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550 PEACHTREE STREET, NE

ATLANTA, GA 30308

GOVERNING BODY

Tag No.: A0043

CARE OF PATIENTS

Tag No.: A0063

Based on the facility's Governing Body Bylaws, quality presentation reports, patients' medical records, and interviews with facility staff, the facility's governing body failed to ensure the Quality Assessment Performance Improvement Plan (QAPI) was sufficient to protect the health and needs of four of four (P) patients ( P#1, P#2, P#3, P#4) related to the prevention and treatment of pressure ulcers. In addition, the facility's governing body failed to ensure that the QAPI plan included monitoring where it related to treatment of pressure ulcers and hospital acquired conditions.

Findings:

A review of the facility's Governing Body By-Laws approved on 9/13/18, revealed the Board's Corporation is organized and shall be operated (1) to organize and coordinate an integrated healthcare system for the delivery of healthcare services by the Supported Organizations and those hospitals, physicians and other healthcare providers that become affiliated with, or related to, the Corporation; (2) to enhance the accessibility, quality and cost-effectiveness of healthcare services rendered to the communities served. In addition, the Bylaws revealed at least one Board Director shall serve on the Patient Safety and Quality Committee.

A review of the facility's quality presentation reports dated from September 2021 through Jan 2022, revealed no further information that addressed, or plan to mitigate the facility's reported increase of hospital acquired pressure ulcers and gaps of wound treatment care.

A review of Patient (P) #1 medical record revealed that P#1 was presented by the Emergency Medical Services (EMS) to the facility's Emergency Department (ED) on 1/2/22 at 9:01 p.m. with a chief complaint of swollen right side of her neck and breathing difficulty. A review of the facility's medical-surgical critical care history and physical (H &P) note revealed that P#1 had a sore throat that progressed to rapidly spreading bilateral neck swelling with difficulty in breathing. P#1's skin was warm, dry, and intact and no pressure ulcer present on admission. On 1/3/22 at 1:30 a.m., review of the nursing flowsheet titled "iView- Patient Assessment "revealed that P#1's initial nursing assessment was completed. P#1's skin was intact, warm dry and pink. P#1 had no pressure injury. At 8:00 a.m. P#1 ' s Braden score was 9 (< 13 (The lower the number, the higher the risk is for developing an acquired ulcer or injury from 1-23.)). Further review of the nutrition follow-up notes on 1/13/22 revealed that P#1 remained intubated, tube feeing at 50ml/hr. Stage 1 pressure injury was noted on her buttocks. P#1 depended on facility staff to position her because she was unable.

On 1/3/22 at 3:17 pm the nursing care plan for pressure ulcer prevention was initiated, further review revealed that P#1 was to be repositioned every 2 hours (Q2hr). Detailed review of the record revealed that P#1 was not repositioned during the following times.

-On 1/4/22 from 12:20 p.m. to 4:33 pm,
-1/5/22 from 7:59 p.m. to 11:22 pm,
-1/6/22 from 8:31 a.m. to 3:09 p.m.,
-1/7/22 from 4:57 p.m. to 8:23 p.m.,
-1/9/22 from 6:00 a.m. to 12:36 p.m.,
-1/9/22 from 12:36 p.m. to 5:18 p.m.,
-1/9/22 from 5:18 p.m. to 8:00 p.m.,
-1/10/22 from 6:17 p.m. to 9:02 p.m.

On 1/17/22 at 11:53 a.m. a review of progress note revealed an initial wound care consultation by the wound care nurse (WOCN) WOCN PP documented P#1 had developed a bilateral denuded wound (loss of skin caused by prolonged moisture and friction) that was 5cm*9cm*0.1cm (Length*width*depth). WOCN PP ordered to cover wound with Mepilex sacral foam and change dressing daily and as needed.

A review of nursing flow sheets for P#1 titled, "iView Patient Assessment-Wound" revealed the following findings:

On 1/12/22 at 6:00 a.m. P#1 was noted to have developed a pressure injury stage I on the buttocks with bony prominence, dressing pad was applied.

On 1/13/2 at 8:00 p.m. P#1 was noted to have developed a pressure injury stage II with bony prominence, wound dressing was assessed and reinforced.

On 1/14/22 at 8:00 p.m. P#1 was noted with pressure ulcer stage II, dressing applied.

