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Based on record review and interviews, facility staff failed to perform nursing assessments, interventions, and evaluate patient skin care needs to prevent skin breakdown in 4 of 10 medical records reviewed (Patient (Pt) #1, 2, 5, 6), in a total sample of 10 medical records reviewed and 2 of 7 interviews (Registered Nurse (RN) D, Family A), in a total sample of 7 interviews; failed to ensure that nursing care plans were opened to address skin/wound care needs in 2 of 10 medical records reviewed (Patient (Pt) #8, #10); failed to ensure nursing care plans are kept current and updated based on patient assessments in 3 of 10 medical records reviewed (Patient (Pt) #1, #5, #6); and failed to ensure that nursing interventions are implemented based on ongoing assessments of patient care needs in 3 of 10 medical records reviewed (Pt #1, #5, #6), in a total of 10 medical records reviewed.

Findings Include:

The facility staff failed to perform nursing assessments, interventions, and evaluate patient care needs to prevent skin breakdown. See Tag A-0395.

The facility staff failed to ensure that nursing care plans were opened to address skin/wound care needs; failed to ensure nursing care plans are kept current and updated based on patient assessments; and failed to ensure that nursing interventions are implemented based on ongoing assessments of patient care needs. See Tag A-0396.

Based on record review and interviews, facility staff failed to perform nursing assessments, interventions, and evaluate patient skin care needs to prevent skin breakdown in 4 of 10 medical records reviewed (Patient (Pt) #1, 2, 5, 6), in a total sample of 10 medical records reviewed and 2 of 7 interviews (Registered Nurse (RN) D, Family A), in a total sample of 7 interviews.

Findings Include:

Review of policy and procedure titled, "Ascension Wisconsin Skin Assessment & Pressure Injury Prevention" last revised on 10/22/2024 revealed:
- "A nurse will conduct a skin assessment on in-scope patients upon admission, every shift, and with any change in condition...Identification of an individual's risk for skin breakdown will be identified utilizing the Braden Scale Skin Risk Assessment Tool. If a patient is found to be at risk, with a Braden score of 18 or lower, pressure injury prevention measures will be put into place..."
- "Braden Scale--For Predicting Pressure Score Risk...High Risk: Total score 10-12...Moderate Risk: Total score 13-14...Mild Risk: Total score 15-18."
- "Document all assessments and plan of cares in the electronic health record per facility policy.
- "B. Surface...3. Utilize devices that minimize friction/shear (multi layer foam dressings...)...C. Keep Turning...1. Reposition/turn patients with limited mobility...D. Incontinence Management...3. Clean and dry the skin after incontinence episodes and apply protective skin barriers to protect and maintain skin integrity..."

Review of policy and procedure titled, "Basic Wound Care and Pressure Injury Treatment" last revised 06/30/2022 revealed:
- "Wound measurements (length x width x depth) should be performed on admission, weekly, and at discharge per facility recommendations."
- "If patient is at risk for or develops a pressure injury, the proper plan of care, including repositioning and pressure relief interventions, needs to be initiated."
- "CWOCN (Certified Wound Care Nurse) consult must be initiated for any hospital acquired pressure injury."
- "Stage 1--Intact skin with non-blanchable erythema (redness)...Provide pressure relief and repositioning...If friction and shear are a factor, consider placing a foam boarder dressing to protect the area (skin integrity to be assessed daily beneath dressing and documented accordingly)...CWOCN consult not indicated unless hospital acquired or shows signs of deterioration."
- "Stage 2--Partial-thickness skin loss with exposed dermis or serum (clear) filled blister...If dermis is exposed, normal saline or wound cleanser...cover with foam boarder dressing-change every 3 days and as needed."

Pt #1:

Review of Pt #1's medical record revealed Pt #1 was admitted as an inpatient on 01/27/2025 at 12:41 AM with a diagnosis of Acute hypoxic respiratory failure, COPD (Chronic Obstructive Pulmonary Disease), and shortness of breath; Pt #1 was discharged to a skilled nursing facility for rehabilitation (Rehab) on 02/18/2025 at 2:19 PM.

