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Based on medical record review, staff interview, and policy review, the hospital failed to ensure a Registered Nurse (RN) notified the Charge Nurse, and provided skin care interventions in accordance with accepted standards of nursing practice and hospital policy for one of eight records reviewed (Patient (P)1). Failure to follow standards of care could lead to negative outcomes and deterioration of skin integrity for all patients receiving inpatient care at this hospital.


Findings Include:


Review of the hospital policy titled, "Skin Assessment (includes Braden Scale [a numerical scoring system to assign level of risk])/Wound Prevention/Wound Protocols," effective date 07/2014, revealed, "A Wound/Incision Assessment Intervention will be documented on by the RN/LPN [Licensed Practical Nurse], who first observes any skin impairment. Wound treatment will be according to the stage/type of wound. Continuing Assessments [sic] will be made by the RN/LPN and documented daily and with each dressing change ...Document presence of any skin alterations on the Wound/Incision Assessment. Report any changes to the Charge Nurse ...Treatment Measures: are listed according to stage or type of wound. All wounds should be treated and documented as individual sites. Describe the area of skin including location of wounds, size and depth, stage, character of the wound, drainage, color, s/s [signs and symptoms] of infection, dressings, and pressure relieving devices."

Review of the hospital policy titled, "Assessment/Reassessment," effective date 01/2014, revealed, "Reassessments (by RNs) ... are performed and documented using the Nursing Shift Assessment ...Additional problems may be added throughout the patient's course of hospitalization ...Physician and family will be notified upon identification of a change in patient's condition ..."

Review of P1's "Admission Physical Assessment," under "Nursing Shift Assessment" section in the electronic medical record (EMR), showed an admission date of 12/13/21, diagnosis fractured left femur (upper leg bone), and an entry at 3:51 AM under "Integumentary (skin): Symptoms: No Symptoms, Temperature: Warm, Moisture: Dry, Turgor (resilience to touch, showing adequate hydration): Good, Color: Pink, Texture: Intact, Integumentary Concerns: None."

Review of P1's "Nursing Shift Assessment," dated 12/18/21 at 8:57 AM revealed the entry, by Registered Nurse (RN)10 "b/l [sic] blister/pressure injury to b/l [sic] buttocks. Review of the "Nursing Shift Assessment," dated 12/20/21 at 9:00 PM revealed the entry, by RN8, "bursted blisters X 2 on coccyx [tailbone area]. Review of the "Nursing Shift Assessment," dated 12/21/21 at 7:54 AM revealed the entry, by RN9, "Blister on coccyx area."

No documentation was found in the medical record to show that RN 10 notified the physician, the family, or the Charge Nurse of the change in patient condition. No documentation was found of RN 10 initiating any new interventions on behalf of the patient.


During a telephone interview on 02/15/21 at 10:50 AM, RN 10 was unable to recall P1. Upon review of RN10's documentation, RN10 defined the abbreviation "b/l" as "bilateral (both sides)." RN 10 was unable to confirm if any interventions were initiated or if the physician, family, or Charge Nurse, were notified of the patient's change in condition.

During an interview on 02/15/21 at 7:50 AM, RN 8 was unable to recall P1. Upon review of RN8's documentation, RN 8 was unable to confirm if any interventions were initiated or if the physician, family, or Charge Nurse, were notified of the patient's change in condition.

During a telephone interview on 02/15/21 at 11:15 AM, RN9 was unable to recall P1. Upon review of RN9's documentation, RN9 was unable to confirm if any interventions were initiated or if the physician, family, or Charge Nurse, were notified of the patient's change in condition.

During a joint interview with the hospital Risk Manager (RM) and Quality Coordinator (QC) on 02/15/21 at 9:50 AM, the above documentation was reviewed and found to be complete. The RM stated that the hospital expectation and policy require an RN to notify the Charge Nurse of any change in a patient's skin condition and agreed there was no documentation to show any interventions were initiated after discovery of P1's skin breakdown. The RM and QC agreed no documentation was found of a complete description of P1's skin breakdown by the RNs who discovered the wound.

Based on medical record review, staff interview, and policy review, the hospital failed to ensure staff revised the patient's plan of care (POC) after a change in condition for one of eight patient (Patient (P)1) records reviewed. Failure to make revisions to a patients POC as needed could lead to inappropriate nursing care and negative outcomes for all patients receiving in-patient care at this hospital.


Findings Include:


Review of the hospital policy titled, "Skin Assessment (includes Braden Scale [a numeric scoring system used to designate patients' risk level for skin breakdown during a hospital stay]/Wound Prevention/Wound Protocols," effective date 07/2014, revealed, "The patient's plan of care must reflect alterations in the skin integrity or infection. From the data gathered in the initial assessment, the nurse will identify the diagnosis/problems. The nurse adds that diagnosis creating the Care Plan/Plan of Care. The Plan of Care is to be individualized to each patient prior to saving ...These problems or any identified problems can be added anytime throughout the patient's hospitalization ..."