On 1/27 22 at 9:00 a.m. RN documented P#1's buttock wound was a stage III pressure injury.

On 2/9/22 at 11:45 a.m. P#1 buttock pressure ulcer was unstageable with bony prominence.

A review of P#1's Patient Assessment revealed missing documentation of wound dressing activities for the following days:

1/21/22, 1/22/22, 1/23/22, 1/24/22, 1/25/22, 1/26/22, 1/30/22, 1/31/22, 2/5/22, 2/12/22, 2/13/22.

A review of progress notes for P#1 revealed on 2/2/22 at 11:50 am, a reassessment of P#1's wound was conducted by WOCN DD. WOCN DD documented that P#1's buttock bilateral wound had developed into an unstageable pressure ulcer that was 7cm* 11.5cm* 0cm (Length*width*depth).

A review of Patient (P) #2 medical record revealed that P#2 was presented by the EMS to the facility's ED on 11/27/20 at 8:53 p.m. with a chief complaint of abdominal pain, nausea, vomiting.

A review of the "iView" Patient Assessment Wound records for P#2 revealed that on 12/16/21 at 3:44 pm, P#2 was noted to have a left ankle ulcer by the wound care nurse. WOCN ordered dressing changes once in 3 days. Further review of the medical record failed to reveal dressing changes form P#2's ankle ulcer for 1/1/21 to 1/13/21.

A review of Patient (P) #3 medical record revealed that Patient #3 arrived at the facility's ED on 12/27/21 at 4:36 a.m. with an altered mental status, fever and vomiting for three days. P#3 was diagnosed with sepsis shock and was admitted at the facility.

On 12/27/21 at 8:00 a.m. a review of facility's iView patient assessment revealed that P#3 had a fissure on her buttock on initial skin assessment. P#3 had a Braden score of 13.

On 12/30/21 at 7:58 a.m. a registered nurse (RN) documented P#3's wound was a stage IV pressure injury with bony prominence

On 12/31/21 at 1:30 p.m. WOCN DD assessed P#3, WOCN DD documented that P#3 had developed a stage IV sacral ( bony area at the bottom of the spine) pressure ulcer. WOCN ordered a specialty bed and administration of antimicrobial. Further review of the facility's iView Bed interventions failed to reveal documentation that the specialty bed was initiated.

A review of the facility's flowsheet for P#3 failed to reveal a dressing change on 1/9/22.

A review of Patient (P) #4 medical record revealed that P#4 was presented at the facility on 10/18/21 at 6:04 a.m. for right mandibular (Jawbone) resection due to cancer of buccal mucosa (the lining of the cheeks and the back of the lips, inside the mouth where they touch the teeth). P#4 was admitted at the facility's surgical unit at 11:24 a.m.

On 10/18/21 at 11:35 p.m., review of the nursing flowsheet titled "iView- Patient Assessment" wound revealed that P#4 had no documented skin abnormality. Further review revealed that on 10/19/21 at 2:14 a.m. P#4 had an abdominal surgical incision. There was no pressure injury documented upon admission. P#4 ' s Braden score was 21.

On 10/19/21 at 6:03 p.m. the nursing care plan for pressure ulcer prevention was initiated, further review revealed that P#4 was to be repositioned every 2 hours (Q2hr).

On 10/21/21 at 9:00 p.m., RN documented a stage II pressure ulcer on P#4's right buttock.

On 10/22/21 at 12:29 p.m. wound care consult was ordered at 2:14 p.m. WOCN PP documented that P#4 had developed a sacral pressure ulcer that was 6cm* 8cm* 0.1cm (Length*width*depth).

On 10/27/21 at 9:49 a.m. WOCN PP noted that P#4's sacrum pressure injury was unstageable WOCN PP ordered P#4 bilateral buttock cleanse with normal saline and form dressing changed once in three days.

Detailed review of the record failed to reveal documentation of P#4 repositioning during the following times:

-10/29/21 from 12:35 pm to 3:04 p.m.,
-10/30/21 at 11:05 pm to 2:19 p.m.,
-11/1/21 at 11:51a.m. to 3:52 p.m.,
-11/1/21 at 7:29 p.m. to 11:55 p.m.,
-11/2/21 at 5:29 p.m. to 9:54 p.m.

A review of the facility's flowsheet failed to reveal a dressing change on 1/9/22.

