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A. Based on document review and interview, it was determined for 2 of 3 (Pt. #1 and Pt. #9) patients with hospital acquired pressure ulcers, the Hospital failed to ensure skin interventions were put into place for patients identified to be at risk.

Findings include:

1. The Hospital's policy titled, "Skin-Wound Assessment and Documentation (revised 9/1/13)" was reviewed on 3/4/19 and required, "A registered nurse will perform: 1. Braden Risk assessment and skin assessment for all patients on admission. Patients with Braden score of 18 or less are considered at risk. Appropriate pressure ulcer prevention measures will be initiated. Braden risk assessment is performed: a. Acute care - every 24 hours."

2. The clinical record of Pt. #1 was reviewed on 3/4/19. Pt. #1 was an 86 year old male, admitted on 9/14/18, with the diagnoses of fever and urinary tract infection, from a nursing home. A nursing flow sheet entry, dated 9/15/18 at 9:45 AM, included a Braden score of 15 (high risk for pressure ulcer). Nursing orders for interventions were not entered into the computer until 9/17/18 for the at risk Braden score of 15, identified on 9/15/18 (2 days later).

3. The clinical record for Pt #9 was reviewed on 3/5/19. Pt #9 was admitted to the Hospital's 4 Northwest telemetry unit on 9/26/18 with a diagnosis of aspiration pneumonia. The nursing admission skin assessment, dated and timed 9/26/18 at 6:58 AM, included that Pt #9's skin was intact with bruising, and Pt #9 had a Braden risk score of "15" (at risk for pressure ulcer). Nursing notes indicated that the only intervention for Pt #9 regarding skin was elevating heels off of the bed. Nursing notes documented that a right gluteal (buttock) stage II pressure ulcer (skin breakdown where the skin is broken) was identified during Pt #9's skin assessment, dated 9/30/18. Pictures were taken of the wound at the time of identification on 9/30/18, and a foam dressing was applied. Pt #9's clinical record indicated that no skin/wound interventions were ordered by the physician or nursing in response to the initial Braden score of "15" or following the identification of the pressure ulcer on 9/30/18.

4. During an interview on 3/4/19 at 2:30 PM, the Wound Nurse (E#1) stated, "There is an order set with skin interventions, in the computer, for the nurses to use for any patient that is at risk for a pressure ulcer. The order set is required to be used for any patient with a Braden score of 18 or less or if wound is identified, to prevent skin breakdown or further breakdown."

B. Based on document review and interview, it was determined that for 1 of 6 (Pt. #1) patients with pressure ulcers, the Hospital failed to ensure wound assessments, including measurements, and photographs were taken when identified.

Findings include:

1. The Hospital's policy titled, "Skin-Wound Assessment and Documentation (revised 9/1/13)" was reviewed on 3/4/19 and required, "A registered nurse will perform: ...Assessment and documentation of wounds/lesions "present-on-admission" and "hospital-acquired," upon identification, will include the following, as indicated: a. location of wound; b. type of wound; c. pressure ulcer stage; ... e. measure in cm ... h. wound bed appearance ... 6. Photography of pressure ulcers ... upon admission and upon identification of new wounds ..."

2. The clinical record of Pt. #1 was reviewed on 3/4/19. Pt. #1 was an 86 year old male, admitted on 9/14/18, with the diagnoses of fever and urinary tract infection, from a nursing home. The nursing admission skin assessment, dated 9/14/18 at 10:10 PM, included, "skin integrity: scars, incisions, pressure ulcers." The description was carried over from a previous admission and lacked updated information. The clinical record included pictures of all wounds, dated 9/18/18 at 10:47 AM (4 days after admission when first identified).

3. During an interview on 3/4/19 at 2:30 PM, the Wound Nurse (E#1) stated, "A photograph of every wound is required, upon identification, so we can monitor the progress of the wound."

Based on doument review and interview, it was determined that for 2 of 3 (Pt #4 and Pt #12) clinical records reviewed for patients who received blood transfusions, the Hospital failed to ensure blood was administered in accordance with policy.

Findings include:

1. The Hospital's policy titled, "Transfusion Adminisration of Blood/Blood Component" (reviewed by the Hospital on 9/5/17) was reviewed on 3/4/19 and required, "... TRANSFUSION PREPARATION/PROCEDURE...,. Take and record vital signs minimally 5-15 minutes prior to starting the transfusion as a baseline for subsequent comparison...q. Take and record vital signs 15 minutes after the initiation of transfusion then hourly during transfusion and at completion. Hourly is from when the blood is initiated..."

2. The clinical record for Pt #4 was reviewed on 3/4/19 at approximately 11:30 AM and included that Pt #4 was a 78 year old male who was admitted to the Hospital's Orthopedic Unit (2 West) on 2/28/19 with a diagnosis of left hip fracture. Physician's orders, dated 3/3/19, included orders for the transfusion of 2 units of packed red blood cells (PRBC).

- The blood transfusion record for the first unit of PRBC for Pt #4 indicated that the transfusion was started on 3/3/19 at 12:00 PM. Pt #4's vital signs were recorded at 11:55 AM (5 minutes prior to start time), 12:15 PM (15 minutes after start time), 12:30 PM (30 minutes after start time), 1:00 PM (1 hour after start time), and 2:00 PM (hourly from start time). The blood transfusion record included that the completion of the transfusion of the first unit of blood was at 3:00 PM. However, the transfusion record lacked documentation of vital signs at the completion of the transfusion (at 3:00 PM).

- The blood transfusion record for the second unit of PRBC for Pt #4 indicated that the transfusion was started on 3/3/19 at 4:25 PM. Pt #4's vital signs were recorded at 4:25 PM (start time of transfusion), 5:00 PM (35 minutes after start time), 6:00 PM (one hour after the previous set of vitals, not one hour after start time), and at 8:00 PM (2 hours after previous set of vital signs). The transfusion record lacked completion of the vital signs 15 minutes after the start of the transfusion, hourly from the start time of the transfusion, and at the completion of the transfusion. The transfusion record also lacked documentation of the completion time of the transfusion.

3. The clinical record for Pt #12 was reviewed on 3/5/19 and included that Pt #12 was a 37 year old male, admitted on 1/7/19, with a diagnosis of wound evaluation. Physician's orders, dated 1/8/19, included orders for the transfusion of 1 unit of PRBC.

- The blood transfusion record indicated that the transfusion was started on 1/8/19 at 9:15 PM. Pt #12's vital signs were recorded at 8:50 PM (25 minutes prior to start time of transfusion), 9:30 PM (1 hour and 15 minutes after the blood was initiated), 10:30 PM (hourly from last set of vital signs), 11:30 PM (hourly from last set of vital signs), and at 12:41 AM on 1/9/19 (one hour and 11 minutes from last set of vital signs/completion time). The blood transfusion record indicated that the transfusion completion time was 12:41 AM on 1/9/19. The transfusion record lacked documentation of the vital signs 5-15 minutes prior to the transfusion start time and hourly from the start time.

4. On 3/4/19 at approximately 11:40 PM, an interview was conducted with the 2 West Charge Nurse (E #2). E #2 stated that the vital signs for Pt #4 should have been completed at the start time of the transfusions, 15 minutes after the start times, hourly during the transfusions, and at the completion of the transfusions. E #2 stated that the transfusion completion time should have been recorded on the transfusion record for Pt #4's second unit of PRBC.

5. On 3/6/19 at approximately10:00 AM, an interview was conducted with the Director of Quality and Patient Safety (E #7). E #7 stated that the vital signs should be recorded at the start of the transfusion, fifteen minutes after start, hourly during transfusion, and at completion of the transfusion.