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Based on staff interview, record review, policy review, and review of hospital grievance documentation, it was determined the hospital failed to provide written grievance resolutions which included the name of the contact person, steps taken to investigate, all results of the grievance process, and the date of completion for 2 of 6 patients (#2 and #7) whose grievances were reviewed. This had the potential for incomplete grievance investigations and resolutions communicated to patients. Findings include:

Facility policy, "Concern and Grievance Management Program -- SAHS," approved 5/30/2018, was reviewed. The policy stated:

- "The resolution of a formal grievance should be completed within seven (7) days of receiving the grievance. If the grievance cannot be completed within 7 days, the patient will be contacted in writing within the initial 7 days and informed they will be contacted with additional information concerning the status of the review within thirty (30) days. If the investigation requires longer than 30 days, the patient will be provided a letter of extension indicating the circumstances and the date for final review, within 30 days."

- "Once the grievance investigation is completed, the patient will be contacted in writing, unless the complainant specifically states they do not want a written response (such requests should be documented)."

- "Written notice will include the name of the facility contact person appropriate to the grievance; the steps taken on behalf of the patient to investigate the grievance; the results of the grievance process, date of completion, as well as the contact information for the Bureau of Facility Standards and the Joint Commission."

This policy was not followed. Examples include:

1. Patient #7's grievance file was reviewed. It included a grievance, received by the hospital on 2/08/19. The file included an acknowledgement letter sent on 2/15/19, signed by the Patient Relations Coordinator, stating an investigation into the allegations would be completed, and Patient #7 would be contacted by letter no later than 3/15/19.

Patient #7's grievance file included an email, dated 3/12/19, from the Patient Relations Coordinator, to the Risk Manager. It stated the resolution letter was due by 3/15/19. The file included another email, dated 3/20/19, from the Patient Relations Coordinator to the Risk Manager. It stated Patient #7 called because he had not received his resolution letter, due by 3/15/19. An email, dated 4/04/19, written by the Risk Manager stated "Spoke to [Patient #7] informing him no resolution at this time..."

Patient #7's grievance file included a letter, dated 4/17/19, stating his demand for monetary settlement would not be met. His file included an entry, dated 4/18/19, stating his case was closed. The letter did not meet regulations for grievance resolution, as follows:

a. The letter was sent 34 days after the date specified in the acknowledgement letter.

b. The letter did not state who Patient #7 should contact with additional information or questions.

c. The letter did not include the steps taken to investigate the grievance.

d. The letter did not state the date of completion of the investigation.

The Patient Relations Supervisor and the Risk Manager were interviewed on 5/15/19 at 8:45 AM. They reviewed Patient #7's grievance documentation and confirmed it was not sent by the date specified in the acknowledgement letter, and Patient #7 did not receive a letter informing him of the delay. Additionally, they confirmed the letter did not include the name and contact information of the hospital contact person, steps taken by the hospital to investigate the grievance, or the date the investigation was completed.

The hospital failed to ensure Patient #7 received all required information regarding the resolution of his grievance.



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2. Patient #2's grievance file was reviewed. It included a grievance, received by the hospital on 3/04/19. It stated the complainant alleged Patient #2 complained of leg pain repeatedly, and staff dismissed his pain as normal and did not look at the site of his complaint, and that a large pressure ulcer was not found until he was being evaluated for discharge.

A letter of response, dated 4/03/19, documented sending the complainant's concerns to managers for the telemetry unit and the rehabilitation unit. The letter, addressed to Patient #2, acknowledged concerns, stating "Your wife voiced frustration that our staff seemed to dismiss your leg pain concerns and did not identify your pressure ulcer sooner."

The letter of response stated "In review of your Electronic Medical Record, it is documented that there were daily skin and wound assessments charted while on the telemetry floor. While on Rehab [rehabilitation unit], the pain you experienced was noted to be incisional pain not pain where the pressure ulcer was located."

The letter of response did not address skin assessment on Patient #2 while on the rehabilitation unit. There were no documented skin assessments of Patient #2's left leg under his CAM boot, ACE wrap, and dressing, included in his medical record from the time of admission to the rehabilitation unit on 2/18/19 until 10 days later, on 2/28/19.

The information in the hospital's letter of response, describing Patient #2's pain as incisional pain, did not match the information surveyors viewed in his record. Patient #2's record for the inpatient stay to the rehabilitation unit, beginning 2/18/19, included nursing documentation on the "Direct Charting Flowsheet" that Patient #2 reported "leg pain" one or more times on 2/19/19, 2/20/19, 2/21/19, 2/22/19, 2/23/19, 2/24/19, and 2/27/19. There was no documentation nursing staff (or medical staff) examined his left leg for 10 days, after admission to the rehabilitation unit on 2/18/19 until 2/28/19, just prior to Patient #2's discharge on 3/01/19.