During an interview with Director CC (Dir CC) in the conference room on 2/16/22 at 10:08 a.m., Dir CC stated the facility's system identified an increase of Hospital Acquired Pressure Injuries (HAPIs). In addition, Dir CC stated resources to address HAPIs were a challenge including but not limited to review and assessment of a HAPI. Dir CC stated the quality team had not developed solutions as of yet to address gaps in care with HAPIs and that the team planned to meet in March 2022 to discuss solutions and root causes.

QAPI

Tag No.: A0263

Based on the facility medical record reviews, quality plan, quality presentation meeting minutes, and interview
the facility failed to maintain an effective ongoing, hospital-wide, data-driven quality assessment and performance improvement program which identied increased trends in hospital acquired pressure ulcers (HAPU), determine the cause of the increase in HAPU, develop measures to decrease hospital acquired HAPU, monitoring those activities and report on findings through the QAPI process.

Findings:

Cross reference A-0283 as it relates to the identification of opportunities for improvement and changes related to mitigation of wound care treatment that will lead to improvement; and to take actions aimed at performance improvement, and after implementation of those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained.

QUALITY IMPROVEMENT ACTIVITIES

Tag No.: A0283

Based on medical record reviews, the facility's quality plan, quality presentation meeting minutes complaint and grievance log, and interview, the facility failed to use the data collected to monitor the effectiveness and safety of services and quality of care that addressed gaps of wound treatment care for four of four (P) patients (P#1, P#2, P#3 and P#4).

Findings:

A review of the facility's quality plan dated 11/2021, revealed the facility's Quality and Patient Safety Plan defines and facilitates a systematic approach to identify and pursue opportunities to improve services and resolve identified problems.

A review of the facility ' s quality presentation reports dated from September 2021 through Jan 2022, revealed no further information that addressed, or plan to mitigate the facility's reported increase of hospital acquired pressure ulcers and gaps of wound treatment care.

A review of the facility Complaint and Grievance Log revealed a continued complaint that resulted in a grievance dated 2/10/22, related to concerns of P#1' s care that included but not limited to P#1 acquired bedsores after P#1's admission and treatment of P#1's bedsores.

A review of Patient (P) #1 medical record revealed that P#1 was presented by the Emergency Medical Services (EMS) to the facility's Emergency Department (ED) on 1/2/22 at 9:01 p.m. with a chief complaint of swollen right side of her neck and breathing difficulty. A review of the facility's medical-surgical critical care history and physical (H &P) note revealed that P#1 had a sore throat that progressed to rapidly spreading bilateral neck swelling with difficulty in breathing. P#1's skin was warm, dry, and intact and no pressure ulcer was present on admission. On 1/3/22 at 1:30 a.m., review of the nursing flowsheet titled "iView- Patient Assessment "revealed that P#1's initial nursing assessment was completed. P#1's skin was intact, warm dry and pink. P#1 had no pressure injury. At 8:00 a.m. P#1 ' s Braden score was 9 (< 13 (The lower the number, the higher the risk is for developing an acquired ulcer or injury from 1-23.)). Further review of the nutrition follow-up notes on 1/13/22 revealed that P#1 remained intubated, tube feeing at 50ml/hr. Stage 1 pressure injury was noted on her buttocks. P#1 depended on facility staff to position her because she was unable.

On 1/3/22 at 3:17 pm the nursing care plan for pressure ulcer prevention was initiated, further review revealed that P#1 was to be repositioned every 2 hours (Q2hr). Detailed review of the record revealed that P#1 was not repositioned during the following times.

-On 1/4/22 from 12:20 p.m. to 4:33 pm,
-1/5/22 from 7:59 p.m. to 11:22 pm,
-1/6/22 from 8:31 a.m. to 3:09 p.m.,
-1/7/22 from 4:57 p.m. to 8:23 p.m.,
-1/9/22 from 6:00 a.m. to 12:36 p.m.,
-1/9/22 from 12:36 p.m. to 5:18 p.m.,
-1/9/22 from 5:18 p.m. to 8:00 p.m.,
-1/10/22 from 6:17 p.m. to 9:02 p.m.

On 1/17/22 at 11:53 a.m. a review of progress note revealed an initial wound care consultation by the wound care nurse (WOCN) WOCN PP documented P#1 had developed a bilateral denuded buttocks wound (loss of skin caused by prolonged moisture and friction) that was 5cm*9cm*0.1cm (Length*width*depth). WOCN PP ordered to cover wound with Mepilex sacral foam and change dressing daily and as needed.

