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Based on interview and record review, the facility failed to follow nursing policies and procedures for patient safety for one patient (Patient 1) when:

1. Nursing staff left Patient 1 sitting on a bedpan on an unknown date, for an indeterminate length of time;
2. Nursing staff did not document any details about the incident involving the bedpan or when it happened;
3. Nursing staff did not photograph a new wound found on Patient 1's skin after removing the bedpan;
4. Nursing staff did not complete an Occurrence Report about the incident;
5. Nursing staff did not notify Patient 1's representative about the skin injury in a timely manner.

These failures caused Patient 1 to suffer a deep tissue injury (DTI-a localized area of intact skin that was discolored due to damage of underlying tissue from pressure) and had the potential to lead to complications such as pain, infection, further skin breakdown leading to pressure sores, prolonged hospital stay, as well as emotional distress. This failure put Patient 1 at risk for further injury due to a lack of communication with other members of the healthcare team and administration about the incident.

Findings:

A facility policy titled, "Skin Integrity (health)," revised 11/1/23, was reviewed. The policy indicated that skin risk prevention techniques included repositioning the patient as frequently as the patient could tolerate; clarifying and documenting any limitations per physician or any patient refusal; avoiding direct pressure over bony areas or ulcer (sore) sites; and routinely checking the patient for any pressure ulcers from medical devices (e.g. wires . . tubing . . and bedpans). Nursing was instructed to photograph any new wound upon discovery, and if unable to obtain a photograph, to document the reason in the medical record.

A facility policy titled, "Occurrence Reports," revised 1/1/24, was reviewed. The policy indicated that completion of the Occurrence Report was the foundation of the risk/quality/safety management program and involved all departments within the facility. Occurrence Reports were to have been completed on all occurrences involving patients. The purpose of the Occurrence Report was to promote the improvement of quality and safety of patient care. A reportable occurrence was defined as an occurrence that was not consistent with the routine operation of the hospital or the routine care of a patient or patients. Injury did not have to occur. The potential for accident, injury or illness was sufficient for an occurrence to have been considered a Reportable Occurrence. The occurrence should have been reported to the Performance Improvement Department within 24 hours and included any follow up investigation.

Review of Patient 1's clinical record indicated the patient was admitted to the facility on 2/25/24 and discharged on 3/11/24, a total stay of 15 days. Patient 1's conditions included falling at home, pneumothorax (a collapsed lung), atrial fibrillation (an irregular heart rhythm), arthritis, and dementia (a mental disorder that caused memory loss and confusion). An initial skin assessment documented on 2/26/24 indicated no skin issues, with a Braden Scale (a tool used to predict a patient's pressure sore risk. A score of less than or equal to nine indicated severe risk; a score of 15-18, mild risk) score of 16, which indicated Patient 1 was at mild risk for developing a pressure sore. Patient 1's subsequent Braden Scale scores were documented as 17 on 3/1/24 (day five) and 12 (high risk of developing pressure ulcer) on 3/11/24 (day of discharge).

Record review on 3/20/24 at 9:56 am, showed photos of Patient 1's DTIs. The first photo, dated 3/4/24 at 9:50 am, was taken eight days after admission to the facility. Descriptions written by Licensed Nurse (LN) C, the Wound Care Nurse, indicated, "site location: right sacrum (base of the spine) to hip 25 centimeters (cm), (approximately 10 inches) by three cm, (approximately 1.25 inches). Left sacrum to hip 25 cm by four cm." The marks depicted in the photo were long and rectangular, medium to dark red in color. LN C documented the reason for the photo was "new finding," and classified the wounds as "DTI," with severity as "acute."

Record review of an Order Audit Trail showed a Wound Care Consult, entered on 3/1/24, at 10:39 pm, by RN G. There was no note explaining why the consult had been ordered.

During a concurrent interview and record review, on 3/20/24, at 11:48 am, LN C and RN F, also a Wound Care Nurse, stated that the type of marks in the photos of Patient 1's wounds were usually caused by pressure. LN C stated that the message wasn't always clear about why a wound care consult was placed. LN C stated they had received a report about some skin breakdown but no one said what caused it. LN C stated the nurse should have photographed any wound and sent the photo with the consult order.

During a telephone interview, on 3/22/24, at 4:48 pm, RN G stated they never saw the long wounds on Patient 1's skin as depicted in the photos taken on 3/4/24. RN G stated the request for a wound consult placed on 3/1/24 at 10:39 pm was for slight redness on Patient 1's coccyx (tailbone), not for the larger wounds.

Record review of a nursing assessment, dated 3/11/24 (day of discharge), at 8 am, by LN E, indicated LN E had written, "pressure area to sacrum from bedpan."

