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Based on a review of policy and procedures, medical record review, and interviews with staff, it was determined that the nursing staff failed to assess the presence of wounds during each nursing shift and failed to include wound management in the nursing care plan.

Findings included:

A review of the facility's policy titled "Wound Management" policy #646, revised 1/27/23, revealed that each patient would be assessed on admission, each shift, and upon transfer by the nursing staff for the potential risk of skin breakdown, the occurrence of skin breakdown, and the presence of wounds. If a patient was noted to have an alteration in skin integrity, a wound assessment would be completed. The policy further revealed that Stage I pressure wounds involved redness or darkness of an area. Stage 2 and higher included a loss of skin tissue, blisters, or ulcers (sores). Any pressure injury Stage 2 or higher would have a consult with the Wound Healing Center. At the time of discharge from the hospital, the physician would determine if outpatient wound care was needed. The wounds would be photographed and documented in the electronic medical record.

A review of the facility's policy titled "Interdisciplinary Assessment and Reassessments" policy #9953 revealed that all patients admitted to the behavioral health program would be assessed by the nurse, physician, and psychiatrist within 24 hours of admission. A nursing reassessment would occur each 12-hour shift and as needed when there was a significant change in the patient's condition. The interdisciplinary treatment team would reassess the overall status of patients at least every seven days and document the reassessment process in the treatment plan.

A medical record review revealed that Patient (P) #1 arrived by ambulance at an Emergency Department (ED) near P#1's home on 4/9/22 at 7:07 p.m. A Rapid Initial Assessment by the Registered Nurse (RN) DD was completed at 7:17 p.m. and revealed that P#1 was violent, agitated, and restless. A review of an ED nursing note by RN EE on 4/11/22 at 4:16 p.m. revealed that P#1 was being observed by a sitter when P#1 stood up, fell to her knees, then onto her hands. P#1 had three skin tears on her left wrist and hand. A review of an ED nursing note by RN LL on 4/11/22 at 5:23 p.m. revealed an additional skin tear to P#1's left knee from the previous fall. P#1 was transferred to the geriatric Behavioral Health Unit on 4/12/22 at 12:42 a.m. for dementia with behavioral problems.

A review of the Nursing Admission Assessment by RN FF on 4/12/22 at 12:52 a.m. revealed no integumentary (skin) symptoms upon admission to the facility. A review of a Braden Scale (screening tool used to determine the risk of developing pressure wounds) during the admission assessment revealed that P#1 was rarely moist, walked frequently, had no limitations to mobility, and nutrition was probably inadequate. The total Braden Score was 21 (15-18 indicated a mild risk of developing pressure wounds. A lower score would have indicated a greater risk).
A review of the Braden Scale Screening protocol listed on the Braden Scale form revealed that bed and chairbound individuals or those with impaired ability to reposition should have been assessed upon admission for their risk of developing pressure ulcers. Patients with established pressure ulcers would be reassessed periodically.

A review of a Nurse Note by RN FF on 4/12/22 at 6:45 a.m. revealed that P#1 was sitting in the dayroom recliner, stood up, then fell to the floor on her left side. P#1 had a very small tear on her hand next to her wrist. P#1 was placed back into the recliner and continued to sleep.

A review of the history and physical examination on 4/12/22 revealed that P#1 was in no acute distress, thin, and chronically ill appearing. A routine skin exam revealed P#1's skin to be intact, dry, and warm.

A review of a Nurse Note by RN KK on 4/24/22 at 6:11 p.m. revealed that P#1 was walking down the hallway, ran into the computer on wheels, and fell onto her buttocks. P#1 had a small skin tear on her left hand but no other injuries.

A review of the Discharge Continuing care pan by RN LL on 4/25/22 at 11:31 a.m. revealed that P#1's skin was intact.

A review of nursing, physician, and case management progress notes throughout admission failed to reveal that P#1 had more than one wound on her wrist. There were no nursing skin assessments documented other than at admission. The medical record failed to reveal a wound care consult, wound care, or documentation of a developing pressure wound. Braden Scale Screening for P#1 was conducted twice daily throughout the admission with a score of 18-21, which was a mild risk of developing pressure wounds.

