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Based on record review and interview, facility staff failed to perform nursing assessments, interventions, and evaluate patient skin care needs to prevent skin breakdown in 4 of 10 medical records reviewed (Patient (Pt) #1, #3, #5, #8); failed to ensure that nursing care plans were initiated as per policy to address skin/wound care needs and interventions in 4 of 10 medical records reviewed (Pt #2, #3, #7, #10); failed to ensure nursing care plans are kept current and updated based on patient assessments in 3 of 10 medical records reviewed (Pt #1, #3, #10); and failed to ensure that nursing interventions are implemented based on ongoing assessments of patient care needs in 3 of 10 medical records reviewed (Pt #1, #3, #10), in a total sample of 10 medical records reviewed.


Findings Include:

The facility staff failed to perform nursing assessments, interventions, and evaluate patient care needs to prevent skin breakdown. See Tag A-0395.

The facility staff failed to ensure that nursing care plans were initiated as per policy to address skin/wound care needs and interventions; failed to ensure nursing care plans are kept current and updated based on patient assessments; and failed to ensure that nursing interventions are implemented based on ongoing assessments of patient care needs. See Tag A-0396.

Based on record review and interview, facility staff failed to perform nursing assessments, interventions, and evaluate patient skin care needs to prevent skin breakdown for 4 of 10 patients (Patient (Pt) #1, #3, #5, #8), in a total sample of 10 medical records reviewed.

Findings Include:

Review of policy and procedure #18006238 titled, "Ascension Wisconsin Pressure Injury Risk Assessment & Prevention" last revised 04/17/2025 revealed:
- "The Braden Scale is a tool used to assess a patient's risk for developing pressure injuries. It evaluates six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. A person that scores 18 or lower on the scale is considered to be at risk for skin breakdown."
- "A pressure injury is localized damage to the skin and underlying tissue, primarily occurring over a bony prominence, caused by prolonged pressure, shear, or friction. Pressure injuries commonly occur in individuals with limited mobility..."
- "HAPI (hospital acquired pressure injury) risk assessment should be conducted using the Braden Scale for predicting pressure sore risk."
- "Skin assessments should be conducted at a minimum of the following: A. Admission B. Every Shift..."
- "HAPI prevention interventions should be tailored to address specific risks identified during the HAPI risk and skin assessments and as recommended in the...algorithm."
- "Interventions aligned with Braden Subscaled scores less than 3. A. Sensory perception recommendations...iii. Sacrum: Consider application of multi-layer foam dressing with silicone adhesive...B. Moisture/Incontinence management recommendations. i. Single layer, breathable, high absorbency incontinence pads: no incontinence briefs in bed. ii. Cleanse skin using non-alkaline cleansers, apply moisture barrier...iv. apply moisture to dry skin...C. Activity recommendations...iv. Sacrum/lower buttocks: Consider application of multi-layer foam dressing with silicone adhesive. D. Mobility recommendations...iv. Sacrum: Consider application of multi-layer foam dressing with silicone adhesive. v. consider use of high specification reactive foam or reactive air mattress/overlay...F. Friction & Shear recommendations...iii. Sacrum: Apply multi-layer foam dressing with silicone adhesive to minimize friction/shear..."

Review of policy and procedure #12500967 titled, "Management of Skin breakdown" last revised 10/10/2022 revealed:
- "Patients with existing skin breakdown on admission or that develop skin breakdown during their hospital stay will be treated with established evidenced-based interventions."
- "Measure wound and document at minimum every 4 days."
- "Assess wound with every dressing change including skin surrounding wound, and document both assessment and dressing change."
- "If WOC RN (Wound Care Registered Nurse) consult has been completed, complete wound care as ordered per recommendations."

Review of policy and procedure #18231547 titled, "Hospital Based Assessment & Documentation..." last revised 05/23/2025 revealed:
- "Each discipline documents their interventions and the patient's response to these interventions in the patient's health record."

Review of Pt #1's medical record revealed Pt #1 was a 63 year old admitted to the inpatient Intensive Care Unit (ICU) on 03/06/2025 at 6:27 PM after having a "Whipple" procedure (surgical operation that removes the head of the pancreas, the first part of the small intestine, and sometimes a portion of the stomach, gallbladder, and common bile duct) for pancreatic cancer. Pt #1 was placed on comfort cares and passed away at the hospital on 06/03/2025 at 3:08 PM.