Review of Pt #1's nursing flowsheets revealed Pt #1's admission Braden Scale was documented as a "12" (High Risk) on 01/27/2025 at 1:00 AM and 8:00 PM.

Review of Pt #1's admission nursing skin assessment on 01/27/2025 at 1:00 AM revealed, "Coccyx redness blanchable intact."

Review Pt #1's wound nursing flowsheets revealed a "Pressure Injury Bilateral Sacrum," was "first assessed" on 02/07/2025 at 9:56 PM (11 days after admission). The wound was documented as a "Pre-Existing Wound (before admission)." No wound measurements were documented on identification as per policy.

Review of Wound Nurse progress note dated 02/10/2025 at 9:59 AM, revealed that Pt #1's "Pressure Injury Bilateral Sacrum" was a "suspected deep tissue injury," measuring 3 centimeters (cm) (length) x 3.2 cm (width). The wound nurse progress note revealed, "Deep tissue injury to the bilateral sacral area due to intact and open areas of purple and maroon discoloration. Left sacrum has a stage II pressure injury due to open moist areas with minimal depth and non-blanchable erythema. The wound care plan for the sacrum revealed to "cleanse with soap and water...Apply sacral foam border...change dressing every 3-5 days and when saturated...Reposition every 2 hours while in bed..."

Review of Pt #1's Mobility flowsheet data from 01/27/2025 through 02/16/2025 revealed the following documentation of repositioning:
-On 01/27/2025 staff repositioned Pt #1 at 8:00 AM, there was no documented evidence of repositioning again until 11:53 AM (3 hours and 53 minutes later).
-On 01/29/2025 staff repositioned Pt #1 at 4:00 PM, there was no documented evidence of repositioning again until 8:00 PM (4 hours later).
-On 01/30/2025 staff repositioned Pt #1 at 2:00 AM, there was no documented evidence of repositioning again until 8:00 AM (6 hours later).
-On 01/31/2025 staff repositioned Pt #1 at 8:00 AM, there was no documented evidence of repositioning again until 12:00 PM (4 hours later).
-On 02/02/2025 staff repositioned Pt #1 at 4:00 PM, there was no documented evidence of repositioning again until 8:00 PM (4 hours later).
-On 02/03/2025 staff repositioned Pt #1 at 4:00 PM, there was no documented evidence of repositioning again until 8:00 PM (4 hours later).
-On 02/04/2025 staff repositioned Pt #1 at 4:00 PM, there was no documented evidence of repositioning again until 8:00 PM (4 hours later).
-On 02/05/2025 staff repositioned Pt #1 at 8:00 AM, there was no documented evidence of repositioning again until 12:00 PM (4 hours later).
-On 02/10/2025 staff repositioned Pt #1 at 8:30 AM, there was no documented evidence of repositioning again until 1:39 PM (5 hours and 9 minutes later).
-On 02/11/2025 staff repositioned Pt #1 at 12:00 AM, there was no documented evidence of repositioning again until 5:35 PM (5 hours and 35 minutes).
-02/15/2025 staff repositioned Pt #1 at 2:00 AM, there was no documented evidence of repositioning again until 8:00 AM (6 hours).

Review of Pt #1's Mobility flowsheet revealed that there was no documented evidence of staff repositioning Pt #1 every 2 hours to address the risk for pressure injury and skin breakdown as per policy and per Pt #1's Braden Scale assessment (high risk).

Per Pt #1's wound/skin assessments, the redness to the coccyx on admission (01/27/2025) worsened to a Stage II sacrum pressure injury (02/07/2025), which led to a Wound Nurse consult on 02/10/2025.

Per review of Pt #1's "Pressure Injury Bilateral Sacrum" wound nursing assessments from 02/10/2025 to 02/17/2025, there was no documented evidence of nursing staff performing a wound assessment and interventions on every shift (day shift 7:00 AM to 7:00 PM and night shift 7:00 PM to 7:00 AM) (as per policy) on 02/10/2025, 02/11/2025, 02/12/2025, 02/13/2025, 02/14/2025, 02/15/2025, 02/16/2025, and 02/17/2025.