A review of nursing flow sheets for P#1 titled, "iView Patient Assessment-Wound" revealed the following findings:

On 1/12/22 at 6:00 a.m. P#1 was noted to have developed a pressure injury stage I on the buttocks with bony prominence, dressing pad was applied.

On 1/13/2 at 8:00 p.m. P#1 was noted to have developed a pressure injury stage II on the buttocks with bony prominence, wound dressing was assessed and reinforced.

On 1/14/22 at 8:00 p.m. P#1 was noted with pressure ulcer stage II on the buttocks , dressing applied.

On 1/27 22 at 9:00 a.m. RN documented P#1's buttock wound was a stage III pressure injury.

On 2/9/22 at 11:45 a.m. P#1 buttock pressure ulcer was unstageable with bony prominence.

A review of P#1's Patient Assessment revealed missing documentation of wound dressing activities for the following days:

1/21/22, 1/22/22, 1/23/22, 1/24/22, 1/25/22, 1/26/22, 1/30/22, 1/31/22, 2/5/22, 2/12/22, 2/13/22.

A review of progress notes for P#1 revealed on 2/2/22 at 11:50 am, a reassessment of P#1's wound was conducted by WOCN DD. WOCN DD documented that P#1's buttock bilateral wound had developed into an unstageable pressure ulcer that was 7cm* 11.5cm* 0cm (Length*width*depth).

A review of Patient (P) #2 medical record revealed that P#2 was presented by the EMS to the facility's ED on 11/27/20 at 8:53 p.m. with a chief complaint of abdominal pain, nausea, vomiting.

A review of the "iView" Patient Assessment Wound records for P#2 revealed that on 12/16/21 at 3:44 pm, P#2 was noted to have a left ankle ulcer by the wound care nurse. WOCN ordered dressing changes once in 3 days. Further review of the medical record failed to reveal dressing changes form P#2's ankle ulcer from 1/1/21 to 1/13/21.

A review of Patient (P) #3 medical record revealed that Patient #3 arrived at the facility's ED on 12/27/21 at 4:36 a.m. with an altered mental status, fever and vomiting for three days. P#3 was diagnosed with sepsis shock and was admitted at the facility.

On 12/27/21 at 8:00 a.m. a review of facility's iView patient assessment revealed that P#3 had a fissure on her buttock on initial skin assessment. P#3 had a Braden score of 13.

On 12/30/21 at 7:58 a.m. Registered Nurse (RN) documented P#3's wound was a stage IV pressure injury on the buttocks with bony prominence

On 12/31/21 at 1:30 p.m. WOCN DD assessed P#3, WOCN DD documented that P#3 had developed a stage IV pressure ulcer on her sacrum. WOCN ordered a specialty bed and administration of antimicrobial. Further review of the facility's iView Bed interventions failed to reveal documentation that the specialty bed was initiated.

A review of the facility's flowsheet for P#3 failed to reveal a dressing change on 1/9/22.

A review of Patient (P) #4 medical record revealed that P#4 was presented at the facility on 10/18/21 at 6:04 a.m. for right mandibular (Jawbone) resection due to cancer of buccal mucosa (the lining of the cheeks and the back of the lips, inside the mouth where they touch the teeth).
P#4 was admitted at the facility's surgical unit at 11:24 a.m.

On 10/18/21 at 11:35 p.m., review of the nursing flowsheet titled "iView- Patient Assessment" wound revealed that P#4 had no documented skin abnormality. Further review revealed that on 10/19/21 at 2:14 a.m. P#4 had a abdominal surgical incision. There was no pressure injury documented upon admission. P#4 ' s Braden score was 21.

On 10/21/21 at 9:00 p.m., RN documented a stage II pressure ulcer on P#4's right buttock.

On 10/22/21 at 12:29 p.m. wound care consult was ordered at 2:14 p.m. WOCN PP documented that P#4 had developed a sacral pressure ulcer that was 6cm* 8cm* 0.1cm (Length*width*depth).

On 10/27/21 at 9:49 a.m. WOCN PP noted that P#4's sacrum pressure injury was unstageable WOCN PP ordered P#3 bilateral buttock cleanse with normal saline and foam dressing changed once in three days.

