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Based on medical record review, policy review, guideline review, and staff interview, the facility failed to provide skin assessments upon admission to assess for the presence of a pressure ulcer, failed to notify the physician of a wound, and failed to obtain a timely wound consult. This affected two (Patient #5 and Patient #6) with the potential to affect all patients cared for in this facility. (A0395) . The cumulative effects of these systemic practices resulted in the agency's inability to ensure patient care needs would be met.

Based on medical record review, policy review, guideline review, and staff interview, the facility failed to provide skin assessments upon admission to assess for the presence of a pressure ulcer, failed to notify the physician of a wound, and failed to obtain a timely wound consult. This affected two (Patient #5 and Patient #6) with the potential to affect all patients cared for in this facility.

Findings include:

1. Review of the medical record revealed Patient #5 admitted on 01/14/24 at 4:45 AM by squad after a fall at her home. The emergency department history and physical dated 01/14/24 listed diagnoses as congestive heart failure, end stage renal disease with dialysis three times per week, diabetes mellitus, hypothyroidism, and schizophrenia. The history and physical states the patient had no wounds. Emergency room notes stated X-ray's were completed of Patient # 5's neck, arms and right hip with a fracture noted in the right hip.

Patient # 5 was transferred and admitted to the medical-surgical floor on 01/14/24 at 12:30 PM. A care plan was completed by Staff H stating to monitor the skin for breakdown or redness. No documentation was found a skin assessment was completed for Patient #5 upon arrival to this unit.

Patient #5 had a open reduction internal fixation (ORIF) to the right hip on 01/15/24. Documentation was found of incisional assessment. There continued to be no documentation of a skin assessment until a deep tissue injury (DTI) wound was documented to the right heel and sacral area on 01/24/24, 10 days after admission. Wound measurements were documented by the wound care nurse on 01/25/24 with the sacral area measuring 8.0 centimeters (cm) in length by 6 cm width with no documentation of depth. A mepilex foam dressing was applied.

The physician notes of 01/26/24 document the presence of a DTI to the coccygeal area and heel. It was unknown if the patient had the DTI upon arrival, but it was noticed the prior day. There are no signs of infection and the areas were likely to evolve and open up. Wound care included mepilex, aggressive offloading, turning every two hours, elevate heels off bed with pillows, heel suspension boots, high protein diet, and follow up with wound care after discharge.

Dressing changes of silver alginate and foam dressing were ordered and completed three times per week for Patient #5. Documentation on 01/29/24 at 8:00 AM stated the sacral area had red and black areas with tan drainage noted. The right heel had orders to apply a foam dressing change three times a week and as needed and to keep the heel elevated to prevent friction. Notes on 02/01/24 had measurements for the right heel listed as 2.5 cm length by 2.0 cm width, with no depth and purple in color. The sacral area listed a necrotic area of thick, leathery, eschar measurements of 7 cm length by 8.5 cm width, 0.3 cm depth, with watery bloody drainage noted.

Notes from the vascular surgery nurse practitioner on 02/05/24 state DTIs to sacral area and right heel, unsure if present upon admission. The sacral wound was unstageable with leathery eschar centrally, which is stable. Surrounding tissue has yellow slough and pink granulation with small amount of drainage no redness or odor. Right heel small DTI with skin intact and non-infected.

Infectious disease physician discharge notes on 02/09/24 revealed the presence of unstageable sacral ulcer and DTI to right heel with complaints of intermittent pain to both these areas.

Patient #5 was discharged to a skilled nursing facility on 02/09/24 at 7:30 PM with orders to complete dressing changes three times per week, skin prep to the right heel, and to follow up with vascular surgeon related to the deep tissue injuries.

Review of the facility policy titled "Assessment/Reassessment" lists a registered nurse (RN) assesses the patient's needs for nursing care on admission to any area/department in which nursing care is provided and the nursing assessment will be completed within 24 hours of admission. The RN will report assessment and screening data to other members of the health care team.

Review of a "Skills Admission or Guideline to Assess for Pressure Injuries" reveals to complete a skin assessment upon admission and clearly document any wounds and their characteristics. Start by assessing the patients skin over pressure points, inspect for skin discoloration (redness, purplish or bluish in dark pigmented skin) palpate the discolored area for blanching and notify the practitioner of any abnormal findings.

Interview on on 8/08/24 at 3:00 PM Staff B, Staff C, and Staff D verified the findings of not completing a skin assessment upon admission and per shift. Staff B stated all admissions now should have two registered nurses assess skin and signing. This began sometime in April 2024.


2. Review of the medical record revealed Patient #6 was transferred from an outside hospital on 07/21/24 with a diagnosis of congestive heart failure.

On 07/21/24 at 3:51 PM an admission skin assessment was completed by two RNs with pictures completed. The photos showed redness with a measuring tape next to it to represent the size. The nurse documented in the medical record the redness to the buttocks with peeling skin, redness to bilateral heels, scrotum, abdominal fold and back. No documentation was found the physician was informed of this or the wound care nurse to follow as per the policy.

An order to consult wound care was not placed until nine days later on 07/30/24. The wound care nurse assessed the patient 07/31/24 at 9:27 AM. The sacral area measured 4.3 cm length by 4.3 cm wide with no depth. Wound care orders were received on 07/31/24 to wash the coccyx wound area with normal saline, apply a foam dressing and to change every other day. Orders for the groin area and bilateral buttocks were to wash with mild soap and water, pat dry and apply zinc oxide. On 08/08/24 the sacral area measured 6.5 cm length by 4 cm wide with a depth of 0.1 cm.

The findings of not notifying the provider when the abnormal skin findings were discovered on admission for Patient #6 per the Skill Admission Guidelines was verified with Staff B on 08/08/24 at 3:00 PM.