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Based on medical record review and staff interviews, it was determined the facility failed to ensure patient care plans are updated appropriately to follow patient goals and nursing care to meet patient's needs in one of six medical records reviewed for wound care (Medical Record [MR] 1).

Findings include:

On 2/13/2025, a review of Patient (P)1's medical record was reviewed in the presence of Staff (S) 1, Senior Director of Nursing, Nursing Operations, and Adult Inpatient Services, S2, Director of Quality, Patient Safety, and Risk Management, S3, Patient Safety and Risk Management, S6, Coordinator Academic Partnerships and Nurse Residency and revealed the following:

P1 was admitted to the facility on 9/10/2024, for a scheduled surgery to remove a gangrenous right leg. P1 had a right below the knee amputation (BKA) on 9/10/2024.

On 9/11/2024 at 5:14 AM, a consult for "Wound/RN [Registered Nurse]/Ostomy care" was placed by Staff (S) 18, Registered Nurse (RN). Reason for consult states, "sacral PI [Pressure Injury]."

At 8:14 AM, a consult with S13, Wound Care Advanced Practice Nurse (APN) was completed. The wound evaluation documentation states, "... Assessment: ... Skin characteristics: sacral area with dry flakey [sic] skin. There is an area of hypopigmented skin over this area from previously [sic] wounds, now healed and resolved. [He/she] has been using triad paste as protective coating ... Pressure Injury: No"

On 9/22/2024 at 12:05 AM, S21, RN, documented in the Wound Pressure Injury Assessment, stating, "... Pressure Injury Stage: Stage 2." P1's MR lacked evidence of a wound care plan.

On 2/13/2025 at 2:30 PM, when asked the process of care planning, S6, Coordinator of Academic Partnerships and Nurse Residency stated, if there is a new or worsening wound, nursing is supposed to consult wound care and update the care plan.

At 2:36 PM, S6 navigated through P1's MR and confirmed the MR lacked evidence of an updated care plan for wound care.

Based on medical record review, staff interviews, and policy and procedure review, it was determined the facility failed to ensure that nursing staff implemented policies and procedures for skin integrity in one of six medical records reviewed for wound care (Medical Record [MR] 1).

Findings include:

Protocol titled, "Alteration in Skin Integrity Protocol," reviewed on 12/2024, states, "... Prevention:... Maintain the following on all patients with a risk score of < [less than or equal to] 18 on Braden Scale... Reposition patient every 2 hours... Stage 2 Management: ... Contact CWOCN-APN [Certified Wound Ostomy Continence Nurse-Advanced Practice Nurse] for consultation ...Nutrition Management ... Discuss with MD [Medical Doctor]/RD [Registered Dietician] the need for Nutrition Support Consultation for all patients with pressure injuries ... Reportable conditions: Report to CWOCN-APN ... deterioration of wound ... evaluate progress at least weekly and determine if modification in the treatment plan is indicated. Notify CWOCN-APN for consultation."

A review of Patient (P)1's medical record in the presence of the Staff (S)1, Senior Director of Nursing, Nursing Operations, and Adult Inpatient Services, S2, Director of Quality, Patient Safety, and Risk Management, S3, Patient Safety and Risk Management, S6, Coordinator Academic Partnerships and Nurse Residency and revealed the following:

On 9/10/2024, P1 was admitted to the facility for a scheduled surgery to remove a gangrenous right leg. P1 had a right below the knee amputation (BKA) on 9/10/2024.

On admission and throughout the hospitalization, P1's Braden Score was documented as a score of 13. A Braden Score is a standardized assessment tool to assess a patient's risk for developing a pressure injury, with a range of 6 to 23; a lower score indicates a higher risk for pressure injury. Braden Scale ranges as follows: 18 or higher: Low Risk; 15-17: Moderate Risk; 13-14: High Risk; 12 or lower: Very High Risk.