On 10/19/21 at 6:03 p.m. the nursing care plan for pressure ulcer prevention was initiated, further review revealed that P#4 was to be repositioned every 2 hours (Q2hr). Detailed review of the record failed to reveal documentation of P#4 repositioning during the following times:

-10/29/21 from 12:35 pm to 3:04 p.m.,
-10/30/21 at 11:05 pm to 2:19 p.m.,
-11/1/21 at 11:51a.m. to 3:52 p.m.,
-11/1/21 at 7:29 p.m. to 11:55 p.m.,
-11/2/21 at 5:29 p.m. to 9:54 p.m.

A review of the facility's flowsheet failed to reveal a dressing change on 1/9/22.

During an interview with Director CC (Dir CC) in the conference room on 2/16/22 at 10:08 a.m., Dir CC stated the facility's system identified an increase of Hospital Acquired Pressure Injuries (HAPIs). In addition, Dir CC stated resources to address HAPIs were a challenge including but not limited to review and assessment of a HAPI. Dir CC stated the quality team had not developed solutions as of yet to address gaps in care with HAPIs and that the team planned to meet in March 2022 to discuss solutions and root causes.

NURSING SERVICES

Tag No.: A0385

Based on review of medical records, staff interviews, policies, and procedures, it was determined that the facility's staff failed to treat pressure ulcer injuries for four patients (P#1, P#2, P#3, P#4) out of four sampled patients as ordered.

Findings:

Cross refer to A-0396 as it relates to the facility's failure to ensure appropriate prevention and treatment plans for patients with pressure ulcers.

NURSING CARE PLAN

Tag No.: A0396

Based on a review of medical records, staff interviews, policies, and procedures, it was determined that the facility failed to ensure that the nursing services followed the care plans and treatment orders related to pressure ulcers prevention and management of three of 4 sampled patients (P#1, P#3, P#4). The facility's staff failed to properly document and implement treatment orders for two of 4 sampled patients' hospital-acquired pressure injuries (P#1, P#4). In addition, the facility's staff failed to follow the wound care treatment plan as ordered for four of 4 sampled patients (P#1, P#2, P#3, P#4).

Findings include:

A review of Patient (P) #1's medical record revealed that P#1 was presented by the Emergency Medical Servives (EMS) to the facility's Emergency Department (ED) on 1/2/22 at 9:01 p.m. with a complaint of the swollen right side of her neck and breathing difficulty. P#1's past medical history included hypertension (high blood pressure), dementia (memory loss), back pain. P#1 was alert to herself but could not speak due to neck pain. P#1 was intubated (inserting a tube into the trachea to maintain an open airway for ventilation) at the emergency unit and admitted to the facility's ICU (intensive care unit) on 1/3/22 at 12:30 a.m. P#1 differential diagnosis included localized swelling mass or lump of the neck, neck swelling, pharyngitis (inflammation of the pharynx, which is in the back of the throat). P#1 depended on facility staff to position her because she was unable.

On 1/3/22 at 1:30 a.m., a review of the nursing flowsheet titled "iView- Patient Assessment "revealed that P#1's initial nursing assessment was completed. P#1's skin was intact, warm dry, and pink. P#1 had no pressure injury. At 8:00 a.m. P#1 Braden's score was 9 {severe risk (<9), high risk (10-12), moderate risk (13-14)}. Further review of the iView - Sacral Silicon Border Dressing (prevention) revealed no documented silicon/Mepilex pressure injury prevention dressing other than on 1/8/22 at 8:00 pm.

On 1/3/22 at 3:17 pm the nursing care plan for pressure ulcer prevention was initiated, further review revealed that P#1 was to be repositioned every 2 hours (Q2hr). Detailed review of the record revealed that P#1 was not repositioned during the following times.

-On 1/4/22 from 12:20 p.m. to 4:33 pm,
-1/5/22 from 7:59 p.m. to 11:22 pm,
-1/6/22 from 8:31 a.m. to 3:09 p.m.,
-1/7/22 from 4:57 p.m. to 8:23 p.m.,
-1/9/22 from 6:00 a.m. to 12:36 p.m.,
-1/9/22 from 12:36 p.m. to 5:18 p.m.,
-1/9/22 from 5:18 p.m. to 8:00 p.m.,
-1/10/22 from 6:17 p.m. to 9:02 p.m.

