HospitalInspections.org

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The facility failed to proactively prevent a patient's significant weight loss; the facility failed to proactively monitor patients for weight changes; the facility failed to obtain a re-weight on patients with identified weight changes; and the facility failed to proactively prevent patients from developing hospital acquired pressure sores.

A discussion took place with the survey team and the facility's administrative staff (EMP2, EMP3, EMP4, EMP7, EMP11, EMP17 and EMP18) regarding the survey team's concerns related to Patient Rights on December 2, 2021, at approximately 1620.

Cross reference
482.13 (c)(2) Patient Rights: Care in Safe Setting

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to proactively prevent significant weight loss in one of one applicable medical record reviewed (MR1); the facility failed to proactively monitor weight changes for one of one applicable medical record reviewed (MR3); the facility failed to obtain a re-weight on patients with identified weight changes for two of two applicable medical records reviewed (MR5 and MR6); and the facility failed to proactively prevent patients from developing hospital acquired pressure sores for four of four applicable medical records reviewed (MR1, MR2, MR3 and MR4).

Findings include:

Review on December 2, 2021, of the facility's "Nutrition Care of the Hospitalized Patient-Adult" policy, last approved July 2, 2021, revealed "Purpose The purpose of this policy, "Nutrition Care of the Hospitalized Patient", is to provide nutrition care for adult hospitalized patients in a safe, effective, and timely manner...The Registered Dietitian Nutritionist (RDN) communicated nutrition care plans and recommendations to patients, caregivers, and members of the interdisciplinary team..."

Review on December 2, 2021, of the facility's "Clinical Dietitian II" job description, last date of change September 28, 2021, revealed "Job Profile Summary Provides safe, competent evidence-based nutritional therapy that meets the standards of practice and the scope of practice as stated by the Academy of Nutrition and Dietetics...Job Description Assesses individual needs through...discussion with other members of the interdisciplinary health care team...Confers with the health care team to develop goals related to patient..."

Review on December 2, 2021, of the facility's "Associate Vice President - Nursing Services" job description, no review date, revealed "Job description Summary Responsible for overseeing the operational activities and the ongoing enhancement of assigned nursing units. Is responsible for directing operational management teams and building relationships with departments that interface with Nursing Services and the overall system nursing strategy. Job Description Responsible for the day to day flow and operations of assigned nursing units. Facilitates nursing practice based on evidence and best practices consistent with nursing standards ..."

Review on December 2, 2021, of the facility's "Operations Manager - Nursing" job description, no review date, revealed "Job description Summary Manages nursing personnel and daily operational related activities. Leads Nursing team for assigned units or departments with responsibility for all operational functions of the team. Works in partnership with the Medical Director and Physician Liaison of the department to provide administrative and medical staff support to the operations of the unit. Responsible for developing and initiating improvements in the organization and delivery of high quality, cost effective patient care. Responsible for nursing clinical practice, budgetary personnel activities, and regulatory activities associated with the unit or department, and continuing support of Electronic Medical Record.... Job Description...Ensures the patient safety improvement and management program will be given high priority and will support the program...Ensures adequate staffing and competent care delivery... Develops and promotes service standards that foster a customer sensitive environment, using a proactive approach... Works closely with other departments and services and administration to maximize quality patient outcomes ... "

Review on December 1, 2021, of the facility's "Pressure Injury Prevention" policy, last approved April 15, 2021, revealed "... Policy Evidence-based standards will guide the prevention of pressure injuries for patients...Definitions Pressure Injury: Localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs because of intense pressure, prolonged pressure, or pressure in combination with shear..."

1) Review of MR1 on December 1, 2021, revealed a physician order dated October 17, 2021, instructing nursing staff to obtain daily weights. Review on December 2, 2021, revealed this physician order was still active on the date of the state agency review.

Interview with EMP7 on December 2, 2021, at approximately 0945. confirmed the physician order dated October 17, 2021, instructed nursing staff to obtain daily weights and this physician order was still active on December 2, 2021.

Review of MR1 on December 1, 2021, revealed nursing obtained the following weights:
October 18, 2021 an admission weight of 130.1 pounds.
December 1, 2021, 98 pounds.

There was no documentation in MR1 indicating nursing staff obtained daily weights from October 10, 2021, through November 30, 2021 as instructed by this patient's physician.

Interview with EMP4 on December 2, 2021, at approximately 0945. confirmed MR1's admission weight on October 18, 2021, was 130.1 pounds and on December 1, 2021, nursing staff obtained MR1's weight of 98 pounds. EMP4 confirmed there was no documentation in MR1 indicating nursing staff obtained daily weights on this patient from October 10, 2021, through November 30, 2021 as per physician's order.

2) Review of MR3 on December 2, 2021, revealed nursing initiated a Care Plan for Potential for Alteration in Nutrition with a goal to monitor daily weights.

Review of MR3 on December 2, 2021, revealed nursing staff obtained the following weights:
September 14, 2021 an admission weight of 163 pounds.
December 1, 2021, 180 pounds.

There was no documentation in MR3 indicating nursing staff obtained any additional weights from September 16, 2021 through December 1, 2021.

Interview with EMP5 on December 1, 2021, at approximately 1045. confirmed MR3's admission weight was 163 pounds on September 14, 2021 and MR3's weight on December 1, 2021, as 180 pounds. EMP5 confirmed there was no documentation in MR3 indicating nursing staff obtained any additional weights from September 16, 2021 through December 1, 2021.

Interview with EMP5 on December 2, 2021, at approximately 1045. revealed this patient receives dialysis and any weight increase could be detrimental to a dialysis patient.

Review of MR3 on December 2, 2021, revealed the following Registered Dietitian Nutritionist documentation:
September 29, 2021, EMP10 documented there was no significant weight change on this patient.
October 6, 13, 20, 27, 2021, EMP6 documented there was no significant weight change on this patient.
November 2, 18, and 24, 2021, EMP6 documented there was no significant weight change on this patient.
November 11, 2021, EMP12 documented there was no significant weight change on this patient

Interview with EMP5 on December 2, 2021, at approximately 1050. confirmed the EMP10, EMP6 and EMP12 were Registered Dietitian Nutritionists and EMP5 confirmed EMP10's, EMP6's and EMP12's documentation on the above dates indicating there was no significant weight change on this patient.

Interview with EMP5 on December 2, 2021, at approximately 1050. confirmed there was no documentation in MR3 indicating nursing staff obtained weights on this patient from September 16, 2021 to December 1, 2021. EMP5 revealed uncertainty how EMP6, EMP10 and EMP12 were able to determine and document MR3 had no significant weight change.

Review of MR3 on December 2, 2021, revealed EMP6 (RDN) documentation dated, December 1, 2021 indicating this patient's weight change was likely secondary to fluid.

Interview with EMP5 on December 2, 2021, at approximately 1050. revealed there was no documentation in MR3 indicating how EMP6 determined this patient's weight of 180 pounds was related to fluid since there was no previous weight to compare.

3) Review of MR5 on December 2, 2021, revealed nursing documented the following weights:
September 2, 2021, admission weight as 174 pounds.
September 30, 2021 as 178 pounds.
October 2, 2021, as 193 pounds.
November 11, 2021 as148 pounds.

Interview with EMP5 on December 2, 2021, at approximately 1100. confirmed MR5's admission weight of 174 pounds; on September 30, 2021 as 178 pounds; on October 2, 2021, as 193 pounds and 148 pounds on November 11, 2021.

Review of MR5 on December 2, 2021, revealed EMP5 documented on October 5, 2021, this patient's weight of 193 pounds and that MR5 had no significant weight gain and a weight gain of 7 kg (kilograms) in less than one week, accuracy of weights is questionable.

There is no documentation in MR5 indicating EMP5 requested a re-weight on this patient to determine the accuracy of 193 pounds on October 2, 2021.

Interview with EMP5 on December 2, 2021, at approximately 1100 confirmed this employee documented on October 5, 2021, MR5's weight of 193 pounds; MR5 had no significant weight gain and a weight gain of 7 kg in less than one week, accuracy of weights is questionable. EMP5 confirmed there is no documentation in MR5 indicating this employee requested a re-weight on MR5 to determine accuracy of 193 pounds on October 2, 2021.

