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Based on policy review, medical record review and interview, nursing services failed to provide necessary care and services to reduce the incidence of adverse healthcare-associated conditions and other pressure injuries.

The findings included:

1. Nursing services failed to perform ongoing accurate assessments of patients in order to prevent healthcare-associated unstageable wounds and other pressure injures.

Refer to A 392.

Based on policy review, medical record review, and interview, the hospital failed to ensure nursing services provided nursing care as needed to all patients and followed the hospital's policy for performing accurate assessments to identify and prevent the occurrence of healthcare associated adverse events and other pressure injuries for 1 of 3 (Patient #1 ) sampled patients with deep tissue pressure injuries.

The findings included:

1. Review of the facility's "Pressure Injury and Management" policy revealed, "...A skin assessment will be performed by two (2) RN's on admission and at any shift change. This will include, but not limited to: all abrasions, bruised , pressure injuries, lesions, petechiae, rashes, scars, tears...Any wound noted during an skin assessment will be documented by the nurse describing the location, color, discharge, size, skin condition, dressing and etc ...Consult wound care for any wounds noted on admission or during daily skin assessments...A photo of the wound must be taken on admission, at the time of occurrence, and at discharge and will be placed in the chart per the Wound Digital Photograph-Inpatient policy...The pressure injury will be assessed at a minimum for: exudate, presence for necrotic tissue, appearance of wound bed, odor, appearance of surrounding skin, pain level with injury and injury dressing change, stage, size in centimeter, and location..."

2. Record review revealed Patient #1 resided in a long term group care home, and was profoundly intellectually disabled at baseline, nonverbal, bedbound and required total care.

Patient #1 has diagnoses which include Seizures, Bilateral Contractures of the Upper and Lower Extremities, Microcephaly, Gastrostomy tube, Osteoporosis, Quadriplegia and Bilateral Hip Dysplasia.

Review of the Group Care Home (where Patient #1 resides) transfer form revealed Patient #1 was transferred to the hospital on 5/2/2020 by ambulance. There was no documentation of any skin breakdown on Patient #1 at the time of transfer to the ED on 5/2/2020.

On 5/2/2020 at 7:03 PM, Patient #1 presented to the Emergency Department (ED) via ambulance with complaints of Seizures, Hypothermia and Urinary Tract Infection (UTI).

Review of the ED Nursing/Clinical Info sheets dated 5/2/2020 at 9:12 PM revealed Nurse #4 documented Patient #1 had a sacral decubitus. There was no documentation the nurse followed the hospital's policy and photographed the decubitus or documentation of the description, size, color, discharge, skin condition and dressing of the decubitus. There was no documentation the nurse consulted wound care per the hospital's policy.

Review of the physician's History and Physical note dated 5/2/2020 at 10:37 PM revealed no documentation Patient #1 had any pressure wounds.

Patient #1 was admitted to the hospital's Step down/Telemetry unit on 5/3/2020 at 1:05 AM with diagnoses of Seizures, Hypothermia and UTI.

On 5/3/2020 at 2:52 AM Nurse #1 documented Patient #1's skin assessment as the patient had "pinkness on sacrum and pinkness and dryness between buttocks". There was no documentation of the patient's sacral decubitus.

Review of the nursing notes for 5/4/2020 revealed no documentation nursing performed a skin assessments for Patient #1.

On 5/5/2020 at 2:55 PM Patient #1 was transferred to the hospital's medical unit and remained there until discharge on 5/12/2020.

On 5/5/2020 at 7:00 PM Nurse #6 documented Patient #1's skin assessment as 'skin assessment during shift change, see chart for details". There was no other documentation found in Patient #1's chart that a skin assessment had been performed on 5/5/2020

On 5/6/2020 at 7:00 AM Nurse #7 documented Skin assessment completed. There was no description of Patient #1's skin assessment.

On 5/6/2020 at 11:30 PM Nurse #9 documented, "... Right hip Medplex..." (a foam dressing). There was documentation of the decubitus description, size, color, discharge, skin condition or what decubitus care was provided if any..

On 5/7/2020 at 7:00 AM Nurse #8 documented "Skin assessment done at bedside shift report". There was no documentation of a description of the skin assessment. At 7:11 PM Nurse #12 documented "a skin audit was performed". There was no documentation of a description of the skin audit.

On 5/7/2020 at 8:00 PM Nurse #8 documented "skin description: red". There was no documentation of the location of the redness.

On 5/8/2020 at 7:10 AM Nurse #11 documented "skin assessment performed". There was no documentation of a description of the skin assessment.

On 5/8/2020 at 8:00 RN #13 documented "skin: fragile, red". There was no documentation of the location of the redness.

On 5/9/20202 at 8:15 PM Nurse #3 documented "redness to left heel, right ankle and abdomen". There was no other documentation of skin assessments.

On 5/10/2020 at 8:00 PM Nurse #3 documented "skin assessment performed. See integumentary". Review of the "Integumentary" revealed on 5/10/2020 at 8:45 PM Nurse #3 documented "multiple pressure areas-bilateral feet/ankles, front and back right thigh, upper back and abdomen". There was no pressure areas description, size, color, or discharge documented or if wound care had been performed.

