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Based on record review and interview the facility failed to: 1) ensure interventions were implemented to address an increase in the numbers of hospital acquired pressure injuries identified and 2) monitor the effectiveness of an action plan to decrease hospital acquired pressure injuries. Specifically, the facility failed to institute interventions for patients who had documented hospital acquired pressure injuries. This failed practice placed patients at risk for further harm. Findings:

Review of the facility Quality Assurance and Performance Improvement data on hospital acquired conditions, dated February 2016, revealed "Pressure Ulcer rate" as one of the hospital acquired conditions being monitored. Review of the graph "Acquired Pressure Ulcers Number per 100 patient days" revealed, in the months of November 2015 and February 2016, 5 new patients in each month had hospital acquired pressure ulcers. For 2 consecutive quarters there were a total of 10 patients who had acquired new pressure ulcers while in the hospital. Review of the data revealed the patients were from the patient care units: CCU; 5E; 5W; 4W; and Pediatrics.

During an interview on 8/24/16 at 11:13 am, when asked what the facility implemented to improve outcomes upon discovering the increase in facility acquired pressure injuries, House Supervisor #1 replied the facility implemented an action plan after the first spike in numbers in November 2015. The plan included "In-the-moment" training to the staff and discussed opportunities for improvement. She stated not all nursing staff was reached during this education, nor was there documentation of who was provided with the education. There were no specific in-services and/or formal education provided regarding pressure injury prevention, after the increase in facility acquired pressure injuries had been identified. New specialty patient beds were purchased in October 2015. Even with this action plan in place, the following quarter showed another spike of 5 new patients with facility acquired pressure injures.

On 8/24/16 at 1:45 pm Surveyors requested documentation the plan of action was being monitored for effectiveness.

During an interview on 8/24/16 at 2:00 pm Staff #2 confirmed there was no monitoring of the effectiveness of the action plan put in place for decreasing hospital acquired pressure injuries.





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Based on record review and interview the facility failed to ensure clinical staff were implementing consistent preventative interventions and mechanisms to prevent hospital acquired pressure injuries. This failed practice had the potential to cause more patients to have hospital acquired pressure injuries during their inpatient stay at the facility. A pressure injury also known as a pressure ulcer is a localized injury to the skin and/or underlying tissue as a result of pressure, or pressure in combination with friction and/or sheer. Findings:

Review of the facility Quality Assurance and Performance Improvement data on hospital acquired conditions, dated February 2016, revealed "Pressure Ulcer rate" as one of the hospital acquired conditions being monitored. Review of the graph "Acquired Pressure Ulcers Number per 100 patient days" revealed, in the months of November 2015 and February 2016, 5 new patients in each month had hospital acquired pressure ulcers. For 2 consecutive quarters there were a total of 10 patients who had acquired new pressure ulcers while in the hospital. Review of the data revealed the patients were from the patient care units: CCU; 5E; 5W; 4W; and Pediatrics.

During an interview on 8/24/16 at 11:13 am, when asked what the facility implemented to improve outcomes upon discovering the increase in facility acquired pressure injuries, House Supervisor (HS) #1 replied the facility implemented an action plan after the first spike in numbers in November 2015. The plan included "In-the-moment" training to the staff and discussed opportunities for improvement. The HS stated not all nursing staff was reached during this education, nor was there documentation of who was provided with the education. There were no specific in-services and/or formal education provided regarding pressure injury prevention, after the increase in facility acquired pressure injuries had been identified. New specialty patient beds were purchased in October 2015. Even with this action plan in place, the following quarter showed another spike of 5 new patients with facility acquired pressure injures.

Review of all the policies and procedures, including "Skin Protocol for Alaska Native Medical Center...Skin Care Protocol; Provision of Care, Treatment and Services #500 C; and Competence Verification & Learning Guide" , which were provided during the survey, revealed nursing preventative measures included turn and/or repositioning patient; skin breakdown prevention; initiate skin preventative interventions for a Braden score less than 18; nursing assessments to be done at least once a shift and document results. Review of the "CCU Unit-Based Council" meeting minutes, dated 9/3/15, revealed "Wound Documentation and Turns -Wounds not being assessed and documented every shift - Patients not being turned..." Despite the identified concern that preventative measures were not being addressed by nursing staff, there was no specific training on preventative interventions and mechanisms that addressed the increased number of hospital acquired pressure injuries.




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Based on record review and interview facility failed to ensure preventative nursing measures were implemented and documented to prevent a pressure injury (a pressure injury also known as a pressure ulcer is a localized injury to the skin and/or underlying tissue as a result of pressure, or pressure in combination with friction and/or shear) for 1 patient. Failure to implement and document preventative nursing measures were causative factors towards the development of a hospital acquired pressure injury for Patient #2 and created a delay in recovery and healing. Finding:

Record review was conducted 8/22-24/16.

Record review revealed Patient #2 was admitted to the facility 9/27/15 with diagnoses that included recent acute CVA (cerebral vascular accident, a stroke); diabetes; and altered mental status.

Admission nursing assessment, dated 9/27/15 revealed the Patient was admitted with no pressure injuries and had a Braden score of 11. Braden scoring is a system used to evaluate a patient 's risk of developing a pressure ulcer. A Braden score of 10-12 would be high risk where preventive intervention would be implemented.

Record review of the "Medical Progress Note-Inpatient", dated 10/3/15, revealed "Skin...decube [pressure injury] on coccyx..."

