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The facility failed to meet the Condition of Participation for Nursing Services when the facility's Nursing staff did not thoroughly complete Skin Alteration assessments, document patient's skin and did not follow physician's orders placing patients at risk of infection, worsening wounds, pain, loss of limbs and possible death.

Cross Refer: A0386, A0438

Based on interview, record review, and observations, the facility's Nursing Services failed to provide care in an organized manner when, (3) three patients with altered skin integrity were not assessed and treated according to the facility's Clinical Practice Guidelines for Skin Alterations, resulting in a possible delay or inappropriate treatments for 3 out of 5 patients. (Patient #8, 7, and 11) The current nursing practices place patients at risk of developing or experiencing worsening skin breakdowns, infections, pain, loss of limbs and possible death.

Findings Include:

Patient #8
Review of Patient #8's medical records reflected an 83-year-old male admitted on 5/03/22, with a complaint of left-sided weakness.

Review of Patient #8's Photographic Skin Alteration Documentations reflected the following:
5/9/22- Pressure related Altered stage: Stage 2 (The document did not include measurements or the deep tissue injury to the right sacral area. The document indicated this was not present on admission.)
5/23/22- Pressure related Altered stage: Stage 2 (The document did not include the two additional opened wound measurements. The document indicated this was not present on admission.)
6/5/22- Pressure related Altered stage: Stage 3 (The document did not include wound measurements. The document indicated this was not present on admission.)
7/5/22- Pressure related Altered stage: Stage 4 (The document indicated this was present on admission.)
7/18/22- Pressure related Altered stage: Stage 4 (The document indicated this was not present on admission.)
8/1/22- Pressure related Altered Right knee: (The document did not indicate if this was present on admission and did not include wound measurements.) The wound was approximately 3cm x 1.5cm. The wound bed had dried skin over the wound.
8/1/22- Pressure related Altered Left knee: (The document did not indicate if this was present on admission and did not include wound measurements.) The wound was approximately 2cm x 2cm. While reviewing Patient #8's medical record on the morning of 8/30/22, Staff #3, wound care nurse stated, "It looks like a Stage 3, it has a granulation."
8/8/22- Pressure related Altered stage: Stage 4 (The document indicated this was not present on admission.)

An observation on the morning of 8/30/22, on the facility's 6HT inpatient unit revealed, Patient #8 lying in bed with two dressings to his bilateral inner knees. The dressings did not have a date or initials to indicate who or when the dressing had been applied. The patient was positioned on his back and did not have a wedge or pillow between his knees to prevent further injury to the bilateral knees. Staff #9, Nursing 6HT Unit Director stated, "The dressing should be dated when it was applied." Staff #9 confirmed the patient did not have a pillow or wedge between Patient #8's knees to prevent further rubbing and injury.

Review of Patient #8's Hourly Patient Safety Logs from 5/9/22 through 8/30/22 reflected the following documentation:
5/18/22- Positioned on back for (8 hours), from 9:00 am to 5:00 pm. No position was marked from 6:00 pm to 6:00 am.
5/19/22- Positioned on back for (13 hours), from 7:00 am to 9:00 am and from 7:00 pm to 6:00 am. There was no documentation from 10:00 am through 6:00 pm.
5/20/22- Positioned on back for (11 hours), from 7:00 pm to 6:00 am. There was no documentation from 7:00 am to 5:00 pm.
5/24/22- Positioned on back for (4 hours), from 7:00 am. to 11:00 am. There was no documentation from 12:00 pm through 6:00 pm.
7/26/22- Positioned on back for (4 hours), from 7:00 am. to 11:00 am. There was no documentation from 12:00 pm to 5:00 pm, and from 9:00 pm to 6:00 am.
8/4/22- There was no documentation and no position marked from 1:00 pm to 6:00 am, the following morning.
8/7/22- There was no documentation and no position marked from 7:00 am to 6:00 pm.
8/12/22- There was no documentation and no position marked from 11:00 am to 6:00 am, the following morning.
8/15/22- Positioned on back for (8 hours), from 7:00 am to 3:00 pm. There was no documentation and no position marked at 4:00 pm and 5:00 pm and from 7:00 pm through 6:00 am the following morning.
8/16/22- Positioned on back for (11 hours), from 7:00 am. to 6:00 pm. There was no documentation and no position marked from 9:00 pm to 6:00 am.
8/17/22- Positioned on back for (9 hours), from 7:00 am. to 4:00 pm. There was no documentation and no position marked from 2:00 am to 6:00 am.
8/29/22- Positioned on back for (11 hours) from 7:00 pm through 6:00 am. There was no documentation and no position marked from 12:00 pm to 6:00 pm.

