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Based on a review of medical records, Braden scale skin assessments, Wound Care documentation, nurse's notes, staff interviews, policies and procedures, personnel files and tour, it was determined that the facility failed to prevent the Patient #2 from developing multiple pressure injuries.

Findings were:

Review of the medical record for Patient #2 revealed that the 38-year-old patient was a direct admission from another facility's Emergency Department (ED) on 01/26/19 at 2:50 a.m. to the 6 South Green Unit (orthopedic, surgical spine and overflow unit for stroke and acute neurology). Patient #2's admitting diagnosis was neck pain.

On 01/26/19 at 4:09 a.m. the attending physician completed Patient #2's medical History and Physical examination. The physician noted that Patient #2 was involved in a bicycle accident, in which the patient did not wear a helmet, four (4) days prior to the ED visit. The physician noted that Patient #2 reported sharp, intermittent neck pain also had a headache and abdominal pain. The physician noted that the pain caused "electric shock" that ran through Patient #2's whole body. The physician noted that Patient #2 had a history of significant intravenous (within the vein) drug use of heroin and methamphetamines (a highly-addictive stimulant). Patient #2's last reported use of heroin was the day before admission. An MRI (magnetic resonance imaging) of the cervical spine was completed on 01/25/19, which revealed an acute herniated (abnormal protrusion) disc at C6-C7 (spinal neck bones) and some cord deformation (deformity to spine). During the medical work-up, a Computed Tomography (CT of Abdomen and Pelvis- a form of x-ray to examine internal organs) revealed that Patient #2 had pneumonia and a kidney injury. A urine toxicity test revealed that Patient #2 was positive for amphetamines and opiates.

On 01/26/2019 at 4:40 a.m. an in-patient neurosurgery consult was completed on Patient #2. Consult notes indicated that upon transfer of Patient #2 to the bed, Patient #2 reported severe pain and then was unable to move his arms and legs shortly afterward. The primary team notified neurosurgery at that time. Neurosurgery notes revealed that Patient #2 complained of neck pain, numbness in the body and burning in arms. An emergent surgical procedure, Anterior Cervical Discectomy and Fusion (ACDF C6-7- a surgical procedure to treat nerve root or spinal cord compression) occurred on 01/26/19 at 4:59 a.m. Consent for the procedure was verbally obtained from Patient #2 as he was unable to sign.

Admission orders included a Physical Therapy (PT) and Occupational Therapy (OT) consult, Vancomycin, and Zosyn (antibiotics), intravenous fluids, indwelling catheter, and neurology checks.

On 01/26/19 at 4:00 a.m. the initial nursing assessment noted that Patient #2's bilateral hand grips were absent, bilateral upper extremities (arms) were weak, decreased sensation on the right lower leg, and unable to assess left lower leg. Nursing documentation revealed Patient #2's Braden Scale (a tool to help health professionals assess a patient's risk of developing a pressure ulcer on a scale of 1-23 with a higher score indicating a lower risk of developing a pressure ulcer) of 17. No wounds were documented other than the cervical neck surgical incision after surgery.

Review of the Braden Scale skin assessments indicated that the assessments are completed once every 12 hours (each shift) from the time of admission until discharge. Documentation of the skin assessments from 01/26/19 through 03/30/19 revealed that Patient #2 had a score of 17 or less the entire admission with various scoring depending on the nurse.

Review of Wound Care notes from the Wound Care and Ostomy Nurse (WOCN), nurse's notes and P.T. note revealed the following:
--On 02/13/19 at 12:50 p.m.- initial visit for "device-related Pressure Injury (PI), found on skin assessment for prevalence study (facility-wide study in which every patient is assessed for skin breakdown quarterly). The WOCN (LL) documented that Patient #2 was resting in bed in semi-fowlers (on the back at a 30-45 degree angle) position, alert and oriented x 3. The note indicated the patient was paraplegic and had a foley catheter for urinary elimination. The note further explained that the patient had a light indentation and blister on the back of the right leg. The WOCN ordered foam and a Vaseline gauze for treatment of the injury.

--On 02/15/19 at 12:28 p.m. the P.T. note revealed he/she was asked by the acute care therapy manager and charge RN to evaluate Patient #2 for appropriate heel offloading devices. The notes revealed Patient #2 was assessed and the result was that Patient #2 would benefit from multi-podus boots for heel pressure relief and positioning. The notes revealed bilateral multi-podus boots were ordered.