Review of Pt #1's Discharge Summary dated 06/03/2025 at 1:36 PM revealed on 03/23/2025 Pt #1 became hypotensive (low blood pressure) and tachycardic (fast heart rate) and was intubated (breathing tube inserted for breathing) in the ICU. Per the Discharge Summary, on the evening of 03/23/2025 Pt #1 returned to Surgery for active bleeding from previous surgical site. Pt #1 remained on ventilation (breathing machine) after surgery and underwent a tracheostomy for respiratory failure and ventilator dependence.

Review of Pt #1's ICU admission skin assessment on 03/06/2025 at 8:00 PM revealed Pt #1's buttocks was red, foam dressing applied.

Review of Pt #1's Braden score from 03/06/2025 through 05/23/2025 revealed Pt #1's Braden score ranged from 12 to 16 (at risk for skin breakdown) throughout the inpatient stay.

Review of Pt #1's skin/wound assessments revealed the redness to Pt #1's buttocks on admission (03/06/2025) worsened to an unstageable pressure injury measuring 5 cm x 10 cm x 1.5 cm (05/09/2025).

Review of Pt #1's wound flowsheets revealed, "Deep Tissue Injury (DTI) Bilateral Buttocks" was "first assessed" on 03/25/2025 at 12:00 AM (19 days after admission).

Review of Pt #1 Wound Care progress notes from 03/25/2025 to 05/23/2025 revealed:
-03/25/2025 3:55 PM: "Hospital acquired DTI across bilateral buttocks measuring 4 (length in centimeters) x 7 cm (centimeters) (width) with non blanchable deep purple tissue...Writer applied Allevyn boarder foam...Pt is at risk for skin breakdown due to decreased mobility, moisture, friction/shear, inadequate nutrition. Goals of Treatment:...Prevent skin breakdown, Manage incontinence...Recommendations: Wound Care to Bilateral Buttocks...1. Cleanse with peri wipes...2. Apply Allevyn boarder foam...3. Assess under dressing every shift...4. Change dressing every other day, PRN (as needed) soiling...Preventative Measures:...5. Utilize incontinence management as needed: Cleanse with: Soap and water, Sage Barrier Wipes. Apply: Critic-Aid Clear (barrier cream)...Frequency: PRN with Incontinence...6. Only remove soiled layer of barrier cream, reapply to ensure frosting like consistency."
-04/1/2025 at 10:45 PM: "Hospital acquired DTI across bilateral buttocks measuring larger 4 x 7 cm (to) 6 x 9 cm with non blanchable deep purple tissue...Writer applied Allevyn boarder foam" (Recommendations and Preventative Measures same as 03/25/2025).
-04/04/2025 at 1:58 PM: "Apply Desitin to wound bed BID (twice daily)."
-04/22/2025 at 12:35 PM: "Wound Care to Bilateral Buttocks: 1. Cleanse with soap and water...2. Apply Medihoney to wound bed...3. Cover with Allevyn...4. Change and assess q (every) day and PRN with saturation."
-04/29/2025 at 12:50 PM: "Hospital acquired DTI across bilateral buttocks is now an unstageable pressure injury measuring 5 (cm) x 10 (cm) x 0.5 cm (depth) which is starting to evolve revealing red moist tissues."
-05/02/2025 at 10:38 PM: "Hospital acquired DTI across bilateral buttocks is now an unstageable pressure injury measuring 5 x 10 x 1 cm...Wound Care to Bilateral Buttocks...1. Cleanse with soap and water...2. Apply Santyl (wound ointment) to wound bed...3. Cover with Allevyn...4. Change and assess q (every) day and PRN with saturation."
-05/09/2025 at 1:43 PM: "Hospital acquired DTI across bilateral buttocks is now an unstageable pressure injury measuring 5 x 10 x 1.5 cm...Wound Care to Sacrum...1. Cleanse with soap and water...2. Apply Santyl to wound bed...3. Moisten Hydrofera Blue (antibacterial foam dressing) with NS (normal saline), cut to fit wound and apply to wound bed...4. Cover with Allevyn...5. Change and assess q day and PRN with saturation."
-05/23/2025 at 1:59 PM: "Wound Care to Sacrum...1. Cleanse with soap and water...2. Apply wet to dry dakins (solution) to wound beds...3. Cover with Allevyn or ABD (abdominal) pad...4. Change and assess q day and PRN with saturation."

