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Based on record review, observation, and interview, the registered nurse responsible for supervision and evaluation of the nursing care failed to ensure that care was provided in accordance with accepted standards of nursing practice and hospital policy relative to wound care assessment. This deficient practice was evidenced by:

1) inaccurate staging of a pressure ulcer in 1(#3) of 1 (#3) current patients with pressure ulcerations from a sample of 6 patients; and
2) failure of the nurse to initiate impaired skin integrity plan per protocol in 1 (#3) of 2 (#2, #3) current patients at risk for skin breakdown; and
3) failure of the nurse to communicate "at risk status" for skin breakdown to staff after admission evaluation was performed in 1(#3) of 2 (#2, #3) current patients confined to geriatric chairs; and
4) failure to provide timely skin assessments per facility protocol in 2 (#3, #4) of 2 (#3, #4) current patients with skin lesions; and
5) failure of the nurse to notify the physician of a change in the status of the pressure ulcer in 1(#3) of 1 (#3) current patients with pressure injury of the skin; and
6) failure of the nurse to implement bed alarms per hospital policy for 1(#4) of 1 ( #4) current patients with documented falls out of a sample of 6.

Findings
1. Inaccurate staging of pressure ulcer in 1(#3) of 1 (#3) patients with pressure ulcerations from a sample of 6 patients
Review of facility policy, "Skin/Wound Care," in part revealed: Staging of pressure injuries
o Stage 1- Non-blanchable erythema of intact skin
o Stage 2- Partial -thickness skin loss
o Stage 3- Full thickness skin loss
o Stage 4- Full thickness skin loss and tissue loss

Review of the medical record for Patient #3 revealed an admission assessment dated 04/21/2021 was performed. S4RN documented "1/4" very small skin tear on L inner buttocks. Pictures taken." A Braden score of 14 was documented.

In combined interview with S2DON via phone and S3RN on 04/28/2021 at 12:00 p.m., both S2DON and S3RN agreed the presence of an open wound in a pressure area should have been classified as Stage II Pressure Injury.

2. Failure of the nurse to initiate impaired skin integrity plan per protocol in 1 (#3) of 2 (#2, #3,) patients at risk for skin breakdown.

Review of facility policy titled "Skin/Wound Care," in part revealed: Description of skin abnormalities should be documented according to the assessed findings including the initiation of the impaired skin integrity treatment plan. The registered nurse initiates the skin care integrity treatment plan.

Review of the nurse notes for Patient #3 dated 04/16/2021 revealed S4RN documented "1/4" very small skin tear on L inner buttocks. Pictures taken."

In combined interview on 04/28/2021 at 12:00 p.m., both S2DON and S3RN agreed that impaired skin integrity treatment should have been added to the multidisciplinary treatment plan and S3RN verified that it was not in the treatment plan. S3RN also verified that the Wound Prevention / Protocol box on the daily sheet labeled "Observation Check Sheet," remained unchecked from 04/16/2021- 04/26/2021. She also verified that the daily sheet for 04/27/2021 was not on the chart for review.

3. Failure of the nurse to communicate "at risk status" for skin breakdown to staff after admission evaluation was performed in 1(#3) of 2 (#2, #3) current patients confined to geriatric chairs.

Review of facility policy titled "Skin/Wound Care" in part revealed:
Braden Scale Skin Assessment is completed by the registered nurse on all patients upon admission, weekly, and prn.
If the Braden score is less than 18, the wound care Prevention/Protocol will be implemented as applicable and as ordered by the Physician/ NPP.

The nurse communicates "at risk" status to staff to implement the prevention interventions.
Review of the medical record for Patient #3 revealed on the admission assessment performed 04/16/2021, S4RN documented that the patient had a tear in the skin and a Braden scale score of 14. On 04/24/2021 S4RN documented, "Dime size open wound on L buttocks 9:00 p.m. 4/24/21" on the photograph and a Braden scale score of 15.

In interview on 04/28/2021 at 12:00 p.m., S3RN reviewed the multidisciplinary notes and verified that the physician was not notified of the change in status. S3RN verified that the patient record contained no other documentation that the patient had received the wound prevention interventions listed in the protocol for patients with Braden scale less than 18 and for chair bound individuals. These interventions were first noted on the overnight shift 04/27/2021 - 04/28/2021. S3RN indicated that the patient was able to shift position in the chair and bed and that she was now receiving turning every 2 hours and that pillows were being used to decrease pressure in the area when sitting.


