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A. Based on document review and interview, it was determined that for 3 of 3 (Pts. #1 - #3) clinical records reviewed for pressure ulcer care, the Hospital failed to ensure that a registered nurse supervised the care of each patient with pressure ulcers by ensuring that patients were turned and repositioned every two hours, as required.

Findings include:

1. On 4/6/2021, the Hospital's policy titled, "Clinical Documentation Guideline" (revised by the Hospital 6/19/2019) was reviewed. The policy required, "...II. Daily Documentation Requirements a. Document routine care, assessment, and interventions based on the SOC [standard of care]...Critical Care SOC - Activity/Reposition - Q2 hours (every 2 hours)"

2. On 4/6/2021, Pt. #1's clinical record was reviewed. Pt. #1 was admitted on 12/29/2020 with a diagnosis of COVID-19.
-The nursing admission skin assessment, dated 12/29/2020, included documentation that Pt. #1 was admitted without any pressure ulcers.

-The nursing skin assessment, dated 1/5/2021 at 2:00 AM, included, "Pressure injury present - yes. Pressure ulcer assessment label - buttock left lower ...superficial, pinkish, shear-like open area- length 2.00 cm - width 2.0 cm ...stage II."

-The nursing skin assessment, dated 1/21/2021 at 6:00 PM, included, "Pressure ulcer assessment label - buttock left lower... yellow slough noted and a large black eschar center ...Length 10.0 cm width 16.000 cm depth 0.20 cm ...exudate amount - light - tissue type - necrotic eschar stage suspected deep tissue injury."

-The General Surgeon/Wound Physician (MD #1) consult note, dated 1/22/2021, included, " ...Physical exam ...Back: Stage III sacral decubitus ulcer present..."

-The clinical record lacked documentation that Pt. #1 was turned and/or repositioned every 2 hours to help prevent the development and/or decline of pressure ulcers. Nursing activity flowsheets included the following:
- Pt. #1 remained in the supine position on 12/30/2020 from 6:00 AM - 10:00 AM (4 hours).
- Pt. #1 remained in the supine position on 1/4/2021 from 12:00 PM - 4:00 PM (4 hours) and again on 1/4/2021 from 6:00 PM - 10:00 PM (4 hours)
- Pt. #1 was not turned and/or repositioned from 6:00 PM on 1/13/2021 to 11:30 PM on 1/13/2021 (9 hours and 27 minutes) and again from 11:30 PM on 1/13/2021 to 8:00 PM on 1/14/2021 (20 hours and 30 minutes).
- Pt. #1 was not turned and/or repositioned from 11:19 PM on 1/21/2021 to 8:46 AM on 1/22/2021 (5 hours and 30 minutes).

3. The clinical record of Pt. #2 was reviewed on 4/6/2021. Pt. #2 was admitted on 3/15/2021 with a diagnosis of urinary tract infection. Pt. #2's admission nursing assessment, dated 3/16/2021 at 1:53 AM, indicated that Pt. #2 was bedfast and mobility was very limited. Pt. #2 had three stage 4 pressure injuries on admission, located on the coccyx (tailbone), and left and right ischia (lower buttocks). From 4/2/2021-4/6/2021, Pt. #2's skin risk assessment scores (risk of developing a pressure ulcer) were between 7 to 10 indicating high risk. Skin care interventions included "Turn every 2 Hours." Nursing notes from 4/2/2021-4/6/2021 were reviewed on 4/6/2021, at approximately 2:00 PM, and indicated the following:
- From 4/2/2021 at 8:59 PM until 4/3/2021 at 7:00 AM (10 hours and 1 minute), Pt. #2 was documented in the left position.
- From 4/3/2021 at 8:10 PM to 4/4/2021 at 2:25 AM (6 hours and 15 minutes), the record lacked documentation that Pt. #2 was turned/repositioned.
- On 4/5/2021, from 4:02 AM to 11:25 AM (7 hours and 23 minutes), Pt. #2 was documented in the back position.
- On 4/5/2021, from 11:25 AM to 6:06 PM (6 hours and 41 minutes), the record lacked documentation that Pt. #2 was turned/repositioned.
- From 4/5/2021 at 6:06 PM to 4/6/2021 at 12:23 AM (6 hours and 17 minutes), Pt. #2 was documented in the back position.
- On 4/6/2021, from 12:23 AM to 8:43 AM (8 hours and 20 minutes), the record lacked documentation that Pt. #2 was turned/repositioned.