-- On 03/02/19 at 10:00 a.m. nurse's notes revealed that Patient #2 had a mid bilateral site assessment described as red and the skin peeling off.

--On 03/03/19 at 8:00 a.m. nurse's notes site assessment described as excoriation to the buttocks.

--On 03/03/19 at 7:25 p.m. nurse's notes site assessment described as a pressure injury-red.

--On 03/05/19 at 7:06 p.m. nurse's notes site assessment described a pressure injury red.

--On 03/11/19 at 10:16 a.m. An order was placed for a Wound Care Consult. WOCN consult initial visit for "Bilateral heel, possible pressure wound." The WOCN LL notes revealed wound #1 was a Suspected Deep Tissue Injury (sDTI) and friction/shear with a small amount of drainage on bilateral buttocks. The notes revealed the treatment goals were to provide comfort to the patient, offload (relieve) and protect (using a barrier cream aloe vesta #3) the area. The WOCN LL's notes revealed the left heel with blanchable (becoming white or pale) erythema noted (plan of care-offload with primo boot). The right heel was noted with an unstageable PI with sDTI (plan of care- betadine to heel and offload with primo boot).

-- On 03/19/19 at 12:08 p.m. The WOCN LL's note revealed the patient was seen resting in bed on back with feet elevated in primo boots, but heels not seated well, and was re-adjusted. The WOCN noted Patient #2 had three (3) pull-ups on and were saturated, two (2) Covidian pads (disposable underpad for heavy incontinence), two (2) cloth pads and one (1) drawsheet. The WOCN notes revealed that he/she ordered a purple turning sheet to be used to decrease friction and shear and assist with turning. The WOCN noted the purple sheet was in a bin in the corner of the room. The WOCN revealed he/she placed the purple turning sheet under the patient and educated Patient #2 and the nurse on the policy about having no pull-ups on the patient when in bed.

-- On 03/20/19 at 10:08 a.m. nutrition supplements Juven and Ensure were ordered.

--On 03/26/19 at 3:34 p.m. the WOCN LL's noted revealed the visit was to follow-up on the previous wounds assessed. The notes revealed that reportedly Patient #2 had been refusing off-loading (patient was educated per notes).

Review of Activities of Daily Living documentation completed by Care Partners (CPs- nurse assistants) revealed that from 01/26/19 (admission) through 03/30/19, Patient #2 was documented in various positions. Some charting included the patient as a "turns self patient" and other documentation noted CPs turning Patient #2 to semi-fowlers for consecutive hours at a time, or turning to the right or left side-lying with support. Documentation revealed no consistency with positioning, and/or interventions for high skin risk patients.

An interview was conducted with the Wound Care Manager (WOCN GG) on 05/20/19 at 2:15 p.m. in the conference room. WOCN GG stated the nurses do not stage pressure ulcers, the nurse will only indicate if the patient has a partial-thickness or full-thickness injury. WOCN GG stated the nurses receive education on wounds in orientation. WOCN GG stated that mandatory computer-based education is not required annually, however, the WOCN will provide "spot" education as needed for any clinicians. WOCN GG stated in-services are provided often by representatives for equipment and supplies. WOCN GG stated the facility has a Skin Wound Assessment Team (SWAT), in which a nurse and CP from each unit meets monthly with all of the wound care members, to review any issues, data, education and will take the information back to the department. WOCN GG stated these SWAT members are the champions/super users of wound care for their unit. WOCN GG stated Prevalence Studies are conducted quarterly, in which the Wound Care Team assess the skin of every patient, and report any found injuries in the incidence reporting system.

An interview was conducted with RN (AA) on 05/21/19 at 8:05 a.m. in the conference room. RN AA stated she had worked for the facility for four (4) years and vaguely remembered Patient #2. RN AA stated she took care of Patient #2 for about three (3) days at the beginning of his admission. RN AA stated she did not remember Patient #2 having any wounds, but did have a foley and was turned every two (2) hours. RN AA explained that she remembered the patient could not move his hands or legs. RN AA stated Patient #2 primarily wanted to stay in the cardiac chair every day. RN AA stated Patient #2 had a wedge and pillows and primo boots in the room. RN AA stated Patient #2 would get feisty, curse out staff, and call names because of his dependent situation. RN AA stated the skin assessments should be completed on admission and every shift after and that if an injury was found the WOCN should be consulted. RN AA revealed the nurses do not stage wounds, the WOCN's stage, and order treatment. RN AA stated the Braden Scale measures for high skin risk patients was implemented when there was a score of 16. RN AA stated the particular interventions include turning a patient every two (2) hours, utilizing pillows/wedge, and boots. RN AA explained that when a patient is repositioned, the decision of who would chart the intervention is decided at the time, between the two (2) individuals completing the task.

