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Based on policy review, medical record review, document review and staff interview, it was determined the facility failed to sufficiently analyze adverse patient events and implement preventive actions and mechanisms that included feedback and learning throughout the hospital to ensure patient safety related to hospital acquired pressure ulcers.

Findings included:

A review of the Quality Assessment Process Improvement (QAPI) Plan to include number and scope of Process Improvement (PI) Program showed a review of the QAPI plan showed significant event reviews are performed by RM with a thorough and credible root cause analysis (RCA) using the Human Factor Analysis and Classification System to determine whether the event is deemed a sentinel or serious safety event. All event action plans are sent to the Medical Executive Committee (MEC). The plan shows the selection of Quality Improvement Priorities are selected both proactively and in response to problems that are identified through ongoing assessment of data analysis of adverse events.

A review of the pressure ulcer event reports, submitted by facility nurses from 10/04/17 through 08/31/18 from the facility Risk Master Event Reporting System, showed 90 hospital acquired pressure ulcers (HAPU's). The report total showed the date the patient was admitted to the facility and the date the pressure ulcer (PU) developed. To ensure the accuracy of the information provided on the report, the peer review manager verified that accuracy by entering the patient records to ensure the patient did obtain the PU after admission. The peer review manager confirmed the reports accuracy.


On 09/27/18 at 2:20 PM, an interview with the Director of Risk Management (RM) revealed that the facility had not performed any analysis of the 90 HAPU's or had the facility put into place corrective measures to prevent future patients from developing HAPU's.

A review of the report facility AHRQ quality safety indicators for pressure ulcer rates (PSI 03) presented to the Quality Improvement Council, Performance Improvement Executive Council and the Governing Board, showed a rate of 0.0 from Feb 2018 to present. This data includes Stage III or IV pressure ulcers or unstageable (secondary diagnosis) pressure ulcers per 1,000 discharges among surgical or medical patients ages 18 years and older that are not present on admission. Patients with HAPU's stage I, II and unstageable deep tissue injuries (DTI's) were not reported to the aforementioned committees by the facility Quality Department.

On 09/27/18 at 2:05 PM, an interview performed with the Director of Quality Management (QM) confirmed the above findings. The Director also confirmed the facility had not analyzed or put in place plans for prevention or improvement of HAPU's. Additionally, the QM Director stated she was unaware of the 90 HA PU's shown in the facility event reporting system that the RM department receives. The QM Director stated she recently started work at the facility and had only been in the position for three weeks.

Based on policy review, document review, medical record review and staff interview it was determined the nursing failed to:

1. Nursing staff failed to report patients change in condition and failed to provide nursing interventions according to standard nursing practice. (Refer to A0395)

2. Nursing failed to turn and document patient turning/positioning as ordered. (Refer to A0395)

3. Assess patient needs, change in condition, and provide interventions according to standard nursing practice. The nursing staff failed to meet the needs of the patient related to turning/positioning and prevention and development of pressure sores. These inactions lead to a continued deterioration of the patient's skin resulting in a severe pressure ulcer, mulitple surgeries, and a diverting colostomy. (Refer to A0395)

4. Ensure a registered nurse supervised and evaluated nursing care for each patient on an ongoing basis. (Refer to A0395)

The cumulative effect of the above findings determined the facility was not in compliance with the Condition of Participation for Nursing Services.

Based on review of medical records, facility policy and procedures and staff interview it was determined the facility failed to ensure a registered nurse supervised and evaluated nursing care for each patient on an ongoing basis, report changes in the patient's condition, and follow physician orders in accordance with hospital policy for six (#1, #2, #3, #4, #6, #8) of eight medical records sampled.

Findings included:

A review of the policy entitled, "Pressure Ulcer/Wound Prevention and Treatment," #10-8-016, revised 03/18, showed that a patient at risk of developing pressure ulcers will be identified and interventions will be taken to minimize the risk...the RN determines the patient's risk upon admission and each shift using the Braden Scale. It the patient's Braden score is 18 or less, the patient is considered to be at risk to develop a pressure ulcer. The RN may also consider other risk factors to determine if the patient's condition increases their risk for pressure sore development...if the patient is determined to be at risk, interventions will be implemented to decrease the risk of pressure sore development...the RN documents the admission and shift skin observation appropriately in the electronic health record (EHR). Initial skin assessment is performed by two RN's. Additionally, photographs will be taken of any skin alterations and placed in the EHR...if the wound is not healing, has worsened, is full thickness, or was acquired since admission, consult the wound care nurse...the RN will the photographs..at discovery of pressure ulcer...photos are applied to the skin/wound photographic documentation form and placed in the patient's chart...and will be accessible in the EHR. The RN will document wound observation on each shift or at each dressing change. Wound care measurements are done by the wound care team. A review of the policy recommended interdisciplinary prevention and treatment of pressure ulcers wounds included the following:
1. The RN may consult with the wound care team to assist with the prevention and treatment of pressure ulcers.
2. Medical nutrition therapy is consulted when a wound consult if placed in the EHR.
3. The RN obtains order for physical therapy (PT) and/or occupational therapy (OT) to assist with mobility and strengthen as patient condition warrants.
Contained review of the policy showed the recommended pressure ulcer/wound treatment for reddened areas, skin tears and partial thickness wounds include:
1. Notify the physician. Apply foam dressing and/or topical therapy. Obtain physician order if necessary.
2. Notify the wound care nurse for any new or chronic pressure ulcers.
For treatment of full thickness wounds...notify physician...consult wound care nurse.

