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Based on medical record review, document review and interview, in three (3) of 14 medical records reviewed, it was determined the facility failed to provide patients or their representatives with information of their rights as patients (Patient #2, 4 and 5).

Findings include:

The policy titled "PAS Core Registration Process & Procedure," which was last revised 5/2020 states, "required patient forms are distributed to patients include Patient Rights and Responsibilities Pamphlet and New York State Your Rights Booklet."

Review of medical record for Patient #2 identified the following: The patient is a 60 year old patient who presented to the Emergency Department (ED) on 5/27/2020 at 11:15 AM with a complaint that she had fallen off a ladder 10 feet high and landed on her right ankle. She could not bear weight on either leg and she reported left knee and right ankle pain. The patient was alert and oriented to person, place, time and situation. She was subsequently admitted to an inpatient unit for observation and discharged home on 5/29/2020.

There was no documented evidence that the patient during her hospitalization was provided the package that contained patient rights information.

Patient #4 is a 90-year-old patient who was admitted from a nursing home to the facility on 5/25/2020 with complaints of chills and fever and she was found to be septic upon admission. The patient was awake but confused and she had a history of dementia. The patient was discharged back to the nursing home on 6/1/2020.

There was no documented evidence in the medical record that the patient or her representative was provided information regarding the patient's rights and responsibilities.

Patient #5 is a 92-year-old patient who was admitted to the facility from a nursing home on 5/24/2020 for respiratory distress and vomiting. The patient had a history of Advanced Dementia and was mostly non-verbal. The patient's care included treatment for Sepsis secondary to an Acute Urinary Tract Infection, high sodium levels and an Acute Kidney Injury. The patient's condition stabilized and he was discharged to the nursing home on 5/29/2020 to start hospice care.

There was no documentation in the medical record that the patient's representative who was his daughter was informed of her father's rights as a patient while he was hospitalized in the facility.

These findings were shared with Staff F, Manager Patient Access on 11/20/2020 at approximately 11:30 AM.

Based on medical record review, document review and interview, in three (3) of 12 medical records reviewed, it was determined the facility failed to prevent the development and deterioration of pressure ulcers in patients (Patients #s 1, 3, and 6).

Findings include:

The policy titled "Skin Care," which was last revised 4/15/2020 states, "All patients will be assessed for skin breakdown and pressure ulcer risk on admission and then daily... The patient's skin will be monitored for integrity and the prevention of pressure injuries areas ..."

Review of medical record for Patient #1 identified the following: This is an 85-year-old patient who presented to the facility on 9/3/2020 from her home with complaints of chest pain and shortness of breath. The patient was alert and oriented and her skin was intact, warm, dry and there was no rash. The Braden Scale assessment (Evidenced-based tool that predicts the risk for developing a hospital acquired pressure ulcer/injury; total score of 12 and below represents high risk; 13-14 a moderate risk; 15-18 a mild risk; and 19-23 is not at risk) of the patient on 9/3/20 at 7:00 PM noted the patient was not at risk evidenced by a score of 19. On 9/8/20 at 8:00 AM, the score was 14 (moderate risk) but on the same day at 8:33 PM, it was 18 (mild risk).

On 9/10/2020, the patient was identified with an open blister and injury at the coccyx. On 9/11/2020 at 1:30 PM, the wound was described as 1cm x 1cm darkish discoloration with a small peri-injury skin breakdown. This entry also noted that a previous assessment by a wound care practitioner indicated there was a suspected deep tissue injury. By 9/15/2020 at 8:40 AM, the patient wound was described as a deep tissue injury, decreased turgor, purple, maroon, intact blood blister at the site. At 2:10 PM on the same day, the wound was described as unstageable, with eschar and slough.

On 9/17/2020 at 5:28 AM, the wound had open blisters, the edges were separated, tender and it was painful and at 1:56 PM on the same day, it was described as a partial thickness Stage II wound. The next day, on 9/17/2020 at 8:43 AM, the Braden Scale assessment was documented as 18 (mild risk).

There was no documented evidence the patient was consistently and accurately assessed for her risk for developing pressure ulcers. After the patient developed a pressure ulcer on 9/10/20, the patient was still being classified as mild to moderate risk. Nursing interventions to prevent further deterioration of the patient's skin condition were not consistently documented.

The patient presented to the hospital with intact skin on 9/3/2020 and she was discharged from the hospital on 9/19/2020 with a Stage II wound to her sacrum.


