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Based on document review and interview, the registered nurse failed to ensure hospital policies and procedures were followed related to turning/repositioning the patient q2h (every 2 hours) in two (2) instances (Patient 1 and Patient 6), failed to document the patient heels were elevated in one (1) instance (Patient # 6), failed to ensure a waffle mattress was ordered and/or implemented in a timely manner in four (4) instances (Patient # 2, Patient # 4, Patient # 5, and Patient # 6), failed to complete "Wednesday" weekly skin assessments in six (6) instances (Patient # 1, Patient # 2, Patient # 3, Patient # 4, Patient # 5, Patient # 6), failed to order a "wound care consult" in one (1) instance (Patient # 3), failed to document and/or notify a family member related to a change in condition in three (3) instances (Patient # 2, Patient # 4, and Patient # 6), failed to document and/or notify the physician of a new and/or existing pressure injury/wound in three (3) instances (Patient # 1, Patient 2, and Patient # 4), failed to complete a daily "Braden Scale Assessment" for a patient in three (3) instances (Patient # 1, Patient # 5, and Patient # 6), failed to provide care in a safe setting preventing an adverse event which resulted in harm to a patient in three (3) instances. (Patient # 2, Patient # 4 and Patient # 6), failed to complete an electronic risk control report related to a patient safety incident in two (2) instances. (Patient # 4 and Patient # 6) (see tag 395), failed to ensure the nursing staff followed the policies and procedures related to developing and updating the patients plan of care for five (5) of ten (10) patient closed medical records (MR's) reviewed. (Patient # 1, Patient # 2, Patient # 4, Patient # 6, and Patient # 7) (see tag 396), and failed to ensure the "Registered Nurse Skin Champion" received the necessary specialized training competency, in accordance with patient needs, related to wound/pressure injury "staging" in eight (8) instances (NS # 2, NS # 3, NS # 4, NS # 5, NS # 6, NS # 7, NS # 8, and NS # 9), and failed to ensure annual wound/pressure injury training was completed for the facilities registered nursing staff. (see tag 397)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that Nursing Services provided quality health care in a safe environment.

Based on document review and interview, the registered nurse failed to ensure hospital policies and procedures were followed related to turning/repositioning the patient q2h (every 2 hours) in two (2) instances (Patient 1 and Patient 6), failed to document the patient heels were elevated in one (1) instance (Patient # 6), failed to ensure a waffle mattress was ordered and/or implemented in a timely manner in four (4) instances (Patient # 2, Patient # 4, Patient # 5, and Patient # 6), failed to complete "Wednesday" weekly skin assessments in six (6) instances (Patient # 1, Patient # 2, Patient # 3, Patient # 4, Patient # 5, Patient # 6), failed to order a "wound care consult" in one (1) instance (Patient # 3), failed to document and/or notify a family member related to a change in condition in three (3) instances (Patient # 2, Patient # 4, and Patient # 6), failed to document and/or notify the physician of a new and/or existing pressure injury/wound in three (3) instances (Patient # 1, Patient 2, and Patient # 4), failed to complete a daily "Braden Scale Assessment" for a patient in three (3) instances (Patient # 1, Patient # 5, and Patient # 6), failed to provide care in a safe setting preventing an adverse event which resulted in harm to a patient in three (3) instances. (Patient # 2, Patient # 4 and Patient # 6), and failed to complete an electronic risk control report related to a patient safety incident in two (2) instances. (Patient # 4 and Patient # 6)

Findings include:

1. Review of the hospital policy titled, "Nursing Practice", policy number NSI-STND_01, original date 07/2004, indicated the "Registered Nurse" at H # 1 "executes all assigned responsibilities" and "is accountable for his or her own nursing practice". This policy was last reviewed in 02/2018.

2. Review of the hospital policy titled, "Risk Control Reporting of Patient/Visitor Incidents", policy number RM_21, original date 09/01/2011, indicated the definition of an "ADVERSE EVENT" to be "harm to a patient caused by the management of the patient's care rather than harm that occurred due to the underlying condition". The "Nursing Staff" are responsible to ... "12. Notify the appropriate physician if the event involved patient harm. 13. Notify the family if the event involved patient harm". The procedure indicated "all employees" are responsible for completing an incident report. This policy was last revised in 09/2017.

