HospitalInspections.org

Based on the review of medical records, the facility's policies/procedures, and staff interviews, it was determined that nursing services failed to turn and reposition patient every two hours as per protocol and failed to perform wound care as per wound care nursing orders for one patient (P) (P#1) of three patients (P#1, P#2, and P#3) reviewed.


Findings included:


A review of Patient (P) #1 ' s medical record revealed that P#1 was admitted to the facility via the emergency department on 5/25/25 at 12:49 p.m.


Documentation under the nursing flowsheets revealed that P#1 had a wound consultation on 5/25/25 at 6:11 p.m., and documentation revealed that P#1 had a mild moisture-associated skin damage (MASD) proximal to the rectum. Wound care plan included comfort, decrease bacterial load, and offloading., Cleanse with body wash and water twice daily and as necessary (PRN). Apply zinc oxide to the affected areas.


A review of the Nursing skin assessment documentation on 5/25/25 at 8:12 p.m. revealed that P#1 ' s skin was within defined limits (WDL). Documentation revealed that P#1 ' s Braden score (a widely used assessment tool in healthcare to predict the risk of a patient developing pressure ulcers) was 16.


A review of the nursing skin assessment notes on 5/26/25 at 9:58 p.m. revealed that a documentation of "Epidermis (outermost layer of the skin) thin with loss of subcutaneous tissue (deepest layer of the skin), and foam dressing (wound care product used to manage moderate to heavy exudate and maintain a moist wound environment) applied. "

Documentation under the nursing skin assessment notes on 5/29/25 at 1:00 p.m., revealed documentation that P#1 ' s skin was dry and intact.


Documentation under the nursing skin assessment notes on 6/1/25 at 10:00 p.m. revealed that P#1 ' s skin was within defined limits (WDL). However, documentation revealed a scar on the gluteal fold (crease where the upper thighs meet the buttocks).


A continued review of the nursing skin assessment notes on 6/3/25 at 9:00 a.m. revealed documentation that P#1 had moisture-associated skin damage (MASD - refers to skin inflammation or erosion caused by prolonged exposure to moisture), and foam dressing (wound care products used to manage moderate to heavy wound fluid and maintain a moist wound environment) was applied.


An electronic medical record review, which took place in the facility ' s conference room on 6/30/25 at 1:00 p.m., failed to reveal any wound care documentation as per order (Cleanse with body wash and water twice daily and as necessary (PRN). Apply zinc oxide to the affected areas) from 5/25/25 to 6/3/25.


A continued review of P#1 ' s medical record revealed that P#1 was readmitted to the facility on 6/4/25 at 1:14 p.m.


A review of the nursing skin assessment notes on 6/6/25 revealed documentation that P#1 had a pressure ulcer to the sacrum. P#1 ' s Braden score was documented to be 13. Documentation failed to reveal any wound consultation orders.


A review of the skin assessment under the nursing flow sheets on 6/15/25 at 5:16 p.m. revealed that P#1 had a pressure ulcer on the sacrum and coccyx, and wound consultation was ordered.


On 6/16/25 at 1:24 p.m., nursing documentation revealed that P#1 was seen by the wound care nurse and a moist-to-dry dressing was ordered, and the wound was to be cleansed with Dakins solution (antiseptic solution typically used for cleaning and disinfecting wounds) twice a day.


An electronic medical record review under the nursing flowsheets, took place in the facility ' s conference room on 6/30/25 and failed to reveal that P#1 was turned every two hours as per protocol.


A review of the facility ' s policy titled " Maintenance of Skin Integrity Job Aid " , Policy #PS-48-03, published 4/25/24, revealed that the facility ' s staff:
Provided care to patients as listed below to prevent skin breakdown
o Assessed for reddened areas over bony prominences
o Repositioned patient in bed or chair every two hours if unable to reposition self
o Instructed patient on causes and prevention of skin breakdown
o Kept skin clean, dry, and moisturized
o Used proper positioning, transferring, and turning techniques to prevent injury or friction
o Limited use of adhesive products on thin, fragile skin
o Minimized skin exposure to moisture from incontinence, perspiration, or wound drainage
? Documented areas of redness that do not disappear within 30 minutes or any breaks in the skin
? Notified Wound Care when assistance is needed.