Review of Pt #1's "Deep Tissue Injury (DTI) Bilateral Buttocks" wound flowsheets from 03/25/2025 through 05/23/2025 revealed:
-On 03/28/2025 to 04/01/2025 (5 days), 04/12/2025 to 04/15/2025 (4 days), 04/20/2025 to 04/23/2025 (3 days), nursing wound documentation revealed "No dressing in place" and "Open to air." This was inconsistent with Wound Care orders to "Cover with Allevyn (foam dressing)."
-On 03/26/2025 to 04/01/2025 (7 days), 04/12/2025 to 04/15/2025 (4 days), 04/20/2025 to 04/22/2025 (3 days), 04/26/2025 to 04/29/2025 (4 days), and 05/10/2025, there was no documentation of cleansing of the wound and/or treatment interventions completed as per Wound Care orders.
-On 03/26/2025, 03/27/2025, 04/26/2025 to 05/02/2025 (7 days), 05/06/2025, 05/07/2025, 05/10/2025 to 05/13/2025 (4 days), and 05/16/2025 to 05/19/2025 (4 days), there was no documentation of a comprehensive wound assessment for this pressure injury as per Wound Care orders (daily with dressing change).

Review of Pt #1's "Hygiene" flowsheets from 03/25/2025 through 05/20/2025 revealed there were no "Skin" interventions documented on 03/26/2025, 03/28/2025 to 03/30/2025 (3 days), 04/01/2025, 04/05/2025, 04/09/2025 to 04/13/2025 (5 days), 05/08/2025, 05/09/2025, 05/12/2025 to 05/17/2025 (6 days), 05/19/2025, and 05/20/2025.

Per review of Pt #1's "Infectious Disease" physician progress note dated 06/02/2025 at 8:32 AM, on 05/31/2025 the buttock wound culture revealed growth of "Enterococcus faecium (bacteria)" and "Candida auris (yeast)." Per the "Infection Disease" note, Pt #1's blood cultures on 05/30/2025 showed Enterococcus Faecium (same as wound cultures). The Infectious Disease physician progress note "Assessment" revealed, "VRE (Vancomycin-resistant Enterococcus) bacteremia (blood stream infection)...multiple potential sources including...necrotic buttock ulcer..."

Pt #3:

Review of Pt #3's medical record revealed Pt #3 was admitted to the inpatient ICU on 06/03/2025 at 5:00 AM with Acute Encephalopathy (brain dysfunction that causes change in mental status); Pt #3 was an inpatient at the time of the medical record review on 06/12/2025 at 8:40 AM.

Review of Pt #3's Braden score from 06/03/2025 to 06/11/2025, revealed Pt #3's Braden score ranged from 11 to 16 (at risk for skin breakdown) throughout the inpatient stay.

Review of Pt #3's "Stool" assessment nursing flowsheets revealed documentation that Pt #3 was incontinent of stool on 06/06/2025 (3:00 PM, 8:00 PM), 06/07/2025 (12:00 AM, 4:00 AM, 2:00 PM), 06/08/2025 (8:00 AM, 12:00 PM, 4:00 PM, 7:36 PM), 06/09/2025 (12:00 AM), 06/10/2025 (12:00 PM, 2:25 PM, 4:00 PM, 10:44 PM), 06/11/2025 (2:00 AM, 10:33 PM), and 06/12/2025 (2:00 AM).

Review of Pt #3's "Hygiene" flowsheets from 06/06/2025 through 06/11/2025 revealed there was no documentation of "Skin" interventions (i.e. incontinence cleanser, barrier cream, moisturizer) addressing Pt #3's risk for skin breakdown due to moisture from incontinence.

Review of Pt #3's "Skin" nursing flowsheets from 06/06/2025 to 06/11/2025 revealed there was no documentation of staff initiating preventative wound/skin interventions as per policy; including but not limited to, barrier cream, incontinence cleanser, moisture wicking incontinence pads, and preventative foam dressing.