The Patient Relations Coordinator was interviewed on 5/15/19 at approximately 9:55 AM. She stated the letter of response to the grievance was written based on information provided by unit managers and that it was her understanding Patient #2 had reported incisional pain (ankle area) instead of leg pain. She acknowledged the letter did not address whether Patient #2's skin had been assessed on the rehabilitation unit.

The letter of response did not include complete or accurate information as to the steps taken on behalf of Patient #2 to investigate the grievance and the results of the investigation.

Based on medical record review, hospital policy review, and staff interview it was determined the hospital failed to ensure the patient/family was informed of video monitoring for 1 of 1 rehabilitation patient (Patient #1) for whom video monitoring was implemented and whose record was reviewed. This resulted in a patient under video surveillance without his knowledge and had the potential for violation of his privacy. Findings include:

The hospital's policy, "Patient Safety Monitoring--SAHS," approved 3/04/19, stated, "In an attempt to keep our patients safe who are most at risk from harm, a Patient Safety Attendant or AvaSys Visual Monitoring Unit (where available) will be utilized as detailed in this Policy. The type of monitoring will be based on nurse assessment and recommendations." The policy included "Appendix A: Roles and Responsibilities Grid." The section of the grid titled "Staff RN" stated, "Notify patient, family, and LIP that continuous monitoring will be implemented to promote patient safety."

Patient #1 was an 85 year old male, admitted to the hospital's rehabilitation unit on 4/11/19, for care following a TKA. He was discharged on 4/24/19.

Patient #1's record included a "Handoff Form." An entry, dated 4/11/19 at 8:27 PM, stated Patient #1 had repeatedly gotten out of bed without waiting for assistance. The entry stated video monitoring was ordered for the night shift. Entries dated 4/13/19 at 4:23 AM and 6:48 PM, 4/14/19 at 3:13 AM and 7:35 PM, and 4/15/19 at 2:46 PM, signed by RNs, stated video monitoring was being used in his room for safety. Patient #1's record did not include documentation stating he or his family were notified that video monitoring was implemented.

During an interview on 5/15/19 at 1:10 PM, the Director of Acute Care stated no patient/family consent or notification of video monitoring was required because the video was not recorded.

The hospital failed to ensure Patient #1 and his family were informed that video monitoring was used in his room.

Based on staff interview and review of medical records, the contents of a "Welcome" packet, a brochure addressing rights and responsibilities, admission consent forms, and hospital policy, it was determined the facility failed to ensure 6 of 6 patient records (#'s 1-6) included documentation that patients or their representatives were informed of visitation rights. This had the potential to interfere with the exercise of patient visitation rights. Findings include:

A brochure, titled "Your Rights and Responsibilities as a Patient," was reviewed. It did not include rights information related to visitation.

An admission consent form, "CONSENT TO MEDICAL CARE AND PATIENT SERVICES AGREEMENT," revised 3/2013, was reviewed. It did not address visitation rights or include acknowledgment that visitation rights were provided.

A policy, "Visitation," approved 1/09/2017, was reviewed. It included general visiting hours, restrictions based on number of people ("no more than four people at one time"), restrictions related to children under age 18 ("children 14 and under must be accompanied by an adult" and "children between 15-17 years of age must come with an adult who remains in the building"). The policy did not address how visitation rights would be communicated to patients and their representatives.

A "Welcome" packet of information was reviewed. According to the CNO, during an interview on 5/13/19 at 4:15 PM, the packet was included in patient rooms. The packet included the following information related to visitation rights:

- "You, or your support person, have the right to decide who can visit."
- "For your benefit or the benefit of other patients, visiting may be limited by time of day, frequency, length, or number of visitors as determined by you, your support person or nursing staff."
- "Reasons for limiting visitation may include:
- Your condition
- Your sleeping patterns
- Your reaction to previous visitation such as increased anxiety, fatigue, or change in vital signs
- Nursing care and treatment at the time of visitation
- The health of the visitor. Visitors must not have been exposed to any communicable disease, have fever or symptoms of infection"

The visitation information included in the patient welcome packet did not include:

- the specific restrictions listed in hospital policy related to children and length of stay
- the right to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

Patient records #1-6 were reviewed. There was no documentation Patients #1-6 were informed of their visitation rights or were given the welcome packet that included visitation rights.

The CNO was interviewed on 5/13/19 at 4:15 PM. She acknowledged the hospital did not document that patients were informed of visitation rights or given welcome packets. When the surveyor pointed out that hospital policy included some restrictions that were not included in the welcome packet, she responded "We have open visitation."