3. Review of the hospital policy titled, "Skin and Tissue Inspection, Assessment and Management Procedure", policy number NSI-ACT_60, original date 08/2016, indicated the purpose of the policy was to provide guidance for "prevention of loss of skin integrity, pressure injuries and/or wounds" and to provide guidance and protocols to help "prevent deterioration of existing pressure injuries and/or wounds". Patients identified to be "at risk or have wounds" and/or pressure injuries; "complete a risk control report"... when patients "are admitted with pressure injuries/wounds" and/or patients who "develop pressure injuries/wounds during their length of stay". Implement Pressure Ulcer "Prevention Measures, including ordering of and implementation of appropriate pressure ulcer relief/reduction devices/products". Assess each patient's ongoing "risk for further pressure injury formation by using the Braden Scale" assessment (Predicting Pressure Score Risk Tool) upon admission, everyday thereafter, and "with any change in condition". If a patient's "Braden score is 14 or below" (moderate risk-score 13-14, high risk-score 10-12, severe risk-score 9 and below), the "wound ostomy nursing consult is to be ordered". The patient should be turned and repositioned at "least every two hours", and for bed-ridden patients "use off-loading boots or pillows to relieve pressure on the heels". Comprehensive wound assessments will then be done at least weekly, "on Wednesdays", with dressing changes, or whenever a change occurs in the wound. This policy was last revised on 07/2016.

4. Review of the hospital policy titled, "Patient Admission, Assessment, Reassessment and Documentation Guidelines, and Vital Signs Procedures", policy number NSI-ACT_30, original date 07/1996, indicated "a registered nurse shall perform or validate a health history ... and physical assessment on all patients" admitted to H # 1 (Acute Care Hospital). This policy was last reviewed in 02/2018.

5. Review of the hospital policy titled, "Patient Rights", policy number CORP_02, original date 04/05/1993, indicated "Patients have the right to: Receive care in a safe setting". This policy was last reviewed on 10/10/2018.

6. Review of the closed MR (medical record) for patient # 1 indicated the patient was a 85 y/o (year/old) admitted from the ED (Emergency Department) to H # 1's inpatient on 11/30/2018 at 10:05 pm with diagnoses which included, but were not limited to, pneumonia, atrial fibrillation, and dementia.
The MR summary for patient # 1's admission on 11/30/2018 indicated the following:
A. The nurses note dated 11/30/2018 at 6:34 am by NS # 10 (RN) indicated the patient (pt) was received from the ED, indicated "pt has ulcer to sacral area that is pink in color, pt has wound noted to right lateral foot area with dressing in place, pt's left heel has old healed wound in place".
B. The patients admission "Braden Scale Assessment" dated 11/30/2018 at 10:48 pm indicated a severe risk score of "9" (nine).
C. The physician order dated 12/04/2018 at 1:31 am, indicated for the "Wound Care Nurse" to treat and evaluate.
D. The physician order dated 12/04/2018 at 8:06 am, indicated to "turn patient every 2 hours, elevate heels off of bed" and "staff to obtain a waffle mattress" for the patient's bed.
E. The MR lacked documentation that the "dependent (level of assistance-does less than 25%)" patient was turned/repositioned on the following date/times: 12/01/2018 at midnight, 2:00 am, and 4:00 am.
F. The MR lacked documentation that the "Braden Scale Assessment" was completed on the following dates 12/13/2018 and 12/20/2018.
G. The MR lacked documentation that the "Wednesday" weekly skin assessment was completed on 12/02/2018.
H. The "Skin Champion Note" dated 12/09/2018 by NS # 8 (Skin Champion), indicated the patient "has foam to sacrum, left gluteal and left hip ... has kerlix wraps to ankles and feet bilaterally ... has excoriated and weeping scrotum". The "Skin Assessment" lacked measurements and staging documentation.
I. The MR lacked documentation that the physician and family were notified of skin status change.

