm x d 0 cm) wound bed patchy purple and red center with red-pink edges, no open or draining area noted, periwound area pink...".

Review of the Frequent Documentation, Patient Positioning, revealed the following documentation:

On 9/28/21 at 6:00 PM the patient was on the left side. The next documented position change was on 9/29/21 at 11:00 PM when PI # 7 was turned to the right side, which was 15 hours later. The next position change was on 9/29/21 at 5:00 PM, which was 6 hours later.

Further review of the Frequent Documentation, Patient Positioning revealed on 10/2/21 at 10:00 AM PI # 7 was supine position. The position was not changed until 7:00 PM to the prone position.

An interview was conducted on 10/7/21 at 3:14 PM with EI # 1 who confirmed PI # 7 was not turned every 2 hours as ordered.



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4. Review of the personnel file for EI # 4, RN, Wound Nurse, revealed a hire date of 5/6/11. Further review of the personnel file revealed no documentation that EI # 4 was a Certified Wound Care Nurse, per the facility Position Title for RN Wound Care.

An interview was conducted on 10/6/21 at 11:35 AM with EI # 1, who stated EI # 4 started in the position of Wound Care Nurse on 10/25/2020, but was not a Certified Wound Care Nurse. EI # 1 further confirmed there was no signed Position Description/ Competency Based Evaluation form completed and signed by EI # 4, and no documentation of annual competency skills.