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Based on record review, and interviews the facility failed to provide nursing services in an organized manner when (4) four out of (10) ten patients identified as having altered skin integrity on admission, did not have an initial nursing skin assessment. This failure to assess the patient's wounds, places patients at risk of, a delay and implementation of preventative measures to prevent further skin breakdown, infections, and pain.

Findings include:

Review of the facility provided policy, "Tissue and Pressure Ulcer Management "(revised 6/3/2021) reflected,
Policy: Guidelines are established to:
o Identify patients at risk for developing tissue integrity issue and/or a pressure ulcer
o Institute pressure redistribution interventions appropriate to level of risk
o Ensure comprehensive assessment, documentation, and accurate description of pressure ulcer
o Ensure uniform terminology for documentation
Procedure:
I. Assessment
A. Initial assessment of tissue integrity is completed during the nursing admission assessment and is to include the completion of the Braden Risk Assessment Scale (adult) to identify risk factors for development of tissue integrity alterations. The Braden-Q Scale will be used for pediatric patients.
B. At the time of the patient admission, the RN will ensure:
1. Objective assessment data collection that is based on a systematic tissue assessment including:
a. Tissue Color
Describe the color of the tissue. Include any notation of cyanosis, jaundice, pallor, bruising, uneven pigment distribution, or any area of discoloration.
b. Tissue Condition, especially over bony prominences
Describe the condition of the tissue. Include the intactness, temperature, moisture /dryness; consider the turgor, elasticity; note any break in tissue integrity and/or trauma such as abrasions, tissue tears, insect or other bites, edema, surgical or other wounds including pressure ulcers; note any scars and any areas with exudate and describe.
c. Identify Effectiveness of Tissue Care
Describe the cleanliness, any odors, observe bony prominence for evidence of pressure.
d. Inspection Under Dressings
Any dressing found at the time of admission will be removed (utilizing appropriate technique in accordance with standards of care) and the condition of the tissue covered by the dressing will be assessed and documented.
e. Wound VAC must be removed, unless patient has orders for no removal, consult Wound Care Nurse.
2. Wound Care Consultation
a. A request for consultation for the Wound Care Nurse will be entered in the computer upon completion of the admission assessment for all patients admitted with the existing pressure ulcer State II or greater or non-healing wounds. Patients assessed with pressure ulcers greater than Stage II will require physician notification. Patients with a Braden Scale total of 18 or less (moderate risk), <+ 25 on Braden Q scale for pediatrics, neonatal/infant Braden Q score of 19 or less for birth to one year or have a history of pressure ulcer will have Tissue Load Management
nursing protocol initiated.
b. The Wound Care Nurse will assess the patient wounds and assist with the plan of care and which nursing protocols are applicable. Additional consultation with the medical staff may be indicated and will be initiated by the Wound Care nurses as requested or indicated.

ADMISSION OF A PATIENT" (updated 4/1/2021) reflected,
"I. SCOPE:
This policy applies to all departments at the Hospitals of Providence Memorial Campus with nurses that obtain a patient history and/or completed an initial admission assessment.

II. PURPOSE:
To ensure a systematic approach to the comprehensive assessment of the patient's physical, emotional, cultural, social history, and educational and functional needs, through thorough investigation, observation and physical examination.

III. POLICY:
An interdisciplinary approach is utilized upon admission of a patient to all inpatient units. Reassessment of initial screening need to be completed after initial Pre-Assessment Testing (PAT) screening for all surgical procedures. Initial screens should be completed to include:

1. General information (chief complaint, advanced directives, etc.)
2. Medical and procedural history
3. Communication preferences
4. Cultural/spiritual preferences
5. Functional level
6. Infectious disease history
7. Pain history
8. Psychosocial aspects
9. Social aspects
10. Nutritional screen
11. Abuse/neglect assessment
12. Physical assessment
13. Suicide Assessment
14. Vaccination status
15. Home Medications ..."

Patient #1

Review of Patent #1's medical records revealed a 66-year-old- female, admitted on 10/07/23 with a Braden score of 14.

Review of the Emergency Department Physician's note dated 10/07/23, reflected a Stage 1 to the sacrum.