A review of the facility ' s policy titled " Nursing Plan of Care for High-Risk Pressure Injury Prevention Job Aid, " Policy #PS-48-02, published 2/12/24, revealed that:
If the patient had impaired mobility, the patient would be repositioned every two hours, more frequently if necessary
o Do not position on the area of impaired skin integrity
If the patient was in a chair, the patient would be repositioned every hour, more frequently if necessary
o Instructed patient to perform weight shifts every 15 minutes if possible
o Limited chair time to one hour if the patient had an ischial or sacral wound
Used proper positioning, transferring, and turning techniques to prevent skin injury by friction or shearing forces
Used foam dressings, pillows, wedges, or blankets to pad skeletal prominences from direct pressure, especially between the knees.
Activated heel suspension on the Total Care Bed®, if applicable
Instructed the patient and family on the causes and prevention of skin breakdown



A review of the facility ' s policy titled " Prevention of Pressure Injuries " , Policy #PS-48, published 4/25/24, revealed that the Registered Nurse (RN) would assess all skin surfaces of the patient (including skeletal prominences) on admission and every shift, assess patient ' s risk for developing pressure injury using Braden or Braden QD Scale depending on the patient population, utilizing appropriate Skin Assessment Form or Pressure Injury Assessment Form in order to implement interventions for low-risk and high-risk patients.


A review of the facility ' s policy titled " Treatment of Pressure Injuries, " Policy #PS-49, published 4/25/24, revealed that Nurse-driven wound treatment protocol would be implemented in the Electronic Medical Record (EMR) as applicable, and consult with the wound, ostomy, continence (WOC) Nurse regarding altered skin integrity or for additional assistance.


A review of the facility ' s policy titled " Wound, Ostomy, Continence Nursing Consultation, Assessment, and Evaluation, " Policy #PS-22, published 4/25/25, revealed that the wound, ostomy, and continence (WOC) RN collaborated with all members of the healthcare team to provide a comprehensive plan of care for patients with selective disorders of gastrointestinal, genitourinary, and integumentary systems.
Recommendations or concerns were discussed with the provider prior to implementation.
A consultation with a WOC RN may be initiated by a physician, patient, or any member of the healthcare team and occur within 72 hours of the request for consult. Hospitals with limited WOC RN coverage could use phone consultation with a WOC RN from other facilities as needed.


An interview took place in the facility ' s conference room on 7/1/25 at 9:40 a.m. with Wound Care Nurse (WCN) AA, who stated that the floor nurses did not have to stage a wound, however, she would expect them to put in wound consultation for any pressure injuries, non-blanchable wounds, or any wounds that were concerning, also take photographs. WCN AA stated that the floor nurses also had a wound care protocol they could follow on the electronic medical record (EMR) system, pending the time the patient was seen by a wound care nurse if required.
WCN AA stated that when she saw P#1 during her (P#1) first encounter on 5/26/25 at 10:20 a.m., P#1 only had Moisture Associated Skin Damage (MASD - a type of skin damage caused by prolonged exposure to moisture, like sweat, urine, or wound drainage), and she (WCN AA) recommended zinc oxide (a white, powdery, inorganic compound with a wide range of uses) twice daily. WCN AA stated that she did not go back to check if the floor nurses followed the wound care orders, as she expected the nurses to be accountable.
WCN AA stated that another wound consultation was put in on 6/15/25 at 5:17 p.m., and she (WCN AA) saw P#1 on 6/16/25 at 12:00 p.m., but at that time, P#1 ' s wound had already progressed to an unstageable pressure ulcer. WCN AA stated that she expected the floor nurses to have reconsulted her (WCN AA) earlier, as P#1 was readmitted on 6/4/25, but she (WCN AA) had no idea why the wound consultation was not put in earlier.