Review of MR5 on December 2, 2021, revealed nursing obtained and recorded a weight of 148 pounds on November 11, 2021.

Interview with EMP5 on December 2, 2021, at approximately 1100 confirmed nursing obtained and recorded a weight of 148 pounds on MR5 on November 11, 2021.

Review of MR5 on December 2, 2021, revealed EMP5 documented on November 15, 2021 this patient's weight of 148 pounds; MR5 had no significant weight gain and a weight loss was noted since last assessment but accuracy remains questionable.

There is no documentation in MR5 indicating EMP5 requested a re-weight on this patient to determine accuracy of 148 pounds on November 11, 2021.

Interview with EMP5 on December 2, 2021, at approximately 1100 confirmed this employee documented on November 15, 2021, MR5's weight of 148 pounds; MR5 had no significant weight gain and a weight loss was noted since last assessment but accuracy remains questionable. EMP5 confirmed there is no documentation in MR5 indicating this employee requested a re-weight on this patient to determine accuracy of 148 pounds on November 11, 2021.

Review of MR6 on December 2, 2021, revealed nursing obtained and recorded the following weights:
October 17, 2021, admission weight of 270 pounds.
November 17, 2021 as 245 pounds

Interview with EMP5 on December 5, 2021, at approximately 1105 confirmed nursing documented a weight of 270 pounds on October 17, 2021 and on November 17, 2021 as 245 pounds.

Review of MR6 on December 2, 2021, revealed EMP10 documented on November 17, 2021, indicating MR6 had a weight change since admission and questioned the accuracy of the weight.

There was no documentation in MR6 indicating EMP10 requested a re-weight on this patient to determine the accuracy of 245 pounds on November 17, 2021.

Interview with EMP5 on December 2, 2021, at approximately 1105 confirmed EMP10 documented on November 17, 2021, MR6 had a weight change since admission and questioned the accuracy of the weight and there was no documentation in MR6 indicating EMP10 requested a re-weight on this patient to determine the accuracy of 245 pounds on November 17, 2021.

Interview with EMP5 on December 3, 2021, at approximately 1015 revealed the Registered Dietitian Nutritionist (RDN) role is consultative and they do not become involved in reviewing a patient's nutrition concerns until a consultation is written by either the physician or the nurse. EMP5 further revealed that RDN's question the accuracy of patient weights obtained by the nursing staff. EMP5 confirmed the RDN's role in a patient's alteration in nutrition is reactive to treating the weight loss and not proactive in preventing a patient's weight loss.

4) Review of MR1 on December 1, 2021, revealed nursing completed a skin assessment on this patient while in the Emergency Department (ED) on October 19, 2021 and documented MR1 had an erythematous (an abnormal redness of the skin or an inflammation) blanchable area with a scabbed skin tear to the buttocks and consulted wound care for alteration in skin integrity to the sacrum.

Interview with EMP4 and EMP7 on December 1, 2021, confirmed MR1 nursing completed a skin assessment on this patient while in the ED and documented MR1 had an erythematous blanchable area with a scabbed skin tear to the buttocks and nursing consulted wound care for alteration in skin integrity to the sacrum.

Review of MR1 on December 1, 2021, revealed wound care documentation dated October 19, 2021, indicating this patient was a high risk for skin breakdown; had an Adult Braden Score of 12 (A Braden Scale is a tool that predicts the risk for developing a facility acquired pressure ulcer or injury) and had a non-blanchable pressure area to the sacrum with skin sloughing. On October 29, 2021 and November 3, 2021, EMP15 documented MR1's sacrum area measured 5.5 centimeters (cm) circumferentially had a 25 percent of heavy tan slough with edges that were macerated (breaking down of tissue) slight purple hue and sloughing. The area is opened right at the bony prominence.

Interview with EMP15 and EMP16 on December 2, 2021, at approximately 1145. confirmed EMP15's documentation dated October 19, 2021, indicating MR1 was a high risk for skin breakdown and had a 12 for Adult Braden Score and now had a non-blanchable pressure area to the sacrum with skin sloughing. EMP15 and EMP16 confirmed on October 29, 2021 and November 3, 2021, MR1's sacrum area measured 5.5 cm circumferentially had a 25 percent of heavy tan slough with edges that were macerated slight purple hue and sloughing. The area is opened right at the bony prominence.

Review of MR1 on December 1, 1021, revealed EMP15 documentation dated November 11, 2021, indicating this patient's area was evolving and for nursing to consult plastic surgery for possible debridement of the area. There were no documented measurements of MR1's sacral wound. On November 22, 2021, EMP15 documented MR1's sacral coccygeal ulceration measures 7 circumferentially with areas of tunneling at 7 - 9 o'clock tunneling for 1.4 cm and at 2 - 4 o'clock tunneling for 1.5cm. On December 1, 2021, EMP15 documented MR1's sacrococcygeal area was Stage IV (involves full thickness tissue loss of underlying tissue with exposure of muscle and bone) with measurements of 7 cm x 5.5 cm x 1 cm with tunneling from 2 - 3 o'clock at 2 cm and 3 - 4 o'clock at 4 cm.

Interview with EMP15 and EMP16 on December 2, 2021, at approximately 1145. confirmed EMP15's documentation dated November 11, 2021, indicating MR1's area was evolving and for nursing to consult plastic surgery for possible debridement of the area and there were no documented measurements of MR1's sacral wound. EMP15 confirmed MR1's sacral coccygeal ulceration measurements and that the ulceration was now a Stage IV.

Review of MR2 on December 2, 2021, revealed nursing documentation dated November 10, 2021, indicating this patient developed a discolored area to the sacral / buttock area and MR2's physician wrote an order to consult wound care.

Interview with EMP4 and EMP7 on December 2, 2021, at approximately 0945. confirmed MR2's nursing documentation dated November 10, 2021, indicating this patient developed a discolored area to the sacral / buttock area and this patient's physician wrote an order to consult wound care.

Review of MR2 on December 2, 2021, revealed EMP15 documented on November 11, 2021, this patient had a dark maroon, non-blanching wound draining small amounts of serous fluid. On November 24, 2021, EMP15 documented MR2's sacrococcygeal ulceration had a white/yellow base with erythematous wound skin that blanches; a moderate amount of drainage and the area measure 1.7 cm x 5.5 cm.

Interview with EMP15 and EMP16 on December 2, 2021, at approximately 1150 confirmed this employee documented description of MR2's sacral area on November 11, 2021.

Review of MR3 on December 2, 2021, revealed nursing staff completed a skin assessment on September 18, 2021 and determined this patient had skin breakdown. There was no documentation in MR3 describing the location and description of this patient's skin breakdown.

Interview with EMP4 and EMP7 on December 2, 2021, at approximately 0945. confirmed MR3's nursing staff documentation of the skin assessment on September 18, 2021 and determined this patient had skin breakdown and there was no documentation in MR3 describing the location and description of this patient's skin breakdown

Review of MR3 on December 2, 2021, revealed documentation dated September 24, 2021, indicating nursing consulted wound care for alteration in skin integrity to the coccyx/sacrum area.

Review on December 2, 2021, revealed EMP15 documented on September 29, 2021, that MR3 had a small opening at the sacral area measuring 2.2 cm x 1.4 cm x 0.1 cm with the edges macerated with sloughing and this patient had a back scratcher which could result in skin tears. There was no documentation of any skin tears on MR3's back.

Interview with EMP15 on December 2, 2021, at approximately 1150. confirmed this employee documentation on MR3's sacral area dated September 24, 2021 and that there was no documentation of any skin tears on MR3's back.

Review of MR4 on December 2, 2021, revealed nursing documentation this patient's sacral area was reddened on November 15, 2021, and MR4's physician wrote an order to consult wound care.

Interview with EMP4 and EMP7 on December 2, 2021, at approximately 0945. confirmed nursing documentation this patient's sacral area was reddened on November 15, 2021, and MR4's physician wrote an order to consult wound care.

Review of MR4 on December 2, 2021, revealed EMP15 documented on November 16, 2021, indicating this patient's sacral area was soft, purple with pink blanching and there as an open blister at the coccyx area measuring 2 cm circumferentially.