4. Failure to provide timely skin assessments per facility protocol in 2 (#3, #4) of 2 (#3, #4) current patients with skin lesions.

Review of facility policy titled" Skin/Wound Care" in part revealed: A skin assessment is completed by the registered nurse on all patients at admission, weekly, after a fall/injury, upon new skin findings and at discharge. If a patient is identified to have a wound, wound photography is performed and documentation of the wound is completed on the hospital skin assessment wound care documentation form. Wounds are to be photographed on admission and every three days.

Patient #3
Review of the medical record of Patient #3 revealed on 4/16/2021 a skin assessment was performed by S4RN. A 1/4" tear of the skin was documented. On 04/24/2021 a photograph was taken 8 days after the initial assessment. The photograph had the note, "Dime size open wound on L buttocks 9:00 p.m. 04/24/2021."

In the combined interview on 04/28/2021 at 12:00 p.m., S2DON and S3RN both agreed that skin assessments should have been done on 04/19/2021 and then by 04/22/2021. They also agreed that the form, "Skin Assessment & Wound Care" should have been filled out and S3RN verified that it was not on the chart for the date of 04/24/2021.

Patient #4
Review of the medical record for Patient #4 revealed On 04/05/2021 the patient was noted on the nurses notes to have a new lesion on her forehead and the nurse failed to fill out the "Skin Assessment & Wound Care documentation" sheet per protocol.

In interview on 04/26/2021 at 8:30 a.m. S6RN verified that she was the person that had documented the new lesion and that a skin assessment for the new skin lesion was not performed per protocol. In interview on 04/27/2021 at 11:00 a.m., S2DON also verified that the findings on 04/05/2021 should have been followed up with complete skin assessment and photographs per protocol.

5. Failure of the nurse to notify the physician of a change in the status of the pressure ulcer in 1(#3) of 1 ( #3) current patients with pressure injury of the skin.

Review of the medical record for Patient #3 revealed on 04/16/2021 S4RN noted a ¼" tear of skin. There was no documentation the physician was notified.

On 04/24/2021, S4RN noted a "dime size" lesion in the same spot. There was no documentation the physician was notified.
On the wound care nurse's note, dated 04/26/2021 revealed 2 Stage I lesions. The physician was notified and orders for topical treatment given. Review of the physician orders revealed on 04/27/2021 an order for a wound care consult and there was notation that the consult would be performed 04/28/2021 around noon by the wound care consultant.

In the interview on 04/28/2021 at 12:00 p.m., S3RN verified that the physician should have been notified on 04/16/2021 and on 04/24/2021 and Patient #3's medical record indicates that the physician was first notified of the change in status on 04/26/2021.

6. Failure of the staff to implement bed alarms per the hospital's policy in 1(#4) of 1( #4) current patients with documented falls out of a sample of 6.

Review of the policy titled "Fall assessment/ Re-assessment and Precautions" in part reveals: Fall precautions- Interventions for high risk include: all moderate risk interventions and bed alarms and/or chair alarms are highly recommended for nighttime use.

Review of Patient #4 nurse notes dated 04/05/2021 and 04/06/2021 revealed the patient was noted to have new lesions to the head and face.

In interview on 04/26/2021 at 4:25 p.m. S6RN verified that she documented a new lesion on 04/05/2021 to the forehead of Patient #4 and no further actions were taken. On 04/06/2021 after new lesions of the eye and forehead were documented, an incident report and interviews were performed, but were inconclusive as to the source of the injury. No new interventions were implemented.

In interview 4/26/21 at 4:25 p.m., S6RN verified the failure to implement new preventative actions. S6RN reviewed Patient #4's care plan and verified that there were reprioritizations of previous interventions, but no new interventions were implemented. She verified that Patient #4 was identified as high risk for falls on admit and because the injuries occurred at night, per the Fall Assessment Policy, bed alarms could have been used and were available on the unit. S6RN then reviewed the daily nurses notes and verified that no new interventions were listed under "Fall Risk Assessment" after 2 documented injuries of unknown source.












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