On 1/12/22 at 8:53 a.m. review of nursing documentation revealed that registered nurse (RN) OO notified the provider that P#1 had developed a stage 1 pressure injury in her left buttock.

On 1/15/22 at 7:25 a.m. Wound care consult was ordered for P#1.

On 1/17/22 at 11:53 a.m. a review of progress note revealed an initial wound care consultation by the wound care nurse (WOCN) WOCN PP documented P#1 had developed a bilateral denuded wound (loss of skin caused by prolonged moisture and friction) that was 5cm*9cm*0.1cm (Length*width*depth). WOCN PP ordered to cover wound with Mepilex sacral foam and change dressing daily and as needed.

On 2/2/22 at 11:50 a.m., a review of the progress note revealed a reassessment of P#1's wound by WOCN DD. WOCN DD documented that P#1's buttock bilateral wound had developed into an unstageable pressure ulcer that was 7cm* 11.5cm* 0cm (Length*width*depth). WOCN DD ordered to absorbent foam dressing, change the dressing daily and apply triad cream.

On 2/3/22 at 2:43 p.m., WOCN PP documented that P#1 had been transferred from the ICU. WOCN placed an order for a specialty bed Dolphin air immersion mattress for skin support.

On 2/11/22 at 12:09 p.m., WOCN DD documented that she was consulted because P#1's family members were concerned about P#1's wound status. WOCN DD noted she educated P#1's daughter about the wound care treatment plan and reassured P#1's daughter that P#1 will be reassessed by the wound care nurse. Detailed review failed to reveal that P#1's family was notified that P#1's pressure injury was hospital-acquired.

A review of the facility's nursing flow sheet titled "iView Patient Assessment" skin assessment included but was not limited to the following skin assessments:

On 1/3/22 at 1:30 a.m. P#1's skin integrity was intact warm, dry, and elastic.
On 1/4/22 at 8:00 a.m. RN noted P#1's skin was intact, warm, dry, and elastic.
On 1/5/22 at 8:00 a.m. RN noted P#1's skin was intact, warm, dry, and elastic.
On 1/5/22 at 8:00 p.m. P#1's skin was noted to be not intact.
On 1/6/22 at 8:00 a.m. P#1's skin was noted to be not intact.

A review of nursing flow sheets for P#1 titled, "iView Patient Assessment-Wound" revealed the following findings:

On 1/12/22 at 6:00 a.m. P#1 was noted to have developed a pressure injury stage I on the buttocks with bony prominence, dressing pad was applied.

On 1/13/2 at 8:00 p.m. P#1 was noted to have developed a pressure injury stage II on the buttocks with bony prominence, wound dressing was assessed and reinforced.

On 1/14/22 at 8:00 p.m. P#1 was noted with pressure ulcer stage II on the buttocks, dressing applied.

On 1/27 22 at 9:00 a.m. RN documented P#1's buttock wound was a stage III pressure injury.

On 2/9/22 at 11:45 a.m. P#1 buttock pressure ulcer was unstageable with bony prominence.
A detailed review of the iView Patient Assessment revealed missing documentation of wound dressing activities for the following days:

1/21/22, 1/22/22, 1/23/22, 1/24/22, 1/25/22, 1/26/22, 1/30/22, 1/31/22, 2/5/22, 2/12/22, 2/13/22.

A review of Patient (P) #2 medical record revealed that P#2 was presented by the EMS to the facility's ED on 11/27/20 at 8:53 p.m. with a chief complaint of abdominal pain, nausea, vomiting. Patient #2 past medical history included diabetes, asthma. P#2 was reported to be alert, oriented to person, place, and time with warm, intact dry skin. P#2 differential diagnosis included diabetes ketoacidosis (a complication of diabetes, excess acid in the blood), hyperglycemia (high blood sugar), pneumonia (infection of the lungs).

A review of the facility's flowsheet revealed that P#2's initial nursing assessment was completed on 11/28/20 at 11:08 a.m. P#2's skin was intact, warm dry, and pink.

A review of the facility's iView Patient Assessment Wound revealed that on 12/16/20 at 3:44 pm, P#2 was noted to have a left ankle ulcer by the wound care nurse. WOCN ordered dressing changes once in 3 days. Further review of the medical record failed to reveal dressing changes from P#2's ankle ulcer from 1/1/21 to 1/13/21.