Review of Pt #3's "Wound Care" nurse progress note dated 06/11/2025 at 10:39 AM, revealed Wound Care was consulted for a wound to buttocks (not present on admission). Per "Wound Care" note, "Buttocks: partial thickness shearing throughout, in total measuring 8 (cm) x 10 (cm) x 0.1 cm. Wound bed 20 % pink moist tissue, 10 % peeling skin, 70 % fragile intact skin. Scant serous (clear to yellow fluid) drainage, increased moisture throughout related to stool/urinary incontinence."

Review of Pt #3's nursing skin assessments on 06/11/2025 and 06/12/2025 revealed documentation of "WDL (within defined limits)" on 06/11/2025 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 8:00 PM, and 06/12/2025 at 12:00 AM. This was inconsistent with the Wound Care nurse assessment on 06/11/2025.

Pt #5:

Review of Pt #5's medical record revealed Pt #5 was admitted to the inpatient ICU on 06/09/2025 at 3:44 PM with an Intracranial Hemorrhage (brain bleed); Pt #5 was an inpatient at the time of the medical record review on 06/12/2025 at 10:28 AM.

Review of Pt #5's nursing flowsheets revealed on 06/09/2025 at 3:45 PM, Pt #5's Braden score was "12".

Review of Pt #5's Wound flowsheets revealed a "Skin tear" on Pt #5's back was first assessed on 06/09/2025 at 9:00 PM.

Review of Pt #5's "Wound" flowsheets from 06/09/2025 through 06/12/2025 revealed there was no documentation of nursing assessments and treatment interventions for the "Skin tear" wound. Review of the "Wound" flowsheets revealed "No dressing in place" was documented on 06/09/2025, 06/10/2025, and 06/11/2025.

Review of Pt #5's "Stool" assessment nursing flowsheets revealed documentation that Pt #5 was incontinent of stool on 06/10/2025 (4:00 PM, 8:00 PM), 06/11/2025 (12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, and 4:00 PM), and 06/12/2025 (8:00 AM).

Review of Pt #5's "Hygiene" flowsheets from 06/09/2025 through 06/12/2025 revealed there was no documentation of "Skin" interventions addressing Pt #5's risk for skin breakdown due to moisture from incontinence.

Pt #8:

Review of Pt #8's medical record revealed Pt #8 was admitted to the inpatient ICU on 06/06/2025 at 11:30 AM with Metabolic Encephalopathy and Acute Kidney Injury; Pt #8 was an inpatient at the time of the medical record review on 06/12/2025 at 11:00 AM.

Review of Pt #8's nursing flowsheets revealed on 06/06/2025 at 11:45 AM, Pt #8's Braden score was "13".

Review of Pt #8's "Wound" nursing flowsheets revealed a "Red moist scab + hypopigmented (light area) vs. resolving pressure injury area" to the coccyx; the wound was first identified on 06/06/2025 at 6:32 AM (prior to inpatient admission).

Per review of "Wound" flowsheets from 06/06/2025 through 06/11/2025, only "Intact" was documented for the "Wound Assessment (s)." There was no documentation of a comprehensive nursing assessment describing the appearance of the wound. "Wound" flowsheets revealed "Open to Air" documented for "Dressing." There was no documentation of nursing staff applying a preventative foam dressing to protect the wound as per policy.

Review of Pt #8's "Stool" assessment nursing flowsheets revealed documentation that Pt #8 was incontinent of stool on 06/12/2025 (1:01 AM, 11:36 AM), 06/10/2025 (4:29 AM, 10:49 AM, 4:18 PM), 06/09/2025 (12:43 AM, 6:33 AM, 11:12 AM, 12:27 PM, 9:24 PM), 06/08/2025 (12:25 AM, 5:55 AM, 12:10 PM, 5:27 PM), and 06/07/2025 (8:49 PM).

Review of Pt #8's "Hygiene" flowsheets from 06/06/2025 through 06/12/2025, revealed there was no documentation of "Skin" interventions addressing Pt #8's risk for skin breakdown due to moisture from incontinence.

