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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.635 PROVISION OF SERVICES, was out of compliance.

A-1004 Nursing services must meet the needs of patients. Based on document review and interviews the facility failed to provide nursing care to meet the patient needs. Specifically interventions and preventative measures were not performed for three of three patients with a Braden score (an assessment tool used to evaluate skin risk for patients admitted to hospital.), less than 18.

Based on document review and interviews the facility failed to provide nursing care to meet patients' needs. Specifically, interventions and preventative measures specified by facility policy to prevent skin breakdown were not performed according to facility policy for three of three medical records reviewed for patients with a Braden score (an assessment tool used to evaluate skin risk for patients admitted to hospital) less than 18 (Patient 3, Patient #7, and Patient #8 ).

Findings include:

Facility policies:

The Documentation Requirements policy read, all care completed was documented by staff. All documentation was expected to be accurate, timely and complete. A care pathway was selected based on diagnosis and patient care needs. Individualized plans of care were updated throughout hospital stay to reflect the current patient needs. Free text charting was used to document frequent changes in condition and interventions provided.

The Nursing Documentation policy read, required nursing documentation included but was not limited to comprehensive assessment and care plan, daily nurse assessment, and activity assessment. A complete skin assessment was completed upon admission by two nurses and documented in the first four hours of admission. Daily nursing activity will be documented in shift assessments, electronic medication administration record (eMAR) and flowsheets for skilled swing bed patients.

The Hourly Rounding policy read, purposes of the hourly rounding process included but were not limited to decreased risk of skin breakdown and pressure ulcers to improve clinical outcomes. Hourly rounding is alternated between the RN/LPN and the CNA, so each staff member will see the patient every two hours. The rounding will be documented in the Athena charting system. The staff member will address multiple patient needs including position, bathroom needs, and pain. Weekly Hourly Rounding audits will ensure active participation of staff. Feedback and education and changes will be provided to staff at monthly meetings.

The Plan for Providing Nursing Care read, patients were evaluated and examined to determine interventions for abnormal conditions found. Admissions to the Medical/Surgical unit for acute healthcare conditions, needed observations, and medical interventions to prevent complications and promote wellness. Patients were assessed each shift to include additional assessments related to patient specific conditions.

The Pressure Ulcer Prevention and Care policy read, a head to toe examination of the patient's skin was completed upon admission. Skin assessments were to occur daily and as needed. Five interventions were provided to patients which included, a daily Braden Score to determine skin risk level, management of skin moisture and incontinence contamination, nutrition and hydration were monitored and supplemented as needed, patient repositioning every two hours, and pressure reduction and relief interventions. Interventions included; alternating air mattresses, pillows, chair pads, support wedge, heel/elbow pads, and elevated extremities. Braden scores less than 18 required the five interventions daily. Additional interventions included keeping linen wrinkle free to prevent uneven pressure distribution, documenting wound assessment and reporting any change in condition or size of the ulcer to the provider.

The Air Mattress Use policy read, the facility will use an alternating air mattress for patients with a Braden score less than 18. Documentation of air mattress use include, date, time, type of mattress, when applied, reason for use. The effectiveness of mattress intervention included a Braden score each shift and skin assessment.

The General Wound Care for Wounds Using Clean, Aseptic Technique policy read, coordination between nursing and the wound care nurse on who will perform wound care. Documentation of the wound with date, time, size; length, width, depth in centimeters (cm), appearance, complexity, surrounding skin and dressing type. Document patient's comfort and interventions, place the date, time and initials of staff changing the dressing on the dressing. .

1. The facility failed to provide nursing care and interventions according to facility policies for patients who were at risk for skin breakdown or had noted wounds upon admission to the facility.