A review of the policy entitled, "Assessment/Reassessment, Organization-wide Plan for Patient, #2-1-003, reviewed 02/2018, showed the goal of patient assessment/reassessment is to determine what kind of care is required to meet the patient's initial needs, as well as his/her needs as they change in response to care...the assessment begins at the time of admission and continue throughout the patient's hospitalization...reassessments and reprioritization of the patient and his/her needs is performed by the RN(s) and physicians when there is a change in the patient's status, as indicated by the patient condition and/or treatment...assessment components to be addressed in the complete admission process include...identification of patient problems, including...complete skin assessment...nursing care needs are reassessed a minimum of once in a 12 hour period for inpatients. Reassessment may be performed more frequently for changes in the patient's condition or in response to treatment modalities.

1. A review of the RN initial assessment for Patient #1 dated 08/0618 at 10:00 AM showed a Braden scale score of 22 with skin intact. There were no pressure ulcers or photographs of wounds present on admission.

A review of the primary care RN skin assessment showed the following inconsistent documenation of Patient #1's Braden score and actiivty level:
08/10/18 at 11:00 AM, showed a Braden skin score of 18 and the patient activity was noted to be bedfast and skin intact.
08/11/18 at 8:00 AM showed a Braden skin score of 20 and the patient was noted to now walk occasionally and skin intact.
08/20/18 at 8:00 AM showed a Braden skin score of 20 and the patient activity noted as walks occassionally and skin intact.
08/20/18 at 7:38 PM showed a Braden skin score of 14 and the patient activity was noted to be bedfast and skin intact.
08/21/18 at 7:00 AM showed a Braden skin score of 18 and the patient activity was noted as walks occassionally.
08/25/18 at 7:56 AM showed a Braden skin score of 20 and the patient activity was noted as walks occassionally.
08/25/18 at 8:00 PM showed a Braden skin score of 14 and the patient activity was noted as bedfast.
08/26/18 at 8:40 AM showed a Braden skin score of 14 and the patient activity was noted as bedfast and no new areas of skin breakdown was documented.
08/26/18 at 7:35 PM showed a Braden skin score of 17 and the patient activity was noted as walks occassionally and no new areas of skin breakdown was documented.
09/03/18 at 7:00 PM showed a Braden skin score of 18 and the patient activity was noted as chairfast
09/04/18 at 8:00 AM showed a Braden skin score of 14 and the patient activity was noted as chairfast and no new areas of skin breakdown was documented.
09/04/18 at 4:00 PM showed a Braden skin score of 14 and the patient activity was noted as chairfast and a skin tear was noted in the coccyx area and a sacral spone and barrier cream was placed on the wound.
09/05/18 at 8:00 AM showed a Braden skin score of 13 and the patient activity was noted as chairfast and no new areas of skin breakdown was documented.
09/05/18 at 7:30 PM showed a Braden skin score of 14 and the patient activity was noted as chairfast and no new areas of skin breakdown was documented.
09/06/18 at 8:00 AM showed a Braden skin score of 13 and the patient activity was noted as walks occassionaly with no documentation of a coccyx wound.
09/06/18 at 1:00 PM showed an assessment was performed by the WOCN and a coccyx wound was present that measured 2.5 x 2.2 x 0.1.
There was no documentation the WOCN was consulted once the patinet's Braden score fell below 18. There was no documentation nursing notified the physican of the patient's Braden score or the risk of the patient developing a pressure ulcer. There were no photographs in the medical record of the coccyx wound.

A review of the physician wound care orders dated 09/05/18 at 5:54 PM, showed an order to consult the wound ostomay continence nurse (WOCN).