Review of the Wound Care note, dated 10/08/23, revealed a left elbow skin tear that measured 1 cm (centimeter) x 1.7 cm and Psf (foam barrier) was also applied to bony prominence of the sacrum. The wound care team did not take a photograph of this wound.

Review of the nurse's skin assessments revealed the wound was not identified or documented on until 10/09/23, the skin was documented as pink, clean and dry.

During an interview, on the afternoon of 10/30/23, Staff #1, CNO (Chief Nursing Officer) confirmed the nurses had not started documenting on the wound until 10/09/23.

Patient #8

Review of Patient #8's medical records reflected a 79-year-old male admitted on 10/20/23 with a Braden score of 13.

Review of the Initial nursing assessment, dated 10/20/23 at 9:47 pm, did not include an assessment of the right or left heel.

Review of the wound care nurse's notes, dated 10/21/23, reflected the left heel as being 2.5 cm x 2.3 cm, unstageable, and did not mention the right heel being at risk.

Review of the facility provided skin photographs taken by the wound care nurse, dated 10/23/23, reflected the left heel to be reddened with a blackened unstageable wound, the right heel was visible and was also reddened and at risk of breaking down.

Patient #5

Review of Patient #5's medical records reflected a 67-year-old female admitted on 10/25/23 with a Braden score of 17.

Review of the facility provided skin photographs taken by the wound care nurse, dated 10/30/23, reflected an approximately 1.5 cm x 1 cm wound, the photo was unclear where the wound was located. The wound had a yellowish scab with darkened reddened edges around the wound.

Review of the nurse's skin assessments revealed the wound was present on 10/25/23 the day of arrival. A description of the wound was not provided until 10/27/23; the care or treatments that were provided to the wound were not documented until 10/27/23.

Review of the physician's orders revealed the wound care was addressed on 10/27/23.

During an interview, on the afternoon of 10/30/23, when asked if the nurses were following standing protocol orders for the care of the wound prior to 10/27/23, Staff #1 CNO stated, "We do not have standing protocols. They (the nurse) should have called the physician for orders."

Patient #7

Review of Patient #7's medical records reflected an 84-year-old male, admitted on 10/20/23, with a Braden score of 16.

Review of the Initial nursing assessment, dated 10/20/23 at 1:00 pm, reflected, "other: pale appearance wound to right foot, clean dry and intact dressing in place." The assessment did not include a description of the wounds.

Review of the facility provided skin photographs taken by the wound care nurse, dated 10/23/23, reflected the following:
- An unstageable right foot ulcer. The right lateral foot had a blackened wound with skin sloughing that measured approximately 7 cm x 2 cm. The right foot had a blackened, unstageable, wound that covered approximately 8 cm x 5 cm. The top of the wound had a beefy red area of approximately 1 cm. The right heel had a dark brown scabbed area with sloughing skin edges and appeared to be reddened around the outer edges of the scab.
- Sacral wounds to the right and left cheeks, approximately 1 cm x 1 cm, the area had dry scaly skin surrounding the wounds and the areas on both the cheeks had large purple and pink skin, indicative of previous damaged skin. The left cheek had two wounds, one with a beefy red center, the other was covered with loose sloughing skin.

Review of the physician's orders reflected orders were placed on 10/23/23, after the wound care nurse assessed the wounds.

During an interview, on the afternoon of 10/30/23 in the administrative office, when asked how the nurse's provide wound care, Staff #2, Patient Safety Director, stated, "I used to be the wound care nurse. The nurses use us as a resource, if they have a wound that they are not sure of, they will reach out for a consult. The wound care team is not available on the weekends. If a patient comes in on a Friday the consult will go in, then we would see them on Monday. Mondays are very busy; we are trying to catch up on the new admissions."
When asked how the nurses care for wounds that do not have a physician's order, Staff #2 stated, "They (the nurses) do whatever they think they need to care for the wound until they (the patient) are seen by the wound care nurse. This usually only happens on the weekends; wound care is not here on the weekends. Many times, we already know they are coming and will order specialty mattresses prior to their arrival. If it is a complicated wound, they will call the physician."