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Based on document reviews and interviews, the hospital failed to ensure that all patients received care in a safe setting. This was evidenced by a failure to identify a pressure injury after three (3) skin assessments by Registered Nurses and over twenty four (24) hours in the hospital for one (1) of ten (10) patients reviewed (Patient #6); and nursing staff did not initiate a plan of care related to a pressure injury, as their policy states for three (3) of twelve (12) patients reviewed (Patient #6, #11 and #12).

Findings:

The hospitals "Pressure Injury Prevention and Management - Skin Care" policy, last revised 6/6/2023 states in part, "Comprehensive skin assessment: a. Upon admission a comprehensive skin assessment which includes inspection and palpation will be completed and documented for inpatient areas, emergency department, pre-operative, and recovery room. This assessment will be completed by a Registered Nurse(s) as follows:

i. Inpatient, observation, and swing bed: Braden and integumentary assessments. In addition, a 4-eyed skin assessment completed within 4- hours of admission or transfer to an inpatient setting (outside facility or internally), if off the unit for greater than 4-hours, and with any change in patient condition.

ii. Emergency Department: Braden assessment. Once a decision related to inpatient admission is known, a 4-eyed skin assessment will be completed and documented".

In addition, these are the definitions outlined in the "Pressure Injury Prevention and Management - Skin Care" policy: " ... 4-eyed skin assessment: a comprehensive head-to-toe skin assessment performed by two (2) RNs to evaluate the patient skin integrity and identify the presence of wounds or pressure injuries ... Braden Assessment: risk assessment tool used to identify patients at-risk for pressure injuries. The scale consists of six subscales and total scores range from 6-23. A lower Braden score indicates higher levels of risk for pressure injury development. Generally, a score of 18 or less indicates at-risk status ... ".

1. Skin Assessments
On 10/20/2023 at 10:58 AM, Patient #6's medical record was reviewed and revealed the following:
- On 7/28/2023 at 12:49 PM, Patient #6 arrived in the Emergency Department ("ED") following a fall;
- Registered Nurse ("RN") #1 completed a skin assessment and documented the skin integrity as intact;
- There was no documented evidence that RN #1 completed a Braden Assessment, per policy;
- On 7/28/2023 at 4:02 PM, the physician completed a decision to admit order;
- On 7/28/2023 at 5:38 PM, the physician ordered a "4-Eyed Skin Assessment";
- On 7/28/2023 at 8:53 PM, RN #2 documented that she and RN #4 completed a 4-Eyed Skin Assessment and Patient #6's skin integrity was fragile and had a score of fourteen (14) on the Braden Assessment;
- On 7/29/2023 at 9:53 AM, RN #4 completed a skin assessment and documented the skin integrity as intact and Braden Assessment of 17;
- On 7/29/2023 at 2:15 PM, RN #5 documented that he and RN #6 completed a 4-Eyed Skin Assessment (which is a duration of four (4) hours and twenty two (22) minutes from the last assessment) and there was a suspected pressure injury present, on admission, on a bony prominence, open to air with slough in the wound bed, describing the skin color as yellow, beefy red;
- On 7/31/2023 at 12:26 PM, RN #7 (who specializes in wound care) documented the following in her consultation report: Coccyx has open wound measuring approximately 1.5 cm x 1.3 cm x 0.3 cm, directly over bone, tender on palpation, wound edges slightly irregular, wound base covered with 100% thick slough. Periwound skin and gluteal cleft macerated.

On 10/20/2023 at 9:38 AM, an interview was conducted with RN #7, who stated the following:
- At the point I saw [Patient #6], it was an open wound, full of slough;
- He/She was at a high risk of pressure injury;
- I think somebody missed something;
- I think the pressure injury was formed at home; and
- When asked if Patient #6's wound could have been created in four (4) hours and twenty two (22) minutes or when Patient #6 was admitted the prior day, she stated, "No ... Something is missing ... after a couple of hours, [Patient #6] would have had erythema or blanching, but it would not have been open as when I saw it. Even friction and shear could have ripped but it could not have been an open wound, full of slough".

On 10/25/2023 at 12:23 PM, an interview was conducted with the Director of Nursing Excellence, who oversees the wound care team. When asked if Patient #6's wound could have been created in four (4) hours and twenty two (22) minutes or when Patient #6 was admitted the prior day, she stated, "It is unlikely that it happened over twenty four (24) hours, but definitely not in four (4) hours".

The hospitals "Patient Assessment, Education and Documentation" policy, last revised 4/6/2023, states in part, "Patient Plan of Care 1. A plan of care will be initiated on all patients admitted or undergoing a procedure within 24 hours of admission/procedure and will reflect the individualized patient problems and expected outcomes. 2. The plan of care will be reviewed each shift and updated to reflect any change in patient condition or care needs".

2. Plan of Care
On 10/20/2023 at 10:58 AM, Patient #6, #11 and #12's medical record were reviewed and revealed the following:
- As of Patient #6's discharge on 8/7/2023, there was no documented evidence that a plan of care was initiated related to the pressure injury;
- Patient #11 was admitted on 9/29/2023 and multiple pressure injuries and a surgical wound were identified upon admission, and; a plan of care was not initiated related to the multiple pressure injuries or surgical wound until 10/12/2023, a duration of thirteen (13) days after they were identified;
- Patient #12 was admitted on 10/16/2023 and a pressure injury was identified upon admission; and a plan of care was not initiated related to the pressure injury until 10/25/2023, a duration of nine (9) days after it was identified.