A telephone interview was conducted with CP (CC) on 05/21/19 at 9:00 a.m. in the conference room. CP CC stated she had worked for the facility off and on since 2003 on the 7 a.m. to 7 p.m. shift. CP CC stated she remembered Patient #2 and that he was rude and curse out the health care team from time to time. CP CC stated she did not remember Patient #2 having any wounds. CP CC stated she remembered Patient #2 would sometimes refuse repositioning or baths, however, CP CC stated she did not chart patient refusals. CP CC stated she remembered Patient #2 with primo boots in the room but the majority of the time they were not on the patient. CP CC stated sometimes Patient #2 would sit in the cardiac chair from 1:00 p.m. until shift change at 7:00 p.m. and the patient would be repositioned every two (2) hours in the chair.

A telephone interview was conducted with RN (DD) on 05/21/19 at 9:35 a.m. in the conference room. RN DD stated she had worked for the facility for two (2) years on the 7 a.m. to 7 p.m. shift. RN DD stated she vaguely remembered Patient #2 and never remembered witnessing any wounds. RN DD stated skin assessments are completed every shift (12 hours). RN DD stated if the patient is immobile, interventions would include minimizing moisture on the skin and reposition every two (2) hours. RN DD stated if she saw any wounds she would consult wound care. RN DD stated that when a patient is repositioned the two (2) individuals would decide who charts the intervention.

Review of facility policies included but was not limited to the following:

1. Prevention of Pressure Injuries, policy number PS-48, last revision 3/2015, revealed the purpose of the policy is to define a process for promotion and maintenance of skin integrity. The policy states there are three (3) Procedure Steps to follow:
--Step One Assessment: (1.1) Assess all skin surfaces on admission and every shift. (1.2) Assess patient risk for developing pressure injury using the Braden Scale.
--Step Two Interventions: (2.1) Implement interventions for patients with Braden score greater than or equal to 18. (2.2) Implement interventions for patients with Braden score less than or equal to 17 or other clinical indicators of high risk for impaired skin integrity. (2.3) Consult a dietitian for patients with clinical indicators of high risk for impaired skin integrity.
--Step Three Documentation: (3.1) Document findings and Braden score.

--The policy continues with the Nursing Plan of Care for High-Risk Pressure Injury Prevention for patients with Braden Score of 17 or less. The Nursing Plan states
(1) If a patient has impaired mobility, reposition every two hours, more frequently if necessary.
(1a) Position patient in a 30-degree lateral position; (1b) Do not position on area of impaired skin integrity.
(2) If a patient in the chair, reposition every hour, more frequently if necessary. (2a) Instruct patient to perform weight shifts every 15 minutes if possible; (2b) Limit chair time to one hour if the patient has ischial or sacral wound; (2c) May use wheelchair pressure-relieving cushion.
(3) Use proper positioning, transferring, and turning techniques to prevent skin injury by friction or shearing forces.
(4) Maintain head of the bed at the lowest degree of elevation consistent with a medical condition.
(5) Use knee gatch with the head of the bed elevation to prevent friction and shearing.
(6) Use foam dressing, pillows, wedges, or blankets to pad skeletal prominences from direct pressure, especially between knees.
(7) Float heels off the bed with pillows placed vertically under leg; may use pressure reduction boots.
(8) Activate heel suspension on Total Care Bed, if applicable.
(9) Instruct patient and family on causes and prevention of skin breakdown. (10) Notify Dietitian for clinical indicators of high risk.