Patient records #1-6 did not include documentation patients or their support persons had been informed of visitation rights.

Based on record review, policy review, "job aide" review, grievance documentation review, staff interview, caregiver interview, and observation, it was determined the hospital failed to ensure nursing services were organized and supervised to effectively address patients' potential or actual skin care issues. This resulted in incomplete care planning and lack of skin assessment and early interventions to reduce the risk of skin breakdown. Finding include:

1. Refer to A-395 as it relates to the failure of the hospital to ensure nursing staff assessed skin in accordance with hospital policy and intervened to address identified skin care needs.

2. Refer to A-396 as it relates to the failure of the hospital to ensure the development of comprehensive care plans to address potential or known skin integrity issues.

3. Refer to A-1133, under the Condition of Rehabilitation Services, as it relates to nursing staff's failure to obtain orders and clarify incomplete orders.

The cumulative effects of these systemic failures significantly impeded the ability of the hospital to provide nursing services of sufficient scope and quality.

Based on record review, policy review, nursing "job aide" review, grievance documentation review, observation, staff and caregiver interview, it was determined the hospital failed to ensure nursing staff assessed skin in accordance with hospital policy and intervened to address skin needs for 5 of 6 patients (#1, #2, #3, #5, and #6) whose records were reviewed. This resulted in skin deterioration in 4 patients and had the potential to result in skin deterioration and unmet patient needs in all patients with identified skin care needs. Findings include:

The hospital policy, "Braden Scale for Predicting Pressure Injury Risk and Skin Assessment," approved 6/22/2017, stated:

- "Reassessment of head to toe skin integrity will be performed and documented at a minimum every shift and as needed."

- "Skin will be assessed underneath medical devices, at minimum, every shift."

A nursing "job aide," (a summary of nursing assessment requirements in table format), included guidance to nursing staff to assess incisions/wounds and do a pressure ulcer assessment on admit and every shift.

A hospital policy, "Charting Guidelines -- Rehabilitation," approved 1/04/2018, stated:

- A "complete review of systems will be performed upon admission and daily."

- "Baseline physical assessment will include a minimum of...Skin Mucosa: head to toe inspection...incision and/or wound assessment"

Hospital policies and "job aides" guidelines for nursing staff assessment requirements were not followed. Examples include:

1. Patient #2 was a 72 year old male initially admitted to the hospital on 2/05/19 for left ankle surgery after a traumatic injury. He was admitted to the rehabilitation unit on 2/18/19 and discharged from the hospital on 3/01/19.

The operative report, dated 2/06/19, indicated Patient #2 "had some fracture blisters on the posterior aspect of his calf that had popped. These were dressed with Xeroform..."

A progress note, dated 2/08/19, signed by a PA, stated "Fresh dressings were reapplied with a Mepilex, Ace [sic] wraps were also placed and he was put into a long-leg walker boot." It could not be determined if the fresh dressings were specific to the surgical site at the left ankle or whether they included the calf wound identified after Patient #2's surgery on 2/06/19.

A progress note, dated 2/16/19, signed by a PA, stated the CAM boot and dressings were removed and the skin examined. "There was a possible prior skin tear noted proximally, just distal to the patient's gastrocnemius. This did not have any surrounding erythema or evidence of infection as well. There did appear to be evidence of granulation tissue formation." "Wound dressings were then replaced with Xeroform and Medipore dressings, Kerlix and an Ace [sic] wrap. The Cam [sic] walking boot was then replaced as well. The neurovascular status was then again checked out and Cam [sic] boot was replaced."

A progress note, dated 2/18/19, signed by a PA, documented "sutures were removed and dressings were replaced." There was no specific reference to the condition of Patient #2's skin at the site of the prior referenced calf wound.

Patient #2 was subsequently admitted to the rehabilitation unit on 2/18/19. There were no specific orders that addressed wound care or the CAM boot, whether the CAM boot should be worn continuously or while out of bed. There was no nursing clarification related to the missing orders.

There was no nursing documentation on the rehabilitation unit indicating Patient #2's skin had been assessed under the CAM boot and dressings, either upon admission to the rehabilitation unit, or per shift, until 10 days later, on 2/28/19.

An RN progress note, dated 2/28/19, related to Patient #2, stated: "MD and this nurse undressed ace [sic] wrap on left ankle, surgical incisions are well approximated slight erythema. However, there appears to be an unstageable pressure injury on left lateral calf that is 100% eschar covered with drainage. The pt [patient] reports that since he has been in the hospital, his dressing has been changed 1 time that he can remember. This nurse received a verbal wound care consult order..."