During a concurrent interview and record review, on 3/20/24, at 11:48 am, LN C and RN F confirmed that LN E had written about a bedpan causing the pressure area on 3/11/24.

During an interview, on 3/20/24, at 2:44 pm, with RN B, stated they were told by LN C that Patient 1 had been left on a bedpan and had a pressure wound. RN B was not sure what date or shift it was. Later that same week RN B claimed that Patient 1 had been found left on a bedpan a second time (date unknown). RN B put signs up in Patient 1's room that read, "no bedpan" (date unknown). RN B was certain there was a sign posted in the room and addressed the issue verbally with Certified Nursing Assistants (CNAs) on the Unit. RN B stated that there should have been two Occurrence Reports completed for the two incidents, but RN B did not complete any Occurrence Reports.

During a telephone interview, on 3/21/24, at 4:48 pm, CNA H stated they did not know when or how the marks occurred on Patient 1's skin, but they did see a sign on the wall in Patient 1's hospital room that indicated to not use a bedpan (date unknown).

During a telephone interview, on 3/25/24, at 4:42 pm, RN A recalled that apparently on the night shift (date unknown) Patient 1 had been left on a bedpan for an extended period of time. RN A assumed care of Patient 1 in the morning of 3/3/24 and there was a red mark on Patient 1's skin, but not as dark at first. It later developed and became more pronounced. The second morning 3/4/24 that RN A assumed care of Patient 1, RN A checked to make sure the Patient was not on a bedpan. RN A stated they received report from the night shift RN J, and they stopped putting the patient on a bedpan. Then LN C came in on 3/4/24, (in response to the wound care consult placed on 3/1/24), and took pictures of the wounds. No order was written to not use a bedpan; the message was passed on verbally to other staff. RN A did not recall any signs posted in the room. RN A thought the Wound Care Nurse would take over, so RN A did not submit an Occurrence Report for the wound/mark.

During a telephone interview, on 3/26/24 at 4:36 pm, RN J stated they cared for Patient 1 during the weekend of 3/2/24 to 3/3/24. One morning early (date unknown) they went to turn the patient, with help from an unidentified CNA, and found Patient 1 was on a bedpan. RN J stated they removed the bedpan, and Patient 1's skin was red. They couldn't find the CNA who had placed Patient 1 on the bedpan. RN J confirmed the whoever placed the bedpan on Patient 1's bottom should not be left unattended for extended period of time. RN J stated they reported it to the charge nurse, but did not document anything about it. RN J could not recall the name of the charge nurse.

During a concurrent interview and record review, on 3/20/24, from 9:45 am to 3:07 pm, the Director of Performance Improvement (DPI) did not locate any documentation about the specific incident that caused the pressure injury on Patient 1's skin, no Occurrence Report, no investigation into the root cause of the wounds, and no written order to not use a bedpan with Patient 1. DPI confirmed an Occurrence Report should have been completed for the injury to Patient 1's skin.

During a telephone interview, on 3/26/24, at 10:39 am, with RN I, indicated they were the Director of the Unit where Patient 1 had received care. RN I stated they had not completed the investigation into the origin of Patient 1's wounds and did not know all the details. RN I had only been Director of the unit since 3/3/24.

A facility policy titled, "Patient/Family Notification Procedure of Adverse Events," approved 6/1/20, was reviewed. The Hospital Patient Safety Plan stated that patients and, when appropriate, their families should have been promptly informed about the outcomes of care, including unanticipated outcomes. The notification procedure should have been initiated as soon as possible after the appropriate level of care had been provided to the patient. Procedure should have included the staff member with the most knowledge of the unanticipated outcome immediately notifying the appropriate Department Supervisor. The Department Supervisor would have notified . . . the Director of Performance Improvement. If the patient was not competent, the team would have made reasonable efforts to locate an appropriate family member or other authorized representative identified in the medical record. All efforts to contact family members or representatives should have been documented in the medical record. The discussion was to have taken place within 24 hours of the unanticipated outcome. The patient/family should have been assured that the hospital and physician were taking the appropriate steps to reduce the likelihood of recurrence. These steps included an internal review of the unanticipated outcome.

During a telephone interview, on 3/26/24, at 9:54 am, Patient 1's Family Member (FM) A, who was also the patient's Power of Attorney, stated that a female nurse informed them on 3/10/24, while at the bedside, that the patient had a bruise from the bedpan. FM A didn't look at the wound at that time. That was the first time FM A had been notified of any skin irregularity or injury, and it was approximately seven days after the injury was discovered and documented by hospital staff.