A. Medical Records

1. Review of Patient #3's medical record revealed Patient #3 was admitted to the facility for COVID-19 with a stage I pressure ulcer wound on 11/5/20. The wound was described as a pea-sized open area to the coccyx.

a. The medical record revealed Patient #3 had documented Braden scores which ranged from 15 on admission on 11/5/20 at 4:10 p.m., to a final Braden score of 11 on 11/12/20 at 6:58 p.m. recorded two days prior to discharge. The medical record further revealed Patient #3 experienced urinary and bowel incontinence and was placed in a disposable brief throughout her hospitalization. The incontinence was documented in the Activities Flowsheet by the RN. As example on 11/7/20 at 1:55 a.m. the RN documented Patient #3 was incontinent in the Activities Flowsheet.

b. According to the facility Pressure Ulcer Prevention and Care policy, Patient #3's wound, decreased skin integrity and Braden scores less than 18 warranted five nursing interventions per day. Nursing staff were to perform a daily Braden Score, reposition the patient every two hours, and perform pressure reduction and relief interventions. According to the policy, additional interventions included an alternating air mattress.

According to the facility Hourly Rounding policy, the patient's position was to be documented every two hours, or 12 times daily.

c. The requirement for two hour turns for patients with skin breakdown and wounds was not met. Daily Braden scores were not charted in the record on five of the ten days of the admission. The Braden score was not recorded on 11/7/20, 11/9/20, 11/11/20, 11/13/20 and 11/14/20.

Continued review of Patient #3's medical record revealed from one to eight times per day the patient had an intervention of either a disposable brief or position change recorded during the hospitalization. This was in contrast to facility policy which required two-hour position changes or brief changes, which totaled 12 interventions daily.

There was no evidence in Patient #3's medical record nursing staff implemented an alternating air mattress to help prevent further skin breakdown during Patient #3's hospitalization. This was in contrast to facility policy.

d. Patient #3's medical record revealed Patient #3's wound progressed from a stage I pressure ulcer to a stage II pressure ulcer during her hospitalization. On 11/10/20 in a Wound Flowsheet the RN documented the size and depth of the wound increased to 1 cm by 1 cm and 0.4 cm in depth.

Similar findings were identified in Patient #7 and Patient #8.

2. Review of Patient #7's medical record revealed the patient was admitted on 10/14/20 for smoke inhalation, an acute urinary tract infection and multiple skin issues. Nursing staff documented on the initial integumentary (skin) assessment a stage I pressure ulcer to her coccyx, which was described as an excoriated area with a 2 cm "I" shaped impairment. In addition, nursing staff documented the following skin issues: Patient #7's groin was excoriated; the patient had scratches on her left groin and bruising to her upper extremities; and she had a hard, raised, painful area on the left shin.

a. The medical record revealed Patient #7 had documented Braden scores which ranged from 13 on 10/14/20 to 18 on 10/16/20 and was scored as a 16 on the day of discharge 10/21/20. Patient #7's record revealed an increased need to be repositioned at night and extensive to total care assistance to clean her perineal area. Patient #7 was also kept in a disposable brief during the hospitalization.

b. According to facility policy, Patient #7's skin conditions and Braden scores less than 18 warranted interventions to include an alternating air mattress and documentation of wound assessment.

c. Patient #3's medical record revealed nursing staff did not implement skin care interventions according to facility policy. There was no evidence in the medical record nursing staff implemented an alternating air mattress. The wound flowsheet was not present to document assessment of Patient #7's wound and follow-up care to existing wounds was not documented in the medical record.

3. Review of Patient #8's medical record revealed the patient was admitted with wound cellulitis (an infection) to the left lower extremity on 1/5/21.

a. The medical record revealed Patient #8 had Braden scores which ranged from 14 to 19 during her hospitalization. Patient #8 had a Braden score of 16 on admission 1/5/21 at 4:16 p.m. The Braden score decreased to 14 on 1/7/20 at 8:00 p.m.

b. According to facility policy, Patient #8's skin condition and Braden scores less than 18 warranted interventions to include an alternating air mattress and to be repositioned every two hours.

c. The use of an alternating air mattress was not documented in Patient #8's medical record. The record revealed on 30 occasions during Patient #8's hospitalization nursing staff did not turn the patient every two hours. Patient #8 should have been turned 12 times on 1/6/21, but was turned three times in the 24 hour period. The total turns documented in the medical record for the next 24-hour period on 1/7/21 revealed of the 12 turns required two were performed.