Grievance documentation indicated Patient #2's significant other had filed a complaint on his behalf on 3/04/19, alleging that Patient #2 had "complained on several occasions that he felt pain in his calf on his left leg" and according to Patient #2 and her own observation, "nursing staff did not remove his ace [sic] bandage to check the area of his complaint."

A phone call was made to Patient #2 on 5/16/19 at 11:25 AM. Patient #2 was not available to talk. His significant other, the complainant, was interviewed. Consistent with the written grievance filed with the hospital, Patient #2's significant other stated Patient #2 had reported his calf pain on multiple occasions to staff, and no-one unwrapped his ACE wrap to look at the area where he was pointing until he was ready for discharge.

Patient #2's record included nursing documentation on the "Direct Charting Flowsheet" that Patient #2 reported "leg pain" 1 or more times after admission to the rehabilitation unit on 2/18/19, including on the following dates: 2/19/19, 2/20/19, 2/21/19, 2/22/19, 2/23/19, 2/24/19, and 2/27/19. There was no documentation nursing staff subsequently examined Patient #2's skin on his left leg in response to his report of pain.

A wound consult RN note, dated 2/28/19, stated "S [subjective]: Wound care evaluation requested for wound to L [left] posterior calf. O [objective]: Soft gray/brown eschar with separating edges measuring 5.5 cm x 6 cm, yellow slough at edges. Surrounding skin is intact, pink. Minimal amount of serous drainage on telfa dressing placed earlier today. A [assessment]: Cleansed with NS and gauze, applied sting free barrier film to surrounding skin. Duoderm thin over wound, covered with tegaderm followed by ABD pad in case dressing becomes overwhelmed with drainage. P [plan]: Will follow up in AM with wound care PA, [name] to provided [sic] sharp debridement if necessary."

A discharge summary, written by a PA, dated 3/01/19, stated "At the end of his [Patient #2's] rehabilitation efforts, he was found to have a wound to the left gastroc [gastrocnemius] area that was related to pressure from the Cam [sic] boot."

The Risk Manager and the Performance Improvement Coordinator were interviewed together on 5/15/19 at 9:55 AM. They confirmed there was no documentation nursing staff had removed the CAM boot and dressing and assessed Patient #2's skin under the boot from the time of admission to the rehabilitation unit on 2/18/19 until 2/28/19, at which time the enlarged wound on the calf was found.

Nursing staff did not assess and evaluate Patient #2's skin care needs under his CAM boot and ACE wrap in accordance with hospital policy.

2. Patient #6 was a 78 year old female admitted to the hospital on 5/02/19 after a motor vehicle collision. A tibial fracture was surgically repaired on 5/04/19. She was moved to the rehabilitation unit on 5/09/19.

A practitioner order, dated 5/09/19, signed by a PA, specified Patient #6 was to wear a "Hinged knee brace to left leg." The order did not say whether the brace was to be worn at all times, whether it could be removed while Patient #6 was in bed, or for BID skin checks.

Nursing notes were reviewed. There was no documentation to indicate nursing staff had assessed Patient #6's skin beneath her knee brace, in accordance with hospital policy, or made attempts to clarify the incomplete practitioner order.

Patient #6 was observed in her room on 5/15/19 at 10:50 AM wearing her knee brace.

The Director of Acute Care was interviewed on 5/15/19 at 2:45 PM. She reviewed Patient #6's medical record and confirmed there was no documentation that nursing had removed Patient #6's hinged knee brace and assessed her skin beneath the brace.

Nursing staff did not assess and evaluate Patient #6's skin condition beneath a knee brace, in accordance with hospital policy.




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3. Patient #1 was an 85 year old male, admitted to the hospital's rehabilitation unit on 4/11/19, for care following a TKA. He was discharged on 4/24/19.

a. The hospital's policy, "Charting Guidelines - Rehabilitation," approved 1/04/18, stated "Incision and/or wound assessment will be done on post-operative patients upon arrival to the floor and once a shift."

Patient #1's record included a "History & Physical," dated 4/12/19, signed by a PA. It stated, "His surgical site has ABD and stockinette, small amount of drainage. We will monitor and manage."

Patient #1's record included a "Direct Charting Flowsheet" that documented assessment of his surgical incision and dressing. It documented an assessment by an RN on 4/11/19 at 4:30 PM. The next assessment was documented on 4/16/19 at 9:00 AM, 5 days later. The flowsheet stated the dressing was reinforced at that time. The next assessment was documented on 4/22/19, at 9:00 AM, 6 days later. No assessment of Patient #1's incision was documented between 4/11/19 and 4/16/19, or between 4/16/19 and 4/22/19.

During an interview on 5/15/19 at 1:10 PM, the Director of Acute Care reviewed Patient #1's record and confirmed his surgical incision was not assessed daily.

