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Based on a review of facility documents, medical records (MR), and staff (EMP) interview, it was determined that the facility's nursing staff failed to adhere to the facility's "Pressure Injury Prevention and Treatment Guidelines" for 7 of 10 medical records reviewed. (MR2, MR3, MR4, MR5, MR7, MR9, and MR10).

Findings include:

On September 8, 2022, review of the facility's policy for "Pressure Injury Prevention and Treatment Guidelines POL-4446334", last approved 9/1/2021, revealed:
(1) " ...Administration ... Using the Braden Scale Risk Assessment tool, the nurse will identify patients at risk for impaired skin integrity and implement appropriate prevention interventions. ... Patients are identified at Risk with a total Braden score of less than or or equal to 18 or a score of 3 or less in each subscale which alerts the RN to initiate prevention interventions. The Prevention Plan of Care is initiated and implemented by the nurse performing the Risk Assessment. Nursing interventions are based on Braden subscale scores. Document interventions as listed in EPIC ...".
(2) " ... RESPONSIBILITY ... Assessment of overall skin integrity and Braden Score will be completed by the nurse and documented in the medical record:
a. Upon admission
b. At least once per shift
c. Upon in-house transfer by the receiving RN
d. Following surgery or procedures
e. With decline in condition. ...".
(3) " ... Enter a CWS/WCC/WCON Nurse Referral (if available) and/or notify the Wound Treatment Associate (WTA) for Stage 3, 4, unstageable, deep tissue injury, and mucosal membrane pressure injury....".
(4) " ... PROCEDURE ... Care of the Patient With Stage 1 Pressure Injury ... Turn and reposition patient q 2-3 hours and as needed. ... " ... Care of the Patient With A Stage 2 Pressure injury ... Turn and reposition patient Q 2-3 hrs and as needed. ...Care of the Patient With A Stage 3 or 4 Pressure Injury ... Turn and reposition patient Q 2-3 hrs and as needed. ... ".
Medical Record Review:
-- On September 9, 2022, review of MR7 revealed that the patient is a 75 year old female who was admitted on May 26, 2022. Further review of MR7 revealed that the patient's Braden score dropped to 15 on May 27, 2022 at 12:00. Skin Injury Prevention was not included in her Nursing Plan of Care.
-- On September 9, 2022, review of MR9 revealed that the patient was admitted on March 31, 2022, and was assigned a Braden score of 18 on admission. Skin Injury Prevention was not included in his Nursing Plan of Care.
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-- On September 8, 2022, review of MR2, admission date June 21, 2022, and reviewed for the time of June 21-25, 2022, revealed that the nursing staff failed to document at least once per shift Skin Interventions for Braden Subscale Scores of 3 or less on June 23, 2022, at 0800; June 23, 2022, at 2000; June 24, 2022, at 0800; June 24, 2022, at 2000; and June 25, 2022.
-- On September 8, 2022, review of MR3, admission date June 14, 2022, and reviewed for the time of June 14-20, 2022, revealed that the nursing staff failed to document at least once per shift Skin Interventions for Braden Subscale Scores of 3 or less on June 18, 2022, at 0800.
-- On September 8, 2022, review of MR4, admission date June 8, 2022, and reviewed for the time of June 8-17, 2022, revealed that the nursing staff failed to document skin integrity during the admission assessment on June 8, 2022, at 9:33pm In addition, nursing staff failed to document at least once per shift Skin Interventions for Braden Subscale Scores of 3 or less on June 8, 2022, at 2133; June 9, 2022, at 0734; June 11, 2022, at 0241; June 11, 2022, at 2000; June 12, 2022, at 2000; June 17, 2022, at 0800; and June 17, 2022.
-- On September 8, 2022, review of MR5, admission date May 10, 2022, and reviewed for the time of May 10-15, 2022, revealed that nursing staff failed to document at least once per shift Skin Interventions for Braden Subscale Scores of 3 or less on May 14, 2022, at 0000 and on May 15, 2022, at 0000.
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-- On September 8, 2022, review of of MR2, admission date, June 21, 2022, revealed the patient had unstageable pressure injury on their coccyx documented on June 25, 2022, at 8:00am. No referral to CWS/WCC/WCON nurse or WTA. Wound nurse note reviewed from June 27, 2022, at 11:46am.
EMP1 confirmed on September 8, 2022, at 12:30pm that there was no referral, but that the wound nurse saw the patient on the RL list and knew then to see the patient.
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-- On September 8, 2022, review of MR3, admission date June 14, 2022, and reviewed for the time of June 14-20, 2022, revealed that the patient was to be turned and repositioned every two hours. The facility failed to document this on June 14, 2022, at 0200, 0400, 0600, 1000, 1200, 1400, 1700, 1900; June 16, 2022, at 0200, 1000, 1200, 1400, 1800; June 17, 2022, at 0800, 1200, 1400, 1800, 2000, 2200; June 18, 2022, at 0000, 0400, 0600, 1200, 1800, 2000, 2200; June 19, 2022, at 0000, 0400, 0600, 1000, 1200, 1400, 1600, 1800, 2200; and June 20, 2022, at 0000, 0200, 0400, 0600.
-- On September 8, 2022, review of MR5, admission date May 10, 2022, and reviewed for the time of May 10-15, 2022, revealed that the patient was to be turned and repositioned every two hours. The facility failed to document this on May 11, 2022, at 0600; May 12, 2022, at 0200, 1400, 1800; May 13, 2022, at 0000, 0200, 0400, 0600, 1115, 1315, 1726, 1926, 2126; May 14, 2022, at 0200, 0400, 0600, 0800, 1000, 1200, 1400; and May 15, 2022, at 0000, 0200, 0400, 0600, 1000, 1200, 1400, 1600, 1800, 2000.
-- On September 9, 2022, review of MR10 revealed admission date of April 5, 2022. Further review of MR10 revealed that the patient was to be turned and repositioned every two hours. The facility failed to document every two hour repositioning on April 18, 2022, at 0600, and between April 19, 2022 and April 20, 2022.
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The above findings were confirmed by EMP5 for MR2, MR3, MR4, and MR5 on September 8, 2022, between 12:00 PM and 2:00 PM

The above findings were confirmed by EMP3 for MR7, MR9 and MR10 on September 9, 2022, between 9:00 AM and 10:30 AM.