Per interview with Family A on 04/16/2025 at 2:46 PM, Family A stated that he was at the hospital with Pt #1 frequently and did not observe staff consistently turning Pt #1 every 2 hours. Family A stated that Pt #1 was discharged with a pressure injury that she did not have on admission due to "neglect." Family A stated that Pt #1 was transferred to a rehab facility where she continued to have a lot of pain as a result of the pressure injury.

Pt #2:

Review of Pt #2's medical record revealed Pt #2 was admitted as an inpatient on 03/30/2025 at 11:56 PM with a diagnosis of altered mental status and liver failure; Pt #2 was an inpatient at the time of medical record review on 04/10/2025.

Review of Pt #2's nursing flowsheets revealed Pt #2's admission Braden Scale was documented as a "12" (High Risk for skin breakdown) on 03/31/2025 at 12:00 PM.

Review of Pt #2's Mobility flowsheet data from 03/31/2025 through 04/10/2025 revealed the following documentation of repositioning:
-On 04/02/2025 staff repositioned Pt #2 at 8:00 AM, there was no documented evidence of repositioning again until 5:00 PM (9 hours).
-On 04/03/2025 staff repositioned Pt #2 at 8:00 AM, there was no documented evidence of repositioning again until 12:00 PM (4 hours).
-On 04/04/2025 staff repositioned Pt #2 at 8:50 AM, there was no documented evidence of repositioning again until 1:16 PM (4 hours 26 minutes).
-On 04/05/2025 staff repositioned Pt #2 at 2:00 PM, there was no documented evidence of repositioning again until 04/06/2025 at 8:00 AM (18 hours).

Review of Pt #2's Mobility flowsheet revealed that there was no documented evidence of Pt #2 repositioning every 2 hours to address the risk for pressure injury and skin breakdown as per policy and per Pt #2's Braden Scale assessment (high risk).

Pt #5:

Review of Pt #5's medical record revealed Pt #5 was admitted as an inpatient on 04/02/2025 at 10:56 PM with a history of quadriparesis (muscle weakness of arms and legs), cerebral palsy (neurological disorder that affects movement, balance, and posture), and a chief complaint of altered mental status; Pt #5 was an inpatient at the time of medical record review on 04/10/2025.

Review of Pt #5's nursing flowsheets revealed Pt #5's admission Braden Scale was documented as a "11" (High Risk for skin breakdown) on 04/03/2025 at 9:29 AM.

Review of Pt #5's wound flowsheet data revealed Pt #5 was admitted with a "Left Medial Buttocks" wound, "a Left Ischium Pressure Injury," and a "Left Mid Buttocks" pressure injury. There was no documented evidence of nursing wound assessments and/or interventions on night shift 04/05/2025 and day shift 04/06/2025.

Review of Pt #5's Mobility flowsheet data from 4/02/2025 through 04/10/2025 revealed the following documentation of repositioning:
-On 04/07/2025 staff repositioned Pt #5 at 1:18 PM, there was no documented evidence of staff repositioning again until 8:49 PM (7 hours and 31 minutes).
-On 04/08/2025 staff repositioned Pt #5 at 3:00 AM, there was no documented evidence of staff repositioning again until 7:00 AM (4 hours); repositioned at 8:29 AM and then not again until 12:44 PM (4 hours and 5 minutes); repositioned at 12:44 PM then not again until 4:55 PM (4 hours and 11 minutes).
-On 04/09/2025 staff repositioned Pt #5 at 11:00 AM, there was no documented evidence of staff repositioning again until 4:00 PM (5 hours); repositioned at 4:00 PM then not again until 9:23 PM (5 hours and 23 minutes).

Review of Pt #5's Mobility flowsheet, revealed that there was no documented evidence of staff repositioning Pt #5 every 2 hours to address the pressure injuries and skin breakdown as per policy and per Pt #5's Braden Scale assessment (high risk).