7. Review of the closed MR for patient # 2 indicated the patient was a 77 y/o admitted to H # 1's inpatient on 11/15/2018 with diagnoses which included, but were not limited to, pulmonary fibrosis and acute on chronic congestive heart failure.
The MR summary for patient # 2's admission on 11/15/2018 indicated the following:
A. The "Skin Assessment" note dated 11/15/2018 at 8:34 pm by NS # 11 (RN), indicated the admission skin assessment was "no open areas noted however dried peeling epidermal area to buttock folds".
B. The "Skin Champion Note" dated 11/21/2018 at 8:07 am by NS # 7 (Skin Champion), indicated "intact skin noted to coccyx" with "prevention measures in place".
C. The physician order dated 11/22/2018 implemented by NS # 1, indicated for "staff to obtain a waffle mattress" and a "waffle chair cushion" for the patient.
D. The patient's "Braden Scale Assessment" upon admission was seventeen (17) and on 12/02/2018 changed to a high risk score of eleven (11).
E. The MR lacked documentation that the waffle mattress and/or waffle chair cushion were obtained and implemented for the patient.
F. The MR lacked documentation that the "Wednesday" weekly skin assessment was completed on 11/28/2018.
G. The nurses note dated 12/01/2018 at 3:55 pm by NS # 12 (RN), indicated the patient had "DTI's" (deep tissue injuries) and "skin tears to buttocks bilaterally with redness to site".
H. The MR lacked documentation that the physician and family were notified of the skin status change.

8. Review of the closed MR for patient # 3 indicated the patient was a 81 y/o admitted to H # 1 on 12/14/2018 with diagnoses which included, but were not limited to, altered mental status, hyperkalemia, hypoxia, pulmonary fibrosis and acute on chronic congestive heart failure.
The MR summary for patient # 3's admission on 12/14/2018 indicated the following:
A. The "Skin Assessment" note dated 12/15/2018 at 7:24 am by NS # 16 (RN), indicated the "patient with coated tongue, crusty nose, open wound to gluteal fold, wound to anterior shaft of penis, excoriated scrotum, redness to base of neck, redness to center back, ... skin on both feet flaky".
B. The patients admission "Braden Scale Assessment" dated 12/15/2018 at 8:39 am indicated a high risk score of "12" (twelve).
C. The MR lacked documentation that the "Wednesday" weekly skin assessment was completed on 01/02 /2018.
D. The MR lacked documentation that an order for "wound/ostomy to evaluate and treat".

9. Review of the closed MR for patient # 4 indicated the patient was a 74 y/o admitted to H # 1 on 12/19/2018 with diagnoses which included, but were not limited to, hypotension (low blood pressure) and failure to thrive.
The MR summary for patient # 4's admission on 12/19/2018 indicated the following:
A. The nurses note dated 12/20/2018 at 9:42 pm, by NS # 13 (RN), indicated the "skin assessment-skin tear to coccyx with foam bandage".
B. The patient's "Braden Scale Assessment" upon admission was fifteen (15) and on 12/24/2018 the score changed to high risk score of eleven (11)
C. The MR indicated the "wound nurse consult" was ordered on 12/21/2018 and again on 12/28/2018.
D. The MR lacked documentation that a waffle mattress and/or waffle chair cushion was ordered for the patient.
E. The wound care service note dated 01/02/2019 at 3:44 pm by NS # 1, indicated the patient had two (2) new hospital acquired DTI's of the right talus (ankle) measuring 1.3 cm (centimeter) x 2.2 cm, and a left talus measuring 3.5 cm x 2.5 cm.
F. The MR lacked documentation that the "Wednesday" weekly skin assessment was completed on 01/09/2019.
G. The "Wound Care Service" note dated 01/02/2019 at 3:44 pm by NS # 1, indicated the patient had the following skin concerns:
1. Right Talus pressure ulcer, suspect DTI, purple and non blanchable, measuring 1.3 cm x 2.2 cm
2. Left Talus pressure ulcer, suspect DTI, purple and non blanchable, measuring 3.5 cm x 2.5 cm.
H. The "Skin Champion Note" dated 01/02/2019 at 4:18 pm by NS # 7, indicated the "waffle mattress" had been "placed on patient bed".
I. The MR lacked documentation that the physician and family were notified of the skin status change.