--The policy continues with Wound Care Treatment Guidelines, implement a plan of care based on assessment. The Wound Care Treatment Guidelines state
(A) Place Pressure Ulcer Assessment documentation in progress notes.
(B) Notify MD if the patient has a pressure ulcer.
(C) Notify MD if local signs and symptoms of infection (i.e. peri-wound erythema, odor, warmth, induration).
(D) Consult WOC Nursing for full-thickness wounds, ankle/heel ulcers or when assistance is needed.
(E) Use Standard Precautions for any open wounds.
(F) Position patient off area of skin impairment.
(G) Establish turning schedule every two hours, more frequently if necessary; if heel ulcer, float heels off the bed with pillows, offloading boot or activate heel suspension on ed, if available, and position patient off area of skin impairment.
(H) Skin Tears. (H.1) Assess area and document with each dressing change. (H.2) Realign skin if skin flap present.
(H.3) Cleanse the area with dermal wound cleanser then apply protective wipe to peri-wound.
(H.4) Apply non-adherent gauze (no Telfa) and wrap with stretch gauze; change daily.
(I) Blancheable Erythema.
(I.1) Assess area and document findings each shift.
(I.2) Establish turning schedule every two hours, more frequently if necessary; if heel ulcer, float heels off the bed with pillows or offloading boot.
(I.3) Use skin moisturizer or barrier ointment daily if area is dry when appropriate.
(J) Non-blanchable Erythema.
(J.1) Assess area and document findings each shift.
(J.2) Use skin moisturizer or barrier ointment daily if area is dry when appropriate.
(J.3) Consult WOC Nurse with Deep Tissue Pressure Injury (DTPI) or purple non-blanchable erythema.
(K) Partial Thickness Ulcer.
(K.1) Assess area and document findings at each dressing change.

2. Wound, Ostomy, Continence Nursing Consultation, Assessment and Evaluation, policy number PS-22, last revision date 07/2014 revealed the purpose of the policy was to define a process for initiation of wound care assessment and treatment by a wound, ostomy, continence nurse (WOC RN). The policy revealed that a consultation with a WOCN may be initiated by a physician, patient or any member of the healthcare team and occurs within 72 hours of request for consult. The policy further revealed that a WOCN consult can be placed for draining wounds and fistulas, skin breakdown and or pressure injury and percutaneous tubes.

3. Patient Rights and Responsibilities, no policy number, last revision date 05/2013, revealed that the purpose of the policy was to define a process to delineate the rights and responsibilities that a patient has within the facility health system. The policy further revealed the patient has the right to be free from neglect, exploitation, and verbal, mental, physical and sexual abuse while under the facility care.

Review of six (6) personnel files on 05/21/19 at 11:30 a.m. in a conference room with HR Manager, revealed documented evidence of specific job descriptions, state licensure as required by their job descriptions, orientation to the facility, and annual competency testing/evaluations.

A tour of the 6 South Green unit was conducted on 05/20/19 at 11:00 a.m. with the Vice President of Quality (VP of Quality KK) and Nurse Manager (RN Manager JJ). The RN Manager stated the unit was an orthopedic, spine surgical, stroke, and overflow for acute neurology and occasional medical-surgical. The unit had a census of 23 patients. The unit had a charge nurse (who was also covering for the unit secretary who called out) and five (5) additional nurses. The RN manager stated at thighs time they only had two (2) CPs and that later in the day they should receive another CP. The unit was quiet and calm, no call lights were ringing, the nurses and CPs were providing patient care. The noted revealed the treatment goals were to offload and protect.

During the Exit conference with the healthcare team on 05/21/19 at 4:00 p.m. in the conference room, the team acknowledged and confirmed the above findings.

Based on review of the patient medical record, a tour of the 6 South Green unit, review of the department description, staffing grids, and staff interview it was determined the facility failed to ensure adequate staffing for the 6 South Green Unit.

Findings were:

Review of the medical record for Patient #2 revealed that the 38-year-old patient was a direct admission from another facility's Emergency Department (ED) on 01/26/19 at 2:50 a.m. to the 6 South Green Unit (orthopedic, surgical spine and overflow unit for stroke and acute neurology). Patient #2's admitting diagnosis was neck pain.

On 01/26/19 at 4:09 a.m. the attending physician completed Patient #2's medical History and Physical examination. The physician noted that Patient #2 was involved in a bicycle accident, in which the patient did not wear a helmet, four (4) days prior to the ED visit. The physician noted that Patient #2 reported sharp, intermittent pain to neck, bilateral shoulders and additionally had a headache and abdominal pain. The physician note that the pain causes "electric shock" that ran through his whole body. The physician's only noted history of Patient #2 at that time was a history of significant intravenous (within in the vein) drug use of heroine and methamphetamines( highly addictive stimulant). Patient #2's last reported use of heroine was the day before admission. An MRI of the Cervical Spine was completed on 01/25/19 (at another facility), which revealed an acute herniated disc at C6-7 with prevent fluid (cerebrospinal fluid) and some cord deformation (deformity to spine). During the medical work-up, a Computed Tomography (CT of Abdomen and Pelvis- a form of x-ray to examine internal organs) revealed Patient #2 had pneumonia and kidney injury. A urine toxicity test revealed Patient #2 was positive for amphetamines and opiates.