Pt #6:

Review of Pt #6's medical record revealed Pt #6 was admitted as an inpatient on 03/31/2025 at 2:20 PM with an abdominal wound, Pt #6 suffers from severe autism and is non-verbal; Pt #6 was an inpatient at the time of medical record review on 04/10/2025.

Review of Pt #6's nursing flowsheets revealed Pt #6's admission Braden Scale was documented as a "13" (Moderate Risk for skin breakdown) on 03/31/2025 at 4:31 PM.

Review of Pt #6's wound flowsheet data revealed Pt #6 was admitted with a "Right Sacrum Pressure Injury." There was no documented evidence of wound assessments and/or interventions on the day and night shifts for the following days; 04/02/2025, 04/03/2025, 04/04/2025, 04/05/2025, 04/06/2025, 04/07/2025, and 04/08/2025.

Review of Pt #6's Mobility flowsheet data from 3/31/2025 through 04/10/2025 revealed the following documentation of repositioning:
-On 03/31/2025 staff repositioned Pt #6 at 5:25 PM, there was no documented evidence of repositioning again until 04/01/2025 at 12:33 AM (7 hours and 8 minutes).
-On 04/02/2025 staff repositioned Pt #6 at 2:00 PM, there was no documented evidence of repositioning again until 04/02/2025 at 8:00 PM (6 hours).
-On 04/03/2025 staff repositioned Pt #6 at 6:00 AM, there was no documented evidence of repositioning again until 04/03/2025 at 10:00 AM (4 hours).
-On 04/04/2025 staff repositioned Pt #6 at 4:00 PM, there was no documented evidence of repositioning again until 04/04/2025 at 8:00 PM (4 hours).
-On 04/06/2025 staff repositioned Pt #6 at 3:00 AM, there was no documented evidence of repositioning again until 04/06/2025 at 9:18 AM (6 hours and 18 minutes); Pt #6 was repositioned at 10:30 PM, then not again until 04/07/2025 at 5:00 AM (6 hours and 30 minutes); Pt #6 was repositioned at 11:00 AM, then not again until 4:00 PM (5 hours).
-On 04/08/2025 staff repositioned Pt #6 at 2:00 PM, there was no documented evidence of repositioning again until 8:00 PM (6 hours); Pt #6 was repositioned at 8:00 PM, and not again until 04/09/2025 at 4:10 AM (8 hours and 10 minutes).

Review of Pt #6's Mobility flowsheet revealed that there was no documented evidence of staff repositioning Pt #6 every 2 hours to address the pressure injuries and skin breakdown as per policy and per Pt #6's Braden Scale assessment (moderate risk).

Per interview with RN Manager D beginning on 04/10/2025 at 9:23 AM, while reviewing medical records, RN D confirmed the findings, and stated that based on the wound/skin assessment and Braden Scale (<18), staff should implement interventions to reposition patients every 2 hours and document these interventions in the Mobility nursing flowsheets. Per RN D, staff should perform wound assessments once per shift and if there is a foam dressing in place, staff should peel back the dressing and visualize and assess the wound. RN D stated that nursing staff should document wound/skin interventions in the wound flowsheets. RN D stated that wound measurements should be done on discovery of the wound, weekly, and on discharge.

Based on record review and interview the facility staff failed to ensure that nursing care plans were opened to address skin/wound care needs in 2 of 10 medical records reviewed (Patient (Pt) #8, #10); failed to ensure nursing care plans are kept current and updated based on patient assessments in 3 of 10 medical records reviewed (Patient (Pt) #1, #5, #6); and failed to ensure that nursing interventions are implemented based on ongoing assessments of patient care needs in 3 of 10 medical records reviewed (Pt #1, #5, #6), in a total of 10 medical records reviewed.

Findings Include:

Review of policy and procedure titled, "Assessment/Reassessment of Patients..." last revised 07/06/2022 revealed:
- "The plan of care should identify the following: a. The need(s) to be addressed. b. The care goal(s) relative to the need identified. c. Interventions planned by the healthcare team to address the need(s) and meet the care goal(s). d. Monitoring of the patient's progress towards achieving the care goal(s)."
- "When the plan of care has been developed, the healthcare team implements it. Each discipline documents their interventions and the patient's response to these interventions in the patient's health care record."
- "Members of the healthcare team revise the plans and goals for care, treatment and services based on patient's needs."