A review of a home health nurse note at an Assisted Living Facility on 4/27/22 revealed that P#1 was admitted to home health for dementia and had a Stage 2 pressure ulcer to her left buttocks that measured 0.4 centimeters (cm) x 6.3 cm x 0.1 cm, upon admission.

A review of a nurse note by the RN QQ at the Assisted Living Facility on 4/28/22 at 11:15 a.m. revealed that P#1 was treated by the home health nurse for a Stage 2 pressure wound to her left buttocks.

An interview took place with the Director of Wound Care (WC) NN on 3/8/23 at 1:02 p.m. in the Quality Conference Room. WC NN stated there was no section on the Silver Care computer for nurses to check the skin daily. Other units included skin assessment on the electronic shift assessment forms.

On 3/8/23 at 2:29 p.m., the Chief Quality Officer (CQO) AA stated that skin assessments were not part of the electronic nursing shift assessment forms for the Silver Care unit, but a section for skin assessments each shift had been added to the electronic form on 3/8/23. The nursing staff was being educated on conducting shift skin assessments.

An interview took place with RN MM on 3/8/23 at 2:30 p.m. in the Quality Conference Room. RN MM stated a skin assessment was included in a patient's initial nursing assessment, with a head-to-toe assessment for skin breakdown, tears, and rashes. A skin assessment would occur every shift and would only be documented if there was a problem.

A telephone interview took place with RN LL on 3/9/23 at 10:09 a.m. RN LL stated that nursing shift assessments and the discharge skin assessment only included assessing wounds being treated while the patient was at the facility. The discharge assessment did not include a head-to-toe skin assessment. When "intact" was documented under the integumentary section of the Discharge Continuing Care Plan, it referred to the skin being intact throughout admission to the unit. It did not indicate that the skin had been assessed at discharge.

A review of four additional medical records (#2, #3, #4, #5) revealed that skin assessments were documented on the initial nursing assessments and the discharge continuing care plans only, and was not documented on the nursing shift assessments for three out of four patients (P#2, P#3, P#4). The shift nursing assessments included documentation that cellulitis (bacterial infection involving several layers of skin) on the legs was assessed each shift for P#5.

Based on a review of policy and procedures, medical records, and interviews with staff, it was determined that the facility failed to ensure that licensed nursing staff adhered to the facility's policies and procedures when five of five (P#1, P#2, P#3, P#4, and P#5) patient records reviewed failed to include skin assessments by nursing staff with each nursing assessment.

Findings included:

A review of the facility's policy titled "Wound Management", policy #646, revised 1/27/23, revealed that the policy was only a guideline and was not intended to replace clinical judgment under a particular circumstance. The purpose of the policy was to outline the procedure for identifying and assessing any areas of actual or impending skin breakdown, to initiate appropriate management protocols, and to document care of pressure injuries, surgical incisions, and other wounds. A Pressure Injury was defined as a localized injury to the skin or underlying tissue as a result of pressure and/or friction. The policy revealed that each patient would be assessed on admission, each shift, and upon transfer by the nursing staff for the potential risk of skin breakdown, the occurrence of skin breakdown, and the presence of wounds. The policy further revealed that patients with a score of less than or equal to 9 (severe risk) and 10-12 (high risk) on the Braden Risk Assessment Scale, or for any patient identified as at risk of pressure ulcer development, would be repositioned every two hours. Support surfaces (wedges, heel protection, additional pillows, etc.) would be provided. If a patient was noted to have an alteration in skin integrity, a wound assessment would be completed. The policy further revealed that Stage I pressure wounds involved redness or darkness of an area. Stage 2 and higher included a loss of skin tissue, blisters, or ulcers (sores). Any pressure injury Stage 2 or higher would have a consult with the Wound Healing Center. At the time of discharge from the hospital, the physician would determine if outpatient wound care was needed. The wounds would be photographed and documented in the electronic medical record.