10. Review of the closed MR for patient # 5 indicated the patient was a 62 y/o admitted to H # 1 on 12/26/2018 with diagnoses which included, but were not limited to, adult failure to thrive, fecal impaction, and anemia.
The MR summary for patient # 5's admission on 12/26/2018 indicated the following:
A. The patients admission "Braden Scale Assessment" dated 12/26/2018 at 10:11 pm indicated a high risk score of "12" (twelve).
B. The MR indicated the "wound nurse consult" was ordered on 12/27/2018 at 3:23 am.
C. The wound care service note dated 12/28/2018 at 11:21 am by NS # 1, indicated the patient had a stage III "sacralcoccygeal left and inner aspect" pressure ulcer with "early/partial granulation" measuring 7.0 cm x 3.0 cm x 0.4 cm. The plan was to implement "pressure relief measures".
D. The MR lacked documentation that a waffle mattress was on the patient's bed from 01/03/2019 through 01/06/2019.
E. The MR lacked documentation that the "Wednesday" weekly skin assessment was completed on 01/02/2019 and 01/09/2019.

11. Review of the closed MR for patient # 6 indicated the patient was a 52 y/o admitted from the ED to H # 1's inpatient on 12/09/2018 at 3:30 am. The patient's diagnoses which included, but were not limited to, UTI (urinary tract infection), anemia, malfunctioning gastrostomy tube, diabetes mellitus, and renal failure.
The MR summary for patient # 6's admission on 12/09/2018 indicated the following:
A. The nurses note dated 12/09/2018 at 3:30 am, by NS # 14 (RN), indicated the the patient was admitted with "healing wound to r. (right) shoulder measuring 3.5 x 1 cm" (centimeter), blister to "inner l (left) thigh measuring 4.5 x 1 cm, 4.5 x 1 cm open wound to r side of coccyx and 2.5 x 2 open wound near the rectum" with "three healing wounds to the r. hip area" and "multiple dark areas/scabs to both legs and feet".
B. The "Nursing communication" dated 12/09/2018 at 5:36 am, indicated to "turn" the patient "q (every) 2 (two) hours".
C. The physician order dated 12/09/2018 at 5:36 am, indicated for "Wound/ostomy" to "eval" (evaluate) and "treat".
D. The physician order dated 12/10/2018 at 7:32 am, indicated to "elevate" the patient's "heels off of bed", and for "staff to obtain a waffle mattress" for the patient.
E. The patient admission "Braden Scale Assessment" dated 12/09/2018 at 3:02 am indicated a high risk score of "12" (twelve).
F. The physician order dated 12/12/2018 at 11:07 am, indicated for "staff to obtain a waffle mattress" for the patient.
G. The MR lacked documentation that the "Braden Scale Assessment" was completed on 12/14/2018.
H. The MR lacked documentation that the dependent patient was turned/repositioned on the following dates/times:
1. On 12/10/2018 at 2:00 am, 4:00 am, 6:00 am, 2:00 pm, 8:00 pm, and 10:00 pm.
2. On 12/11/2018 at midnight, 2:00 am, 4:00 am, 6:00 am, and 8:00 am.
3. On 12/14/2018 at 6:00 am, 8:00 pm, and 10:00 pm.
4. On 12/16/2018 at 4:00 am and 6:00 am.
I. The MR lacked documentation that the patient heels were elevated on the following dates/times:
1. On 12/10/2018 at 2:00 am, 4:00 am, 6:00 am, 2:00 pm, 8:00 pm, and 10:00 pm.
2. On 12/11/2018 at midnight, 2:00 am, 4:00 am, 6:00 am, 8:00 am, 10:00 am, 12:00 pm, 2:00 pm, and 4:00 pm.
3. On 12/12/2018 at midnight, 2:00 am, 4:00 am, 6:00 am, 8:00 am, 10:00 am, 12:00 pm, 4:00 pm, 6:00 pm, 8:00 pm, and 10:00 pm.
4. On 12/13/2018 at midnight, 2:00 am, 4:00 am, 6:00 am, 8:00 am, 10:00 am, 12:00 pm, 2:00 pm, 4:00 pm, and 6:00 pm.
5. On 12/14/2018 at 6:00 am, 12:00 pm, 2:00 pm, 4:00 pm, 6:00 pm, 8:00 pm, and 10:00 pm.
6. On 12/15/2018 at midnight, 2:00 am, 4:00 am, 6:00 am, 8:00 am, 10:00 am, 12:00 pm, 2:00 pm, and 4:00 pm, 6:00 pm, 8:00 pm, and 10:00 pm.
7. On 12/16/2018 at midnight, 2:00 am, 4:00 am, 6:00 am, 8:00 am, 10:00 am, 12:00 pm, 2:00 pm, 4:00 pm, and 6:00 pm.
8. On 12/17/2018 at 6:00 am, 8:00 am, 10:00 am, 12:00 pm, 2:00 pm, and 4:00 pm, 6:00 pm, 8:00 pm, and 10:00 pm.
9. On 12/18/2018 at midnight, 2:00 am, 8:00 am, and 10:00 am.
J. The MR lacked documentation that the patient had a waffle mattress on for the following dates: 12/09/2018, 12/10/2018, 12/11/2018, 12/12/2018, 12/13/2018, 12/14/2018, 12/15/2018, 12/16/2018, and 12/17/2018.
K. The "Wound Care Service" note dated 12/12/2018 at 11:18 am by NS # 1 (Certified Wound Registered Nurse), indicated the patient had the following skin concerns:
1. Blister to the left inner thigh, with skin intact, measuring 1.0 cm x 4.0 cm x 0.3 which was first assessed upon admission.
2. Right trochanter pressure ulcer, with multiple open areas, measuring the surface are of all three wounds 10.5 cm x 4.0 cm x 0.1 cm which was first assessed upon admission.
3. Right ishial pressure ulcer stage III, with full thickness tissue loss, measuring 2.0 cm x 3.5 cm x 2.0 cm which was first assessed upon admission.
4. Mid back pressure ulcer stage II, with partial loss of dermis without slough, measuring 2.5 cm x 2.0 cm x 0.1 cm which was first assessed upon admission.
5. Left lateral ankle suspect DTI, with non blanchable erythemia, measuring 2.0 cm x 3.4 cm which was the first time assessed.

