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Based on document review and interview it was determined that for 1 (Pt. #1) of 10 patients, the Hospital failed to ensure that the nursing services were supervised to ensure notification of the physician when a change of condition is identified, failed to reposition the patients as required and failed to maintain individualized wound nursing care plan for each patient. As a result, the Condition of Participation 42. CFR 482.23 Nursing Services was not in compliance.

Findings include:

1. The Hospital failed to ensure that nursing staff notified the physician after evaluating and identifying the change of condition for Pt. #1. See deficiency A-395 A

2. The Hospital failed to ensure that a registered nurse supervised and evaluated the nursing care of each patient. This failure resulted in patients with pressure injuries not being repositioned every 2 hours as required. See deficiency A-395-B.

3. The Hospital failed to ensure that the nursing staff developed and kept a current wound nursing care plan for each patient. See deficiency A - 396.

A. Based on document review and interview, it was determined that for 1 (Pt. #1) of 10 clinical records reviewed for wound care management, the Hospital failed to ensure that nursing staff notified the physician after evaluating and identifying the change of condition for Pt. #1.

Findings include:

1. On 9/12/19, the Hospital's policy titled "Interdisciplinary Assessment and Re-Assessment (release date 6/2019) was reviewed. The policy included, "15. Notification Responsibilities When an Assessment Reveals a Change or Suspected Change of Condition. a. The nurse assigned to the patient or supervising care of the patient is responsible for notification of and communication to the patient's primary physician or designee using appropriate channels and chain of command for assuring that there is a physician response....d. Notify the Nursing Supervisor of patient change of condition...e. Document change of condition, notification and interventions in the medical record.


2. On 9/10/19, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted on 8/5/19 with a diagnosis of acute postprocedural respiratory failure. Pt. #1's clinical record included the following information:

- The "History and Physical" dated 8/5/19 included, Physical Examination ...Skin; No rash ..."

- The "Integumentary Assessment" from 8/5/19 to 9/9/19 was reviewed. The nursing assessment included the Braden score (assessment tool used on patient's risk to develop pressure sores) rating: (the risk level) and the 6 indicators: sensory perception, moisture, activity, mobility, nutrition, friction and shear. On 8/5/19 and 8/13/19, Pt. #1's Braden score was 10 (10-12 high Risk).

- Pt. #1's physician orders from 8/8/19 to 8/26/19 were reviewed and included, "a physician order dated 8/8/19 for a hypothermia blanket (cooling blanket)."

- The "Vital Signs" from 8/7/19 to 8/26/19 were reviewed. Pt. #1's temperature fluctuated from 98.8 F (Fahrenheit) to 103.2 F (documented on 8/22/19 at 8:00 PM, 10:00 PM). (Normal body temperature is from 97 F to 100 F.)

3 .On 9/12/19, Pt. #1's "Incident Report" dated 8/26/19 at 9:00 AM was reviewed and included, "Nature of Event: Other event or injury; Adverse Event: Body Part: whole patient's back discoloration ...Per Wound Care Team, (Pt. #1) was found to have a large area of dark discoloration involving the entire back. Etiology unknown ...Full investigation revealed... Per interview, discoloration was noted on 8/25/19 at (8:00 PM) but was not escalated to physician notification or any other intervention other than turning the hypothermia unit off."

4. On 9/12/19, Pt. #1's Root Cause Analysis (RCA) for Pt. #1's incident (8/26/19) was reviewed. The following interviews were obtained during the Hospital's investigation:

- On 9/6/19 at 7:30 AM , the Registered Nurse (E #9) was the nurse that initially observed the wound on Pt. #1's back. E #9 indicated during this interview that he had identified the discoloration on 8/25/19 at 8:00 PM. E #9 turned off the blanket and did not report physician because 'he has seen this before in patients with cooling blanket, it resolves after a few hours'. E #9 did not document the findings in Pt. #1's clinical record. E #9 endorsed his findings to E #10 (Registered Nurse) during the change of shift.

- On 9/6/19 at 8:00 AM, E #10 was interviewed. E #10 stated that E #9 had made her aware 'he did not like the look of (Pt. #1's) back.' However, did not mention the urgency or severity of the wound, nor that Wound Care Team had been notified. Upon rounds on 8/26/19, E #10 saw Pt. #1's back and notified Wound Care Team."

5. On 9/11/19 at approximately 1:07 PM, the Wound Care Physician (MD #2) was interviewed via telephone. MD #1 stated "I was notified during the weekly rounds of (Pt. #1's) wound on the back."