A medical record review revealed that Patient (P) (#1) arrived at an Emergency Department (ED) near P#1's home by ambulance on 4/9/22 at 7:07 p.m. P#1 was transferred to the Geriatric Behavioral Health Unit on 4/12/22 at 12:42 a.m. for dementia with behavioral problems.

A review of the Nursing Admission Assessment by RN (FF) on 4/12/22 at 12:52 a.m. revealed that P#1 was asleep upon arrival to the behavioral health unit and refused to wake up during the assessment. The nurse was unable to do a nutritional screening at that time. A family member was present during the assessment. The Integumentary (skin) Assessment revealed no integumentary symptoms upon admission to the facility. A review of a Braden Scale (screening tool used to determine the risk of developing pressure wounds) during the admission assessment revealed that P#1 was rarely moist, walked frequently, had no limitations to mobility, and nutrition was probably inadequate. The total Braden Score was 21 (15-18 indicated a mild risk of developing pressure wounds. A lower score would have indicated a greater risk). A review of the Braden Scale Screening protocol listed on the Braden Scale form revealed that bed and chairbound individuals or those with impaired ability to reposition should have been assessed upon admission for their risk of developing pressure ulcers. Patients with established pressure ulcers would be reassessed periodically. Braden Scale Screening for P#1 was conducted twice daily throughout the admission with a score of 18-21, which was a mild risk of developing pressure wounds.

A review of the nursing assessments during the hospitalization failed to reveal skin assessments on each shift. A review of 'Discharge Information' dated 4/25/23 at 11:15 a.m. revealed that P#1 was discharged to a memory care unit. Documents transported with P#1 included case management discharge, discharge report, and home medications list.

An interview took place with the Director of Wound Care (WC) NN on 3/8/23 at 1:02 p.m. in the Quality Conference Room. WC NN stated a head-to-toe skin assessment would be done at admission, and any wounds present would trigger a wound care consult. The nurses would request a wound care consult if a wound was discovered after admission. WC NN explained there were not many wound care consults from the Silver Care (geriatric behavioral health) unit. WC NN said there was not a section on the computer for nurses to check the skin daily on the Silver Care unit. Other units included skin assessment on the electronic shift assessment forms. WC NN further said that technicians would see patients in the shower and would be able to assess for wounds. The technicians would ask the nurses to look at any concerns.

An interview took place with the Mental Health Technician (MHT) PP on 3/8/23 at 2:10 p.m. in the Quality Conference Room. MHT PP said that when patients with briefs were taken to the restroom, the MHT would check for any redness or sores. MHT PP would let the nurse know if wounds were starting to occur or were already present. MHT PP said she was able to see patients' arms and legs while the patients were wearing scrubs. The MHTs would let the nurses know if any wounds were present. Nurses would ask MHTs to check any wounds that were present at admission.

An interview took place with RN MM on 3/8/22 at 2:30 p.m. in the Quality Conference Room. RN MM said a skin assessment was included in a patient's initial nursing assessment, with a head-to-toe assessment for skin breakdown, tears, and rashes. A skin assessment would occur every shift and would only be documented if there was a problem. RN MM further said the technicians were able to check for wounds when patients went to the restroom. Many patients were high-functioning and would let the nurses know if something was abnormal. Nursing would make a note of minor wounds and would change the dressings daily. RN MM further said patients were changed into scrubs, and RN MM was unsure how any wounds on P#1 would have been missed. RN MM said the medical doctor would do an initial assessment, and there would be documentation about the skin on the discharge assessment.

On 3/8/23 at 2:29 p.m., Chief Quality Officer (AA) stated that skin assessments were not part of the electronic nursing shift assessment forms but a section for skin assessments each shift had been added to the electronic form on 3/8/23. The nursing staff was being educated on conducting shift skin assessments at the time of the survey.

A telephone interview took place with RN (LL) on 3/9/23 at 10:09 a.m. RN LL stated that nursing shift assessments and the discharge skin assessment only included assessing wounds being treated while the patient was at the facility. The discharge assessment did not include a head-to-toe skin assessment. When "intact" was documented under the integumentary section of the Discharge Continuing care plan, it referred to the skin being intact throughout admission to the unit. It did not indicate that the skin had been assessed at discharge.