Patient #1's surgical incision was not assessed daily as required by hospital policy.

b. Patient #1's record included a "History & Physical," dated 4/12/19, signed by a PA. It included, "Skin: The patient has a sore on his buttock, which is being covered with Mepilex. Nursing to follow and manage."

Patient #1's record included a "Handoff Form." An entry, dated 4/11/19 at 8:27 PM, signed by the RN, stated, "Pt has sore on buttock - mepilex applied." The note did not identify which buttock.

Patient #1's record included an "Admission Profile," form, dated 4/11/19 at 4:36 PM, signed by the RN. The profile documented Patient #1's initial assessment upon admission to the rehabilitation unit. It did not include documentation of the sore on his buttock. There was no assessment, description or measurements of the sore.

During an interview on 5/15/19 at 1:10 PM, the Director of Acute Care reviewed Patient #1's record and stated the sore was on his left buttock. She confirmed his record did not include an initial assessment or measurements of the sore on his left buttock. The Director of Acute Care stated wound measurements were not completed by RNs on the floor as they lacked consistency. She stated measurements were completed by the hospital's wound care team, however there was no order for the hospital's wound care team to address Patient #1's sore. The Director of Acute Care stated if the wound care team was not involved in a patient's care, wound measurements were not completed.

Patient #1's left buttock wound was not assessed on admission.

c. Patient #1's record included a "Direct Charting Flowsheet" that documented assessment of his left buttock sore. It documented an assessment by an RN on 4/11/19 at 4:30 PM. The next assessment was documented on 4/18/19 at 11:14 AM, 7 days later.

During an interview on 5/15/19 at 1:10 PM, the Director of Acute Care reviewed Patient #1's record and confirmed the sore on his left buttock was not assessed daily.

Patient #1's left buttock wound was not was assessed daily.

d. Patient #1's record included an "Ostomy/Wound Progress Note," dated 4/17/19 at 4:21 PM, signed by the wound care nurse. The note stated, "Pt with area of partial thickness skin breakdown on R [right] buttock. 1 cm X 1.5 cm, 0.1 cm deep...This appears to be chronic, pt states it has been there approximately 1 year. Stage II pressure injury. No documentation until today so is therefore considered hospital acquired." It could not be determined why Patient #1's pressure ulcer was not identified at the time of his admission to the rehabilitation unit, 6 days earlier.

During an interview on 5/15/19 at 1:10 PM, the Director of Acute Care reviewed Patient #1's record and confirmed the pressure ulcer on his right buttock was first identified 6 days after his admission to the rehabilitation unit.

Patient #1 did not receive a comprehensive skin assessment at the time of his admission to the rehabilitation unit.

e. Patient #1's record included a "Direct Charting Flowsheet" that documented pressure ulcer prevention, including redistribution of weight, avoidance of friction/shear, moisture management, and mobility management. One or more of the pressure ulcer prevention measures were documented by an RN on 4/11/19, 4/12/19, 4/13/19, 4/14/19, 4/15/19, 4/18/19, 4/19/19, 4/22/19, 4/23/19, 4/24/19, and 4/26/19. No pressure ulcer prevention measures were documented on 4/16/19, 4/17/19, 4/20/19, 4/21/19, or 4/25/19.

During an interview on 5/15/19 at 1:10 PM, the Director of Acute Care reviewed Patient #1's record and confirmed pressure ulcer preventions measures were not consistently implemented.

The hospital failed to ensure on-going and consistent pressure ulcer prevention measures for Patient #1.

f. The National Pressure Ulcer Advisory Panel's pressure injury prevention guidelines include a recommendation to reposition patients at least every 2 hours.

Patient #1's pressure ulcer prevention measures included redistribution of weight and mobility management. Both measures included frequent turning to avoid pressure ulcers. His record included documentation of his position, with 50 entries between 4/11/19 and 4/24/19. Two of the 50 entries documented Patient #1 was positioned on his right side. The other 48 entries documented that he was sitting, supine, or supine with head of bed elevated, positions that would not relieve the pressure on his buttocks to avoid worsening of his pressure ulcer.

During an interview on 5/15/19 at 1:10 PM, the Director of Acute Care reviewed Patient #1's record and confirmed it did not document repositioning every 2 hours to avoid pressure to his buttocks.

Patient #1 was not repositioned every 2 hours to avoid pressure ulcers.

4. Patient #5 was a 57 year old male, admitted to the hospital on 4/05/19, with a primary diagnosis of acute encephalopathy. He was discharged on 4/16/19.

The agency's policy, "Intravenous Therapy, Peripheral, Adult," approved 9/28/17, stated "Sterile dressings shall be applied and maintained on all PIVs. Change when it is damp, loose, or soiled and at least every 5-7 days."

