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Based on policy and procedure review, clinical record review, and interviews, it was determined that the facility failed to develop, update, implement, and/or individualize an interdisciplinary integumentary plan of care for 2 (#1 and #6) of 13 (#1-#13) patients in that:
1) The facility failed to provide a hospital wound care nurse consultation per established policies.
2) The facility failed to develop an individualized interdisciplinary integumentary plan of care to assure the skin care policies, and orders were followed to prevent further skin breakdown.
The failed practices did not assure the skin care policies were followed to prevent further skin breakdown and did not assure patients were protected from the likelihood of an injury; the nursing staff could determine when a wound had occurred or improved, remained the same or declined; the nursing staff could readily identify which interventions were linked to which problem; and integumentary goals were measurable to determine if the problem continued or was resolved. The failed practice affected Patient #1 and #6 and had the likelihood to affect all patients admitted to the facility. Findings follow:

A. Review of policy titled, "Skin integrity, Care of the Patient with or at Risk for Impairment," dated 02/1994 along with "Appendix A Central AR - HAPI Prevention Interventions" showed the following:
1) Skin assessments were to be conducted on admission and each shift.
2) Turn patient every 2 hours initiated or clear documentation that the patient can self-turn.
3) Elevate heels off the bed or chair by bridging to leave the heel completely open. May use heel boots or pillows.
4) Pad bony prominences to prevent friction/shear (utilize pillow and Allevyn borders as indicated).
5) Limit time in chair to 1 hour unless patient can shift weight.
6) Consult wound nurse.
7) Pressure ulcers were to be staged and measured in the admission assessment and repeated weekly.
8) Patients with intact skin and Braden score of 14 or less or have high risk diagnosis were to implement "Moderate Risk" or "High Risk" interventions and have preventative measures (consult wound nurse, pressure redistribution mattress, turning every two hours and protective barrier) implemented.
9) Pressure ulcers were to be documented in the wound assessment section of the patients' chart.
10) Pressure ulcers would be photographed on admission, upon detection and weekly by the Wound Ostomy Continence Nurse (WOCN).

B. Review of policy titled, "Core Nursing standards of Practice," dated 01/2022 showed the following:
1) Two licensed clinicians would perform skin assessments on admission, upon discovery, and upon transfers from another unit/department. The Registered Nurse (RN) would perform skin assessment with each shift.
2) Upon discovery of a suspected pressure injury/wound injury, a wound consult be requested.
3) Photograph all wounds/pressure injuries on admission, discovery, weekly, prior to discharge, and/or change in wound status.
4) The RN would develop and implement a plan to provide safe, effective, and efficient patient-centered care.
5) Interprofessional teams were to be consulted according to the patient's condition and health needs.

C. During an interview on 11/29/2023 at 12:45 PM, the WOCN confirmed that a Braden score of 14 or less a wound consult order should be initiated. WOCN confirmed that with a Braden score of 12 patients would be high risk. WOCN confirmed that patients should be turned every 2 hours when the Braden score was 14 or less. WOCN confirmed that patients should be in wheelchair/chair for no more than 1 hour if able to shift weight. WOCN confirmed that wound/pressure ulcers were photographed the day they were found. WOCN confirmed that the WOCN should be consulted when a wound/pressure ulcer was discovered.

D. Review of Patient #1's Clinical record on 11/28/2023, showed the following:
1) Patient #1 was admitted on 9/17/2023 at 8:12 PM with the following diagnosis: Failure to Thrive.
2) On admission, emergency room RN documented Braden score of 14.
3) Braden score of 14 or less per orders should have consult for WOCN nurse. There was no evidence of an order for WOCN consult.
4) On 9/22/2023 at 8:00 PM, Braden Score changed to 12. There was no evidence of an order for WOCN consult.
5) Patient was not repositioned consistently every 2 hours beginning on dates 9/18/2023-10/2/2023, for example: 9/24/2023 patient not repositioned from 12:10 PM to 5:20 PM.
6) Patient sat in wheelchair/chair for longer than 1 hour, for example: 9/22/2023 from 11:00 AM to 7:00 PM.
7) On 9/23/2023 at 7:19 AM, skin tear to the right elbow documented. There was no evidence of a picture of the wound or an order for WOCN consult or Allevyn dressing that was applied to the wound.
8) During an interview on 11/28/2023 at 1:00 PM, the Quality director confirmed the findings of patient #1.

E. Review of Patient #2's Clinical record showed the following.:
1) Patient #2 was admitted on 11/27/2023 3:00 AM, with the following diagnosis: Congestive Heart Failure exacerbation per nutrition assessment on 11/27/2023 12:04 PM.
2) Braden score of 14 or less per orders should have consult for WONC nurse. There was no evidence of an order for WOCN consult.
3) During an interview on 11/29/2023 at 1:30 PM, the Quality Director confirmed the findings of patient #2.
4) On 11/27/2023 7:00 AM, Braden Score changed to a 13. There was no evidence of an order for WOCN consult.