Interview with EMP15 and EMP16 on December 2, 2021, at approximately 1150. confirmed this employee documentation of MR4's sacral area on November 16, 2021, indicating this patient's sacral area was soft, purple with pink blanching and there as an open blister at the coccyx area measuring 2 cm circumferentially.

Interview with EMP15 and EMP16 on December 3, 2021, at approximately 1035. revealed the wound care team's role is consultative and do not become involved in a patient's pressure sore until consulted by the physician or nurse and the patient has already developed a reddened or open area. EMP15 and EMP16 confirmed the wound care team's role in a patient's alteration in skin integrity is reactive when the patient has already begun to have skin breakdown and not proactive in preventing a patient from breaking down.

Cross reference
482.23(b)(3) Rn Supervision Of Nursing Care
482.23(b)(4) Nursing Care Plan
482.23(b)(6) Supervision of Contract Staff
482.28(b),(b)(1)Therapeutic Diets

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The facility failed to ensure nursing staff followed the facility's established policy regarding completing Braden Scores daily to determine a patient's risk for developing pressure sores; the facility failed to follow a physician order to obtain a patient's daily weight; the facility failed to ensure patients unable to turn and reposition self were turned and repositioned every two hours; the facility failed to establish individualized patient care plans based on patient needs and the facility failed to prevent patients from developing hospital acquired pressure sores.

A discussion took place with the survey team and the facility's administrative staff (EMP2, EMP3, EMP4, EMP7, EMP11, EMP17 and EMP18) regarding the survey team's concerns related to Patient Rights on December 2, 2021, at approximately 1620.

Cross reference
482.23(b)(3) Rn Supervision Of Nursing Care
482.23(b)(4) Nursing Care Plan
482.23(b)(6) Supervision of Contract Staff

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure nursing staff followed the facility's established policy regarding completing Braden Scores daily to determine a patient's risk for developing a pressure sore for one of one medical record reviewed (MR1); the facility failed to follow a physician order to obtain a patient's daily weight for one of one applicable medical record reviewed (MR1) and the facility failed to ensure patients unable to turn and reposition self were turned and repositioned every two hours for four of four medical records reviewed (MR1, MR2, MR4, and MR18).

Findings include:

Review on December 1, 2021, of the facility's "Pressure Injury Prevention" policy, last approved April 15, 2021, revealed "... Policy Evidence-based standards will guide the prevention of pressure injuries for patients ...Procedure Prevention Measures: 1. Perform risk assessment and skin assessment at a minimum daily, and upon changes to level of care. 2. Implement appropriate prevention interventions based on the risk assessment findings. Individualized plan based on risk assessment sub-scores (Mobility, Activity, Sensory Perception, Moisture, Nutrition, Friction / Shear)...b. Mild Risk (15-18 Braden Score) i. to manage impaired mobility/activity/sensory perception 1. If a patient is bedbound/chair bound, implement turning schedule. Offload the heels as needed. 2. Turn and reposition patient Q2 hours [every two hours] while in bed. Offload pressure Q1 hours while in chair. c. Moderate Risk (13 - 14 Braden Score) i. Utilize all the interventions listed under "mild risk" ii to manage impaired mobility/activity/sensory perception 1. Consider padding bony prominences with foam dressing, per facility guidelines. 2. Offload any areas of erythema on a bony prominence. Do not rub/massage any areas to erythema on a bony prominence...d. Severe Risk (12 or below Braden score) i. Utilize all of the interventions listed under "mild risk" and "moderate risk" ii. To manage impaired mobility/activity/sensory perception 1. Obtain appropriate advanced support surfaces, per facility guidelines..."

Review on December 2, 2021, of the facility's "Associate Vice President - Nursing Services" job description, no review date, revealed "Job Description Summary Responsible for overseeing the operational activities and the ongoing enhancement of assigned nursing units. Is responsible for directing operational management teams and building relationships with departments that interface with Nursing Services and the overall system nursing strategy. Job Description Responsible for the day to day flow and operations of assigned nursing units. Facilitates nursing practice based on evidence and best practices consistent with nursing standards ..."

Review on December 2, 2021, of the facility's "Operations Manager - Nursing" job description, no review date, revealed "Job Description Summary Manages nursing personnel and daily operational related activities. Leads Nursing team for assigned units or departments with responsibility for all operational functions of the team. Works in partnership with the Medical Director and Physician Liaison of the department to provide administrative and medical staff support to the operations of the unit. Responsible for developing and initiating improvements in the organization and delivery of high quality, cost effective patient care. Responsible for nursing clinical practice, budgetary personnel activities, and regulatory activities associated with the unit or department, and continuing support of Electronic Medical Record Job Description.... Ensures the patient safety improvement and management program will be given high priority and will support the program...Ensures adequate staffing and competent care delivery... Develops and promotes service standards that foster a customer sensitive environment, using a proactive approach... Works closely with other departments and services and administration to maximize quality patient outcomes ... "

1) Interview with EMP4 and EMP7 on December 1, 2021, revealed the Braden Score is a daily skin assessment of a patient's sensory perception, moisture, activity, mobility, nutrition, friction and shear which provides nursing staff with a score to determine the patient's risk of pressure injury prevention and the interventions to be implemented.

Review of MR1 on December 1, 2021, revealed no documentation nursing staff completed a daily Braden Score assessment for this patient on October 22, 2021 and on November 5, 7, and 14, 2021. Nursing documented MR1's oral intake was 25 percent or less during these times; this patient was unable to reposition self and MR1 developed a hospital acquired pressure sore to the sacral area on November 3, 2021.

Interview with EMP4 and EMP7 on December 1, 2021, at approximately 1100 confirmed there was no documentation nursing staff completed a daily Braden Score assessment for this patient on October 22, 2021 and on November 5, 7, and 14 2021; nursing documented MR1's oral intake was 25 percent during these times; this patient was unable to reposition self and MR1 developed a hospital acquired pressure sore to the sacral area on November 3, 2021.

Review of MR1 on December 1, 2021, revealed Wound Care documentation dated October 19, 2021, indicating this patient was a high risk for skin breakdown, and had a 12 for Adult Braden Score and now had a non-blanchable pressure area to the sacrum with skin sloughing. On October 29, 2021 and November 3, 2021, Wound Care documented MR1's sacrum area measured 5.5 centimeters (cm) circumferentially had a 25 percent of heavy tan slough with edges that were macerated (breaking down of tissue) slight purple hue and sloughing. The area is opened right at the bony prominence.

Interview with EMP15 and EMP16 on December 2, 2021, at approximately 1145 confirmed Wound Care documentation dated October 19, 2021, indicating MR1 was a high risk for skin breakdown and had a 12 for Adult Braden Score and now had a non-blanchable pressure area to the sacrum with skin sloughing. EMP15 and EMP16 confirmed on October 29, 2021 and November 3, 2021, Wound Care documented MR1's sacrum area measured 5.5 cm circumferentially had a 25 percent of heavy tan slough with edges that were macerated slight purple hue and sloughing. The area is opened right at the bony prominence.

Review of MR1 on December 1, 1021, revealed Wound Care documentation dated November 11, 2021, indicating this patient's area was evolving and for nursing to consult plastic surgery for possible debridement of the area. There were no documented measurements of MR1's sacral wound. On November 22, 2021, Wound Care documented MR1's sacral coccygeal ulceration measures 7 circumferentially with areas of tunneling at 7 - 9 o'clock tunneling for 1.4 cm and at 2 - 4 o'clock tunneling for 1.5cm. On December 1, 2021, Wound Care documented MR1's sacrococcygeal area was Stage IV (involves full thickness tissue loss of underlying tissue with exposure of muscle and bone) with measurements of 7 cm x 5.5 cm x 1 cm with tunneling from 2 - 3 o'clock at 2 cm and 3 - 4 o'clock at 4 cm.

Interview with EMP15 and EMP16 on December 2, 2021, at approximately 1145 confirmed EMP15's documentation dated November 11, 2021, indicating MR1's area was evolving and for nursing to consult plastic surgery for possible debridement of the area and there were no documented measurements of MR1's sacral wound. EMP15 confirmed MR1's sacral coccygeal ulceration measurements and that the ulceration was now a Stage IV.