Patient #5's record included a "Direct Charting Flowsheet" that documented assessments of his peripheral IV site, from 4/05/19 to 4/16/19. The assessments stated his IV site was intact, with no evidence of infiltration or phlebitis, and was covered with a transparent dressing. Patient #5's record did not include documentation that his IV dressing was changed during his 12 day hospitalization.

Patient #5's record included a "Nursing Progress Note," dated 4/16/19 at 4:58 PM. The note stated, "Upon dc [discontinuation] IV, RN discovered a possible stage 2 pressure ulcer on Right Forearm where IV catheter was inserted, just distal to insertion site, covered by tegaderm and coban."

Coban is an elastic, self-adherent gauze wrap. It is not transparent. Patient #5's record did not document the application or presence of Coban on his IV site. It could not be determined when the Coban was applied, or if the skin under the Coban was assessed prior to 4/16/19.

During an interview on 5/15/19 at 2:00 PM, the Director of Acute Care reviewed Patient #5's record. She stated his IV was inserted in the ED, and his record did not state what type of dressing was applied to his IV site. The Director of Acute Care confirmed Patient #5's flowsheet documented a transparent dressing and it could not be determined if the Coban was applied in the ED or later. Additionally, she confirmed there was no documentation stating his IV dressing was changed during his 12 day hospitalization or that his skin under the Coban was assessed.

Patient #5's IV dressing was not changed as required by hospital policy, and his skin was not assessed to prevent breakdown.

5. Patient #3 was a 12 year old male admitted to the hospital on 3/03/19, with a primary diagnosis of attempted suicide. He was discharged on 3/06/19.

The hospital's policy, "Intravenous Therapy, Peripheral - Pediatric," approved 12/29/17, stated "The IV site is observed every two hours and condition of the site including phlebitis score documented. The IV is discontinued immediately if infiltration or signs and symptoms of inflammation develop at the site."

Patient #3's record included a "Direct Charting Flowsheet" that documented assessments of his peripheral IV site. Assessments were documented on 3/05/19 at 8:00 AM, 12:00 PM, and 7:30 PM. The next assessment was documented on 3/06/19 at 8:00 AM, 12.5 hours after the previous assessment.

Patient #3's record included a "Nursing Progress Note," dated 3/06/19 at 11:45 AM. The note stated, "After removing the coban and tape with tegaderm, the patient's arm had skin that was severly [sic] compromised from the coban that had been left on the patient from the start of the IV. Paper tape underneath the coban had to be removed with a lot of moisture and alcohol. The skin has breakdown and a blister from the IV."

Patient #3's record included a "Handoff Form" with an entry dated 3/06/19 at 4:44 PM, signed by an RN. The entry stated, "IV discontinued and actions taken to aid in damage." His record did not include a physician's order for care to his IV site and did not state what actions were taken.

During an interview on 5/15/19 at 1:50 PM, the Director of Acute Care reviewed Patient #3's record. She confirmed his IV site was not assessed every 2 hours as required by hospital policy. Additionally, she confirmed there was no physician's order for care of the comprised skin at his IV site.

Patient #3's IV site was not assessed as required by hospital policy. Care was provided to his IV site without a physician's order.

Based on medical record review, hospital policy review, and staff interview, it was determined the hospital failed to ensure comprehensive POCs were developed related to skin integrity for 3 of 3 patients (#1, #2, and #6) admitted to the rehabilitation unit and whose care plans were reviewed. This resulted in a lack of direction to staff caring for these patients and had the potential to contribute to skin breakdown. Findings include:

The hospital's policy "Interprofessional Plan of Care - SAHS," approved 7/13/18, stated "Patients receive care and treatment based on an assessment of the patient's individualized needs. The data obtained from the assessment is used to determine and prioritize the patient's plan for care."

This policy was not followed. Examples include:

1. Patient #1 was an 85 year old male, admitted to the hospital's rehabilitation unit on 4/11/19, for care following a TKA. He was discharged on 4/24/19.

Patient #1's record included a "History & Physical," dated 4/12/19, signed by a PA. It included, "Skin: The patient has a sore on his buttock, which is being covered with Mepilex. Nursing to follow and manage.

Patient #1's record included an "Ostomy/Wound Progress Note," dated 4/17/19 at 4:21 PM, signed by the wound care nurse. The note stated, "Pt with area of partial thickness skin breakdown on R [right] buttock. 1 cm X 1.5 cm, 0.1 cm deep...This appears to be chronic, pt states it has been there approximately 1 year. Stage II pressure injury. No documentation until today so is therefore considered hospital acquired."