On 10/23/2023 at 1:24 PM, the Nurse Manager, for the unit that Patient #6 and #12 were admitted to, was interviewed. The expectation, she stated, was that the RN's would update the plan of care to reflect the patients care needs and any changes, and should be done by the end of their shift.

On 10/24/2023 at 10:45 AM, surveyors attended the skin and pressure injury prevention training for the new employee orientation, led by a Clinical Educator. When asked if and when a plan of care would be initiated, he stated, a nurse would update the plan of care every shift. Once you identify the wound, we go through the skin response, we get orders, document that and reflect it in the plan of care.

On 10/24/2023 at 12:23 PM, RN #8 was interviewed [with her manager present]. When asked if she should initiate a plan of care if her patient had a wound, she stated, "Now that I am talking with you, yes. Before now, I had not thought of it".

On 10/25/2023 at 12:23 PM, the Director of Nursing Excellence was interviewed. She stated, in relation to the plan of care, that it is the primary nurses responsibility to open up the plan of care for skin integrity. This would be completed when any concerns with skin are identified.

Based on document reviews and interviews, the hospital failed to ensure the condition of a patient, who was in restraints, was monitored every two (2) hours in accordance with hospital policy for one (1) of five (5) patients reviewed (Patient 2R).

Findings:

The hospital's "Restraint and Seclusion" policy, on 02/01/2023, states in part for violent restraints, " ... Direct continuous observation is required. (i.e., a sitter at bedside). In person assessments must be documented every 15 minutes, with no time lapse of greater than 15 minutes. Each 15-minute check requires an assessment of: - Readiness for Release - Psychological Status - Physical Comfort - Circulation - Continuous Observation ... The patient will be assessed at least every two hours (or more frequently based on assessed needs). This assessment includes: - Check circulatory status - Perform range of motion and positioning - Provide fluids if appropriate - Provide food if appropriate - Offer opportunity to meeting toileting needs ... ".

In addition, nursing documentation is required for the results of the monitoring.

On 10/18/2023 at 9:53 AM, Patient 2R's medical record was reviewed with an Assistant Nurse Manager.

Patient 2R's medical record contained a violent restraint physician order for a physical hold and a vest jacket that were applied at 5:44 PM [physical hold] and 5:45 PM [vest jacket] on 8/14/2023. The order was discontinued at 9:25 PM on 8/14/2023. There was no evidence of the required monitoring documentation by the Registered Nurse from 5:44 PM on 8/14/2023 until the restraint was discontinued at 9:25 PM on 8/14/2023 (a duration of three (3) hours, forty one (41) minutes).

On 10/18/2023, this finding was confirmed by the Assistant Nurse Manager at the time of the review.

Based on document reviews and interviews, the hospital failed to ensure the patient received a face-to-face evaluation by the provider within one (1) hour of initiating a restraint for two (2) of five (5) patients that were restrained (Patient 2R and 4R).

Finding:

The hospital's "Restraint and Seclusion" policy, on 02/01/2023, states in part "When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face to face within 1 hour after initiation of the intervention...".

On 10/18/2023 at 9:53 AM, Patient 2R and 4R's medical records were reviewed with an Assistant Nurse Manager. This review revealed the following:

- On 5/12/2023 from 2:08 PM to 2:40 PM, Patient 4R was in four (4) point restraints; and
- There was no documented evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation.

- On 8/14/2023 from 5:44 PM to 9:25 PM, Patient 2R was in a physical hold [for one (1) minute] and transitioned into a vest jacket for the remainder of the restraint; and
- There was no documented evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation.

On 10/18/2023, this finding was confirmed by the Assistant Nurse Manager at the time of the review.

Based on document reviews and interviews, the hospital failed to ensure that restrained patients received an evaluation within one (1) hour of restraint initiation that documented the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint for two (2) of five (5) patients reviewed (Patient 2R and 4R).

Findings:

The hospital's "Restraint and Seclusion" policy, on 02/01/2023, states in part " ... When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1 hour after the initiation of the intervention by a Physician or other licensed independent practitioner ... The physician/provider must assess AND document: - the patient's condition; - the patient's reaction to the intervention; - the patient's medical and behavioral condition; and - the need to continue or terminate the restraint or seclusion ... ".

On 10/18/2023 at 9:53 AM, five (5) records were reviewed with an Assistant Nurse Manager. This review revealed the following:

1. Patient 4R
- On 5/12/2023 from 2:08 PM to 2:40 PM, Patient 4R was in four (4) point restraints; and
- There was no evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation that documented the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint.

2. Patient 2R
- On 8/14/2023 from 5:44 PM to 9:25 PM, Patient 2R was in a physical hold [for one (1) minute] and transitioned into a vest jacket for the remainder of the restraint; and
- There was no evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation that documented the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint.

On 10/18/2023, these findings were confirmed by the Assistant Nurse Manager at the time of the review.