A review of the wound care RN assessmented for Patient #1 dated 09/06/18 at 1:34 PM, showed a coccyx pressure injury that was unstageable and the wound measured 2.5 x 2.2 x 0.1 with no drainage. The peri-wound was noted to be excoriated and erythemic. The wound care recommendation was to apply Santyl to the wound bed, apply calazime to peri-wound skin, and cover with foam dressing. The note inidcated the primary nurse was to reconsult the WOCN for additional needs. There was no photograph of the wound in the medical record of Patient #1.

2. A review of the registered nurse (RN) initial assessment for Patient #2 dated 07/21/18 at 10:00 PM, showed a Braden scale of 18 with skin intact. No pressure ulcers were documented. There were no photographs of wounds present in Patient #2's medical record on this date.

A review of the thoracic surgeon physician orders for Patient #2, dated 07/21/18, showed an order for foam dressing to the coccyx, Q2 hour turns, when in bed and support with wedges, bariatric low air loss mattress

A review of the registered nurse (RN) documentation dated 07/30/18 at 2:40 PM upon arrival to the CIU, showed Patient #2's Braden scale was an 18 with no skin breakdown and no pressure ulcers present. There were no photographs of wounds present in Patient #2's medical record on this date.

A review of the RN skin assessment documentation of the Braden scale score for Patient #2 showed the following inconsistent scoring of the patient's risk for the development of a pressure ulcer.
07/21/18 - 20
07/22/18 - 18
07/23/18 - 18
07/24/18 - 16
07/25/18 - 20
07/26/18 - 20
07/27/18 - 17
07/28/18 - 21
07/29/18 - 20
07/30/18 - 14
07/31/18 - 16
08/01/18 - 14

A review of the RN patient care activity documentation from 07/31/18 through 08/31/18 showed the following failures to follow physician orders for turning Patient #2 every two hours:
07/25/18 - 9:00 AM to 1:00 PM, not turned for 4 hours
07/28/18 - 3:00 PM to 8:00 PM, not turned for 6 hours
07/29/18 - 8:00 PM to 7:00 AM, not turned for 11 hours
07/30/18 - 7:19 AM to 2:40 PM, not turned for 7 hours and 20 min.
08/02/18 - 8:00 AM to 8:00 PM, not turned for 12 hours
08/07/18 - 5:00 AM to 10:30 AM, not turned for 5 hours 30 min. and 3:00 PM to 7:00 PM, not turned for 4 hours.
08/08/18 - 3:00 AM to 7:00 AM, not turned for 4 hours and 3:00 PM to 7:00 PM not turned for 4 hour
08/17/18 - 12:05 AM to 8:00 AM, not turned for 8 hours
08/18/18 - 12:00 AM to 4:00 AM, not turned for 4 hours, 4:00 - 8:00 AM, not turned for 4 hours, 7:00 PM to 8:00 AM, not turned for 11 hours
08/20/18 - 8:00 AM to 10:10 PM, not turned for 14 hours

A review of the wound care RN consultation documentation dated 07/31/18 at 11:29 AM for Patient #2, showed hospital acquired pressure ulcer wound located on the coccyx and bilateral inner gluteal clefts. The coccyx pressure ulcer was documentation showed a measurement of 11 x 8 x 0 depth, tunneling deep tissue injury (DTI) closed. There was no indication of the measurement was inches, centimeters or millimeters. The right inner gluteal cleft was noted to be partially bleachable. The recommendation was for the pressure ulcer located on the coccyx to be covered with foam dressing and changed twice daily, patient to be turned every 2 hours while when in bed and supported with wedges, and provide a bariatric low air loss mattress. The documentation showed the staff RN was to reconsult the wound care RN if there are any additional needs.

A review of the wound care RN consultation documentation dated 08/0618 at 11:44 AM showed the she attempted to evaluate the patient but the primary nurses stated the patient was too unstable for turning. The note indicated the primary nurse was aware and instructed to place a new consult for additional needs.

A review of a gluteal area photograph dated 08/12/18 at 3:00 PM by the wound care RN, showed a stage 1 pressure ulcer. There was a ruler held next to the gluteal wound that appeared to be the length of 10, but no documented measurements filled in on the document whether this was inches or centimeters. The document also had a line for physician signature that was left blank.