Per interview with ICU Clinical Nurse Specialist (CNS) F, while reviewing medical records on 06/11/2025 beginning at 12:00 PM, CNS F confirmed the findings and stated that staff should be documenting a wound assessment every shift or as per wound care orders. CNS F stated that staff should peel back the preventative foam dressing and assess the skin underneath at least every shift. CNS F stated that staff should document wound and skin interventions in the nursing flowsheets. CNS F stated that documenting "Intact" would not be considered sufficient for a wound assessment.

Per interview with ICU Manager H on 06/12/2025 at 1:17 PM, Manager H stated nursing staff should initiate preventative skin interventions when the Braden scale is less than 18. Per Manager H, nursing staff should provide interventions such as repositioning, skin barrier cream, incontinence cleanser, and preventative foam dressings to protect the skin.

Per interview with Wound Care manager G on 06/12/2025 beginning at 1:20 PM, Manager G stated nursing staff should be cleansing skin tears with soap and water and applying a foam dressing to the wound. Manager G stated that nursing staff should apply a preventative foam dressing on skin at risk for a pressure injury.

Based on record review and interview the facility staff failed to ensure that nursing care plans were initiated as per policy to address skin/wound care needs and interventions in 4 of 10 medical records reviewed (Patient (Pt) #2, #3, #7, #10); failed to ensure nursing care plans are kept current and updated based on patient assessments in 3 of 10 medical records reviewed (Patient (Pt) #1, #3, #10); and failed to ensure that nursing interventions are implemented based on ongoing assessments of patient care needs in 3 of 10 medical records reviewed (Pt #1, #3, #10), in a total of 10 medical records reviewed.

Findings Include:

Review of policy and procedure #18231547 titled, "Hospital based Assessment & Documentation Policy" Last revised 05/23/2025 revealed:
- "As patient care needs are identified, it is the responsibility of the healthcare team to prioritize the care and service delivered to assure that the patient's needs are met."
- "A care plan has individualized patient priorities, expected outcomes with target dates, and appropriate interventions."
- "Members of the healthcare team revise the plans and goals for care, treatment, and services, based on the patient's needs."
- "The...initial plan of care should be completed within 24 hours."
- "Data collection/Reassessment is designed to evaluate the patient's response to care and interventions and to determine if a change to the plan of care is warranted."

Pt #1:

Review of Pt #1's medical record revealed Pt #1 was a 63 year old admitted to the inpatient Intensive Care Unit (ICU) on 03/06/2025 at 6:27 PM after having a "Whipple" procedure (surgical operation that removes the head of the pancreas, the first part of the small intestine, and sometimes a portion of the stomach, gallbladder, and common bile duct) for pancreatic cancer. Pt #1 was placed on comfort cares and passed away at the hospital on 06/03/2025 at 3:08 PM.

Review of Pt #1's "Care Plans" revealed the "Skin Integrity Impairment Risk" care plan was opened on 03/07/2025.

Review of Pt #1's "Wound" flowsheets revealed, "Deep Tissue Injury (DTI) Bilateral Buttocks" was "first assessed" on 03/25/2025 at 12:00 AM (19 days after admission).

Per review of Pt #1's skin care plan, there was no documented evidence of nursing staff updating and/or revising the skin/wound care plan to ensure patient care needs were met, after developing a pressure injury while in the hospital.

Review of Pt #1's "Deep Tissue Injury (DTI) Bilateral Buttocks" wound flowsheets from 03/25/2025 through 05/23/2025 revealed:
-On 03/26/2025 to 04/01/2025 (7 days), 04/12/2025 to 04/15/2025 (4 days), 04/20/2025 to 04/22/2025 (3 days), 04/26/2025 to 04/29/2025 (4 days), and 05/10/2025, there was no documentation of cleansing of the wound and/or treatment interventions completed as per Wound Care orders.
-On 03/26/2025, 03/27/2025, 04/26/2025 to 05/02/2025 (7 days), 05/06/2025, 05/07/2025, 05/10/2025 to 05/13/2025 (4 days), and 05/16/2025 to 05/19/2025 (4 days), there was no documentation of a comprehensive wound assessment for this pressure injury as per Wound Care orders (daily with dressing change).

Pt #1's "Skin integrity Impairment Risk" care plan was not kept current due to a lack of ongoing assessments and evaluations of Pt #1's "Deep Tissue Injury Bilateral Buttocks" wound, to ensure Pt #1's skin/wound needs were being met as per policy.