12. Review of the "Unit Skin Champion Role Expectations", updated June 8, 2018, indicated "each Wednesday (Wound Wednesday)" the Skin Champion "must complete a skin assessment on ALL PATIENTS".

13. In interview on 01/23/2019 at approximately 3:35 pm with administrative staff member A # 2 (Assistant Vice President Nursing), confirmed a "Braden Scale Assessment should be done daily by the day shift". A dependent patient "is not able to turn themselves".

14 In interview on 01/24/2019 at approximately 10:10 am with administrative staff member A # 2, confirmed the patient's "physician and family member should be notified" of a change in condition, and the "wound nurse should be consulted" anytime a patient's Braden Skin Assessment score "is less than fourteen (14)". The "weekly (Wednesday) skin assessments should be completed" for the patients as scheduled by the skin care team.

15. In interview on 01/24/2019 at approximately 11:30 am with administrative staff member A # 2, confirmed once the wound nurse "is consulted" the "wound RN or skin champion should see the patient in a timely manner". It "is a delay in care".

16. In interview on 01/24/2019 at approximately 1:40 pm with administrative staff member A # 2, confirmed any "new pressure" ulcer/wound would fall under the section "adverse event". The "nurse should be notifying the physician and/or family.

17. In interview on 01/24/2019 at approximately 2:23 pm with administrative staff member A # 3 (Assistant Vice President Compliance), confirmed risk control reports had not been completed for patient # 4 and patient # 6 for their new pressure ulcer/wound. "Any new wound should have an incident report filled out". At 4:10 pm confirmed the "reports should be filled out completely including provider/family notification".