A review of Patient (P) #3 medical record revealed that Patient #3 arrived at the facility's ED on 12/27/21 at 4:36 am with an altered mental status, fever and vomiting for three days. P#3 was diagnosed with sepsis shock and was admitted to the facility.

A review of Patient (P) #3 medical record revealed that Patient #3 arrived at the facility's ED on 12/27/21 at 4:36 a.m. with an altered mental status, fever and vomiting for three days. P#3 was diagnosed with sepsis shock and was admitted at the facility.

On 12/27/21 at 8:00 a.m. a review of facility's iView patient assessment revealed that P#3 had a fissure on her buttock on initial skin assessment. P#3 had a Braden score of 13.

On 12/30/21 at 7:58 a.m. Registered Nurse (RN) documented P#3's wound was a stage IV pressure injury on the buttocks with bony prominence

On 12/31/21 at 1:30 p.m. WOCN DD assessed P#3, WOCN DD documented that P#3 had developed a stage IV pressure ulcer on her sacrum. WOCN ordered a specialty bed and administration of antimicrobial. Further review of the facility's iView Bed interventions failed to reveal documentation that the specialty bed was initiated.

A review of the facility's flowsheet for P#3 failed to reveal a dressing change on 1/9/22.

A review of Patient (P) #4 medical record revealed that P#4 was presented at the facility on 10/18/21 at 6:04 a.m. for right mandibular (Jawbone) resection due to cancer of buccal mucosa (the lining of the cheeks and the back of the lips, inside the mouth where they touch the teeth).
P#4 was admitted at the facility's surgical unit at 11:24 a.m.

On 10/18/21 at 11:35 p.m., review of the nursing flowsheet titled "iView- Patient Assessment" wound revealed that P#4 had no documented skin abnormality. Further review revealed that on 10/19/21 at 2:14 a.m. P#4 had an abdominal surgical incision. There was no pressure injury documented upon admission. P#4 ' s Braden score was 21.

On 10/21/21 at 9:00 p.m., RN documented a stage II pressure ulcer on P#4's right buttock.

On 10/22/21 at 12:29 p.m. wound care consult was ordered at 2:14 p.m. WOCN PP documented that P#4 had developed a sacral pressure ulcer that was 6cm* 8cm* 0.1cm (Length*width*depth).

On 10/27/21 at 9:49 a.m. WOCN PP noted that P#4's sacrum pressure injury was unstageable WOCN PP ordered P#3 bilateral buttock cleanse with normal saline and foam dressing changed once in three days.

On 10/19/21 at 6:03 p.m. the nursing care plan for pressure ulcer prevention was initiated, further review revealed that P#4 was to be repositioned every 2 hours (Q2hr). Detailed review of the record failed to reveal documentation of P#4 repositioning during the following times:

-10/29/21 from 12:35 pm to 3:04 p.m.,
-10/30/21 at 11:05 pm to 2:19 p.m.,
-11/1/21 at 11:51a.m. to 3:52 p.m.,
-11/1/21 at 7:29 p.m. to 11:55 p.m.,
-11/2/21 at 5:29 p.m. to 9:54 p.m.

A review of the facility's flowsheet failed to reveal a dressing change on 1/9/22.

An interview with the registered nurse (RN) EE occurred on 2/14/22 at 3:29 p.m. on the facility's medical and surgery unit. RN EE said that on average an RN is assigned to four patients. RN EE explained that the unit has one or two techs that assist with repositioning and activities of daily living (ADLs). RN EE said the repositioning of patients is carried out every two hours and both the RN and tech are equally responsible to ensure the task is done. RN EE said intentional rounding by tech and RN are carried out every hour and that the tech or RN must lay eyes on the patient at least in an hour.

An interview with the nurse tech (NT) GG took place at the facility's unit on 2/14/22 at 3:41 p.m. NT GG explained that her roles included assisting patients to the bathroom, taking blood sugars, helping patients with ADLs, taking vital signs, and repositioning patients that are not ambulatory. NT GG said whenever the blood sugar level is out of range, she would contact the nurse for assistance.

An interview with RN FF took place on 2/14/22 at 3:54 p.m. RN FF explained that when a patient is admitted to the unit, two nurses would do a skin head-to-toe assessment of the patient for skin breakdowns and document their findings. RN further explained that patients with a Braden score less than 18 are placed on a pressure injury preventive measure which included two hours of repositioning and Mepilex dressing. RN FF explained that if a patient developed a new sore at the hospital the nurses would complete an incident report and try to treat the wound. If the wound does not improve within 3 days, they would consult the wound care nurse. RN FF explained that patients with pressure injuries are provided specialty mattresses, waffle cushions, and moon boots. RN FF said dressing is done based on wound care nurse orders and should be documented. RN FF said that care rounding is documented hourly.

