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Based on document review and interview, the hospital failed to ensure 1 of 10 patients (P5) was provided the opportunity to take part in his/her care by means of informed decisions to request or refuse treatment; and failed to ensure the patient/POA was informed of his/her wound.

Findings include:

1. Policy and Procedure review: The policy titled "F1 Alliance Patient's Rights Policy", Last Approved 10/21/2022, indicated the following: (The Hospital) identifies specific Patient's Rights and Responsibilities based upon the following processes and activities: 2. To participate in the development and implementation of your plan of care. 3. To have you representative make informed decisions regarding your care under state law, to be informed of your health status, be involved in care planning and treatment being able to request or refuse treatment.

2. Medical record (MR) review for patient P5 indicated the following: MR indicated on 09/03/2024 that P5 had a deep tissue injury to the sacrum measuring length 3 cm (centimeters), width 12.5 cm, and depth 0.2 cm. Wound Consult was completed on 09/03/2024 at 0038 hours. MR indicated wound dressing orders received as followed cleanse with normal saline, pat dry apply cavilion to peri wound every other day, allow to dry then cover with xeroform and then secure with an abdominal pad. Wound to the left posterior thigh and left lower inner gluteal and left heel treatments ordered were to cleanse with soap and water as needed pat dry, apply venelex bid (two times daily. The patient's MR lacked documentation that the patient and or the patient's power of attorney was notified of this new development.

3. On 09/23/2024 between approximately 1400 hours and 1500 hours., A1, Quality Director, confirmed MR findings for patient P5, including lack of documentation as noted.

Based on document review, nursing administration failed to provide adequate staffing for 5 (five) of 7 (seven) days reviewed on Medical Surgical Unit (MS).

Findings Include:
1. Review of policy "Staffing Plan- Implementation & Assignments", last reviewed 09/19/2024. PolicyStat ID: 16351934. This policy indicated to ensure a sufficient number of qualified nurses are on duty at all times.

2. Review of the Medical Surgical staffing matrix indicated:
a. 22 (twenty-two) patients on the day shift requires 4 (four) Registered Nurse (RN) and 3 (three) Patient Care Assistant (PCA). 22 (twenty-two) patients on the night shift requires 4 (four) Registered Nurse and 3 (three) Patient Care Assistant.

b. 23 (twenty-three) patients on the day shift requires 5 (five) Registered Nurse and 3 (three) Patient Care Assistant. 23 (twenty-three) patients on the night shift requires 4 (four) Registered Nurse and 3 (three) Patient Care Assistant.

c. 24 (twenty-four) patients on the day shift requires 5 (five) Registered Nurse and 3 (three) Patient Care Assistant. 23 (twenty-four) patients on the night shift requires 5 (five) Registered Nurse and 3 (three) Patient Care Assistant.

d. 25 (twenty-five) patients on the day shift requires 5 (five) Registered Nurse and 3 (three) Patient Care Assistant. 23 (twenty-five) patients on the night shift requires 5 (five) Registered Nurse and 3 (three) Patient Care Assistant.


3. Nursing and/or Staffing Review: The Staffing Pattern Worksheets were reviewed for F1 MS unit for the dates 08/30/2024 - 09/05/2024 and indicated the MS unit was not appropriately staffed per facility policy and/or matrix as follows:
a. MS Unit:
08/30/2024 short 2 clinical staff member from 1900 hours - 0700 hours with a patient census of 23 (twenty-three). 7 (seven) clinical staff members needed but only 5 (five) clinical staff members were present.

09/02/2024 short 1 clinical staff member from 1900 hours - 0700 hours with a patient census of 25 (twenty-five). 8 (eight) clinical staff members needed but only 7 (seven) clinical staff members were present.

09/04/2024 short 1 clinical staff member from 1900 hours - 0700 hours with a patient census of 25 (twenty-five). 8 (eight) clinical staff members needed but only 7 (seven) clinical staff members were present.

09/05/2024 short 1 clinical staff member from 0700 hours - 1900 hours with a patient census of 22 (twenty-two) 7 (seven) staff members were needed but only 6 (six) were present.

09/05/2024 short 1 clinical staff member from 1900 hours - 0700 hours with a patient census of 24 (twenty-four). 8 (eight) clinical staff members needed but only 7 (seven) clinical staff members were present.


3. On 09/23/2024 N2 (Chief Nursing Officer) completed and signed "The Staffing Pattern Worksheets" provided by this surveyor as to all information provided accurately reflected the staffing for the Medical Surgical Unit on dates 08/30/2024 through 09/05/2024.

Based on document review, nursing services failed to ensure that the Skin Assessment and Management Procedure policy was implemented for 1 of 10 patient medical records reviewed. (P5)

Findings:
1. Review of policy "Skin Assessment and Management Procedure" last reviewed 08/29/2024. PolicyStat ID: 16130084. To outline Nursing responsibilities in the protection and promotion of skin integrity by utilizing the Braden Scale to identify those patients at risk and implement focused interventions for those who may need preventive measures.
a. Braden Scale will be utilized as evidence-based tool to assess the severity of skin integrity risk.
1. 19 to 23 = No Risk
2. 15 to 18 = Mild Risk
3. 13 to 14 = Moderate Risk
4. 10 to 12 = High Risk
5. 9 or below = Very High Risk
b. Every patient will be assessed for skin integrity risk by utilizing the Braden Scale upon admission, every shift and as patient condition warrants.

2. Review of medical records for P5 indicated:
a. Initial Nurse Admission assessment dated 8/30/2024 indicated that the Braden scale tool was used for predicting pressure risk, P5 scored a 16 (sixteen) (mild risk). Shift assessment on 08/31/2024 indicated P5 was a 1 (one) bed mobility (for rolling, scooting, and boost), friction and shear indicated potential problem, and nutrition was adequate. Skin assessment dated 09/01/2024 on the skin care flow sheet indicated that P5 had redness to his/her buttocks. Skin assessment dated 09/02/2024 indicated that P5 had bruising non-blanchable area noted to the buttocks, sacrum and that there was a fluid filled area to the right foot. Skin assessment dated 09/03/2024 indicated that P5 had a deep tissue injury to the sacrum measuring length 3 cm (centimeters), width 12.5 cm, and depth 0.2 cm. There was a lack of documentation of reevaluation by nursing staff of P5's Braden Scale, and/or implementation of new measures to help prevent further skin pressure area breakdown throughout P5 stay.