2) A request was made of EMP2, EMP3, EMP4, EMP7 and EMP11 on December 2, 2021 for a facility policy, procedure, guideline, or protocol nursing staff would follow or reference regarding following physician orders. None was provided.

Review of MR1 on December 1, 2021, revealed a physician order dated October 18, 2021, instructing nursing staff to obtain daily weights. Nursing staff obtained a weight of 130.1 pounds on MR1 on October 19, 2021, and 98 pounds on December 1, 2021.

There was no documentation nursing staff obtained daily weights on MR1 as per physician order dated October 19, 2021.

Interview with EMP4, EMP7 and EMP11 on December 1, 2021, at approximately 1115 confirmed MR1's physician order dated October 18, 2021, instructing nursing staff to obtain daily weights; nursing staff obtained a weight of 130.1 pounds on MR1 on October 19, 2021, and 98 pounds on December 1, 2021 and there was no documentation nursing staff obtained daily weights on MR1 as per physician order dated October 19, 2021.

3) Review of MR1 on December 1, 2021, revealed this patient was admitted to the facility on October 19, 2021 and was still an inpatient at the time of the complaint survey.

Review of MR1 on December 1, 2021, revealed nursing documentation indicating this patient was unable to turn and reposition and nursing assessed and determined MR1's Braden scale as 11 to 14 from October 19 to November 30, 2021.

Review of MR1 on December 1, 2021, revealed the following nursing documentation indicating MR1 was positioned on the back on:
October 20, 2021, beginning at 2000 through October 22, 2021 at 0900.
October 22, 2021, beginning at 1700 through October 25, 2021, at 0800.
October 25, 2021, beginning at 1900 through October 26, 2021 at 1700.
November 3, 2021, beginning at 0700 through November 4, 2021 at 1900.
November 5, 2021, beginning at 0500 through November 16, 2021 at 1800.
November 7, 2021, beginning at 2000 through November 8, 2021 at 0700.

Interview with EMP4 and MEP7 on December 1, 2021, confirmed the above nursing documentation reflecting MR1's positioning on the back.

Review of MR1 on December 1, 2021, revealed documentation dated October 19, 2021, indicating nursing consulted Wound Care for a non-blanchable pressure area to the sacrum with skin sloughing and on November 3, 2021, Wound Care documented MR1's sacrum area measured 5.5 centimeters (cm) circumferentially had a 25 percent of heavy tan slough with edges that aware macerated (breaking down of tissue) slight purple hue and sloughing. The area is opened right at the bony prominence.

Review of MR1 on December 1, 1021, revealed EMP15 documentation dated November 11, 2021, indicating this patient's area was evolving and for nursing to consult plastic surgery for possible debridement of the area. There were no documented measurements of MR1's sacral wound. On November 22, 2021, EMP15 documented MR1's sacral coccygeal ulceration measures 7 circumferentially with areas of tunneling at 7 - 9 o'clock tunneling for 1.4 cm and at 2 - 4 o'clock tunneling for 1.5cm. On December 1, 2021, EMP15 documented MR1's sacrococcygeal area was Stage IV (involves full thickness tissue loss of underlying tissue with exposure of muscle and bone) with measurements of 7 cm x 5.5 cm x 1 cm with tunneling from 2 - 3 o'clock at 2 cm and 3 - 4 o'clock at 4 cm.

Interview with EMP15 and EMP16 on December 2, 2021, at approximately 1145confirmed EMP15's documentation dated November 11, 2021, indicating MR1's area was evolving and for nursing to consult plastic surgery for possible debridement of the area and there were no documented measurements of MR1's sacral wound. EMP15 confirmed MR1's sacral coccygeal ulceration measurements and that the ulceration was now a Stage IV.

Review of MR2 on December 1, 2021, revealed this patient was admitted to the facility on October 31, 2021 and discharged on November 26, 2021.

Review of MR2 on December 1, 2021, revealed nursing documentation indicating this patient was unable to turn and reposition and nursing assessed and determined MR2's Braden scale as 10 to 11 from October 31 to November 30, 2021.

Review on December 1, 2021, revealed the following nursing documentation indicating MR2 was positioned on the back on:

November 2, 2021, beginning at 1100 through November 3, 2021 at 0400.
November 3, 2021, beginning at 2000 through November 4, 2021 at 2300.
November 10, 2021, beginning at 1400 through November 12, 2021 at 0100.

Interview with EMP4 and EMP7 on December 1, 2021, confirmed the above nursing documentation reflecting MR2 ' s positioning on the back.

Review of MR2 on December 1, 2021, revealed Wound Care was consulted on November 11, 2021 for a dark maroon, non-blanching area on this patient's buttocks/sacrum area.

Review of MR4 on December 2, 2021, revealed this patient was admitted to the facility on November 6, 2021, with diagnoses of COVID, COVID pneumonia and ambulatory dysfunction. MR4 was discharged on November 18, 2021.

Review of MR4 on December 2, 2021, revealed this patient was unable to turn and reposition self. Nursing assessed MR4 and determined MR4's Braden Score was 14.

Review on December 2, 2021, revealed the following nursing documentation indicating MR4 was positioned on the back on:
November 13, 2021, beginning at 1900 through November 14, 2021 at 1000.
November 14, 2021, beginning at 2000 through November 15, 2021 at 0900.
November 15, 2021, beginning at 1000 through November 17, 2021at 0100.

Interview with EMP4 and EMP7 on December 1, 2021, confirmed the above nursing documentation reflecting MR4's positioning on the back.

Review of MR4 on December 2, 2021, revealed Wound Care documentation dated November 16, 2021, indicating this patient's sacral area was soft, purple with pink blanching and there as an open blister at the coccyx area measuring 2 cm circumferentially.

Interview with EMP15 and EMP16 on December 2, 2021, at approximately 1150 confirmed MR4's Wound Care documentation dated November 16, 2021, indicating this patient's sacral area was soft, purple with pink blanching and there as an open blister at the coccyx area measuring 2 cm circumferentially.

Review on December 3, 2021, during the facility's Abatement of Immediate Jeopardy review revealed the following:

Review of MR18 on December 3, 2021, revealed this patient was admitted to the facility on December 2, 2021, for evaluation and treatment of a fractured right hip. MR18 was taken directly to the operating room from the Emergency Department and following surgery was admitted to the orthopedic floor at 1945 on December 2, 2021.

Interview with EMP4, EMP7 and EMP11 on December 3, 2021, at approximately 1110 confirmed MR18 was admitted to the facility on December 2, 2021, for evaluation and treatment of a fractured right hip; MR18 was taken directly to the operating room from the Emergency Department and following surgery was admitted to the orthopedic floor at 1945 on December 2, 2021.

Review on December 3, 2012, of MR18's turning and repositioning for December 2 through 3, 2021 revealed no documentation this patient was turned and repositioned from 1949 on December 2, 2021 through December 3, 2021 at 0700.

Interview with EMP4, EMP7 and EMP11 on December 3, 2021, at approximately 1110 confirmed MR18 these was no nursing documentation patient was turned and repositioned from 1949 on December 2, 2021 through December 3, 2021 at 0700. EMP4 confirmed MR18 was unable to turn and reposition self.

EMP4 and EMP7 brought this to the attention of EMP2 and EMP3 on December 2, 2021, at approximately 1120.

A request was made by the surveyor to meet with EMP2 and EMP3 on December 2, 2021.

Interview with EMP2 and EMP3 on December 3, 2021, at approximately 1130 revealed these employees were made aware MR18's nurse did not complete documentation regarding MR18's turning and repositioning prior to leaving their scheduled work shift. EMP2 and EMP3 revealed MR18's nurse was returning to the facility later that morning to complete MR18's turning and repositioning documentation. EMP2 revealed this employee was not concerned regarding MR18's documentation not being completed prior to the nurse leaving the scheduled work shift because it is facility policy that nursing staff have 98 hours to complete their documentation on a patient.

