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Based on policy and procedure review, clinical record review, and interviews, it was determined that the facility failed to develop, update, implement, and/or individualize an interdisciplinary integumentary plan of care for 2 (#1- #2) patients at risk for altered skin integrity. Failure to develop an individualized interdisciplinary integumentary plan of care did not assure the skin care policies, protocol, and orders were followed to prevent further skin breakdown. The failed practices did not assure patients were protected from potential injury; the nursing staff could determine when a wound had improved, remained the same or declined; the nursing staff could readily identify which interventions were linked to which problem; and integumentary goals were measurable to determine if the problem continued or was resolved. The failed practice affected Patient #1- #2 and had the likelihood to affect all patients admitted to the facility.
See Tag A0396.

Based on policy and procedure review, clinical record review, and interviews, it was determined that the facility failed to develop, update, implement, and individualize an interdisciplinary integumentary plan of care for 2 of 2 (#1-2) patients. Failure to develop an individualized interdisciplinary integumentary plan of care did not assure the skin policies, protocol, and orders were followed to prevent further skin breakdown. The failed practices did not assure patients were protected from potential injury; the nursing staff could determine when a wound had improved, remained the same or declined; the nursing staff could readily identify which interventions were linked to which problem; and integumentary goals were measurable to determine if the problem continued or was resolved. The failed practice affected Patients #1and #2 and had the likelihood to affect all patients admitted to the facility.

A. Review of policy titled, "Pressure Ulcer Prevention and Care," revised 01/09 showed the following:
1) Begins with a thorough risk assessment using the Braden numerical scale which corresponds with the severity of patients risk to develop a pressure ulcer during hospitalization.
2) "The assessment was to be completed by the AM by an RN or LPN".
3) The numerical risk level was to have interventions aimed at managing and improving the risk factors by reducing moisture, improving nutritional status and reducing friction.
4) After appropriate staging of the ulcer, documentation of location and actual measurement must be obtained and documented on the Wound Flow Sheet.

B. Review of policy titled, "Wound Care management for Home Health Care, Hospital Acute Care, and Hospital Outpatients," dated 01/09 showed the following:
1) To provide patients with the most current therapy and treatments in wound management.
2) Documentation was to include the following
a) Date and time of procedure
b) Materials used and procedure performed
c) Assessment of wound bed, including color, size. odor and surrounding tissue amount, color and odor of any drainage
d) Patient's reaction to procedure
e) Patient teaching performed with level of understanding verified by return demonstration as indicated.

C. Review of policy titled, " Wound Assessment and Reassessment," dated 05/15/14 showed the following:
1) Each patient admitted was to receive a complete head-to¿toe assessment by a qualified individual so that a plan of care can be developed to best meet the needs of the patient. The assessment of the care or treatment required to meet the needs of the patient will be ongoing throughout the patient's hospital stay, with the assessment process individualized to meet the needs of the patient population.
2) Skin assessment is a component of the initial assessment. If it is determined, at the time of admission, that the patient is at high risk for developing a wound or if the patient is admitted with a wound, further assessment will be completed by the Wound Care Team.
3) The wound assessment will be documented in the Nurses' Notes and on the Wound Care Flow Sheet.

D. During an interview on 04/09/25 at 2:10 PM, the Risk Manger confirmed the findings in A-C.

E. Review of Patient # 1's Clinical record on 02/19/25 through 03/07/25, showed the following:
1) Patient #1 was admitted on 02/19/25, with the following diagnosis: Pneumonitis, Acute Respiratory Failure with hypoxia, Sepsis, Right Heel pressure ulcer, Type 2 Diabetes, Chronic Kidney disease, Alsheimer's Disease, dysphagia, Depression and Braden score of 12.
2) There was no evidence Patient #1 had a skin assessment on admission, every shift and on discovery per established policy. For example:
a) LPN (License Practical Nurse) patient assessment on 02/19/25 at 1:19 AM, showed a dressing on Left forearm, Bilateral lower extremities.
b) On 02/20/25, at 8:41 AM, the RN (Registered Nurse) assessment showed a Stage II pressure ulcer between the buttocks .
3) There was no evidence of measurements of the wound with changes or upon discovery per established policy on 02/20/25, at 8:41 AM.
4) There was no evidence Patient #1 was repositioned every two hours. For example:
a) On 02/21/25, the patient was turned at 00:31 AM. There was no evidence the patient was turned until 02/21/25, at 2:49 AM.
b) on 02/21/25 at 10:48 pm RN noted Stage II Pressure ulcer between the buttocks. There was no evidence the patient was turned until 03/06/25, at 4:11AM.
c) On 03/06/25, the patient was turned at 11:17 PM. There was no evidence the patient was turned until 03/06/25, at 6:30 PM.
5)There was no evidence of an individualized care plan for the patient's skin breakdown/wound.
6) During an interview on 04/10/25, at 10:00 AM, the Clinical Informatics Nurse confirmed the findings in E.

F. Review of Patient # 2's Clinical record for 02/23/25 through 03/09/25, showed the following.:
1) Patient #2 was admitted on 02/23/25, with the following diagnosis: Pulmonary Edema and Braden score of 18.
2) There was no evidence Patient #2 was repositioned every two hours. On 02/24/25 at 6:12 PM, showed the patient positions self.
3) There was no evidence of a skin assessment each shift per established policy. For example:
a) On 03/01/25 at 9:18 AM, showed the LPN applied mepilex to a small sacral breakdown.
b) On 03/02/25, at 4:00 PM, showed the LPN applied protectant to sacrum and dressing changed.
c) On 03/03/25, at 4:00 PM, the WONC note showed wound care evaluation with sacral pressure injury with instructions for cleaning and was to apply mepilex dressing three times per week.
4) During an interview on 04/10/25, at 10:30 AM, the Clinical Informatics Nurse confirmed the findings in F.