On 9/11/2024 at 5:14 AM, an initial wound care consult was placed by S18, Registered Nurse (RN) for "sacral PI [pressure injury]." At 8:14 AM, P1 was seen by S13, Wound Care Advanced Nurse Practitioner (APN). S13 documented, "... Assessment: ... Skin characteristics: sacral area with dry flakey [sic] skin. There is an area of hypopigmented skin over this area from previously wounds, now healed and resolved."

On 9/15/2024 at 7:37 PM, S20, RN, documented a "Wound Pressure Injury Assessment." Wound Pressure Injury Assessment states, "Pressure Injury Properties: Date First assessed: 9/15/2024, Time First Assessed: 7:30 PM, Primary Wound Type: Pressure Injury... Location: Sacrum."

On 9/17/2024 at 11:45 AM, a Nutrition Note was entered by S15, Registered Dietician (RD), and states the following: "... Skin Integrity:... Sacral area with dry flaky skin. There is an area of hypopigmented skin over this area from previously wounds, now healed and resolved."

On 9/22/2024 at 12:05 AM, S21, RN, documented in the Wound Pressure Injury Assessment stating, "... Pressure Injury Stage: Stage 2."

P1's MR lacked evidence of a consultation for the Wound Care APN after deterioration of the wound. P1's MR lacked evidence of notification of the wound, to Wound Care APN.

Throughout P1's medical record from 9/11/2024 to 9/26/2024, there was documentation of patient repositioning every 2 hours, however, from 9/11/2024 to 9/26/2024, P1's position was documented consistently as "Semi Fowlers, Pillow Support," with inconsistent documentation of turning to the left or right side.

On 2/13/2025 at 2:49 PM, S6, Coordinator Academic Partnerships and Nurse Residency navigated through P1's MR and confirmed that the Wound Care APN was not reconsulted. S6 confirmed that the Wound Care APN should have been notified and reconsulted for the worsening wound, and nursing staff should not have staged the wound. S6 also confirmed that it "looked like" P1 was not turned every 2 hours from Semi Fowlers position for multiple days.

At 3:08 PM, S1, Senior Director of Nursing, Nursing Operations, and Adult Inpatient Services and S2, Director of Quality, Patient Safety, and Risk Management confirmed nursing staff is not allowed to stage wounds. S1 explained, new or worsening wounds must be staged by the Wound Care APN.

On 2/13/2025 at 2:15 PM, an interview was conducted with S1. When asked how often nursing is educated on wound care, S1 explained, nursing is trained at orientation and when there are changes in protocols, but the wound care training is not in the nursing yearly competencies.

On 2/13/2025 at 2:18 PM, S6 reported that staff are educated to all protocols, including the "Alteration in Skin Integrity Protocol," during orientation and with any changes in the protocol. S6 further explained that unit educators continuously reinforce protocols at the unit level.

On 2/13/2025 at 2:20 PM, S14, Director of Nursing, Critical Care and Stepdown, explained that the "Alteration in Skin Integrity Protocol" is triggered when the nurse documents a patient's wound or an alteration in skin integrity, poor nutrition, or a Braden score less than 18. According to S14, turning and repositioning the patient every two hours is included in this protocol. S14 explained that the nurses can see that this protocol is ordered for the patients in EPIC (electronic health record software used to manage patient records, workflows, and clinical decision making).

On 2/13/2025 at 2:36 PM, S1 explained when the Skin Integrity Protocol is initiated, the nursing staff only needs to document, once a shift, that the protocol is being maintained, and that the nurses are supposed to "chart by exception." When asked if repositioning documentation is required, S1 confirmed that the staff nurses are not required to chart patient repositioning every two hours. When asked what the process for nursing and staging of wounds, S1 explained, staff nurses cannot stage wounds, the wound care nurse stages wounds. S1 explained that staff are instructed per protocol to notify the wound care nurse and/or the doctor when a pressure injury develops or worsens.