Cross reference
482.13(c)(2) Patient Rights: Care In Safe Setting
482.23(b)(4) Nursing Care Plan
482.23(b)(6) Supervision of Contract Staff
482.28(b),(b)(1)Therapeutic Diets

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to establish individualized patient care plans based on patient needs for two of two medical records reviewed (MR1 and MR2)

Findings include:

Review on December 9, 2021, of the facility's "Nutritional Deficit" care plan template, no review date, revealed "Alteration in Nutrition Patient will maintain adequate nutritional intake. Assess and monitor food intake and supplements. Collaborate with interdisciplinary team. Assist patient with meals as appropriate. Allow adequate time for meals. Obtain daily weights. Include patient and caregiver in nutritional decisions."

Review on December 9, 2021, of the facility's "Risk for Pressure Injuries" care plan template, no review date, revealed "Actual and Potential for Impaired Skin Integrity. Patient will maintain skin integrity. Identify patients at risk. Assess skin integrity and risk for skin breakdown. Complete skin assessment. Turn and reposition. Relieve pressure to bony prominences. Provide measures to decrease pressure to skin. Avoid shearing. Use lift devices as appropriate. Keep skin clean and dry. Perform incontinence care. Encourage use of lotion and moisturizer on skin. Monitor patient's hygiene practices. Utilize wound care nurse as appropriate. Collaborate with interdisciplinary team. Patient will maintain adequate nutritional intake. Assess and monitor patient's nutritional status. Utilize nutritional screening tool. Consult Nutritionist. Assist patient with meals as appropriate. Allow adequate time for meals. Encourage patient to take supplement as ordered. Monitor patient's weight and dietary intake. Collaborate with the interdisciplinary team. Include patient and caregiver in nutritional decisions."

Review on December 2, 2021, of the facility's "Assessment of the Patient Throughout Hospitalization - 10.434" policy, last approved April 15, 2021, revealed "...Policy The care provided to each patient is determined by the assessment of the patient's age and relevant physical, psychological, social, cultural, and spiritual needs. A systemic data collection of patient's physical condition will be completed within 24 hours of patient's admission to an inpatient status and at minimum daily thereafter...The RN will: Formulate, individualize, and prioritize a nursing plan of care pertaining to the patient's wellness and/or illness to achieve an expected outcomes. Establish the patient's current level of function and needs..."

Review on December 2, 2021, of the facility's "Nursing Care Planning Process" policy, last approved May 20, 2021, revealed "Purpose The purpose of the nursing care planning process is to use a standardized approach, incorporating evidence-based practice (EBP) guidelines to formulate individualized nursing care for patients admitted to the hospital. This method incorporates the five steps of the Nursing Process: assessment, diagnosis, planning, intervention, and evaluation to achieve optimal patient outcomes ...Policy The inclusion of the care plan in nursing documentation provides validation that general nursing care elements and/or regulatory-related elements are defined within 24 hours of admission, daily, and as needed throughout the patient's hospitalization. Care plans are to be used as reference tools for standards of nursing practice and are to be completed upon patient discharge...Procedure 1. Assessment: The Registered Nurse (RN) will review the patient's clinical history and assess the patient......2. Diagnosis: The RN will develop and document appropriate nursing diagnoses (problem and need identification) a. Each nursing diagnosis will identify at least one goal of care. b. Each goal of care will identify at least one intervention. c. The RN reviews and revises the care plan (diagnoses, goals, and interventions) within the "Care Plan" navigator, ensuring care plans address the following: i. patient's primary diagnosis ii. Any pertinent secondary diagnosis or past medical history iii. Individualization of the goals and interventions to meet the patient's unique care needs d. Expected end dates are to be added upon initiation of the care plan and are to be no more than five (5) days from the current date. 3. Planning: The nurse will review and incorporate interdisciplinary care. a. The "My Story Report" is to be utilized as the individualized, interdisciplinary, real-time plan of care for the patient...4. Intervention: The nursing performs and documents patient care throughout the shift. 5. Evaluation: The RN interprets results, evaluates outcomes, and assesses compliance. a. The RN will document within the care plan navigator, addressing the patient's progress with each identified goal, potential barriers to meeting this goal, currently stability of the patient, and recommendations for continued care."

Review on December 2, 2021, of the facility's "Operations Manager - Nursing" job description, no review date, revealed "Job Description Summary Manages nursing personnel and daily operational related activities. Leads Nursing team for assigned units or departments with responsibility for all operational functions of the team. Works in partnership with the Medical Director and Physician Liaison of the department to provide administrative and medical staff support to the operations of the unit. Responsible for developing and initiating improvements in the organization and delivery of high quality, cost effective patient care. Responsible for nursing clinical practice, budgetary personnel activities, and regulatory activities associated with the unit or department, and continuing support of Electronic Medical Record. Job Description... Ensures the patient safety improvement and management program will be given high priority and will support the program ...Ensures adequate staffing and competent care delivery .... Develops and promotes service standards that foster a customer sensitive environment, using a proactive approach ... Works closely with other departments and services and administration to maximize quality patient outcomes ... "

1) Review of MR1 on December 2, 2021, revealed this patient was admitted on October 18, 2021, with diagnoses of failure to thrive in adult and malnutrition of moderate degree.

Review of MR1 on December 2, 2021, revealed documentation nursing staff initiated care plans addressing Fall Risk - Potential for Falls and Fall Risk; General Care Plan - Discharge Barriers; Anxiety and Inadequate Coping, Knowledge Deficit, Potential for Inadequate Coping, Risk for Impaired Physical Mobility, Daily Care and Potential Self-Care Deficit, Safety and Risk for injury, Pain and Impaired Comfort; Isolation - Risk for Social Isolation, Risk for Infection and Contamination and Risk For Infection - Potential for Infection.

Interview with EMP4, EMP7 and EMP11 on December 2, 2021, at approximately 1400. confirmed MR1 was admitted on October 18, 2021, with diagnoses of failure to thrive in adult and malnutrition of moderate degree and nursing staff initiated care plans addressing Fall Risk - Potential for Falls and Fall Risk; General Care Plan - Discharge Barriers; Anxiety and Inadequate Coping, Knowledge Deficit, Potential for Inadequate Coping, Risk for Impaired Physical Mobility, Daily Care and Potential Self-Care Deficit, Safety and Risk for injury, Pain and Impaired Comfort; Isolation - Risk for Social Isolation, Risk for Infection and Contamination and Risk For Infection - Potential for Infection.

Review of MR1 on December 2, 2021, revealed wound care documentation this patient developed a Stage IV pressure on the sacrum on November 16, 2021.

There was no documentation in MR1 indicating nursing staff-initiated a care plan addressing MR1's potential risk for and prevention of pressure sores.

Interview with EMP4, EMP7 and EMP11 on December 2, 2021, at approximately 1445. confirmed MR1's wound care documentation this patient developed a Stage IV pressure on the sacrum on November 16, 2021, and there was no documentation in MR1 indicating nursing staff-initiated a care plan addressing MR1's potential risk for and prevention of pressure sores.

Review of MR1 on December 2, 2021, revealed nursing staff obtained an admission weight of 130.1 pounds on October 19, 2021. The next weight nursing obtained on MR1 was on December 1, 2021 of 98 pounds.

There was no documentation in MR1 indicating nursing staff initiated a care plan addressing MR1's potential for and the prevention of weight loss.

Interview with EMP4, EMP7 and EMP11 on December 2, 2021, at approximately 1445. confirmed MR1's admission weight of 130.1 pounds on October 19, 2021, and the next weight nursing obtained on MR1 was on December 1, 2021 of 98 pounds and there was no documentation in MR1 indicating nursing staff initiated a care plan addressing MR1's potential for and the prevention of weight loss.

2) Review of MR2 on December 2, 2021, revealed this patient was admitted to the facility on October 31, 2021, following a fall, and had ambulatory dysfunction.

Review of MR2 on December 2, 2021, revealed documentation nursing staff initiated care plans addressing Fall Risk - Actual and Potential for Falls; General Care Plan - Discharge Barriers, Knowledge Deficit, Risk for Impaired Physical Mobility, Daily Care and Potential Self-Care Deficit, Safety and Risk for injury and Pain and Impaired Comfort.