Review of policy and procedure titled, "Ascension Wisconsin Skin Assessment & Pressure Injury Prevention" last revised on 10/22/2024 revealed:
- "A nurse will conduct a skin assessment on in-scope patients upon admission, every shift, and with any change in condition...Identification of an individual's risk for skin breakdown will be identified utilizing the Braden Scale Skin Risk Assessment Tool. If a patient is found to be at risk, with a Braden score of 18 or lower, pressure injury prevention measures will be put into place..."

Pt #1:

Review of Pt #1's medical record revealed Pt #1 was admitted as an inpatient on 01/27/2025 at 12:41 AM with a diagnosis of Acute hypoxic respiratory failure, COPD (Chronic Obstructive Pulmonary Disease), and shortness of breath; Pt #1 was discharged to a skilled nursing facility for rehabilitation (Rehab) on 02/18/2025 at 2:19 PM.

Review of Pt #1's nursing flowsheets revealed Pt #1's admission Braden Scale was documented as a "12" (High Risk) on 01/27/2025 at 1:00 AM and 8:00 PM.

Review of Pt #1's admission nursing skin assessment on 01/27/2025 at 1:00 AM revealed, "Coccyx redness blanchable intact."

Review of Pt #1's Care Plans revealed a "Skin integrity Impairment Risk" care plan with the goal to "Maintain intact skin and mucosa" opened on 01/27/2025.

Review Pt #1's wound nursing flowsheets revealed that Pt #1's "Coccyx redness blanchable" worsened to a "Pressure Injury Bilateral Sacrum," that was "first assessed" on 02/07/2025 at 9:56 PM (11 days after admission).

On 02/10/2025 at 9:59 AM, Wound Nurse progress notes revealed that Pt #1's "Pressure Injury Bilateral Sacrum" was a "suspected deep tissue injury," measuring 3 centimeters (cm) (length) x 3.2 cm (width) and there was a left sacrum stage II pressure injury due to open moist areas with minimal depth and non-blanchable erythema. The Plan for the Sacrum revealed to "cleanse with soap and water...Apply sacral foam border...Reposition every 2 hours while in bed..."

Per review of Pt #1's Care Plans, there was no documented evidence of nursing staff updating and/or revising the skin/wound Care Plan to address Pt #1's coccyx redness on admission worsening to a stage II pressure injury despite the skin interventions in place.

Per review of Pt #1's care plan nursing progress notes, there was no documentation of nursing staff addressing the progress towards care plan goals to "Maintain intact skin and mucosa," as per policy on the following days:
-01/28/2025, 01/29/2025, 01/30/2025, 01/31/2025, 02/01/2025, 02/02/2025, 02/04/2025, 02/05/2025, 02/06/2025, 02/10/2025, 02/11/2025, 02/14/2025, 02/15/2025, and 02/16/2025.

Per review of Pt #1's "Pressure Injury Bilateral Sacrum" wound nursing assessments from 02/10/2025 to 02/17/2025, there was no documented evidence of nursing staff performing a wound assessment and interventions (as per wound care orders) on every shift (as per policy) on 02/10/2025, 02/11/2025, 02/12/2025, 02/13/2025, 02/14/2025, 02/15/2025, 02/16/2025, and 02/17/2025.

Pt #1's "Skin integrity Impairment Risk" Care Plan was not kept current due to a lack of ongoing assessments and evaluations of Pt #1's "Pressure Injury Bilateral Sacrum" wound, to ensure Pt #1's skin/wound needs are being met as per policy. Pt #1's "Skin Integrity Impairment Risk" Care Plan document did not list the specific interventions planned by the healthcare team as per policy.