Further review of the documents reflected a legend which indicated "Sleeping=S, Chair=C, Toileting=T, and off unit=OFF." The records were being marked with A, B, and E; these had not been defined in the legend.


Review of Patient #8's Nursing Progress Notes, authored by Staff #1, the facility's Wound Care Nurse Practioner, reflected the following:
6/10: All around assessment revealed the wound is not improving due to mattress and nutritional means. Another mattress will be ordered to specificatyions [sic] of 6/1/22 and might consider veraflo (the wound is irrigated with sterile fluids and removed through suction) for him next week.
6/15: lt was noted that the sacral wound has a slight odor. We will add gentamicin cream along with the Santyl to be applied to the area on a regular basis. Staff encouraged to keep the area offloaded as much as possible.
6/22. Frank pus upon VAC (a wound care device placed against a wound with a suction that removes excess drainage) change today, primary notified, bone scan ordered, culture obtained by wound care team; gen sx (general surgery) for debridement
6/25: Patient has undergone debridement of the wound ...
7/8: Assessment completed, 2 absorbent chucks were found under patient and 1 pulled through patient legs that were saturated with urine, gown was saturated, VAC machine fluids were empty and machine alarming (wound had not been irrigated since last night at 2100) even though suction was still intact and functioning proper, All issues and concerns were discussed with the bedside nurse.
7/15: VAC changed and wound becoming more necrotic in upper lateral wound region.
PATIENT HAS TO BE ON STRICT TURNING SCHEDULE!!!!!!!!!!!!!
7/18: wound even worse than Friday ...
7/27: Patient's wound still has very friable and easily bleeding areas. We will hold the wound VAC at this point continue with the wet-to-dry dressing. Continue offloading of the area ...
8/12: wound is showing signs of further breakdown (not sure if the patient is being turned as frequently as he needs to be, or his body is just breaking down) Will order and follow labs
8/19/2022: The wound appears to be the same. We will continue with the wound VAC. Continue with offloading of the area ..."

During on interview on 8/31/22 at 10:00 am., in the facility's conference room, Staff #1, Wound Care Nurse Practitioner stated, "I saw Patient #8 last Monday (8/29/22). When I saw there was a dressing in place, I didn't remove the dressing. I assumed there was an order in place. That was my fault, I should have checked. I saw his knees yesterday and changed the order." When asked about Staff #1's documentation concerning the patient needing to be on a strict turning schedule, Staff #1 stated, "That was on another unit, I had spoken to that floor's staff, then he was moved to 6HT. It was not a nutritional issue that caused the breakdown..."

Patient #7
Review of Patient #7's Physician's history and physical, dated 8/9/22, reflected, "84-year-old male with past medical of severe PVD (Peripheral Vascular Disease), CAD (coronary artery disease) s/p (status-post) stents, DM (Diabetes Mellites), B (bilateral) chronic foot ulcer who was admitted on 8/9/22 due to BLE (bilateral lower extremity) gangrene. He underwent Right BKA (below knee amputation) on 8/15/22 and was also diagnosed with Left great toe OM, (Osteomyelitis) on 40-day course of lV (Intravenous) antibiotics until 09/20. He is now transferred to inpatient rehab. We were asked to see him for left knee wound which developed due to patient walking on his knees."

Review of Patient #7's Pressure Injury Data Collection Form C, undated, did not reflect the patient's left knee wound.

Patient #11
Review of Patient #11's Medical Record reflected a 61-year-old male admitted on 8/18/22. Wound care progress note dated 8/30/22 revealed Patient #11's chief complaints were sacral ulcers; desquamation over torso, legs, back, sacral improving; Persistent sacral erythema.
Review of Patient #11's Pressure Injury Data Collection Form C, dated 8/30/22, reflected 5 hospital acquired pressure injuries, 4 stage 3 to the sacrum, bilateral buttock, bilateral hips, mid back.
Further record review reflected Patient #11 was diagnosed with Steven Johnson Syndrome, which caused blisters to the patient's sacrum, buttock, hips and back; these wounds were not Stage 3 Pressure Injuries and were identified incorrectly.

During an interview on the morning of 8/30/22, in the facility conference room, Staff #13, Director of Quality, stated, "We still need to complete the training of the Skin Champions on each unit. These Champions will be assessing the wounds and following the wounds. We have been working with our Corporate Office to improve our skin monitoring."

During an interview on the afternoon of 8/30/22, Staff #2, DON (director of nursing), stated, "We discussed this during our accreditation survey." Staff #2 confirmed the facility had not fully implemented the policy, Clinical Practice Guidelines for Skin Alterations, that was approved and effective on 8/2022.