Patient #1's record included a "Care Plan," implemented 4/11/19, that addressed acute pain, activity intolerance, and fall risk. His care plan did not address skin integrity or pressure ulcer prevention.

During an interview on 5/15/19 at 1:10 PM, the Director of Acute Care reviewed Patient #1's care plan and confirmed it did not address skin integrity or pressure ulcer prevention.

The hospital failed to ensure a care plan was developed to address care of Patient #1's skin problems and prevent additional skin breakdown.



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2. Patient #2 was a 72 year old male initially admitted to the hospital on 2/05/19 after a traumatic injury. On 2/06/19, Patient #2 underwent "status post open reduction internal fixation" related to a "left trimalleolar ankle fracture." He was admitted to the rehabilitation unit on 2/18/19 and discharged on 3/01/19

The operative report, dated 2/06/19, indicated Patient #2 "had some fracture blisters on the posterior aspect of his calf that had popped. These were dressed with Xeroform..."

A progress note, dated 2/08/19, signed by a PA, stated "Fresh dressings were reapplied with a Mepilex, Ace [sic] wraps were also placed and he was put into a long-leg walker boot." It could not be determined if the fresh dressings were specific to the surgical site at the left ankle or whether it included the calf wound identified after the surgery on 2/06/19.

A progress note, dated 2/16/19, signed by a PA, stated the CAM boot and dressings were removed and the skin examined. "There was a possible prior skin tear noted proximally, just distal to the patient's gastrocnemius. This did not have any surrounding erythema or evidence of infection as well. There did appear to be evidence of granulation tissue formation." "Wound dressings were then replaced with Xeroform and Medipore dressings, Kerlix and an Ace [sic] wrap. The Cam [sic] walking boot was then replaced as well. The neurovascular status was then again checked out and Cam [sic] boot was replaced."

A progress note, dated 2/18/19, signed by the PA documented "sutures were removed and dressings were replaced." There was no specific reference to the condition of the skin at the site of Patient #2's calf wound.

There was no nursing documentation on the rehabilitation unit that Patient #2's skin had been assessed, under the CAM boot and dressings, either upon admission to the rehabilitation unit on 2/18/19, or per shift, until 10 days later, on 2/28/19.

An RN progress note, dated 2/28/19, related to Patient #2, stated: "MD and this nurse undressed ace [sic] wrap on left ankle... there appears to be an unstageable pressure injury on left lateral calf that is 100% eschar covered with drainage. The pt [patient] reports that since he has been in the hospital, his dressing has been changed 1 time that he can remember. This nurse received a verbal wound care consult order..."

A wound consult RN note, dated 2/28/19, stated "S [subjective]: Wound care evaluation requested for wound to L [left] posterior calf. O [objective]: Soft gray/brown eschar with separating edges measuring 5.5cm x 6cm, yellow slough at edges. Surrounding skin is intact, pink. Minimal amount of serous drainage on telfa dressing placed earlier today. A [assessment]: Cleansed with NS and gauze, applied sting free barrier film to surrounding skin. Duoderm thin over wound, covered with Tegaderm followed by ABD pad in case dressing becomes overwhelmed with drainage. P [plan]: Will follow up in AM with wound care PA, [name] to provided [sic] sharp debridement if necessary."

A discharge summary, written by a PA, dated 3/01/19, stated "At the end of his [Patient #2's] rehabilitation efforts, he was found to have a wound to the left gastroc [gastrocnemius] area that was related to pressure from the Cam [sic] boot."

Patient #2's record included a "Care Plan," initiated at that time of admission to the rehabilitation unit on 2/18/19, that addressed activities of daily living, physical mobility and fall risk. His care plan did not address skin integrity or pressure ulcer prevention, upon initiation of the care plan or throughout his stay in the rehabilitation unit.

The Risk Manager and the Performance Improvement Coordinator were interviewed together on 5/15/19 at 9:55 AM. They confirmed Patient #2's care plan did not address skin integrity or pressure ulcer prevention.

Patient #2's care plan did not address identified skin issues. His care plan was incomplete.

3. Patient #6 was a 78 year old female admitted to the hospital on 5/02/19 after a motor vehicle collision. A tibial fracture was surgically repaired on 5/04/19. She was moved to the rehabilitation unit on 5/09/19.

A practitioner order, dated 5/09/19, signed by a PA, specified Patient #6 was to wear a "Hinged knee brace to left leg." A brace could put pressure on the skin and lead to skin breakdown.

A practitioner wound care order for Patient #6, dated 5/09/19, signed by an MD, specified wound care "daily with normal saline pain [sic] with Betadine cover with Xeroform and dry sterile dressing. Notify MD for drainage or breakdown in skin or any skin changes"

Patient #6's "Care Plan," initiated 5/09/19, addressed activities of daily living, bowel incontinence, and fall risk. Her care plan did not address skin integrity issues or pressure ulcer prevention.