Based on document review and interview, the facility failed to ensure the nursing staff followed the policies and procedures related to developing and updating the patients plan of care for five (5) of ten (10) patient closed medical records (MR's) reviewed. (Patient # 1, Patient # 2, Patient # 4, Patient # 6, and Patient # 7)

Findings include:

1. Review of the hospital policy titled, "Skin and Tissue Inspection, Assessment and Management Procedure", policy number NSI-ACT_60, original date 08/2016, indicated the purpose was to "provide guidance and protocols to help prevent deterioration of existing pressure injuries and/or wounds". Those patients "who have been identified to be at risk MUST have related Care Plans...put in place". This policy was last revised in 09/2017.

2. Review of the hospital policy titled, "Patient Admission, Assessment, Reassessment and Documentation Guidelines, and Vital Signs Procedures", policy number NSI-ACT_30, original date 07/1996, indicated "a registered nurse shall perform or validate a health history...and physical assessment on all patients" admitted to H # 1 (Acute Care Hospital). "Identified problems and interventions shall be entered into the Plan of Care". This policy was last reviewed in 02/2018.

3. Review of the hospital policy titled, "Nursing Practice", policy number NSI-STND_01, original date 07/2004, indicated the "Registered Nurse" at H # 1 "executes all assigned responsibilities" and "is accountable for his or her own nursing practice". This policy was last reviewed in 02/2018.

4. Review of the closed MR for patient # 1 (one) indicated the following:
A. The patient was a 85 y/o (year/old) who was admitted to H # 1 on 11/30/2018 with diagnoses which included, but were not limited to, left lower lobe pneumonia, dementia, and congestive heart failure (CHF).
B. The nurses note dated 11/30/2018 at 6:34 am by NS # 10 (Registered Nurse-RN) indicated the patient (pt) was received from the ER (Emergency Room). The "pt has ulcer to sacral area that is pink in color, pt has wound noted to right lateral foot area with dressing in place, pt's left heel has old healed wound in place".
C. The MR lacked documentation that the patient had a plan of care implemented for "Skin Integrity" during the patients hospital admission.

5. Review of the closed MR for patient # 2 (two) indicated the following:
A. The patient was a 77 y/o (year/old) admitted to H # 1 on 11/15/2018 with diagnoses which included, but were not limited to, acute on chronic CHF, pulmonary fibrosis, and hypertension (high blood pressure).
B. The nurses note dated 11/15/2018 at 8:34 pm, by NS # 11 (RN), indicated the "admission skin assessment" was done and "no open areas noted".
C. The nurses note dated 12/01/2018 at 3:55 pm by NS # 12 (RN), indicated "DTI's (deep tissue injuries) and skin tears to buttocks bilaterally".
D. The MR lacked documentation that the patient had a plan of care implemented for "Skin Integrity" during the patients hospital admission.

6. Review of the closed MR for patient # 4 (four) indicated the following:
A. The patient was a 74 y/o admitted to H # 1 on 12/19/2018 with diagnoses which included, but were not limited to, hypotension (low blood pressure) and failure to thrive.
B. The nurses note dated 12/20/2018 at 9:42 pm, by NS # 13 (RN), indicated the "skin assessment-skin tear to coccyx with foam bandage".
C. The MR lacked documentation that the patient had a plan of care implemented for "Skin Integrity" during the patients hospital admission.

7. Review of the closed MR for patient # 6 (six) indicated the following:
A. The patient was a 52 y/o admitted to H # 1 on 12/08/2018 with diagnoses which included, but were not limited to, UTI (urinary tract infection) and anemia.
B. The nurses note dated 12/09/2018 at 3:30 am, by NS # 14 (RN), indicated the the patient was admitted from the ER with "healing wound to r. (right) shoulder measuring 3.5 x 1 cm" (centimeter), blister to "inner l (left) thigh measuring 4.5 x 1 cm, 4.5 x 1 cm open wound to r side of coccyx and 2.5 x 2 open wound near the rectum" with "three healing wounds to the r. hip area" and "multiple dark areas/scabs to both legs and feet".
C. The "Braden Scale Score" dated 12/09/2018 was twelve (12) which indicated "high risk" for skin complications.
D. The MR indicated the patients plan of care wasn't implemented for "Skin Integrity" until 12/12/2018.