Review of the facility provided Policy: Clinical Practice Guidelines for Skin Alterations (Effective: 08/2022) reflected,
"PURPOSE:
1. Provide standard definitions for pressure injury related classifications.
2. Provide evidence-based guidelines for pressure injury prevention.
3. Outline the standard of care for skin care, risk assessment, prevention, and treatment of pressure injuries.
4. Outline documentation requirements for nursing...

POLICY AND PROCEDURE STATEMENTS:
1. All patients will be evaluated for skin breakdown through completion of a risk assessment process. This will occur upon admission (within 24 hrs.); minimum of once per shift; following a change in medical condition and/or level of care; and at discharge.
2. Based on the level of skin risk, nursing interventions will be initiated and will be captured on the patient's plan of care.
3. Regardless of risk, standard of care pressure injury prevention elements should be implemented on all patients ...

RISK ASSESSMENT:
1. Each patient with admission orders will be assessed for skin risk and the presence of any alterations in skin integrity. If a wound is identified, the following should be included in documentation. Wound documentation and photographs will be completed per each skin alteration weekly and include the following:
a. Wound type;
b. Anatomic location of the wound;
c. Staging of wound;
d. Wound length and width; and
e. Description of wound bed, drainage, tissue type present...

PRESSURE INJURY INTERVENTIONS:
Preventative measure should be applied based on individualized risk ractors. The following interventions may be considered, but are not limited to:
1. Skin Care: a. Keep skin clean and dry...
2. Moisture/Incontinence: a. Minimize skin contact with urine/feces...
3. Mobility/Activity and Repositioning:
b. Provide/assist the patient with repositioning & turning as needed to offload pressure on dependent areas (e.g. sacrum), based on individualized risk factors.
i. For prone patient positioning, assess bony prominences and utilize small shifts to offload pressure.
ii. Elevate heels and offload pressure through effective use of reposition devices...
7. Team Engagement and Education:
a. Interdisciplinary education as applicable to clinical discipline
b. Provide patient and family education on pressure injury risk factors & prevention strategies.

HOSPITAL ACQUIRED PRESSURE INJURY:
1. Prevalence of hospital acquired pressure injuries should be tracked, monitored, and reviewed regularly with an interdisciplinary team.
2. Root cause review should be done for all hospital acquired pressure injuries, stage III and above, including DTIs.(deep tissue injury)
3. The attending provider/practitioner, unit-based leader, and patient's guardian will be notified as soon as possible. All notifications will be documented in the EHR (electronic health record).
4. Pressure injuries acquired throughout the hospital stay should be reported via the facility-specific event reporting system.


DEFINITIONS:

Stage 1 - Pressure Injury: Non-blanchable erythema of intact skin
Intact skin with a localized area of non-blanchable erythema. The erythema may appear differently in darker pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration.
Stage 2 - Pressure Injury: Partial-thickness skin loss with exposed dermis
The wound bed is pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) or deeper tissues are not visible. Granulation tissue, slough and eschar are not present.
Stage 3 - Pressure Injury: Full-thickness skin loss
Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole [sic] (rolled wound edges) are often present. Slough and/or eschar may be visible. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed.
Stage 4 - Pressure Injury: Full-thickness skin and tissue loss
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole [sic] (rolled edges), undermining and/or tunneling often occur.
Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.
Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon, or purple discoloration..."

Based on observation, interview and record review, the facility failed to ensure the Hourly Patient Safety Logs and Photographic Skin Alteration Documentation forms were completed and retained, placing patients at risk of incorrect medical treatments, skin breakdown, and worsening of wounds. (Patient #8)

Findings include:

Review of Patient #8's Physician's history and physical reflected an 83-year-old male admitted on 5/3/22 with a left sided weaknes. Review of Patient #8's Skin Alteration Documentation reflected the developement of a Stage 4 wound to the sacrum and bilateral inner knee wounds.

Review of Patient #8's Hourly Patient Safety Logs from 5/9/22 through 8/30/22 reflected the following missing documentation:

5/21/22 and 5/22/22- No documentation was available.
5/26/22 through 7/24/22- No documentation was available.
7/27/22 through 8/3/22- No documentation was available.
8/5/22 and 8/6/22- No documentation was available.
8/13/22 and 8/14/22- No documentation was available.
8/18/22 through 8/27/22- No documentation was available.

During an interview on the afternoon of 8/30/22, on the in-patient 6HT unit, Staff #9, Nursing Director 6HT when asked if there were additional Hourly Patient Safety Logs, Staff #9 stated in part that, "The documents are kept on the chart. When the patients transfer from another unit, the logs will come with the patient."

During an interview, on the afternoon of 8/30/22 in the administrative Conference room, Staff #13, Director of Quality was informed of the missing documents and a request was made for the facility to provide any additional documents. The facility did not provide additional Hourly Patient Safety Logs for Patient #8.