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Based on medical record (MR) review, document review, and interview, the facility failed to discuss changes in the patient's condition with the patient and/or representative. This finding was evidenced in two (2) of nine (9) medical records reviewed (Patient #3, #4).

MR review revealed Patient #3 was admitted to the facility on 8/24/24 for altered mental status and low blood count. The patient was transfused and was admitted for further evaluation. On 10/2/24 at 7:30 AM, the assigned nurse documented a new stage 2 pressure injury that was not present on arrival. The wound was located on the middle sacrum. On 10/7/24 at 3:10 PM, the Wound Care Nurse (WCN) documented a Nursing Note stating the wound to be a deep tissue pressure injury that was not present on arrival.

MR review revealed Patient #4 was admitted to the facility on 10/9/24 for a sternal fracture after a fall. The patient was admitted for further evaluation and monitoring. On 10/19/24 at 7:00 AM, the assigned registered nurse (RN) documented a new unstageable pressure injury measuring two (2) centimeters by two (2) centimeters that was not present on admission and documented that the doctor was notified.

There was no documented evidence that the findings of the pressure injuries were discussed with the patient or designated family member for Patient #3 or #4.

The facility's booklet, "Your Rights as a Hospital Patient in New York State" (last revised 3/2023), provided to all patients upon admission stated, "As a patient in a hospital in New York State, you have the right, consistent with the law, to Receive complete information about your diagnosis, treatment, and prognosis."

During an interview with Staff Z (Physician) on 2/7/25 at 1:42 PM, Staff Z stated that he did not recall if Patient #3 had a pressure injury and did not recall discussing the pressure injury with the patient's family member. He stated that he would typically receive a notification from the nurse to inform him of a new wound and would typically go examine the patient after receiving the notification, but he could not recall if this occurred for this patient.

During an interview with Staff X (Physician) on 2/7/25 at 12:21 PM, Staff X stated that he did not recall if Patient #4 had a pressure injury. He said that four (4) providers care for the patient as a team and that it could be possible that another member of the team was aware. Staff X did not recall speaking to the patient's family regarding the wound.

Based on medical record review, document review, and interview, it was determined that the nursing staff did not ensure prompt identification of pressure injuries. These findings were evidenced in two (2) of nine (9) records of patients with pressure ulcers (Patient #3, #4).

Findings include:

The facility's policy, "Pressure Injury Protocol: Assessment, Prevention & Management" (last revised 11/2022), states, "A head-to-toe skin assessment and risk assessment shall be completed on admission, every shift, and as indicated by the patient's condition."

Patient #3 was admitted to the facility on 8/24/24 for altered mental status and low blood count. The patient was transfused and was admitted for further evaluation.

The initial nursing assessment for Patient #3 on 8/25/24 at 4:28 AM identified the patient as being at high risk for developing a pressure injury, as evidenced by a Braden Score (clinical tool for predicting pressure injury risk) of 12. There was no sacral pressure injury present on admission.

The daily nursing assessments for Patient #3 failed to identify changes in the patient's skin condition. The patient's sacral pressure injury was identified on 10/2/24 at 7:30 AM as a stage II injury, but it was later documented by the wound care nurse on 10/7/24 at 3:10 PM in a later stage of development as a deep tissue pressure injury measuring seven (7) centimeters in length, eight (8) centimeters in width, and unknown depth. No assessment or treatment was documented for the pressure injury before 10/2/24.

These findings were acknowledged by Staff Y on 2/7/25 at 12:46 PM. During an interview with Staff Y (RN) on 2/7/25 at 12:46 PM, Staff Y was asked regarding the initial documentation of the wound by the primary nurse staged as a stage II versus her assessment as a deep tissue injury. She explained that the wound had an area in the middle with some open skin, which could be mistaken for a Stage II, but her assessment of the sacral area was that the small open area was surrounded by maroon and non-blanchable skin, which would classify the patient's wound as a deep tissue injury.

Patient #4 was admitted to the facility on 10/9/24 for a sternal fracture after a fall. The patient was admitted for further evaluation and monitoring.

The initial nursing assessment for Patient #4 on 10/9/24 at 10:10 AM identified the patient as being at moderate risk for developing a pressure injury, as evidenced by a Braden Score of 14. There was no thoracic pressure injury present on admission.

The daily nursing assessments for Patient #4 failed to identify changes in the patient's skin condition. The patient's thoracic pressure injury was identified on 10/19/24 at 7:00 AM as an unstageable pressure injury measuring two (2) centimeters in length, two (2) centimeters in width, and zero (0) centimeters in depth. No assessment or treatment was documented for the pressure injury before 10/19/24.

During an interview with Staff W (RN) on 2/7/25 at 12:00 PM, Staff W could not recall the patient but referred to her documentation in her nursing note. Staff W acknowledged the surveyor's findings.