Record review of the "Wound Care Consultation", dated 10/6/15, revealed "Chief complaint: Pressure ulcer [injury], unstageable [Unstageable is characterized by full-thickness loss, in which the base of the ulcer in the wound bed is covered by slough, eschar, or both. Until enough slough or eschar [brown, tan or black dead tissue] is removed to expose the base of the wound, the true depth, and therefore stage, can't be determined], coccyx and sacrum...may be a shallow DTI". A Deep tissue injury is a purple or maroon localized area of intact skin or blood-filled caused by damage of underlying soft tissue from pressure or shear. It may be preceded by tissue that's painful, firm, mushy, and/or boggy...the depth of the suspected deep tissue injury is unknown.

Record review of the "Wound Care Consultation", dated 11/24/15, revealed the Patient had a Stage IV pressure injury. A Stage IV pressure injury involves full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Undermining and tunneling are also common.

Record review from 9/27 - 11/24/15 revealed missing and inconsistent documentation the Patient was turned to be given time off his coccyx and missing skin assessments of the pressure injury.

Multiple staff interviews, including Wound Care Nurse #1 from 8/23-24/16 confirmed Patient #2's pressure injury was hospital acquired.

Review of the "Skin Protocol for Alaska Native Medical Center...Skin Care Protocol", provided by the facility, revealed "...Implement this skin protocol if Braden score [less than] 18...Turn and/or reposition all patients who are unable to turn themselves in bed, every two hours or sooner if needed."

Review of the "Provision of Care, Treatment and Services #500 C", not dated, revealed "Patient needs will be reassessed throughout the course of care, treatment and services...The nursing reassessment will be performed at least once per shift."

Review of the "CCU Unit-Based Council" meeting minutes, dated 9/3/15, revealed "Wound Documentation and Turns -Wounds not being assessed and documented every shift - Patients not being turned..."

Review of the documentation for Patient #2 revealed after the Stage I pressure injury had been discovered on 10/3/15, there was no documentation the Patient's skin had been assessed again for several shifts.

Review of the "Competence Verification & Learning Guide", an RN competency for the critical care unit, revealed "The learner will incorporate relevant assessment & intervention (A&I) skills in delivery of care to include the following...Monitor patient to identify complications of critical illness...Review protocols, labs and medications for the following...skin breakdown...Integrate measure to ensure patient safety in the unit setting...Review the following...skin breakdown prevention..."

During an interview on 8/24/16 at 10:30 am, when asked about the deficient documentation for the Patient being turned off his back, Staff #1 stated that if a patient was so ill they could not be turned off their back it should have been documented in the medical record. Staff #1 confirmed the documentation of the Patient being repositioned was lacking and Patient #2's skin had not been assessed for several nursing shifts after the Stage I pressure injury had been discovered on 10/3/15.

During an interview on 8/24/16 at 11:15 am when asked about the lack of documentation for staff turning/repositioning Patient #2, House Supervisor #1 stated the facility needed to improve on their documentation of turning patients.





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Based on record review and interview the facility failed to ensure 1 care plan was updated specifically for wound care once a pressure injury was identified for 1 patient (#2). This failed practice placed the patient at risk of not having the most current level of care and measures the patient required. Findings:

Record review was conducted 8/22-24/16.

Record review revealed Patient #2 was admitted to the facility 9/27/15 with diagnoses that included recent acute CVA (cerebral vascular accident, a stroke); diabetes; and altered mental status.

Admission nursing assessment revealed the Patient was admitted with no pressure ulcers and with a Braden score of 11. Braden scoring is a system used to evaluate a patient's risk of developing a pressure ulcer. A Braden score of 10-12 would be high risk where preventive interventions would be implemented.

Record review of the "Medical Progress Note-Inpatient", dated 10/3/15, revealed "Skin...decube [pressure ulcer] on coccyx..."

Record review of the "Wound Care Consultation", dated 10/6/15, revealed "Chief complaint: Pressure ulcer [injury], unstageable [Unstageable is characterized by full-thickness loss, in which the base of the ulcer in the wound bed is covered by slough, eschar, or both. Until enough slough or eschar [brown, tan or black dead tissue] is removed to expose the base of the wound, the true depth, and therefore stage, can't be determined], coccyx and sacrum...may be a shallow DTI". Deep tissue injury is a purple or maroon localized area of intact skin or blood-filled caused by damage of underlying soft tissue from pressure or shear. It may be preceded by tissue that's painful, firm, mushy, boggy...the depth of the suspected deep tissue is unknown.

Record review of the "Wound Care Consultation", dated 11/24/15, revealed the Patient had a Stage IV pressure injury. A Stage IV pressure injury involves full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Undermining and tunneling are also common.

Review of the "Document In Plan [plan of care for Patient #2] ", starting date 10/3/15, revealed no individualized nursing care plan interventions or goals specific to wound care. After the identification of the pressure injury to Patient #2 on 10/3/15 the plan of care was not updated to include the pressure injury or any interventions or goals for treatment of the injury.

Review of the "Skin Protocol for Alaska Native Medical Center...Skin Care Protocol", provided by the facility, revealed "Critical Elements of the Nursing standard of Care...Implement this skin protocol if Braden score [less than] 18...Turn and/or reposition all patients who are unable to turn themselves in bed, every two hours or sooner if needed...Document all interventions in...plan of care."

Review of the policy "Provision of Care, Treatment and Services #500 C", not dated, revealed "Purpose...To establish, on admission of the patient, a process for an intraprofessional patient assessment, plan of care and ongoing reassessment throughout the episode of care...Care Planning...Documentation will be timely and appropriate according to intraprofessional requirements...All intraprofessional team members will add, update, or resolve problems, interventions or goals related to their specialty."

During an interview on 8/24/16 at 10:15 am the ICU Nurse Manager stated any nurse could update a patient's care plan.

During an interview on 8/24/16 at 10:30 am, when asked about Patient #2's care plan not being updated after the discovery of the pressure injury, Staff #1 said there had been problems with nursing making the care plans current.





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