6. On 9/11/19 at approximately 2:45 PM, the Wound Care Nurse (E #8) was interviewed via telephone. E #8 stated "I was notified by the nurse that was assigned to Pt. #1 on (8/26/19) when the wound care team was rounding on the HAU (High Acuity Unit). The nurse told me that they found something on (Pt. #1's) back."

7. On 9/12/19 at approximately 2:26 PM, the Director of Quality Management (E #6) was interviewed. E #6 stated it is the expectation that the nurses are to notify a change of patients condition to the physician immediately. (E #9) did not notify the physician of his finding after his assessment of (Pt. #1's) back.




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B. Based on interview and document review, it was determined that for 3 of 10 Patients (Pt #1, Pt #2 and Pt #10), the Hospital failed to ensure that a registered nurse supervised and evaluated the nursing care of each patient. This failure resulted in patients with pressure injuries not being repositioned every 2 hours as required.

Findings include:

1. On 9/10/19, the Hospital's policy titled "Clinical Guidelines for Pressure Injury" (release date 06/2019) was reviewed and indicated "...Standard interventions for all patients can include but not limited to...Repositioning orders (minimum every 2 hours)...Considerations for patients requiring every 1-2 hours turn and repositioning: patient unable to turn and reposition self, poor nutrition, multiple wounds, recent change of condition, poor cognition, skin is moist or at risk for friction/shear injury...A Braden Risk Score ( a tool for predicting pressure ulcer risk) of 15-18 (Mild Risk), 13-14 (Moderate Risk), 10-12 (High Risk), 9 or less (Severe Risk)..."

2. On 9/10/19 at 10:00 AM, Pt #1 was observed to have multiple open superficial wounds (quarter size) on his back, a stage 4 pressure injury on his left ear, a deep tissue pressure injury on his right ear and a deep tissue pressure injury on his right lateral foot. Pt #1 was observed as unresponsive and unable to turn or reposition himself.

On 9/10/19, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted on 8/5/19 with a diagnosis of acute postprocedural respiratory failure. Pt #1's Braden Risk Score dated 8/5/19 was 10 (High Risk).

Pt. #1's nursing repositioning flowsheets indicated that Pt. #1 was not repositioned at least every 2 hours as required:

-Pt #1 was on his back on 8/17/19 from 12:29 PM to 7:54 PM (total 7 hours, 55 minutes)
-Pt #1 was on his right side on 8/18/19 from 1:53 PM to 4:33 PM (total 2 hours, 40 minutes)
-Pt #1 was on his right side on 8/18/19 from 7:55 PM to 10:11 PM (total 2 hours, 16 minutes)
-Pt #1 was on his back on 8/19/19 from 5:19 AM to 8:00 AM (total 2 hours, 41 minutes)
-Pt #1 was on his right side on 8/19/19 from 1:52 PM to 4:00 PM (total 2 hours, 8 minutes)
-Pt #1 was on his back on 8/20/19 from 1:30 PM to 4:00 PM (total 2 hours, 30 minutes)
-Pt #1 was on his right side on 8/21/19 from 1:37 PM to 4:18 PM (total 2 hours, 45 minutes)
-Pt #1 was on his right side on 8/24/19 from 7:35 AM to 10:00 AM (total 2 hours, 25 minutes)
-Pt #1 was on his left side on 8/25/19 from 9:56 AM to 12:24 PM (total 2 hours, 28 minutes)
-Pt #1 was on his right side on 8/25/19 from 1:53 PM to 4:11 PM (total 2 hours, 18 minutes)
-Pt #1 was on his left side on 9/1/19 from 1:32 AM to 5:04 AM (total 3 hours, 32 minutes)
-Pt #1 was on his back on 9/1/19 from 7:00 AM to 10:43 AM (total 3 hours, 43 minutes)
-Pt #1 was on his right side on 9/1/19 from 2:54 PM to 5:55 PM (total 3 hours, 1 minute)
-Pt #1 was on his right side on 9/2/19 from 2:10 AM to 11:00 AM (total 9 hours, 10 minutes)
-Pt #1 was on his back on 9/2/19 from 11:01 AM to 2:25 PM (total 2 hours, 26 minutes)
-Pt #1 was on his right side on 9/3/19 from 2:19 AM to 6:31 AM (total 4 hours 49 minutes)
-Pt #1 was on his left side on 9/3/19 from 9:12 AM to 12:04 PM (3 hours, 16 minutes)
-Pt #1 was on his back on 9/4/19 from 10:59 AM to 14:14 PM (3 hours, 15 minutes)
-Pt #1 was his right side on 9/7/19 from 7:05 AM to 10:00 AM (3 hours, 5 minutes)
-Pt #1 was on his right side on 9/8/19 from 6:08 AM to 10:00 AM (4 hours, 8 minutes)
-Pt #1 was on his right side on 9/9/19 from 2:30 PM to 7:06 PM (4 hours, 36 minutes)