Pt #5:

Review of Pt #5's medical record revealed Pt #5 was admitted as an inpatient on 04/02/2025 at 10:56 PM with a history of quadriparesis (muscle weakness of arms and legs), cerebral palsy (neurological disorder that affects movement, balance, and posture), and a chief complaint of altered mental status; Pt #5 was an inpatient at the time of medical record review on 04/10/2025.

Review of Pt #5's nursing flowsheets revealed Pt #5's admission Braden Scale was documented as a "11" (High Risk for skin breakdown) on 04/03/2025 at 9:29 AM.

Pt #5's "Skin Integrity Impairment Risk" Care Plan was opened on 04/03/2025.

Review of Pt #5's wound flowsheet data revealed Pt #5 was admitted with a "Left Medial Buttocks" wound, "a Left Ischium Pressure Injury," and a "Left Mid Buttocks" pressure injury. There was no documented evidence of a wound assessments and/or interventions on night shift 04/05/2025 and day shift 04/06/2025.

Pt #5's "Skin Integrity Impairment Risk" Care Plan was not kept current due to a lack of ongoing assessments and evaluations of Pt #5's pressure injuries, to ensure skin needs are met as per policy.

Pt #6:

Review of Pt #6's medical record revealed Pt #6 was admitted as an inpatient on 03/31/2025 at 2:20 PM with an abdominal wound, Pt #6 suffers from severe autism and is non-verbal; Pt #6 was an inpatient at the time of medical record review on 04/10/2025.

Review of Pt #6's nursing flowsheets revealed Pt #6's admission Braden Scale was documented as a "13" (Moderate Risk for skin breakdown) on 03/31/2025 at 4:31 PM.

Pt #6's "Skin Integrity Impairment Risk" Care Plan was opened on 03/31/2025.

Review of Pt #6's wound flowsheet data revealed Pt #6 was admitted with a "Right Sacrum Pressure Injury." There was no documented evidence of wound assessments and/or interventions on the day and night shifts for the following days; 04/02/2025, 04/03/2025, 04/04/2025, 04/05/2025, 04/06/2025, 04/07/2025, and 04/08/2025.

Pt #6's "Skin Integrity Impairment Risk" Care Plan was not kept current due to a lack of ongoing assessments and evaluations of Pt #6's pressure injury, to ensure wound/skin needs are met as per policy.

Pt #8:

Review of Pt #8's medical record revealed Pt #8 was admitted on 02/02/2025 at 11:56 PM for altered mental status; Pt #8 was discharged on 02/05/2025 at 2:30 PM.

Review of Pt #8's nursing flowsheets, revealed an admission Braden Scale of "16" (Mild Risk for skin breakdown) on 02/02/2025 at 12:00 AM.

Review of Pt #8's Care Plans revealed there was no documented evidence of a "Skin Integrity Impairment Risk" Care Plan opened to address Pt #8 being at risk for skin break down based on the Braden Scale < 18.

Pt #10:

Review of Pt #10's medical revealed Pt #10 was admitted on 04/05/2025 at 10:30 PM with dizziness, dehydration, and hypotension, Pt #10 was a current patient at the time of the medical record review on 04/10/2025.

Review of Pt #10's nursing flowsheets, revealed a Braden Scale of "14" (Moderate Risk for skin breakdown) on 04/08/2025 at 2:00 PM.

Review of Pt #10's nursing assessment dated 04/07/2025 at 11:30 PM revealed, "Buttocks pink blanchable."

Review of Pt #10's Care Plans revealed there was no documented evidence of a "Skin Integrity Impairment Risk" Care Plan opened to address Pt #10 being at risk for skin break down based on the Braden Scale < 18.

Per interview with RN Manager D beginning on 04/10/2025 at 9:23 AM, while reviewing Pt #1's medical record, RN D confirmed the findings, and stated that nursing staff should update and/or revise the Care Plan when goals are not met. RN D stated that nursing staff should document on the Care Plan progress to goals and interventions implemented in a daily Care Plan progress note. RN D stated that a "Skin Integrity Impairment Risk" Care Plan should be opened when a patient has a Braden Scale of <18.