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Based on record review, facility policy review, and interview it was determined the facility failed to provide treatment plan interventions related to a daily discussion of skin care status for one of nine patients (Patient #5). Patient #5 developed skin breakdown of the buttocks and right foot and was transferred to a local hospital for amputation of the right fifth toe. The facility failed to conduct the treatment plan interventions related to skin care and failed to provide appropriate nursing services to address the skin care issues for Patient #5.

The findings included:

Review of Patient #5 (P5)'s medical record indicated a last admission date of 02/23/2024 with diagnoses of Schizophrenia, Hypertension, and Hypothyroidism. Review of an admission assessment performed by MD #9 on 02/26/2024 (time unavailable) indicated that the patient was alert, knew place, and person but did not know time.

Review of RN #4's Progress Note dated 01/03/2024, indicated that Patient #5 reported that his foot was swollen. RN #4 assessed Patient #5's foot and noted the top of the right foot was swollen, red, and hot to touch. The swelling was through the entirety of the right foot and up the calf. Upon further assessment, it was noted that Patient #5 had approximately a half-dollar size wound on the bottom of his right foot under the big toe. Patient #5 was then asked by RN #4 if he had any other sores and he reported he had a spot above his bottom. Patient #5 was noted to have a wound approximately half-dollar size on the left buttock and pinhole-size scabbed area on the right buttock.

Review of RN #4's Wound Assessment dated 01/03/2024 at 1:12 PM, indicated comprehensive measurements for right foot and buttocks were assessed by the RN, measured, and dressings applied per ARNP wound care orders. RN #4's wound assessments indicated a right foot plantar wound measured approximately 2 cm wide and 1 ½ cm long. Additionally, the wound assessment indicated a left buttock wound measured approximately 3 cm wide and 2 cm long.

Review of a post-operative hospital note dated 01/05/2024 at 11:25 AM, from MD #20 confirmed that Patient #5 had the right fifth toe amputated.

Review of RN #11's Nursing Progress Note dated 01/08/2024 at 6:53 PM, indicated Patient #5 was diagnosed with (new) diabetes mellitus and diabetic ulcer and that Patient #5 was on antibiotics at the with a new order for an antibiotic.

Review of MD #14's Physician Progress Note dated 01/09/2024 (time unavailable) indicated that Patient #5 had a new diagnosis of diabetes and one of his toes amputated.

Review of Patient #5's Care Plan initiated on 02/28/20217 and in place during the time of the occurrence indicated that the patient had the problem of multiple psychiatric needs related to schizophrenia with stated goals of demonstrating ability to make his needs known. Accept limit setting and redirection and increase interactions with others. Interventions included nursing monitoring for flight of ideas, monitoring for mood changes, and provide educational activities. The care plan also stated to work with the patient to maintain his skin integrity, every day during 1:1 interactions, encourage to report and/or monitor for signs and symptoms of infection to affected areas.

Review of the hospital's policy entitled "Pressure Ulcers and Wound Care" dated January 2016, revealed that to prevent complications related to pressures ulcers and wounds, the facility would identify patients at risk, implement prevention strategies for patients at risk, and actively treat all identified pressure ulcers and wounds. The policy further revealed that if a braden score required it, weekly skin assessments would be completed on the patient.

During an interview with RN #4 on 05/16/2024 at 11:45 AM, Patient #5 complained about his foot hurting, the night shift nurse went to look at it and the patient refused examination at that time until the following day. She stated that when she evaluated it, she recognized cellulitis. No complaints prior to that day about skin condition from the Patient #5. Stated that patient had ability to walk and did not appear to have any problems related to his feet when he would ambulate prior to this incident. RN #4 stated that the facility did not have any set policy or requirement to conduct skin assessments on patients routinely while they are at the facility unless they have some type of identified skin issue and she was not aware of the care plan requirement to discuss his skin integrity as listed in the care plan. She stated she was not aware of any type of daily skin check requirement, quarterly, or every six months, etc. that would be required by the facility to routinely check patient skin condition. She stated she believed she was the first and only person to discover the wounds on his body, on 01/03/2024 when the wounds were discovered.

During an interview with RN #9 on 05/16/2024 at 1:55 PM, he stated that as a general skin assessments were not required daily on patients unless they had a known identified issue. He stated Patient #5 has known skin issues now and they were really following him close. He stated Patient #5 had a wound care appointment for his foot and had another one about two weeks ago. The wound on his foot was infected at this time and the wound would not drain during his wound care appointment. RN #9 stated Patient #5 was admitted to the hospital because the attempt to drain the wound on his foot was unsuccessful. He stated that for most part Patient #5 was compliant with his wound care orders and allowed them to do dressing changes. He stated Patient #5 was not on antibiotics at this time and during his last admission for this problem he was given antibiotics. He stated Patient #5's buttocks area had healed and required no further care.

During an interview with Advanced Practice Registered Nurse (APRN) #15 on 05/16/2024 at 2:30 PM, she stated she has been employed by the facility since 2014. She stated she had been providing care and had initiated the initial orders for wound care for the Patient #5 when his wounds were identified as a right foot plantar ulcer with cellulitis. She stated at that at that time she wanted him to be seen by wound care and when a wound culture was completed, he was placed on orders for Keflex 250mg orally 3 times a day. APRN #15 stated Patient #5 was sent to an outside wound care center for treatment and also had dressing changes at that time for the foot ulcer with daily changes. She stated with the buttocks, dressing orders were in place and required daily care to get "him by" until wound care facility treatments took place. The APRN stated that as a healthcare provider she completed annual skin assessments on the patients at the facility but did not know of any specifics as far as routine skin checks at the facility for patients who had no complaints and no known issues.

During an interview with the Director of Nursing (DON) #17 on 05/16/2024 at 4:05 PM, she stated there was no requirement for skin assessment for an ambulatory patient. She stated because ambulatory patients had psych issues, "we" talk with them everyday and asked them if they were having any problems and unless they lead "us" to something that required a body audit, it was not something that we would do on a patient like Patient #5 unless something had been identified, then we would check that out. She stated the nurses should have been aware of what was in the treatment plan and they should have been following what the treatment plan said. DON #17 further stated if the treatment plan was not followed, the patient could develop other skin issues. She also stated that upon admission a complete assessment was done for all patients.