The Director of Acute Care was interviewed on 5/15/19 at 2:45 PM. She reviewed Patient #6's medical record and confirmed her care plan did not address impaired skin integrity or pressure ulcer prevention.

Patient #6's nursing care plan did not address her identified skin issues. Her care plan was incomplete.

Based on medical record review, policy review, observation, and staff interview, it was determined the hospital failed to ensure rehabilitation patients' records included orders or complete orders for all necessary care for 3 of 3 patients (#1, #2, and #6) admitted to the rehabilitation unit and whose records were reviewed. This resulted in lack of assessment and care provided to patients' skin. Findings include:

A hospital policy "ORDERS LICENSED INDEPENDENT PRACTITIONERS (LIP)," revised 7/2008, stated:

- "Orders must be clear, legible and completed. Orders that are illegible or incomplete will not be carried out until rewritten or clarified."

- "At each handoff, orders should be reviewed by both the Sending Nurse and the Receiving Nurse at the same time."

Practitioner orders were missing or incomplete. Examples include:

1. Patient #2 was a 72 year old male initially admitted to the hospital on 2/05/19 for left ankle surgery on 2/06/19 after sustaining a traumatic injury. He was admitted to the rehabilitation unit on 2/18/19 and discharged home on 3/01/19.

A "History & Physical" examination, dated 2/19/19, completed by a PA, stated "He [Patient #2] has a CAM boot on the left foot."

Practitioner progress notes, dated 2/21/19, 2/22/19, 2/23/19, 2/25/19, 2/27/19, 2/28/19, documented Patient #2 was wearing a boot on the left lower extremity over an ace wrap.

Practitioner orders were reviewed for the rehabilitation unit stay from 2/18/19 through 3/01/19. There were no orders that addressed Patient #2's lower extremity CAM boot or ACE wrap. It could not be determined whether his boot was supposed to be worn at all times or could be removed for BID skin checks and while in bed.

A discharge summary, dated 3/01/19, written by a PA, stated "At the end of his [Patient #2's] rehabilitation efforts, he was found to have a wound to the left gastroc [gastrocnemius] area that was related to pressure from the Cam [sic] boot."

During an interview on 5/15/19 at 9:00 AM, the Risk Manager confirmed there was no order for the CAM boot or ACE wrap during Patient #2's stay on the rehabilitation unit. She stated "sometimes orthopedic doctors do not want boots or dressings removed. Staff may have assumed they were supposed to stay on."

Practitioner orders for the CAM boot and dressings were missing in Patient #2's medical record.

2. Patient #6 was a 78 year old female admitted to the hospital on 5/02/19 after a motor vehicle collision. A tibial fracture was surgically repaired on 5/04/19. She was moved to the rehabilitation unit on 5/09/19 and was a current patient at the time of the survey.

A practitioner order, dated 5/09/19, signed by a PA, specified Patient #6 was to wear a "Hinged knee brace to left leg." The order did not say whether her brace was to be worn at all times, whether it could be removed at times, such as while she was in bed or for BID skin checks.

Patient #6 was observed in her room on 5/15/19 at 10:50 AM wearing her knee brace.

The Director of Acute Care was interviewed on 5/15/19 at 2:45 PM. She reviewed Patient #6's medical record and confirmed the practitioner's order did not clarify whether Patient #6's brace was to be worn continuously or only while walking.

Practitioner orders for Patient #6's hinged knee brace were incomplete and lacked clarity.




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3. Patient #1 was an 85 year old male, admitted to the hospital's rehabilitation unit on 4/11/19, for care following a TKA. He was discharged on 4/24/19.

Patient #1's record included a "History & Physical" dated 4/12/19, signed by a PA. It included, "Skin: The patient has a sore on his buttock, which is being covered with Mepilex. Nursing to follow and manage. His surgical site has ABD and stockinette, small amount of drainage. We will monitor and manage."

Patient #1's record included a "Handoff Form." An entry dated 4/11/19 at 8:27 PM, signed by the RN, stated, "Pt has sore on buttock - mepilex applied."

Patient #1's record did not include a physician's order for care of the sore on his buttock, including type of dressing to be applied or frequency of dressing changes. His record did not include a physician's order for care of his surgical incision, including if/when the dressing should be removed or changed

During an interview on 5/15/19 at 1:10 PM, the Director of Acute Care reviewed Patient #1's record and confirmed a sore on his buttock was documented at the time of his admission. She confirmed there was no physician's order for care of his sore or his surgical incision.

The hospital failed to ensure Patient #1's record included all physician orders required for his care.