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Based on record review and staff interviews, it has been determined that the hospital failed to meet the Nursing Services Condition of Participation relative to providing the necessary treatment and services, consistent with professional standards of practice, and hospital policy to prevent new pressure ulcers from developing for 1 of 1 patient who developed a hospital acquired pressure ulcer.

-The hospital failed to ensure that skin/wound assessments were completed. (Refer to A0395)

-The hospital failed to follow their policies related to Hospital Acquired Pressure Injury. (Refer to A0395)

-The hospital failed to ensure that physician's orders were obtained for wound care recommendations from the wound care consultant. (Refer to A0395)

-The hospital failed to ensure that the physician reviewed the recommendations for wound care following the identification of a hospital acquired pressure injury. (Refer to A0395)

Based on record review and staff interviews, it has been determined that the hospital failed to provide the necessary treatment and services, consistent with professional standards of practice, and hospital policy to prevent a new pressure ulcer from developing for 1 of 1 patient who developed a hospital acquired pressure ulcer.

Findings are as follows:

Record review revealed that s/he was admitted to the hospital in 6/11/2023 with a medical history of Angelman Syndrome (genetic disorder causing developmental disabilities and nerve related symptoms), disease of the thyroid gland, dysphagia, UTI (urinary tract infection), intellectual disability, non-verbal and seizures. The patient requires total assistance with care needs.

On 6/11/2023 at 12:26 PM, the patient was sent to the emergency department (ED) for evaluation due to making gurgling noises, increased phlegm, and sputum productions. The patient was also noted to have a change in mental status. The patient was diagnosed with pneumonia and referred for inpatient admission.

The record reveals that the patient remained in the ED while waiting for an inpatient bed from 6/11/2023 at 12:26 PM until 6/13/2023 at 8:05 AM when he/she was then transferred to an inpatient unit. The record failed to reveal that skin assessments were completed during the 2 days the patient remained in the ED.

The first documentation of a skin assessment dated 6/13/2023 at 11:17 AM, (two days after presenting to the ED) states skin color red, skin integrity; "redness", location "buttocks. A Braden Scale was completed on 6/13/2023 and revealed a score of 9 which indicates the patient is at severe risk for acquiring pressure ulcers.

Review of a hospital policy titled "Pressure Ulcers/Skin Integrity/Mucosal Injury" revised 3/2021 relative to the Braden scale scores states in part; "Purpose: To provide patient care guidelines for the assessment of skin integrity, assessment for risk of developing pressure ulcers, and the development of an individualized plan of care.

Policy: Assessment and monitoring of wounds.

1.2 Pressure ulcers require a wound consult and staging will be deferred to wound care nurses and physicians/licensed independent practitioners ....

1.3 Skin Integrity a.) The patient's skin integrity from head to toe will be assessed upon admission and for any patient at risk for pressure ulcer based on Braden score each shift.

1.4 Braden Scale a.) The Braden Scale is used on admission and on each shift to help evaluate patient risk of developing pressure ulcers. Patients with a Braden Score of 18 or less are to be considered at risk of developing pressure injuries. (19-23= no risk, 15-18= mild risk; 13-14 moderate risk; 10-12= high risk; and 9 or less are at severe risk). Refer to Addendum A (Braden Score description).

b.) Interventions should be initiated according to the documented Braden Scale score and per the attached "Pressure Ulcer Prevention Guidelines." Refer to Attachment B.
Attachment B states in part; High Risk 10-12 "refer to wound care nurse, increase frequency of turning schedule, supplement with small shifts in position & order pressure redistribution support surface. Severe Risk less than or equal to 9, all interventions above.

Review of the Record reveals that the patient who was identified as having a hospital acquired pressure injury on 6/13/2023 failed to have a consult ordered for the wound nurse to see the patient until 6/15/2023 (4 days after presenting).

Review of the wound nurses consult dated 6/15/23 at 11:05 AM, states consult for sacrococcygeal DTI (deep tissue injury).
-Assessment: patient is nonverbal, discoloration of unknown etiology observed, a thin strip of purple discoloration to left buttock, as well as DTI to sacrococcygeal region as documented below. Origin of wound HAPI (hospital acquired pressure injury) length 12 cm, width 10 cm, depth 0.1 cm. The wound is 100% DTI. A small amount of sanguineous drainage is noted-no odor is associated; patient does indicate discomfort during wound care.

Recommendations include the following:
Cleanse gently with wound cleanser and pat dry, skin prep all intact skin-allow to dry, apply oil emulsion over region, cover with Sacral foam.

Review of the hospital policy titled "Consultations" and revised on 1/2020, states in part Purpose: ...is committed to ensuring that each clinical consult that is requested and ordered is completed, and that consultant recommendations and orders are appropriately communicated and carried out.

Review of the doctors' orders failed to reveal that the recommendations for wound care made by the wound care nurse on 6/15/2023 were ever reviewed by the physician or ordered by the physician.

During a surveyor interview with the wound nurse on 6/26/2023 at approximately 3:30 PM, she was unable to explain why on 6/13/2023 when the patients first documented Braden Score was recorded as a 9 (severe risk), she did not receive a consultation for a wound consult until 6/15/2023. She stated that she expects to be consulted on all patients who receive a score of 14 or less.

When questioned by the surveyor on ( ) about her recommendations for wound care not being reviewed by the physician or ordered as wound treatments, she stated that she thought the recommendations were placed as orders. She then reviewed the patient's record and acknowledged that the recommendations had not been ordered by the physician.

Review of the documentation on the After Visit Summary dated 6/18/2023, which was sent with the patient on discharge to the group home lacked a documentation of the status of the patient's pressure injury and lacked orders for treatment of the pressure injury.

During a surveyor interview with the Risk Manager and the Chief Nursing Officer on 6/22/2023, they were unable to explain why the patient did not have a skin assessment during the 2 days he/she was in the ED awaiting an inpatient bed, why the wound care consultant was not notified of the hospital acquired pressure injury until 6/15/2023 when it was noted 2 days earlier on 6/13/2023, or why the recommendations from the wound nurse consultation on 6/15/2023 were not reviewed or ordered by the physician. Additionally, they could not explain why the discharge information lacked physician orders for wound care or documentation of the status of the patient wound.