B. Interviews

1. On 3/2/21 at 2:59 p.m., an interview was conducted with Registered Nurse (RN) #1. RN #1 stated the initial skin assessment was completed in the first four hours of the patient's admission. RN#1 stated if a wound was found the RN notified the provider or wound care RN to receive wound care orders and interventions. RN #1 stated the RN could also request orders for interventions to prevent further skin breakdown. RN #1 stated alternating air mattresses were available for bed bound patients who needed frequent rotation in position or patients whose Braden score had decreased. RN #1 stated the documentation for interventions was found in the wound care flowsheet.

RN#1 stated disposable briefs were worn by patients who were mobile. RN #1 stated if an incontinent patient had a wound, a flat pad was used to prevent pressure to the wound and to allow for air to reach any excoriated area. This was in contrast to Patient #3's medical record, which revealed Patient #3 was placed in a disposable brief with an open wound to her coccyx, when a flat pad should have been used. RN #1 stated it was important to keep wounds dry as moisture increased bacterial growth and decreased wound healing.

2. On 3/3/21 at 9:30 a.m., an interview was conducted with RN #2. RN #2 stated if a patient was incontinent it was important to keep the skin and wound dry and to closely monitor the wound to prevent wound decline. RN #2 stated skin care interventions such as an alternating air mattress, egg crate cushions or mattress pads, barrier cream or Calmoseptine, a provider prescribed cream could be added to the patient's skin regimen. RN #2 stated nursing staff documented skin care interventions in the Activities of Daily Living (ADL) flowsheet.

RN #2 stated RNs tried to keep less items under patients with wounds to prevent bunching and uneven pressure areas which could increase pressure to a patient's skin. RN #2 stated the purpose of the alternating air mattress was to turn the patient automatically, which assisted staff to prevent the patient's skin from breakdown.

3. On 3/2/21 at 12:25 p.m., an interview was conducted with Certified Wound Care Registered Nurse (Wound RN) #3. Wound RN #3 stated notes for wound care interventions were recorded in the Nurses Notes and Wound flowsheets. Wound RN #3 stated disposable briefs were for patients who could independently reposition. Wound RN #3 stated if a patient wore disposable briefs it was important to verify further damage to the patient's skin did not occur. She stated wounds needed air and to be protected from urine and stool. This was in contrast to Patient #3's medical record, which revealed although the Patient wore a disposable brief, nursing staff did not monitor the patient to ensure further damage did not occur.

Wound RN #3 stated an RN who found a wound was expected to follow up with the provider and the wound care RN to obtain orders for interventions and care.

4. On 3/2/21 at 3:27 p.m., an interview was conducted with Family Nurse Practitioner (FNP) #4. FNP #4 stated patients who were unable to turn independently needed to be turned every two hours and checked for moisture. FNP #4 stated the RN was expected to assess the wound each shift. This was in contrast to review of Patient #3, Patient #7 and Patient #8's medical records, which revealed the patients were not turned every two hours, and the RN did not assess the wound each shift.

5. On 3/3/21 at 10:17 a.m., an interview was conducted with Nursing Manager (Manager) #5. Manager #5 stated interventions available for patients with Braden scores below 18 included egg crate cushions, dressings, heel protectors or pillows to relieve pressure to patient skin. Manager #5 stated alternating air mattresses were available and could be programmed to rotate the patient from side to side. Manager #5 stated when Certified Nursing Assistants (CNAs) and RNs repositioned a patient every two hours, they were expected to document the repositioning in the Nursing notes or ADL flowsheets.

Manager #5 reviewed the medical records for Patient #3, Patient #7 and Patient #8. Upon review of the records Manager #5 was unable to find evidence nursing staff repositioned the patients every two hours according to facility policy.