Interview with EMP4, EMP7 and EMP11 no December 2, 2021 confirmed MR2 was admitted on October 31, 2021, following a fall and had ambulatory dysfunction and nursing staff initiated care plans addressing Fall Risk - Actual and Potential for Falls; General Care Plan - Discharge Barriers, Knowledge Deficit, Risk for Impaired Physical Mobility, Daily Care and Potential Self-Care Deficit, Safety and Risk for injury and Pain and Impaired Comfort.

Review of MR2 on December 2, 2021, revealed nursing documentation dated November 10, 2021, indicating this patient developed a discolored area to the sacral / buttock area and on November 24, 2021, Wound Care documented MR2's sacrococcygeal ulceration had a white/yellow base with erythematous wound skin that blanches; a moderate amount of drainage and the area measure 1.7 cm x 5.5 cm.

There was no documentation in MR2 indicating nursing staff-initiated a care plan addressing MR2's potential risk for and prevention of pressure sores.

Interview with EMP4, EMP7 and EMP11 on December 2, 2021, at approximately 1400. confirmed MR2 developed a discolored area to the sacral / buttock area and on November 24, 2021, MR2's sacrococcygeal ulceration had a white/yellow base with erythematous wound skin that blanches; a moderate amount of drainage and the area measure 1.7 cm x 5.5 cm. EMP4, EMP7 and EMP11 confirmed there was no documentation in MR2 indicating nursing staff-initiated a care plan addressing MR2's potential risk for and prevention of pressure sores.

Cross reference
482.13(c)(2) Patient Rights: Care In Safe Setting
482.23(b)(3) Rn Supervision Of Nursing Care
482.23(b)(6) Supervision of Contract Staff
482.28(b),(b)(1)Therapeutic Diets

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to prevent patients from developing hospital acquired pressure sores for four of four applicable medical records reviewed (MR1, MR2, MR3 and MR4).

Findings include:

Review on December 1, 2021, of the facility's "Pressure Injury Prevention" policy, last approved April 15, 2021, revealed "... Policy Evidence-based standards will guide the prevention of pressure injuries for patients...Definitions Pressure Injury: Localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs because of intense pressure, prolonged pressure, or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue...Procedure Prevention Measures: 1. Perform risk assessment and skin assessment at a minimum daily, and upon changes to level of care. 2. Implement appropriate prevention interventions based on the risk assessment findings. Individualized plan based on risk assessment sub-scores (Mobility, Activity, Sensory Perception, moisture, Nutrition, Friction / Shear)...b. Mild Risk (15-18 Braden Score) i. to manage impaired mobility/activity/sensory perception 1. If a patient is bedbound/chair bound, implement turning schedule. Offload the heels as needed. 2. Turn and reposition patient Q2 hours [every two hours] while in bed. Offload pressure Q1 hours while in chair. c. Moderate Risk (13 - 14 Braden Score) i. Utilize all the interventions listed under "mild risk" ii to manage impaired mobility/activity/sensory perception 1. Consider padding bony prominences with foam dressing, per facility guidelines. 2. Offload any areas of erythema on a bony prominence. Do not rub/massage any areas to erythema on a bony prominence..."

Review on December 2, 2021, of the facility's "Operations Manager - Nursing" job description, no review date, revealed "Job description Summary Manages nursing personnel and daily operational related activities. Leads Nursing team for assigned units or departments with responsibility for all operational functions of the team. Works in partnership with the Medical Director and Physician Liaison of the department to provide administrative and medical staff support to the operations of the unit. Responsible for developing and initiating improvements in the organization and delivery of high quality, cost effective patient care. Responsible for nursing clinical practice, budgetary personnel activities, and regulatory activities associated with the unit or department, and continuing support of Electronic Medical Record. Job Description.... Ensures the patient safety improvement and management program will be given high priority and will support the program ...Ensures adequate staffing and competent care delivery .... Develops and promotes service standards that foster a customer sensitive environment, using a proactive approach ... Works closely with other departments and services and administration to maximize quality patient outcomes ... "

Review on December 2, 2021, of the facility's "Registered Nurse Wound Care PASNAP" job description, last changed August 20, 2021, revealed "Job Profile Summary Assesses plans, organizes, performs, and evaluates nursing interventions to meet the needs of the patient with disorders of the integumentary system including wounds, pressure ulcers, ostomies, and continence disorders...Provides leadership and guidance in coordinating patient care with staff and involves the multidisciplinary team in the patient's plan of care...Job Description.... Functions as the expert clinician in assessing, planning, intervening and evaluating the care of the patient wound, ostomy, continence disorders as well as pressure ulcer treatment and prevention...Initiates collaboration with physicians, ancillary personnel, and other interdisciplinary team members and acts to proactively resolve and facilitate patient needs...Collaborates with leadership and staff to determine wound and ostomy needs for patients and provides consultation and care as assigned..."

1) Review of MR1 on December 1, 2021, revealed this patient was admitted on October 19, 2021, for failure to thrive in adult and malnutrition of moderate degree. Nursing completed a skin assessment on this patient while in the Emergency Department (ED); determined MR1 had an erythematous (an abnormal redness of the skin or an inflammation) blanchable area with a scabbed skin tear to the buttocks and consulted wound care for alteration in skin integrity to the sacrum.

Interview with EMP4 and EMP7 on December 1, 2021, approximately 1145 confirmed MR1 was admitted on October 19, 2021, for failure to thrive in adult and malnutrition of moderate degree; nursing completed a skin assessment on this patient while in the ED and determined MR1 had an erythematous blanchable area with a scabbed skin tear to the buttocks and that nursing consulted wound care for alteration in skin integrity to the sacrum.

Review of MR1 on December 1, 2021, revealed wound care documentation dated October 19, 2021, indicating this patient was a high risk for skin breakdown; had an Adult Braden Score of 12 and had a non-blanchable pressure area to the sacrum with skin sloughing. On October 29, 2021 and November 3, 2021, EMP15 documented MR1's sacrum area measured 5.5 centimeters (cm) circumferentially had a 25 percent of heavy tan slough with edges that were macerated (breaking down of tissue) slight purple hue and sloughing. The area is opened right at the bony prominence.

Interview with EMP15 and EMP16 on December 2, 2021, at approximately 1145 confirmed EMP15's documentation dated October 19, 2021, indicating MR1 was a high risk for skin breakdown and had a 12 for Adult Braden Score and now had a non-blanchable pressure area to the sacrum with skin sloughing. EMP15 and EMP16 confirmed on October 29, 2021 and November 3, 2021, MR1's sacrum area measured 5.5 cm circumferentially had a 25 percent of heavy tan slough with edges that were macerated slight purple hue and sloughing. The area is opened right at the bony prominence.

Review of MR1 on December 1, 1021, revealed EMP15 documentation dated November 11, 2021, indicating this patient's area was evolving and for nursing to consult plastic surgery for possible debridement of the area. There were no documented measurements of MR1's sacral wound. On November 22, 2021, EMP15 documented MR1's sacral coccygeal ulceration measures 7 circumferentially with areas of tunneling at 7 - 9 o'clock tunneling for 1.4 cm and at 2 - 4 o'clock tunneling for 1.5cm. On December 1, 2021, EMP15 documented MR1's sacrococcygeal area was Stage IV (involves full thickness tissue loss of underlying tissue with exposure of muscle and bone) with measurements of 7 cm x 5.5 cm x 1 cm with tunneling from 2 - 3 o'clock at 2 cm and 3 - 4 o'clock at 4 cm.

Interview with EMP15 and EMP16 on December 2, 2021, at approximately 1145 confirmed EMP15's documentation dated November 11, 2021, indicating MR1's area was evolving and for nursing to consult plastic surgery for possible debridement of the area and there were no documented measurements of MR1's sacral wound. EMP15 confirmed MR1's sacral coccygeal ulceration measurements and that the ulceration was now a Stage IV.

2) Review of MR2 on December 2, 2021, revealed this patient was admitted to the facility on October 31, 2021, with diagnoses of ambulatory dysfunction and malnutrition of moderate degree.

Review of MR2 on December 2, 2021, revealed nursing documentation dated November 10, 2021, indicating this patient developed a discolored area to the sacral / buttock area and MR2's physician wrote an order to consult wound care.