Pt #2:

Review of Pt #2's medical record revealed Pt #2 was admitted to the inpatient ICU on 06/09/2025 at 2:13 PM with Chronic Obstruction Pulmonary Disease (COPD); Pt #2 was an inpatient at the time of the medical record review on 06/12/2025 at 8:40 AM.

Review of Pt #2's "Care Plans" revealed the "Skin Integrity Impairment Risk" care plan was opened on 06/09/2025 (no time). There were no skin interventions documented in the care plan.

Pt #3:

Review of Pt #3's medical record revealed Pt #3 was admitted to the inpatient ICU on 06/03/2025 at 5:00 AM with Acute Encephalopathy (brain dysfunction that causes change in mental status); Pt #3 was an inpatient at the time of the medical record review on 06/12/2025 at 8:40 AM.

Review of Pt #3's "Care Plans" revealed the "Skin Integrity Impairment Risk" care plan was opened on 06/05/2025 (no time) (2 days after admission). The skin plan of care was not initiated within 24 hours of admission as per policy.

Review of Pt #3's "Wound Care" nurse progress note dated 06/11/2025 at 10:39 AM revealed Wound Care was consulted for a wound to buttocks (not present on admission). Per "Wound Care" note, "Buttocks: partial thickness shearing throughout, in total measuring 8 (cm) x 10 (cm) x 0.1 cm. Wound bed 20 % pink moist tissue, 10 % peeling skin, 70 % fragile intact skin. Scant serous (clear to yellow fluid) drainage, increased moisture throughout related to stool/urinary incontinence."

Per review of Pt #3's "Skin" care plan, there was no documented evidence of nursing staff updating and/or revising the skin/wound care plan to ensure patients care needs are met after developing a wound to the buttocks while in the hospital.

Review of Pt #3's nursing skin assessments on 06/11/2025 and 06/12/2025 revealed documentation of "WDL (within defined limits)" on 06/11/2025 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 8:00 PM, and 06/12/2025 at 12:00 AM. This was inconsistent with the Wound Care nurse assessment on 06/11/2025.

Review of Pt #3's "Skin" nursing flowsheets from 06/06/2025 to 06/11/2025 revealed there was no documentation of staff initiating preventative wound/skin interventions as per policy; including but not limited to, barrier cream, incontinence cleanser, moisture wicking incontinence pads, and preventative foam dressing.

Pt #3's "Skin integrity Impairment Risk" care plan was not kept current due to a lack of ongoing assessments and evaluations of Pt #3's buttock wound to ensure Pt #3's skin/wound needs are being met as per policy.

Pt #7:

Review of Pt #7's medical record revealed Pt #7 was admitted to the inpatient ICU on 06/08/2025 at 11:41 PM with Gastrointestinal Hemorrhage; Pt #7 was an inpatient at the time of the medical record review on 06/12/2025 at 10:45 AM.

Review of Pt #7's "Care Plans" revealed the "Skin Integrity Impairment Risk" care plan was opened on 06/09/2025 (no time). There were no skin interventions documented in the care plan.

Pt #10:

Review of Pt #10's medical record revealed Pt #10 was admitted to the inpatient ICU on 05/28/2025 at 2:49 PM with a spinal cord injury; Pt #10 was an inpatient at the time of the medical record review on 06/12/2025 at 12:30 PM.

Review of Pt #10's "Care Plans" revealed the "Skin Integrity Impairment Risk" care plan was opened on 05/30/2025 (no time). There were no skin interventions documented in the care plan.

Pt #10's "Skin Integrity Impairment Risk" care plan was not initiated within 24 hours of admission as per policy.

Review of Pt #10's "Wound" flowsheets revealed a "Sacrum Fissure" was first assessed on 06/02/2025 (5 days after admission). There was no documented evidence of nursing staff updating and/or revising the skin/wound care plan to ensure patient care needs are met after developing a wound to the sacrum while in the hospital.

Per interview with Clinical Nurse Leader J on 06/11/2025 beginning at 2:00 PM, Nurse J stated that the skin care plans should be updated and/or revised when a wound develops or when there is deterioration of an existing wound. Nurse J stated that a skin impairment care plan should be opened when there is an actual wound. Nurse J stated that the nurse should add interventions to the care plan document.