Review of the hospital policy titled, "PIE-O (Problem, Intervention, Evaluation and Outcomes) Documentation System," effective date 06/2017, revealed, "Assessment data is used to identify patient physical, psychosocial/environmental, self-care, safety, and initial discharge planning needs. The nursing diagnoses/problem lists are developed from this information and are documented in the Process Plans/Care Plan. Problems may be added to the list as they are identified."

Review of the hospital policy titled, "Assessment/Reassessment," effective date 01/2014, revealed, "Reassessments (by RNs) ... are performed and documented using the Nursing Shift Assessment ...Additional problems may be added throughout the patient's course of hospitalization."

Review of P1's "Admission Physical Assessment," under "Nursing Shift Assessment" section in the electronic medical record (EMR), showed an admission date of 12/13/21, diagnosis fractured left femur (upper leg bone), and an entry at 3:51 AM under "Integumentary (skin): Symptoms: No Symptoms, Temperature: Warm, Moisture: Dry, Turgor (resilience to touch, showing adequate hydration): Good, Color: Pink, Texture: Intact, Integumentary Concerns: None."

Review of P1's "Nursing Shift Assessment," dated 12/18/21 at 8:57 AM revealed the entry, by Registered Nurse (RN)10 "b/l [sic] blister/pressure injury to b/l [sic] buttocks. Review of the "Nursing Shift Assessment," dated 12/20/21 at 9:00 PM revealed the entry, by RN 8, "bursted blisters X 2 on coccyx [tailbone area]. Review of the "Nursing Shift Assessment," dated 12/21/21 at 7:54 AM revealed the entry, by RN 9, "Blister on coccyx area."

Review of P1's "Problem List" located in the "Care Plans" section of the EMR dated 12/13/21 showed diagnoses including, "Femur Fx (fracture); Pneumonia, and Mobility Impaired." Review of P1's "Problem List Review" located in the "Tasks" section of the EMR, dated from admission until discharge on 12/13/21, showed the problems were reviewed daily, with the exception of 12/19/21 and 12/20/21. Review of P1's POC on the date of discharge, 12/23/21, showed there was no revision to the care plan during P1's hospital stay.

During a telephone interview on 02/15/21 at 10:50 AM, RN 10 was unable to recall P1. Upon review of RN10's documentation, RN10 defined the abbreviation "b/l" as "bilateral (both sides)." RN 10 confirmed P1's POC should have been revised to include skin care interventions after discovery of blisters to the buttocks.

During an interview on 02/15/21 at 7:50 AM, RN 8 was unable to recall P1. Upon review of RN8's documentation, RN 8 confirmed any new skin breakdown required a revision to the patient's POC.

During a telephone interview on 02/15/21 at 11:15 AM, RN 9 was unable to recall P1. Upon review of RN9's documentation, RN 9 confirmed any time a patient assessment revealed new skin breakdown, the patient's POC should be reviewed and updated.

During a joint interview with the hospital Risk Manager (RM) and Quality Coordinator (QC) on 02/15/21 at 9:50 AM, the above documentation was reviewed and found to be complete. The RM stated that the hospital expectation and policy require an RN to review every patient's POC daily on the night shift. The RM agreed P1's POC was not reviewed on 12/20/21 or 12/29/21. The RM stated that any RN can review and update/revise the POC of any patient as new issues arise. The RM confirmed that no change to P1's POC was initiated following the change in P1's skin condition, and therefore no new interventions were employed to care for P1's skin breakdown.

Based on medical record review, document review, staff interview, and policy review, the hospital failed to ensure nursing staff adhered to policies for initiation of interventions for skin breakdown and for incident reporting for one of eight medical records reviewed (Patient (P)1). Failure to follow policies caused inappropriate nursing care and the inability of the hospital's Quality Assurance Performance Improvement (QAPI) department to track events of skin breakdown in the hospital, affecting the quality of care of all patients in the hospital.


Findings Include:


Review of the hospital policy titled, "Skin Assessment (includes Braden Scale [a numeric scoring system used to designate patients' risk level for skin breakdown during a hospital stay]/Wound Prevention/Wound Protocols," effective date 07/14, revealed, "The Physician will be notified when wound therapy is indicated."

Review of the hospital policy titled, "2021 Risk Management Plan," approval date 02/21, revealed, " ...all hospital employees directly involved in the delivery of healthcare services must report any 'reportable incident' occurring at a hospital facility which he or she observed or was involved in, to the Risk Manager, Chief Executive Officer (CEO) or Chief of Medical Staff ...In addition to 'reportable incidents,' all healthcare providers and employees are encouraged to report 'events,' which are defined as: an occurrence that is not consistent with the routine operation of the Facility [sic] or the routine care of a patient."

Review of P1's "Admission Physical Assessment," located under the "Nursing Shift Assessment" section in the electronic medical record (EMR) showed an admission date of 12/13/21, diagnosis fractured left femur (upper leg bone) and an entry at 3:51 AM under "Integumentary (skin): Symptoms: No Symptoms, Temperature: Warm, Moisture: Dry, Turgor (resilience to touch, showing adequate hydration): Good, Color: Pink, Texture: Intact, Integumentary Concerns: None."