Interview with EMP4 and EMP7 on December 2, 2021, at approximately 0945 confirmed MR2's nursing documentation dated November 10, 2021, indicating this patient developed a discolored area to the sacral / buttock area and this patient's physician wrote an order to consult wound care.

Review of MR2 on December 2, 2021, revealed EMP15 documented on November 11, 2021, this patient had a dark maroon, non-blanching wound draining small amounts of serous fluid. On November 24, 2021, EMP15 documented MR2's sacrococcygeal ulceration had a white/yellow base with erythematous wound skin that blanches; a moderate amount of drainage and the area measure 1.7 cm x 5.5 cm.

Interview with EMP15 and EMP16 on December 2, 2021, at approximately 1150 confirmed EMP15 documented on November 11, 2021, MR2 had a dark maroon, non-blanching wound draining small amounts of serous fluid and on November 24, 2021, EMP15 documented MR2's sacrococcygeal ulceration had a white/yellow base with erythematous wound skin that blanches; a moderate amount of drainage and the area measure 1.7 cm x 5.5 cm.

3) Review of MR3 on December 2, 2021, revealed this patient was admitted on September 18, 2021, with complaint of weakness of the lower extremity. Nursing staff completed a skin assessment on September 18, 2021 and determined this patient had skin breakdown. There was no documentation in MR3 describing the location and description of this patient's skin breakdown.

Interview with EMP4 and EMP7 on December 2, 2021, at approximately 0945confirmed MR3 was admitted on September 18, 2021, with complaint of weakness of the lower extremity; nursing staff completed a skin assessment on September 18, 2021 and determined this patient had skin breakdown and there was no documentation in MR3 describing the location and description of this patient's skin breakdown

Review of MR3 on December 2, 2021, revealed documentation dated September 24, 2021, indicating nursing consulted wound care for alteration in skin integrity to the coccyx/sacrum area.

Review on December 2, 2021, revealed EMP15 documented on September 29, 2021, that MR3 had a small opening at the sacral area measuring 2.2 cm x 1.4 cm x 0.1 cm with the edges macerated with sloughing and this patient had a back scratcher which could result in skin tears. There was no documentation of any skin tears on MR3's back.

Interview with EMP15 and EMP16 on December 2, 2021, at approximately 1150 confirmed MR3's documentation dated September 24, 2021, indicating nursing consulted wound care for alteration in skin integrity to the coccyx/sacrum area; EMP15 documented on September 29, 2021, that MR3 had a small opening at the sacral area measuring 2.2 cm x 1.4 cm x 0.1 cm with the edges macerated with sloughing and this patient had a back scratcher which could result in skin tears and there was no documentation of any skin tears on MR3's back

4) Review of MR4 on December 2, 2021, revealed this patient was admitted to the facility on November 6, 2021, with a diagnosis of COVID and COVID pneumonia.

Review of MR4 on December 2, 2021, revealed nursing documentation this patient's sacral area was reddened on November 15, 2021, and MR4's physician wrote an order to consult wound care.

Interview with EMP4 and EMP7 on December 2, 2021, at approximately 0945 confirmed MR4 admitted to the facility on November 6, 2021, with a diagnosis of COVID and COVID pneumonia; nursing documentation this patient's sacral area was reddened on November 15, 2021; and MR4's physician wrote an order to consult wound care.

Review of MR4 on December 2, 2021, revealed EMP15 documented on November 16, 2021, indicating this patient's sacral area was soft, purple with pink blanching and there as an open blister at the coccyx area measuring 2 cm circumferentially.

Interview with EMP15 and EMP16 on December 2, 2021, at approximately 1150 confirmed EMP15 documented on November 16, 2021, indicating this patient's sacral area was soft, purple with pink blanching and there as an open blister at the coccyx area measuring 2 cm circumferentially.

Cross reference
482.13(c)(2) Patient Rights: Care In Safe Setting
482.23(b)(3) Rn Supervision Of Nursing Care
482.23(b)(4) Nursing Care Plan
482.28(b),(b)(1)Therapeutic Diets

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The facility failed to prevent a significant weight loss; the facility failed to ensure the Registered Dietitian Nutritionist obtained weights on a patient to monitor potential weight loss; the facility failed to monitor patient's weight changes and the facility failed to obtain a re-weight on patients with identified weight changes.

A discussion took place with the survey team and the facility's administrative staff (EMP2, EMP3, EMP4, EMP7, EMP11, EMP17 and EMP18) regarding the survey team's concerns related to Patient Rights on December 2, 2021, at approximately 1620.

Cross reference
482.28(b),(b)(1)Therapeutic Diets

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to prevent weight loss for one of one applicable medical record reviewed (MR1); the facility failed to ensure the Registered Dietitian Nutritionist obtained weights on a patient to monitor potential weight loss for one of one applicable medical record reviewed (MR1); the facility failed to monitor weight changes for one of one applicable medical record reviewed (MR3) and the facility failed to obtain a re-weight on patients with identified weight changes for two of two applicable medical records reviewed (MR5 and MR6).

Findings include:

Review on December 2, 2021, of the facility's "Nutrition Care of the Hospitalized Patient-Adult" policy, last approved July 2, 2021, revealed "Purpose The purpose of this policy, "Nutrition Care of the Hospitalized Patient", is to provide nutrition care for adult hospitalized patients in a safe, effective, and timely manner...The Registered Dietitian Nutritionist (RDN) communicates nutrition care plans and recommendations to patients, caregivers, and members of the interdisciplinary team..."

Review on December 2, 2021, of the facility's "Clinical Dietitian II" job description, last date of change September 28, 2021, revealed "Job Profile Summary Provides safe, competent evidence-based nutritional therapy that meets the standards of practice and the scope of practice as stated by the Academy of Nutrition and Dietetics...Job Description Assesses individual needs through...discussion with other members of the interdisciplinary health care team...Confers with the health care team to develop goals related to patient..."

Interview with EMP5 (RDN) on December 2, 2021, revealed a patients' physician can write an order authorizing order writing to the Registered Dietitian Nutritionist (RDN).

1) Review of MR1 on December 1, 2021, revealed this patient was admitted to the facility with failure to thrive in adult and malnutrition of moderate degree.

Review of MR1 on December 1, 2021, revealed physician orders dated October 17, 2021, instructing nursing staff to obtain daily weights. Review on December 2, 2021, revealed this physician order was still active on December 2, 2021.

Interview with EMP7 on December 2, 2021, at approximately 0945 confirmed patient was admitted to the facility with failure to thrive in adult and malnutrition of moderate degree; physician orders dated October 17, 2021, instructed nursing staff to obtain daily weights and this physician order was still active on December 2, 2021.

Review of MR1 on December 1, 2021, revealed nursing obtained this patient's admission weight of 130.1 pounds on October 18, 2021.

There was no documentation in MR1 indicating nursing staff obtained daily weights on this patient from October 10, 2021, through November 30, 2021.

On December 1, 2021, nursing staff obtained a weight on MR1 and recorded a weight of 98 pounds.

Interview with EMP4 on December 2, 2021, at approximately 0945 confirmed MR1's admission weight on October 18, 2021, was 130.1 pounds; there was no documentation in MR1 indicating nursing staff obtained daily weights on this patient from October 10, 2021, through November 30, 2021 and on December 1, 2021, nursing staff obtained MR1's weight and recorded a weight of 98 pounds.

Review of MR1 on December 1, 2021, revealed nursing documentation this patient developed a hospital acquired pressure sore to the sacral area on November 3 2021, measuring 5.5 centimeters (cm) circumferentially with 25 percent of heavy tan slough with edges that were macerated (breaking down of tissue) slight purple hue and sloughing. On November 22, 2021, MR1's documentation revealed this sacral area now measured 7 circumferentially with areas of tunneling at 7 - 9 o'clock tunneling for 1.4 cm and at 2 - 4 o'clock tunneling for 1.5cm. On December 1, 2021, Wound Care documented MR1's sacrococcygeal area was Stage IV (involves full thickness tissue loss of underlying tissue with exposure of muscle and bone) with measurements of 7 cm x 5.5 cm x 1 cm with tunneling from 2 - 3 o'clock at 2 cm and 3 - 4 o'clock at 4 cm.