A review of the wound care RN consultation documentation dated 08/14/18 at 11:29 AM, showed the wound care RN reassessed Patient #2 with the following findings:
- Right inner gluteal cleft noted to be an intact DTI that was maroon in color and measures 1.8 cm x 3.0 cm with an intact peri-wound. Wound care orders were to cleanse with bath wipe, pat dry well, apply Calazime and a foam dressing.
- Left inner gluteal cleft that extends to left buttock. Noted 60% yellow adherent slough, 30% intact DTI that is maroon in color and 10% ink granulation tissue. A moderate amount of serosanguinous drainage noted. Edema to periwound present. There was no documentation of the wound size. Wound care orders for this sight were to cleanse with sterile saline, apply Medhoney to wound bed, apply calazime to DTI and periwound and a apply foam dressing twice daily. Reposition patient every two hours.
The note indicated the care was transition back to the primary nurse and nursing was to reconsult if there were any additional needs.

A review of the wound care RN consultation documentation dated 08/21/18 at 1:15 PM showed patient was seen for reassessment of Patient #2's wounds. The note shows report was received from the primary care nurse that the wound to the patient's buttocks were improving and nursing still has wound care orders from 08/14/18. The note showed the wound care RN did not assess the patient's wounds or measure the wounds. The note indicated the primary nurse should reconsult wound care for any additional needs.

A review of the vascular surgeon operative report related to the hospital acquired pressure ulcer for Patient #2, dated 08/31/18 at 11:08 AM, showed the patient was taken to surgery for a debridement of the left buttock/sacral decubitus ulcer, drainage of abscess extending to the skill region left, debridement of mid gluteal cleft decubitus ulcer to the subcutaneous, debridement of right medical buttock ulcer to subcutaneous level was performed. The report indicated the abscess extended into the left anal wall and the patient will require a diverting colostomy.

A review of the vascular surgeon operative report dated 09/02/18 showed laparotomy with a proximal right transverse loop colostomy was performed.

A review of the vascular surgeon operative report dated 09/07/18 showed an excisional debridement of the sacral coccygeal decubitus ulcer pulse lavage was performed.

A review of the urology surgeon operative report by the urologist and vascular surgeon for Patient #2 dated 09/11/18 showed an incision, drainage, and debridement of necrotic scrotal tissue from the sacral decubitus. The operative report documenting by the vascular surgeon on this surgery showed excisional debridement with I&D of necrotic scrotal and perineal tissue, debridement of sacral and left buttock decubitus ulcer was performed.

On 09/26/18 at 2:15 PM Patient' #2's discharge (DC) summaries dated 08/23/18, 08/31/18, and 09/18/18 were requested. The discharge summary received was dated 08/23/18. A review of the DC summary received, failed to mention the patient had acquired a severe coccyx pressure ulcer requiring four surgeries and a diverting colostomy as a result of the HA PU.

3. A review of the physician history and physical (H&P) dated May 17, 2018 at 17:48 showed Patient # 3 was admitted to the facility on May 17, 2018 with chief complaint of bloating and distended abdomen. He had a history of pancreatic head ductal adenocarcinoma and had a total pancreatectomy on 3/20/18. He was diagnosed with hyperglycemia and protein-calorie malnutrition: mild with serum albumin of 2.9; needs protein supplements once taking po (by mouth). The Nursing Assessment, dated 5/17/18 at 19:33 documented a Braden Scale of 15 (per policy 18 and below patient is at risk for skin breakdown) and skin not intact. (wound not staged) Allevyn foam was applied to the coccyx. Allevyn foam on coccyx was documented on 5/18/18 and 5/19/18. Assessments from 5/20/18 to 5/25/18 documented Braden risk for skin breakdown at 19-20 (not at risk) and there was no documentation of any skin breakdown to the coccyx or Allevyn foam dressing applied. There was no documentation that the pressure sore was monitored daily for improvement or that daily interventions were done to prevent further breakdown. It was not until 5/25/18, at 1600 that the nursing assessment documented a Stage II pressure ulcer of the midline coccyx and a foam dressing was applied. A photo was taken of the wound. The Wound Team was not consulted for a Stage II pressure ulcer as per hospital policy. A Nutrition Screening was done on 5/22/18 at 0739 and the patient was found to be on a concentrated carbohydrate, low sodium, soft food diet. There were no interventions. The patient was not prescribed a protein supplement. On 5/24/18 the patient had a nutrition re-screen for a length of stay greater than 4 days and found that his po intake was improving and his skin was intact. No protein supplement was recommended. The Interdisciplinary Plan of Care (IPOC) planned for prevention of skin breakdown as of 5/19/18 with goals of absence of new skin breakdown and absence of pressure ulcers with a focus on prevention and care of any potential breakdown areas. The patient was discharged on 5/26/18 and the Discharge Summary, dated 5/26/18, at 1026 documented that the patient was discharged to a skilled nursing facility with severe protein calorie malnutrition and was ordered TPN (total parenteral nutrition). There was no mention of the Stage II pressure ulcer of the coccyx in the Discharge Summary.