4. The clinical record of Pt. #3 was reviewed on 4/7/2021. Pt. #3 was admitted on 3/24/2021 with a diagnosis of dizziness and hypotension (low blood pressure). Pt. #3's admission nursing assessment, dated 3/24/2021 at 3:45 AM, indicated that Pt. #3 was bedfast and mobility was very limited. Pt. #3 had a skin risk assessment score of 14 (moderate risk). Pt. #3 had two stage 2 pressure injuries on admission, located on the coccyx and sacrum. A physician's order, dated 3/24/2021, included, "Turn/Reposition Q2H [every 2 hours]." Nursing notes from 4/2/2021-4/6/2021 were reviewed on 4/7/2021 and indicated the following:
- From 4/2/2021 at 8:08 PM to 4/3/2021 at 11:52 AM (15 hours 44 minutes), the record lacked documentation that Pt. #2 was turned/repositioned.
- On 4/3/2021 from 11:54 AM to 9:50 PM (9 hours and 56 minutes), the record lacked documentation that Pt. #2 was turned/repositioned.
- From 4/4/2021 at 3:05 PM to 4/5/2021 at 8:00 AM (16 hours 55 minutes), Pt. #3 was documented in the back position.
- From 4/5/2021 at 8:28 PM to 4/6/2021 at 8:00 AM (11 hours and 32 minutes), Pt. #3 was documented in the back position.

5. An interview was conducted with the Director of Nursing (E#3) on 4/6/2021, at approximately 2:30 PM. The clinical records of Pt. #2 and #3 were reviewed with E#3, and E#3 stated that there were a lot of gaps in documentation of turning/repositioning which should have occurred every two hours.

6. On 4/7/2021 at 9:42 AM, an interview was conducted with a Wound Care Team Nurse (E#4). E#4 stated that it is the expectation that nursing will document position change every two hours. E#4 stated that if the position cannot be changed, the reason should be documented.


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B. Based on document review and interview, it was determined that for 2 of 3 (Pt #2 and Pt #3) clinical records reviewed for wound assessments, the Hospital failed to ensure that the registered nurse evaluated the patients' wounds by taking measurements, as required by policy.

Findings include:

1. The Hospital's policy titled, "Skin Wound Assessment and Documentation -MEDITECH Hospitals" (revised 8/20/2019), was reviewed on 4/7/2021 and required, "...Wound measurements are obtained upon identification of wound, weekly and PRN [as needed]..."

2. The open clinical record of Pt. #2 was reviewed on 4/6/2021 with the Director of Nursing (E#3). Pt. #2 was admitted on 3/15/2021 with a diagnosis of urinary tract infection. Pt. #2's admission nursing assessment, dated 3/16/2021, indicated that Pt. #2 had three stage 4 pressure injuries on admission:
- Coccyx (tailbone): Length 3 cm [centimeters]; Width 3 cm; Depth 3 cm. Last measured on 3/17/2021 at 7:45 AM (nearly 3 weeks ago).
- Left Ischium (lower buttocks): Length 5 cm; Width 5 cm; Depth 4 cm. Last measured on 3/19/2021 at 9:21 PM (over 2 weeks ago)
- Right Ischium: Length 2 cm; Width 2 cm; Depth 4 cm. Last measured on 3/19/2021 at 9:21 PM (over 2 weeks ago).

3. The clinical record of Pt. #3 was reviewed on 4/7/2021 with the Director of Nursing (E#3). Pt. #3 was admitted on 3/24/2021 with a diagnosis of dizziness and hypotension (low blood pressure). Pt. #3's admission nursing assessment, dated 3/24/2021, indicated that Pt. #3 had two stage 2 pressure injuries on admission:
- Coccyx: Length 1 cm; Width 0.2 cm; Depth 0 cm. Last measured on 3/24/2021 at 3:00 AM (nearly 2 weeks ago)
- Sacrum: No measurements documented in record as of 4/7/2021.

4. An interview was conducted with the Wound Care Team Nurse (E#4) on 4/7/2021, at approximately 9:40 AM. E#4 stated that wound measurements should be taken upon identification and at least weekly thereafter.