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Based on document review and interview, nursing services failed to document admission and/or weekly skin assessments in 8 of 10 patient (Patients 1, 2, 3, 4, 5, 6, 7, and 8) medical records reviewed; failed to document a complete wound admission assessment in 1 of 10 patient (Patient 3) medical records reviewed; failed to notify the provider of medications not administered for 2 of 10 patient (Patient 4 and 7) medical records reviewed; and failed to accurately complete the daily fall risk assessment in 6 of 10 patient (Patients 1, 2, 5, 6, 7, and 8) medical records reviewed.

Findings include:

1. Facility policy titled, Skin Assessment, PolicyStat ID 12385990, last approved on 09/2022 indicated under Procedure: Assessment, 1. A head-to-toe assessment should be done prior to or upon admission to the unit. Additional skin assessments should be completed one time per week or as ordered by provider; under f. Identification additional risk factors for developing pressure ulcers; and under I. If a skin condition, wound, pressure ulcer is noted, the wound should be assessed by the nurse and documented on the skin/wound form.

2. Facility policy titled, Standardized Medication Administration, PolicyStat ID 12197198, last approved 08/2022, indicated under General Knowledge, E. All medications will be administered within one hour (before or after) of administration time or physician will be notified with reason medication not administered and an incident report will be completed if needed.

3. Review of Patient 1's medical record indicated the following:
a. The patient was admitted on 03/07/2025.
b. Medical record lacked documentation of the weekly skin assessment on 03/08/2025 and 03/15/2025.
c. Medical record lacked documentation of the daily fall risk assessment for day shift on 03/08/2025.
d. The patient was discharged on 03/18/2025.

4. Review of Patient 2's medical record indicated the following:
a. The patient was admitted on 03/10/2025.
b. Medical record lacked documentation of the weekly skin assessment on 03/15/2025.
c. Medical record lacked completed documentation of daily fall risk assessment on 03/13/2025 day shift and 03/14/2025 day shift.
d. The patient was discharged on 03/21/2025.

5. Review of Patient 3's medical record indicated the following:
a. The patient was admitted on 03/13/2025.
b. The medical record indicated on the admission skin assessment the patient had a scabbed sacral pressure ulcer that measured 4 by 4 by 1; lacked documentation of metrics used for measuring, documentation on the skin/wound form, and wound care during hospitalization.
c. Medical record lacked documentation of the weekly skin assessment on 03/15/2025.
d. The patient was discharged on 03/20/2025.

6. Review of Patient 4's medical record indicated the following:
a. The patient was admitted on 03/13/2025.
b. Medical record lacked documentation of the weekly skin assessment on 03/15/2025 and 03/22/2025.
c. On 03/13/2025, the provider ordered to continue Ivermectin 3 milligrams by mouth every two weeks.
d. Medication administration record lacked documentation that Ivermectin was administered to the patient on 03/28/2025 and lacked documentation that the provider was notified the reason the medication was not administered.
e. The patient was discharged on 03/28/2025.

7. Review of Patient 5's medical record indicated the following:
a. The patient was admitted on 03/20/2025.
b. Medical record lacked documentation of the admission skin assessment on 03/20/2025.
c. Medical record lacked documentation of the weekly skin assessment on 03/22/2025.
d. Medical record lacked documentation of the daily fall risk assessment on 03/25/2025 on day shift.
e. The patient was discharged on 03/28/2025.

8. Review of Patient 6's medical record indicated the following:
a. The patient was admitted on 03/21/2025.
b. Medical record lacked documentation of the weekly skin assessment on 03/22/2025 and 03/29/2025.
c. Medical record indicated the patient's day shift fall risk assessment was marked low to moderate risk on 03/22/2025, 03/29/2025, 03/30/2025, and 04/01/2025 with a score of 90 on all dates using the Morse Fall Scale. The Morse Fall Scale indicates a score greater than 45 is high risk.
d. The patient was a current inpatient.

9. Review of Patient 7's medical record indicated the following:
a. The patient was admitted on 03/23/2025.
b. Medical record lacked documentation of the weekly skin assessment on 03/29/2025.
c. Medical record lacked complete documentation of the admission fall risk assessment on on day and night shift on 03/27/2025.
d. On 03/24/2025, the provider ordered to continue Sunosi 150 milligrams by mouth daily and the facility should obtain the medication.
e. Medication administration record indicated the medication was scheduled to be administered daily and lacked documentation that the patient received the medication for the duration of their hospitalization from 03/24/2025 through 03/31/2025 and lacked documentation that the provider was notifed the reason the medication was not administered.
f. The patient was discharged on 03/31/2025.