3. Pt #2's Kardex dated 9/10/19 included "Altered skin conditions - Pressure injury: back of head, stage 4; left ear, unstageable slough (dead white blood cells and devitalized tissue) and eschar (dead tissue); right lateral (side) ankle, stage 4; left lateral lower leg extending to ankle, unstageable slough and eschar; right buttocks, stage 3 and right plantar foot inferior aspect, unstageable slough and eschar..." Pt #2's physician order dated 8/30/19 noted "...Reposition every 2 hours..." Pt #2's Braden Risk Score dated 8/29/19 was 10 (High Risk).

Pt #2's nursing repositioning flowsheets noted the following:
-Pt #2 was on his back on 9/9/19 from 12:35 AM to 3:03 AM (total 3 hours, 28 minutes)
-Pt #2 was on his back on 9/10/19 from 4:00 PM to 7:08 PM (total 3 hours, 8 minutes)
-Pt #2 was on his back on 9/10/19 from 5:53 AM to 8:53 AM (total 3 hours)

4. Pt #10's Braden Risk Score dated 8/26/19 was 12 (High Risk). Pt #10's wound assessment dated 9/9/19 indicated "...Sacrum (lower back) stage 3 pressure injury, anterior neck, unstageable pressure injury and left hip, unstageable pressure injury..."
Pt #10's repositioning nursing flowsheets indicated the following:
-Pt #10 was on her right side on 9/7/19 from 2:29 AM to 10:00 AM (7 hours, 31 minutes)
-Pt #10 was on her right side on 9/8/19 from 7:53 PM to 10:26 PM (2 hours, 19 minutes)
-Pt #10 was on her left side on 9/9/19 from 2:00 AM to 4:20 AM (2 hours, 20 minutes)
-Pt #10 was on her right side on 9/9/19 from 2:36 PM to 5:41 PM (3 hours, 5 minutes)

5. On 9/10/19 at 11:00 AM, an interview was conducted with the Certified Nursing Assistant (E #5). E #5 stated that patients should be turned every 2 hours to prevent pressure injuries.

6. On 9/11/19 at 11:45 AM, an interview was conducted with the Registered Nurse (E #2). E #2 stated that a nurse ensures that patients are repositioned every 2 hours by making rounds and checking to see if patients are turned every 2 hours.

Based on interview and document review, it was determined that for 2 of 10 Patient's (Pt #1 and Pt #2) wound care plan reviewed, the Hospital failed to ensure that the nursing staff developed and kept a current wound nursing care plan for each patient.

Findings include:

1. On 9/10/19, the Hospital's policy titled "Clinical Guidelines for Pressure Injury" (release date 06/2019) was reviewed and indicated "...Each patient should have an individualized plan of care created around the identified risk level..."

2. Pt #1's Braden scale score 10 - High Risk (dated 8/5/19). Pt #1's care plan undated indicated "...Healable wound goal: early identification/intervention for increasing bioburdeen (defined the number of bacteria living on a surface that has not been sterilized), infection, clinical signs & symptoms of infection resolving, decreasing measurements for wound size, comorbities and/or deterrents to wound healing managed or eliminated..." Pt #1's care plan lacked documentation regarding an individualized plan of care.

3. Pt #2's Braden scale score 10 - High Risk dated 8/29/19. Pt #2's care plan undated indicated "...Healable wound goal: early identification/intervention for increasing bioburden, infection, clinical signs & symptoms of infection resolving, decreasing measurements for wound size, comorbidities and/or deterrents to wound healing managed or eliminated..." Pt #2's care plan lacked documentation regarding an individualized plan of care.

4. On 9/11/19 at 11:50 AM, an interview was conducted with the Registered Nurse (E #2). E #2 stated that wound care plans should be individualized because each patient has specific needs related to their wounds. E #2 stated that the care for each wound should be included in the care plan.

5. On 9/11/19 at 3:00 PM, an interview was conducted with the Wound Care Nurse (E #8). E #8 stated that care plans are individualized for the options that are best for each patient with a wound.