On 01/26/2019 at 4:40 a.m. an inpatient neurosurgery consult was completed on Patient #2. Consult notes indicated that upon transfer of Patient #2 to the bed, Patient #2 reported severe pain and then was unable to move his arms and legs shortly afterwards. The primary team notified neurosurgery at that time. Neurosurgery notes revealed that Patient #2 complained of neck pain, numbness down body and burning in arms. An emergent surgical procedure, Anterior Cervical Discectomy and Fusion (ACDF C6-7- a surgical procedure to treat nerve root or spinal cord compression) occurred on 01/26/19 at 4:59 a.m. Consent for the procedure was verbally obtained from Patient #2 as he was unable to sign. Patient #2 was considered to have quadraparesis (condition characterized by weakness in all four limbs, the weakness may be temporary or permanent after surgery.

A tour of the 6 South Green unit was conducted on 05/20/19 at 11:00 a.m. with the Vice President of Quality (VP of Quality KK) and Nurse Manager (RN Manager JJ). The RN Manager stated the unit was an orthopedic, spine surgical, stroke, and overflow for acute neurology and occasional medical-surgical. The unit had a census of 23 patients. The unit had a charge nurse (who was also covering for the unit secretary who called out) and five (5) additional nurses. The RN manager stated at this time they only had two (2) CPs and that later in the day they should receive another CP. The unit was quiet and calm, no call lights were ringing, the nurses and CPs were providing patient care.

Review of the Department Description, Organization, Staffing and Reporting document revealed that 6 South Green was an Orthopedic/Neurology 24 bed Telemetry unit. The document further describes that the unit serves Orthopedic, Neurology, Neurosurgery and overflow of Medical-Surgical patients. The document revealed that the nurse patient ration on 7 a.m. shift is 1:5/6 and on 7 p.m. to 7 a.m. are usually 1:5/6. There are usually three (3) Care Partners (CP- nurse assistants) on 7 a.m. to 7 p.m. and two (2) CPs on 7 p.m. to 7 a.m. shift for this unit. The document further revealed a staffing grid as follows:
A. Schedule Shifts: 12 hours

B. Daily Staffing Plan (based on 24 beds): Average Daily Census 21.2
--7 a.m. to 7 p.m.
-Nurse Manager-1
-Assistant Nurse Manager-1 shift
-Clinical Nurse Leader-1
-RN-6
-CP-3
-Unit Secretary- 6:45 a.m to 5:15 p.m.
-Nurse Educator- 1 every other week

7 p.m. to 7 p.m.
-RN-5
-CP-3

Review of five (5) weeks of the nurse staffing matrix based on the staffing (B- above) revealed the following:
--Week 01/26/19 through 02/02/19- six (6) out of seven (7) day shifts 7 a.m. to 7 p.m. the unit was understaffed by one (1) Registered Nurse (RN). Two (2) out of seven (7) night shifts 7 p.m. to 7 a.m. the unit was understaffed by one Care Partner (CP- nurse assistant).

--Week 02/17/19 through 02/23/19- four (4) out of seven (7) day shifts 7 a.m. to 7 p.m. the unit was understaffed by one (1) RN and one (1) of these days understaffed by an RN and CP. Two (2) out of seven (7) night shifts 7 p.m. to 7 a.m. the unit was understaffed by one CP.

-- Week 02/10/19 through 02/16/19- four (4) out of seven (7) day shifts 7 a.m. to 7 p.m. the unit was understaffed by one (1) RN and one (1) of these days understaffed by an RN and CP. One (1) out of seven (7) night shifts 7 p.m. to 7 a.m. the unit was understaffed by one CP.

--Week 03/03/19 through 03/09/19- Two (2) out of seven (7) day shifts 7 a.m. to 7 p.m. the unit was understaffed by one (1) RN.

--Week 03/24/19 through 03/31/19- Two (2) out of seven (7) day shifts 7 a.m. to 7 p.m. the unit was understaffed by one (1) RN. One (1) out of seven (7) night shifts 7 p.m. to 7 a.m. the unit was understaffed by one CP.

A telephone interview with the RN Manager JJ was conducted on 05/21/19 at 2:30 p.m. in the conference room. RN Manager JJ stated that the staffing grids that were provided were reflective of the staffing pattern on the 6 South Green unit from January to the time of the survey. RN Manager JJ stated that on occasion the unit is understaffed. RN Manager JJ stated sometimes it will be the charge nurse and three (3) or four (4) nurses which may make the assignment tight because of staff sick call outs.