8. Review of the closed MR for patient # 7 (seven) indicated the following:
A. The patient was a 70 y/o admitted to H # 1 on 12/30/2018 with diagnoses which included, but were not limited to, adult failure to thrive, fecal impaction, and anemia.
B. The nurses note dated 12/30/2018 at 9:00 pm, by NS # 15 (RN), indicated the the patient was admitted from the ER with an "open wound to sacral/coccyx area".
C. The MR lacked documentation that the patient had a plan of care implemented for "Skin Integrity" during the patients hospital admission.

9. In interview on 01/24/2019 at approximately 4:00 pm with A # 2 (Assistant Vice President Nursing), confirmed individualized "Skin Integrity" care plans should have been implemented and/or updated during the above patients hospital admission.

Based on document review and interview, the facility failed to ensure the "Registered Nurse Skin Champion" received the necessary specialized training competency, in accordance with patient needs, related to wound/pressure injury "staging" in eight (8) instances (NS # 2, NS # 3, NS # 4, NS # 5, NS # 6, NS # 7, NS # 8, and NS # 9), and failed to ensure annual wound/pressure injury training was completed for the facilities registered nursing staff.

Findings include:

1. Review of the hospital policy titled, "Nursing Practice", policy number NSI-STND_01, original date 07/2004, indicated the "Registered Nurse" at H # 1 "executes all assigned responsibilities" and "is accountable for his or her own nursing practice". This policy was last reviewed in 02/2018.

2. Review of the hospital policy titled, "Skin and Tissue Inspection, Assessment and Management Procedure", policy number NSI-ACT_60, original date 08/2016, indicated the purpose of the policy was to provide guidance for "prevention of loss of skin integrity, pressure injuries and/or wounds" and to provide guidance and protocols to help "prevent deterioration of existing pressure injuries and/or wounds". Those patients "who have been identified to be at risk "implement pressure ulcer prevention measures, including ordering of and implementation of appropriate pressure ulcer relief/reduction devices/products". All wounds/pressure injuries should be assessed according to etiology, location, "stage" (pressure injuries are only staged by "trained staff" a certified wound nurse and/or physician). Skin assessments will be performed "daily". Comprehensive wound assessments will then be done at least weekly, "on Wednesdays". This policy was last revised in 09/2017.

3. Review of the hospital policy titled, "Patient Admission, Assessment, Reassessment and Documentation Guidelines, and Vital Signs Procedures", policy number NSI-ACT_30, original date 07/1996, indicated "a registered nurse shall perform or validate a health history ... and physical assessment on all patients" admitted to H # 1 (Acute Care Hospital). "Identified problems and interventions shall be entered into the Plan of Care". This policy was last reviewed in 02/2018.

4. Review of the "Unit Skin Champion Role Expectations", updated June 8, 2018, indicated "each Wednesday (Wound Wednesday) the Skin Champion must complete a skin assessment on ALL PATIENTS". If the Skin Champion has been scheduled off on Wednesday-the unit "must have a nurse that has been cross-trained to fill the position for the day".

5. Review of the current "Job Description" for NS # 1 (Certified Wound Registered Nurse), indicated the duties and responsibilities were to "provide leadership and direction" for interdisciplinary "skin care teams" for the prevention and treatment of decubitus ulcers.

6. In interview on 01/23/2019 at 1:50 pm with NS # 1, confirmed "I do not have any documentation that the Skin Champions were trained in wound staging". We had eight (8) Skin Champions in 12/2018. The nursing staff on the units "are not cross trained for wounds". When a wound nurse consult "is ordered for a patient" and "I'm not able to see the patient", unfortunately the "information does not get passed to the skin champions" that the evaluation needs to be completed. "The system is flawed".

7. In interview on 01/24/2019 at approximately 1:45 pm with administrative staff member A # 2 (Assistant Vice President Nursing), confirmed the hospital "annual competencies" for the staff registered nurses "does not include wound care staging, location, treatment and/or preventions".