On 5/11/2020 at 8:30 PM Nurse #3 documented "multiple pressure areas-right upper back, front and back right thigh, bilateral feet/ankles and abdomen". There was no description, size, color, discharge, skin condition of the pressure areas documented. There was no documentation wound care had been performed.

On 5/12/20202 at 9:53 AM Nurse #10 documented "multiple wounds - heels, r (right) thigh, r hip, shoulder, l (left or lower) and, l (left) foot". There was no description, size, color, discharge, skin condition of the multiple wounds documented. There was no documentation wound care had been performed.

3. Review of the Assessment - ADL (Activities of Daily Living) forms revealed no documentation Patient #1 had been turned and/or repositioned every 2 hours as ordered on 5/3/2020 through 5/12/2020.

4. Review of the physician Progress notes dated 5/4/, 5/5, 5/7, 5/8, 5/10 and 5/12/2020 revealed no documentation Patient #1 had pressure injuries or wounds.

On 5/11/2020 at 3:10 AM Nurse #3 entered a Wound Care Consult order for Patient #1.

5. Review of the wound Care note dated 5/12/20202 at 9:35 AM revealed Nurse #2 documented, "...Patient seen on consult for wound management. Noted to have a DTI (Deep Tissue Injury) pressure injury to the right upper back measuring 8.0 x [by] 4.0, dark red/purple with no drainage noted. Noted to have a blister area to the left abdomen measuring 2.5 x 8.0 and a blister area to the left thigh measuring 9.0 x 3.0, red with scant serous drainage noted. Noted to have a DTI pressure injury to the right hip measuring 7.0 x 4.5, dark red/purple with no drainage noted. Noted to have a DTI pressure injury to the right medial ankle measuring 6.0 x 5.5 , dark red/purple with no drainage, noted to have a DTI to the right heel measuring 6.5 x 6.0, dark red/purple with no drainage. Noted to have a DTI pressure injuries to the left medial foot measuring 1.0 x 1.5, 2.0 x 2.0 and 1.5 x 4.0 dark red with no drainage and a DTI pressure injury to the left heel measuring 5.0 x 8.5 dark red/purple with no drainage noted. Noted to have some blanchable redness to the left elbow measuring 3.5 x 2.0. Photo documentation completed. The wounds cleansed with wound cleanser, no sting barrier applied, foam dressings applied. Repositioned on the left side and the heels positioned off the bed using a pillow under the knees. The patient is on a turn q [every] 2 hour activity level. The dietician is following the patient for nutrition. Spoke with the nurse, stated the patient is being discharged today".

A Wound Care note dated 5/12/2020 at 2:05 PM revealed Nurse #2 documented, "... Notified named physician of the patient's wounds noted on assessment today..."

Patient #1 was discharged back to his group home on 5/12/2020 at 11:40 AM.

6. Review of Discharge Instructions dated 5/12/2020 revealed an order for Patient #1 to have "Miconazole Topical apply topically to buttocks every diaper change to prevent skin breakdown". There were no other wound care instructions documented.

7. In an interview on 5/19/2020 at 3:55 PM, the Director of Quality (DOQ) stated she could not say if additional photographs of patient #1's pressure wounds were taken. The DOQ stated she could not say how or when Patient #1's pressure wounds were acquired or deteriorated because she had not reviewed Patient #1's chart.

In a telephone interview on 5/20/2020 at 10:17 AM, the Director of Quality stated she did not have any additional documents.

8. In a telephone interview on 5/21/2020 at 10:04 AM, Nurse #1 stated she had admitted Patient #1 to the unit on 5/3/2020. Nurse #1 stated Patient #1 had "real dry skin" but did not have a sacral decubitus or any wounds.

9. In a telephone interview on 5/21/2020 at 12:37 PM, Nurse #10 stated the first day she noticed the wounds on Patient #1 was on 5/12/2020. Nurse #10 stated, "...The night nurse reported the wounds. I went back and looked in his chart but there were no pictures of the wounds in the chart..."

10. In a telephone interview on 5/21/2020 at 12:45 PM, Nurse #3 stated she provided care for Patient #1 on 5/10/2020 and 5/11/2020. Nurse #3 stated she notified the wound care nurse for a consult and stated, "...every time we turned him I saw a different spot. I placed a Mediplex dressing to the bony prominence areas and tried to keep him positioned off the worst..." She verified there were no photographs of the pressure wounds in Patient #1's chart.

11. In a telephone interview on 5/21/2020 at 1:20 PM, Nurse #5 verified she admitted Patient #1 to the medical unit from the step-down unit on 5/5/2020. Nurse #5 stated she remembered a nurse saying "something about the patient's right hip having a Mediplex on it". Nurse #5 stated Patient #1 did not any wounds that she could remember.

12. In a telephone interview on 5/21/2020 at 10:55 AM, the Group Home Registered Nurse stated the patient did not have any wounds or skin issues at all prior to transfer and admission to the hospital on 5/2/2020.