10. Review of Patient 8's medical record indicated the following:
a. The patient was admitted on 03/25/2025.
b. Medical record lacked documentation of the weekly skin assessment on 03/29/2025.
c. Medical record lacked complete documentation of the admission fall risk assessment on 03/25/2025 and daily fall risk assessment on day and night shift on 03/27/2025.
d. The patient was a current inpatient.

11. Interview with A2 (Director of Risk and Quality) and A3 (Director of Nursing) on 04/02/2025 at approximately 2:15 p.m. confirmed the above findings.

Based on document review and interview, nursing services failed to report allegations of patient abuse in one (1) instance (Patient 7).

Findings include:

1. Facility policy titled, Patient Abuse and Neglect, last approved on 04/2024, indicated under Purpose: To provide procedures for reporting, investigating, and following up when an allegation of patient abuse or neglect is made, or when other information is received indicating that patient abuse or neglect may have occurred; under Responsibilities: Employee Responsibilities and Initial Notification Procedures, Employees who witness or have knowledge of patient abuse shall immediately report the incident to the CEO and Director of Nursing, or designee.

2. Review of Patient 7's medical record indicated the following:
a. The patient was admitted on 03/23/2025 and the admission skin assessment indicated the patient had a bruise on the back right shoulder, back of right arm, bruise on the upper left arm, and a skin tear on the right finger.
b. On 03/24/2025, the medical record indicated in a nursing note the patient accused staff of old bruises on arm.
c. On 03/26/2025, the nursing note indicated patient 7 requested to talk to a nurse about filing a grievance. The patient indicated that they had been physically assaulted and berated by staff. Patient 7 indicated that they had an accident in bed and called for S1 (Behavioral Health Associate) to help; S1 asked S2 (Behavioral Health Associate) to help. Patient 7 indicated that S1 and S2 were rough, threw them around the bed, and S2 held their upper body.
d. On 03/28/2025, the skin monitoring form indicated the patient had bruising on their back left shoulder, bruising down the upper and lower left arm indicated by 9 circles versus the initial assessment upon admission which indicated a bruise on the right shoulder, back of right arm, bruise on the upper left arm and a skin tear on the right finger.

3. Interview with S1 on 04/02/2025 at approximately 3:55 p.m. confirmed that they cared for patient 7 on 03/24/2024 day shift. S1 indicated S1 and S2 changed patient 7. S1 indicated that patient 7 indicated they could not move due to a neurological condition. S1 indicated patient 7 informed S1 that S2 bruised patient 7. S1 indicated they told a staff nurse about patient 7's allegations.

4. Interview with A2 (Director of Risk and Quality) and A3 (Director of Nursing) on 04/02/2025 at approximately 2:15 p.m. confirmed the above findings.

Based on document review and interview, nursing services failed to administer ordered and scheduled medications for 2 of 10 patient (Patient 4 and 7) medical records reviewed.

Findings include:

1. Facility policy titled, Standardized Medication Administration, PolicyStat ID 12197198, last approved 08/2022, indicated under General Knowledge, E. All medications will be administered within one hour (before or after) of administration time or physician will be notified with reason medication not administered and an incident report will be completed if needed.

2. Review of Patient 4's medical record indicated the following:
a. On 03/13/2025, the provider ordered to continue Ivermectin 3 milligrams by mouth every two weeks.
b. On 03/28/2025, the medication administration record indicated that the medication was scheduled to be administered.
c. Medication administration record lacked documentation that Ivermectin was administered to the patient on 03/28/2025.

3. Review of Patient 7's medical record indicated the following:
a. On 03/24/2025, the provider ordered to continue Sunosi 150 milligrams by mouth daily and the facility should obtain the medication.
b. Medication administration record indicated the medication was scheduled to be administered daily and lacked documentation that the patient received the medication for the duration of their hospitalization from 03/24/2025 through 03/31/2025.

4. Interview with A2 (Director of Risk and Quality) and A3 (Director of Nursing) on 04/02/2025 at approximately 2:15 p.m. confirmed the above findings.