Review of medical record for Patient #3 revealed this 75-year-old patient was admitted to the facility on 8/29/2020 in respiratory failure with oxygen saturation of 88% while on nasal oxygen and atrial fibrillation (irregular heart rate). The patient had a previous medical history of morbid obesity, advanced Chronic Obstructive Pulmonary Disease for which he was on home oxygen, Hypertension and an ejection fraction of 45%. The patient was intubated while he was in the ED and placed on a ventilator after he coded. He was admitted to an inpatient unit where he received care from an interdisciplinary team. The Braden Scale assessment was 11 (High Risk). Upon admission on 8/29/2020 at 8:00 PM, his skin was assessed as intact and fragile. On 8/31/2020 at 10:00 AM, the Braden Scale assessment was 9 (High Risk).

On 9/16/2020 at 10:00 AM, the patient was noted to have multiple purplish discoloration on the dorsal part of the foot/ankle and a left heel Stage II pressure injury measuring 4 cm x 2 cm with some discoloration.

There was no documented evidence that pressure ulcer preventive measures were consistently implemented. The patient with an intact skin on admission on 8/29/20 developed a Stage II pressure ulcer on the left heel by 9/16/2020.

Review of medical record for Patient #6 revealed a 78-year-old patient who was admitted from his home to the facility on 6/27/2020 with complaints of weakness, malaise, poor appetite and confusion. The patient's previous medical history included Diabetes Mellitus, Hypertension, End Stage Renal Disease on dialysis and an ulcerated lesion on his left fifth metatarsal area. The admitting diagnoses were Acute Cholecystitis, Osteomyelitis and Failure to Thrive. A wound vacuum was at the toe and he underwent hyperbaric treatments three (3) times per week. He had no further skin breakdown.

Upon admission, the patient was assessed as alert and oriented to person, place and time. He had active and full range of motion in his extremities. The patient's assistive device was a wheeled walker with one-person assistance, and he had bathroom privileges with assistance. A right heel ulcer was present on admission.

By 7/4/2020 at 10:30 PM, nursing documentation revealed the patient developed a left heel ulcer. On 7/5/2020 at 8:50 AM, nurse identified a "boggy" and erythematous (redness due to inflammation) area on the coccyx which measured 1.0 cm x 1.5 cm wide. The next day, on 7/5/20, the area was described as non-viable tissue, with eschar, black in color and it measured 4 cm long and 3 cm wide. On 7/9/20 at 10:39 AM, the patient had an excoriation to the coccyx. On 7/15/2020 at 1:05 PM, nursing documentation revealed there was a left buttock 1.5 cm long x 1 cm wide x 0.1 cm deep wound which had separated edges and a right buttock 1cm long x 1cm wide x 0.1 cm deep wound.

There was no consistent documentation of pressure ulcer preventive measures implemented by nursing staff.

These findings were shared with Staff A, the Performance Improvement Specialist on 11/20/2020 at 11:45 AM.

Based on medical record review, document review and interview, in one (1) of four (4) medical records reviewed, it was determined the nursing staff failed to formulate a nursing care plan in a timely manner when a patient developed a pressure ulcer in the hospital (Patient #2).

Findings include:

The policy titled "PCS: Nursing Documentation: Assessments, Reassessments, Plan of Care and General Documentation," which was last revised 2/20/19 states, "the plan of care will include a plan of action, established measurable goals individualized to each patient, target dates, and an initial discharge plan ... Assessments incorporate both immediate and emerging needs and the plan of care is reviewed and/or revised based on changes of the patients, to include, but not limited to: physical and functional status ..."

Review of medical record for Patient #1 revealed the patient was admitted to the facility on 9/3/2020 from her home with diagnoses that included Acute Congestive Heart Failure, Acute on Chronic Renal Failure and Acute Respiratory Failure. Upon admission the patient was alert and oriented and her skin was intact, warm, dry and there was no rash. On 9/10/2020 the medical record showed that the patient had developed an open blister and injury at the coccyx.

By 9/15/2020 at 8:40 AM the patient's wound was described as a deep tissue injury, which had decreased turgor, it was purple, with a maroon intact blood blister and at 2:10 PM, the wound was described as unstageable, with eschar and slough.

The nursing staff did not develop a nursing care plan to address the changes in the patient's skin integrity until 9/16/2020, six (6) days after the nursing staff identified the open blister and tissue injury on the patient's coccyx.

This finding was shared with Staff A, the Performance Improvement Specialist on 11/20/2020 at approximately 11:30 AM.