An interview with the WOCN DD was conducted on 2/17/22 at 10:36 a.m. at the conference room. WOCN DD said whenever a patient is at risk of pressure injuries upon assessment at admission, they are placed on pressure injuries prevention protocol which included offloading boots, dressing around sacral borders, repositioning, and barrier creams for stage 1 and 2 pressure injuries. WOCN DD explained that the nurses would care for the patient with stage 1 and 2 pressure injuries within a 72-hour window which they can then consult a wound, ostomy, and incontinent nurse if there is no improvement. WOCN DD explained that the wound care nurse would access the patient and put in an order for the management of the pressure injury. WOCN DD said she expected the nurses to follow her orders and continue to access and care for the wound. WOCN DD explained that she expected the nurses to contact her if for any reason they can't follow the written orders. WOCN DD said for hospital-acquired pressure injuries (HAPI), she would complete an electronic apparent cause analysis ( eACA ) once a HAPI is discovered and this would be discussed in the meeting minutes. WOCN DD said patients are assessed and followed up by the wound care nurse every week. WOCN DD acknowledged remembering P#1 she said P#1 was nonverbal and she met P#1's daughter at the bedside. WOCN DD said P#1's daughter had many questions about P#1's pressure injuries. WOCN DD said they had questions about the product used as the barrier cream. WOCN DD said the triad cream was her recommendation for P#1 because it helps to debride necrotic tissue and also has a zinc component but P#1's daughter seems adamant on zinc. WOCN DD said she tried to explain and reassured P#1's daughter that P#1's wound care plan would be reassessed at each visit. WOCN DD acknowledged that P#1 developed a HAPI and said an eACA was completed. WOCN DD said patients with pressure injuries are reassessed every week and acknowledged that P#1 was not followed every week based on the review of wound care documentation.

A review of the facility's procedures titled, "Lippincott Procedures Pressure Injury Prevention" revised 2/19/21 revealed the facility adopted the procedures for successful pressure injury treatment Successful pressure injury treatment involves relieving pressure, restoring circulation, promoting adequate nutrition, and, if possible, resolving or managing related disorders. In addition, Preventive measures include off-loading pressure, maintaining adequate nourishment, and ensuring mobility to relieve pressure and promote circulation. A risk assessment may be an important part of an overall prevention plan. The procedure listed the Braden scale as a tool to predict pressure injuries. The lower the score, the greater the risk. The procedure further revealed that when a pressure injury develops despite preventive efforts, treatment includes methods to decrease pressure, such as frequent repositioning to shorten pressure duration and the use of special equipment to reduce pressure intensity. Treatment may also involve pressure redistribution devices, such as special beds, mattresses, mattress overlays, and chair cushions.

A review of the facility policy titled, Consulting the Wound, Ostomy and Continence Nursing Staff effective date, 2/9/22 revealed the facility defined the process for consulting the Wound, Ostomy, Continence (WOC) Nursing Staff in managing patients with select disorders of the gastrointestinal, genitourinary, and integumentary system. The policy revealed that a consult to the WOC nurse can be initiated by a nurse, APP, physician, or any provider and that the provider should be notified if their patient has a wound whether the wound is present on admission or develops while hospitalized. In addition, the policy revealed stage 1 and 2 pressure injuries and medical adhesive related skin tear (MARSI), skin tears/fissures should be managed by nurse-driven protocols rather than WOC nurse consult, unless not improving after 3 days.

The policy further revealed that a thorough skin/integumentary assessment and pressure injury risk screening should be completed and documented on all new admissions and transfers within the first 8 hours. In addition, the policy revealed If a patient is admitted with a wound, for nursing staff to remove the dressing unless otherwise ordered not to remove by the provider. In addition, the policy revealed if a patient is admitted with a pressure injury, staff were to initiate the nurse-driven stage 1 and 2 pressure injury management protocol. If you are unsure about the best treatment option in the nurse-driven protocol, normal saline moist gauze dressing may be applied and changed every 12 hours and PRN (as needed).