Review of P1's "Nursing Shift Assessment," dated 12/18/21 at 8:57 AM revealed the entry, by Registered Nurse (RN)10 "b/l [sic] blister/pressure injury to b/l [sic] buttocks. Review of the "Nursing Shift Assessment," dated 12/20/21 at 9:00 PM revealed the entry, by RN 8, "bursted blisters X 2 on coccyx [tailbone area]." Review of the "Nursing Shift Assessment," dated 12/21/21 at 7:54 AM revealed the entry, by RN 9, "Blister on coccyx area." No documentation was found following these entries of notification of P1's physician of the change in his/her condition.

Review of the hospital's Incident Log entries from 08/05/21 to 02/10/22 revealed no reports related to the discovery of new skin breakdown of P1.

During a telephone interview with on 02/15/21 at 10:50 AM, RN10 was unable to recall P1. Upon review of RN 10's documentation, RN 10 defined the abbreviation "b/l" as "bilateral (both sides)." RN 10 confirmed P1's physician should have been notified and an incident report generated following assessment of new skin breakdown.


During an interview on 02/15/21 at 7:50 AM, RN 8 was unable to recall P1. Upon review of RN8's documentation, RN 8 confirmed any new skin breakdown required notification of the patient's physician and an incident report.

During a telephone interview on 02/15/21 at 11:15 AM, RN 9 was unable to recall P1. Upon review of RN 9's documentation, RN 9 confirmed any time a patient assessment revealed new skin breakdown, the patient's physician should be notified, and an incident report be created.

During a joint interview with the hospital Risk Manager (RM) and Quality Coordinator (QC) on 02/15/21 at 9:50 AM, the above documentation was reviewed and found to be complete. The RM stated that the hospital expectation and policy require an RN to notify the patient's physician in order to decide if new interventions, such as wound therapy, should be ordered. The RM also stated the RN is expected to generate an incident report for any patient injury, which includes new skin breakdown. The RM stated that incident reporting allows the QAPI department to track and trend skin breakdown occurrences in order to study the cause and make improvements to nursing procedures as needed.

Based on medical record review, staff interview, and policy review, the hospital failed to ensure appropriate monitoring of blood administration for three of three patient (Patient (P)1, P6, and P7) who had blood transfusions. Failure to monitor patients during blood transfusions could lead to undetected complications for all patients receiving blood at this hospital.


Findings Include:


Review of the hospital policy provided, titled, "Administration of Blood/Blood Components," effective date 11/19, revealed, "Transfusion Procedure ...Transfusion Vital Signs (temperature, pulse, respirations, and blood pressure) are recorded in the TAR (Transfusion Administration Record) at the following intervals: 1. Before starting transfusion, 2. Five (5) minutes after transfusion is started, 3. Fifteen (15) minutes later, 4. Every 30 minutes thereafter, 5. Upon completion of the transfusion unit."


1. Review of P1's "Physician Orders," dated 02/18/22 in the electronic medical record (EMR) showed an order for transfusion of one unit of packed red blood cells (PRBCs). Review of the "History Record/Transfusions," in the EMR showed the transfusion was started on 02/18/22 at 9:29 PM. Vital signs were not obtained per hospital policy. Vital signs were documented at 9:49 PM, then not again until 46 minutes later at 10:35 PM. Vital signs were documented at 11:00 PM, then not again until 33 minutes later at 11:33 PM.


2. Review of P6's "Physician Orders" dated 02/14/22 in the EMR showed orders for transfusion of two units of PRBCs. Review of the "History Record/Transfusions," in the EMR showed transfusion of the first unit started on 02/14/22 at 10:43 PM. Vital signs were not obtained per hospital policy. Vital signs were documented at 11:33 PM, then not again until 40 minutes after the blood transfusion was started and then not again until one hour and five minutes later, at 12:38 AM on 02/15/22, following the transfusion of the first unit of blood. The second unit blood was started on 02/15/22 at 12:38 AM. Vital signs were documented at 1:06 AM, 28 minutes after the second unit of blood was started and then not again until one hour and twenty-five minutes later at 2:31 AM.


3. Review of P7's "Physician Orders" dated 02/13/22 in the EMR showed orders for transfusion of two units of PRBCs. Review of the "History Record/Transfusions," in the EMR showed transfusion of the first unit was administered per policy on 02/13/22 starting at 9:29 PM and ending at 11:49 PM. Further review showed the second unit of blood was started on 02/14/22 at 2:05 AM. Vital signs were not obtained per hospital policy during the transfusion of the second unit of blood. Vital signs were documented at 3:01 AM, then not again until 46 minutes later at 3:47 AM. Vital signs were then documented at 4:11 AM, the transfusion ended one hour and 43 minutes later at 5:54 AM. Vital signs were not obtained for 2 hours and 49 minutes between the hours of 4:11 AM and 7:00 AM.


During a joint interview with the hospital's Risk Manager (RM) and Quality Coordinator (QC) on 02/16/22 at 12:10 PM, the above documentation was reviewed and found to be complete. The RM and QC confirmed the transfusion vital signs were not obtained per hospital policy.