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A. Based on document review and interview, it was determined that for 3 of 6 (Pt. #1, Pt. #6 & Pt. #12) clinical records reviewed, the Hospital failed to ensure that the registered nurse supervised the patient care by failing to conduct a complete physical assessment including the screening for skin risk assessment (Braden) as required.

Findings include:

1. On 07/27/2021, the Hospital's policy titled, "Pressure Ulcer, Prediction, Prevention and Management (Revised 10/2020) was reviewed and required, " ...Braden risk assessments and skin assessments should be performed for all patients on admission within 24 hours Patients with Braden score of eighteen (18) or less are considered at risk ...Daily risk assessments using the Braden Scale should be performed ..."

2. On 07/27/2021, the Hospital's policy titled, "Nursing Assessment and Reassessment (revised 10/2020) was reviewed and included, "...inpatients are to receive an initial nursing admission assessment within 24 hours of admission...The initial assessment is custom designed to reflect the unique needs of critical care,general medical-surgical and specialty areas...initial assessment included but is not limited to: 1. Physical Assessment...6. Screening for safety assessment including:...Skin risk assessment..."

3. The clinical record of Pt. #1 was reviewed 07/27/2021. Pt. #1 was admitted on 07/30/2020 with a diagnosis of Sepsis (generalized infection) and was discharged on 08/27/2020. The initial nursing admission assessment dated 07/30/2020 indicated that Pt. #1 did not have a pressure injury present upon admission. However, the wound care nurse consult dated 08/04/2020 indicated that Pt. #1 had a stage IV pressure sore that was present upon admission.

4. The clinical record of Pt. #6 was reviewed on 07/27/2021. Pt. #6 was admitted on 07/22/2021 with a diagnosis of Acute Cardiorespiratory Arrest. The clinical record included initial Braden Risk Assessment dated 07/22/2021-Prevention Protocol by level of Risk: Score 10: High Risk (10-12). The clinical record lacked documentation of Braden/Skin Assessment on 07/23/2021 and 07/24/2021.

5. The clinical record of Pt. #12 was reviewed on 07/30/2021. Pt. #12 was admitted on 07/15/2021 with a diagnosis Schizoaffective Disorder. The clinical record lacked documentation of Braden/Skin assessments from 07/15/2021 through 07/30/2021.

6. On 07/27/2021 at approximately 10:30 AM, the findings were discussed with the Director of Nursing (E #18). E #18 stated, "I'm not sure why the Braden assessments for those two days are missing."

7. On 07/30/2021 at 2:30 PM and interview was conducted with the Chief Nursing Officer ( E #19). E #19 stated that the nurses are expected to complete a full head to toe nursing assessment to examine the condition of the skin.


B. Based on document review and interview, it was determined that for 1 of 2 clinical records reviewed, the Hospital failed to ensure that the registered nurse supervised the patient care by failing to complete weekly wound measurements.

Findings include:

1. On 07/27/2021, the Hospital's policy titled, "Pressure Ulcer, Prediction, Prevention and Management (Revised 10/2020) was reviewed and required, " ...The purpose of this policy is to identify patients for risk for skin breakdown to institute skin and wound prevention and treatment measures, and to assess and document the condition of the skin and wounds ...3. Skin inspections should be performed daily ...5. The effectiveness of the plan of care for patients with actual/potential altered skin integrity will be evaluated and revised as necessary ...6. A referral to wound and ostomy resource specialist can be made for consultation on Stage III, Stage IV and unstageable pressure ulcers ...treatments requiring clarification and any cases requiring further expertise in wound care.

2. The clinical record of Pt. #1 was reviewed 07/27/2021. Pt. #1 was admitted on 07/30/2020 and was discharged on 08/27/2020. The clinical record included the following.

- Wound Consult dated 08/04/2020 (entered by E #1) at 11:18 AM, " Reason for consultation: Wound present on Admission ...Wound Care consult completed: Pt (Pt. #1) intubated and non-responsive at this visit ...Sacral Coccyx: Healing full thickness/stage 4 scar tissue with central area remaining open 0.5 x0.5 CM (centimeters), 0.4CM deep, granular tissue, expressed serosanguinous drainage, no purulent drainage seen as reported ...placed Polymem silver foam dressing however will order Silvercel non-Adherent (wound dressing) as it will be easier to pack ...The following orders were placed: Sacral/Coccyx: Cleanse with N.S (Normal Saline) loosely pack silvercel non-adherent Drsg (dressing) Q 24 to hrs (every 24 to 48 hours) ...Frequency of wound measurements: weekly ...Next wound measurement to start on 08/08/20 ...Wound Nurse follow up plan: Please re-consult for wound deterioration, new breakdown as needed ..." The clinical record failed indicate the sacral/coccyx wound was measured weekly 08/08/2020 and 08/15/2020.

-Wound Consult dated 08/20/2020 (entered by E #1) at 11:11 AM, "Reason for consultation:
Deteriorating wound and new skin breakdown identified ...Wound Care consult completed: Pt (Pt. #1)
awake and responsive ...Sacral/Coccyx: Unstageable, total are 8 x 6 CM, scattered areas of eschar (dead tissue) over existing scar tissue."

3. On 07/30/2021, an interview was conducted with the Wound Care Nurse Practitioner (E #1). E #1 stated, "wound measurements are to be assessed on Saturdays ...looking at the Skin/Abnormality assessment, the nurse did not document the measurements of the wounds ...Wound measurement is a part of the criteria for assessing the wounds..."