A telephone interview occurred in the facility ' s conference room on 7/1/25 at 10:40 a.m. with Registered Nurse (RN) BB, who stated that she could not recall P#1. However, if a patient came in with a wound or pressure injury/ulcer, a photograph would be taken, and protocols would be followed depending on the level of the wound, as there were different nursing protocols depending on the different levels of the wound.


A telephone interview occurred in the facility ' s conference room on 7/1/25 at 11:00 a.m. with Registered Nurse (RN) CC, who stated that she could not recall P#1. RN CC also stated that Certified Nursing Assistants (CNAs) were mostly responsible for turning patients, and Registered Nurses only supervised or assisted as required.


An interview took place in the facility ' s conference room on 7/1/25 at 11:15 a.m. with Registered Nurse (RN) DD, who stated that due to P#1 ' s incontinence and immobility, she was at high risk of developing a wound/pressure ulcer because sometimes it took a while for the staff to get to P#1 to clean her up due to the frequent bowel movement and incontinence.


An interview occurred in the facility ' s conference room on 7/1/25 at 11:45 a.m. with Unit Manager, 3W (UM) EE, who stated that she was at P#1 ' s bedside with WCN AA when P#1 ' s family expressed concerns about P#1 ' s pressure ulcer, and she (UM EE) emailed UM FF (Unit 1W manager) to get more information because P#1 was admitted unit 1W during her (P#1) first encounter, but she (UM EE) never got a response from UM FF.
UM EE also stated that sometimes during her rounding, she would notice that P#1 had been lying in one position for a long period of time, and she (UM EE) would call the attention of the floor nurses and the Certified Nursing Assistants (CNAs) to ensure they turned P#1, but she (UM EE) never could tell if the turning was done as she (UM EE) never got back to recheck.


An interview occurred in the facility ' s conference room on 7/1/25 at 12:15 p.m. with Unit Manager, 1W (UM) FF, who stated that the facility did not have a standard in the workflow regarding who supervised or ensured patients were turned as per protocol, or if patients were receiving wound care as per order, as that was not part of the rounding.
UM FF stated that if a patient had a Braden score of less than 18, he would communicate with the staff every day during the hurdle to remind them that the patients needed to be turned every two hours, but he (UM FF) did not monitor to ensure the turnings were actually done.
UM FF also stated that he received an email from UM EE, which he responded to, and he did a medical record review on P#1, where he (UM FF) found out that the staff were not 100% compliant with documentation, which was what brought about the HAPI (Hospital Acquired Pressure Injury) learning curve.


An interview occurred in the facility ' s conference room on 7/1/25 at 12:45 p.m. with Certified Nursing Assistant (CNA) GG, who stated that she could not recall P#1. CNA GG stated that the turning of patients was a collaborative effort between the registered nurses and the certified nursing assistants (CNAs). CNA GG further stated that CNAs did not document patients ' turning, that it was the responsibility of the nurses, so whenever she (CNA GG) turned a patient, she would notify the nurse, who would document the turning.


An interview occurred in the facility ' s conference room on 7/1/25 at 1:30 p.m. with Certified Nursing Assistant (CNA) II, who stated that P#1 was immobile on admission, did not move at all, and required the assistance of two staff to be repositioned. CNA II also stated that there was no section on the electronic medical record system (EMR) where CNAs could document that a patient was turned every two hours, that it was the responsibility of the nurse to document.
CNA II stated that she could only recall that P#1 had a discoloration on her back, and did not recall seeing any wound/ulcer on her (P#1) sacrum.


An interview occurred in the facility ' s conference room on 7/1/25 at 2:30 p.m. with Director of Quality and Management (DQ) KK, who stated that tracking HAPIs was one of the quality measures in place. DQ KK stated that wound care education and prevention of HAPIs were included in the staff ' s orientation at hire, but she (DQ KK) was not certain if the staff did an annual training on wound care/prevention of HAPIs.
DQ KK also stated that there was no supervision or monitoring currently in place to ensure that the nursing staff were turning patients as per protocol and performing wound care as per order.