4. Review of the history and physical (H&P) dated September 20, 2018, at 1746 revealed that Patient #4 was admitted to the facility on 9/2018 after a fall resulting in a right hip fracture. The patient underwent a closed reduction and intramedullary rod of the right femur. The Braden Scale was recorded as 20 (not at risk for skin breakdown) and there was no nursing documentation of skin breakdown during the hospital stay. The IPOC did not document a plan for potential for skin breakdown. The physician Discharge Summary, dated 9/24/18 did not document any skin breakdown. The patient was admitted to the hospital's rehab unit on 9/25/18. The H&P, dated 9/25/18, at 2008 documented that the patient's right heel had a dark purple area of tissue with a questionable deep tissue injury. Wound care notes, dated 9/26/18, at 1013, documented an intact deep tissue injury to the right posterior heel measuring 1.0 cm x 0.5cm area maroon in color. The plan was to cleanse with sterile saline, paint with Betadine and allow to dry and cover with a foam dressing and change daily. Apply bilateral heel boots while in bed. Failure to apply preventive measures to prevent skin breakdown during the hospital stay resulted in a hospital acquired pressure ulcer.

5. Review of the H&P dated 9/15/18 at 0255 revealed that Patient #6 was admitted to the hospital on 9/14/18 with a diagnosis of non ST segment myocardial infarction (NSTEMI) and chest pain. The patient's Braden Scale on 9/14/18 was 16 (18 or less is at risk for skin breakdown). An IPOC for prevention of skin breakdown was started on 9/17/18. Daily Braden scores from admission until 9/20/18 ranged from 19 and below. The patient had a coronary artery bypass grafting on 9/20/18. On 9/20/18 the Braden Scale was 16 and the patient was placed on a low air loss mattress as documented in "Patient Care Activity" but there was no documentation of skin breakdown. On 9/23/18 the Braden Scale was 13 and the patient was placed on a lateral rotation system bed and utilization of a prophylactic sacral foam dressing. There was still no documentation of skin breakdown. On 9/24/18 the nursing assessment documented "shearing, pressure injury ecchymosis posterior, lower buttocks". A pressure ulcer care plan was started on 9/25/18 and a wound care note, dated 9/25/18 at 0955 documented "deep tissue injury to coccyx and right medial buttock-coccyx measure 1.3cm x 0.3cm, area maroon in color. No exudate." A Dolfin mattress was ordered. Another wound care note on 9/27/18 documented the same. The Patient Care Activity Notes documented that the patient required maximum assistance with activity and ADL's from 9/20/18 to 9/24/18. There was no documentation in the Patient Care Activity notes that the patient was repositioned every 2 hours as recommended in the facility's policy on Pressure Ulcer/Wound Prevention and Treatment.

6. Review of the H&P dated 4/9/18, at 0615 revealed that Patient #8 was admitted to the facility on 4/9/18 unresponsive, intubated and sedated after being reported thrown out of a bar and found unresponsive outside. A CT of the head showed intracranial hemorrhagic contusions, petechial hemorrhaging and subtle subarachnoid hemorrhage. The initial Braden Score on 4/9/18 at 1100 was 14 (high risk for skin breakdown). Documentation showed high risk skin assessment for coccyx, heel, left, heel, right and "not intact". No new areas of skin breakdown were documented from 4/9/18 to 4/18/18. On 4/18/18 documentation showed a foam dressing applied to the coccyx. On 4/19/18 at 1900 documentation of the Braden score was 13 and the skin was described as "not intact" with no body location or wound staging defined. On 4/20/18 review of the Wound Care Notes revealed that there was an intact serous filled blister to the right plantar foot measuring 2.8 cm x 5.1 cm. The wound was cleansed with sterile saline, painted with Betadine and allowed to dry, covered with Cuticerin and foam dressing. The next wound care note was dated 5/1/18 at 1056 (10 days later) and the coccyx showed a stage 3 pressure ulcer 3x1x0,35 50% pink and small amount of serosangueinous drainage with surrounding tissue within normal limits. Right plantar foot bullae with no drainage notes. The Operative Report, dated 5/7/18 showed debridement of the right plantar foot ulcers. The IPOC dated 4/28/18 showed pressure ulcer prevention that included repositioning the patient every 2 hours. The IPOC dated 5/26/18 showed Pressure Ulcer with wound healing goals. Other than the wound care nurse notes, nursing did not document a description of the patient wounds throughout the stay. The patient was discharged to Rehab on 5/26/18. There was no documentation of the coccyx wound in the Discharge Summary.