Interview with EMP15 and EMP16 on December 2, 2021, at approximately 1145 confirmed EMP15's documentation dated November 11, 2021, indicating MR1's area was evolving and for nursing to consult plastic surgery for possible debridement of the area and there were no documented measurements of MR1's sacral wound. EMP15 confirmed MR1's sacral coccygeal ulceration measurements and that the ulceration was now a Stage IV.

2) Review of MR1 on December 1, 2021, revealed EMP6 (RDN) wrote an order on October 28, 2021 and on November 29, 2021 instructing nursing staff to obtain a weight.

There was no documentation in MR1 indicating nursing staff obtained a weight on this patient as ordered by EMP6 on October 28, 2021 and on November 29, 2021.

There was no documentation in MR1 indicating EMP6 followed through on ensuring nursing staff obtained a weight on MR1 on October 28, 2021 and on November 29, 2021.

Interview with EMP5 on December 2, 2021, at approximately 10:15 a.m. confirmed EMP6 wrote an order on October 28, 2021 and November 29, 2021 instructing nursing staff to obtain a weight; there was no documentation in MR1 indicating nursing staff obtained a weight on this patient as ordered by EMP6 on October 28, 2021 and on November 29, 2021 and there was no documentation in MR1 indicating EMP6 followed through on ensuring nursing staff obtained a weight on MR1 on October 28, 2021 and on November 29, 2021.

3)Review of MR3 revealed this patient was admitted on September 13, 2021, with a diagnosis of weakness of the lower extremity.

Review of MR3 on December 2, 2021, revealed nursing staff obtained the following weights:
September 14, 2021 an admission weight of 163 pounds.
December 1, 2021, 180 pounds.

There was no documentation in MR3 indicating nursing staff obtained any additional weights from September 16, 2021 through December 1, 2021.

Interview with EMP5 on December 1, 2021, at approximately 1045 confirmed MR3 was admitted on September 13, 2021, with a diagnosis of weakness of the lower extremity; MR3's admission weight was 163 pounds on September 14, 2021; nursing obtained and documented weights on September 16, 2021, as 161 pounds on December 1, 2021, as 180 pounds and there was no documentation in MR3 indicating nursing staff obtained any additional weights from September 16, 2021 through December 1, 2021.

Interview with EMP5 on December 2, 2021, at approximately 1045 revealed this patient receives dialysis and any weight increase could be detrimental to a dialysis patient.

Review of MR3 on December 2, 2021, revealed the following Registered Dietitian Nutritionist documentation:
September 29, 2021, EMP10 documented there was no significant weight change on this patient.
October 6, 13, 20, 27, 2021, EMP6 documented there was no significant weight change on this patient.
November 2, 18, and 24, 2021, EMP6 documented there was no significant weight change on this patient.
November 11, 2021, EMP12 documented there was no significant weight change on this patient.

Interview with EMP5 on December 2, 2021, at approximately 1050 confirmed the EMP10, EMP6 and EMP12 were Registered Dietitian Nutritionists and EMP5 confirmed EMP10's, EMP6's and EMP12's documentation on the above dates indicating there was no significant weight change on this patient.

Interview with EMP5 on December 2, 2021, at approximately 1050 confirmed there was no documentation in MR3 indicating nursing staff obtained weights on this patient from September 16, 2021 to December 1, 2021. EMP5 revealed uncertainty how EMP6, EMP10 and EMP12 were able to determine and document MR3 had no significant weight loss.

Review of MR3 on December 2, 2021, revealed EMP6 (RDN) documentation dated, indicating this patient's weight change was likely secondary to fluid.

Interview with EMP5 on December 2, 2021, at approximately 1050 revealed there was no documentation in MR3 indicating how EMP6 determined this patient's weight of 180 pounds was related to fluid since there was no previous weight to compare.

4) Review of MR5 on December 2, 2021, revealed this patient was admitted to the facility's Intensive Care Unit (ICU) on September 3, 2021, with a diagnosis of COVID and COVID pneumonia; was on a ventilator (breathing machine) and was receiving enteral nutrition (nutrition taken through the mouth through a tube that goes directly to the stomach).

Review of MR5 on December 2, 2021, revealed nursing documented the following weights:
September 2, 2021, admission weight as 174 pounds.
September 30, 2021 as 178 pounds.
October 2, 2021, as 193 pounds.
November 11, 2021 as 148 pounds.

Interview with EMP5 on December 2, 2021, at approximately 1100 confirmed MR5's admission weight of 174 pounds; on September 30, 2021 as 178 pounds; on October 2, 2021, as 193 pounds and 148 pounds on November 11, 2021.

Review of MR5 on December 2, 2021, revealed EMP5 documented on October 5, 2021, this patient's weight of 193 pounds and that MR3 had no significant weight gain and a weight gain of 7 kg (kilograms) in less than one week, accuracy of weights is questionable.

There is no documentation in MR5 indicating EMP5 requested a re-weight on this patient to determine the accuracy of 193 pounds on October 2, 2021.

Interview with EMP5 on December 2, 2021, at approximately 1100 confirmed this employee documented on October 5, 2021, MR5's weight of 193 pounds; MR3 had no significant weight gain and a weight gain of 7 kg in less than one week, accuracy of weights is questionable. EMP5 confirmed there is no documentation in MR5 indicating this employee requested a re-weight on MR5 to determine accuracy of 193 pounds on October 2, 2021.

Review of MR5 on December 2, 2021, revealed nursing obtained and recorded a weight of 148 pounds on November 11, 2021.

Interview with EMP5 on December 2, 2021, at approximately 1100 confirmed nursing obtained and recorded a weight of 148 pounds on MR5 on November 11, 2021.

Review of MR5 on December 2, 2021, revealed EMP5 documented on November 15, 2021 this patient's weight of 148 pounds; MR5 had no significant weight gain and a weight loss was noted since last assessment but accuracy remains questionable.

There is no documentation in MR5 indicating EMP5 requested a re-weight on this patient to determine accuracy of 148 pounds on November 11, 2021.

Interview with EMP5 on December 2, 2021, at approximately 1100 confirmed this employee documented on November 15, 2021, MR5's weight of 148 pounds; MR5 had no significant weight gain and a weight loss was noted since last assessment but accuracy remains questionable. EMP5 confirmed there is no documentation in MR5 indicating this employee requested a re-weight on this patient to determine accuracy of 148 pounds on November 11, 2021.

Review of MR6 on December 2, 2021, revealed this patient was admitted on October 18, 2021, to the facility's ICU with a diagnosis of COVID and COVID pneumonia; was on a ventilator and was receiving enteral nutrition. Nursing obtained and recorded MR6's weight as 270 pounds.

Interview with EMP4 on December 2, 2021, at approximately 1105 confirmed MR6 admitted on October 18, 2021, to the facility's ICU with a diagnosis of COVID and COVID pneumonia; was on a ventilator; was receiving enteral nutrition and nursing obtained and recorded MR6's weight as 270 pounds.

Review of MR6 on December 2, 2021, revealed nursing documented a weight on this patient on November 17, 2021 as 245 pounds.

Interview with EMP5 on December 5, 2021, at approximately 1105 confirmed nursing documented a weight on MR6 on November 17, 2021 as 245 pounds.

Review of MR6 on December 2, 2021, revealed EMP10 documented on November 17, 2021, indicating MR6 had a weight change since admission and questioned the accuracy of the weight.

There was no documentation in MR6 indicating EMP10 requested a re-weight on this patient to determine the accuracy of 245 pounds on November 17, 2021.

Interview with EMP5 on December 2, 2021, at approximately 1105 confirmed EMP10 documented on November 17, 2021, MR6 had a weight change since admission and questioned the accuracy of the weight and there was no documentation in MR6 indicating EMP10 requested a re-weight on this patient to determine the accuracy of 245 pounds on November 17, 2021.

Review of MR6 on December 2, 2021, revealed nursing documentation this patient developed a hospital acquired an unstageable pressure sore to the sacral area on November 2, 2021, with sacral sloughing, dark black tissue with yellow edges.

Interview with EMP4 and EMP7 on December 2, 2021, at approximately 1000 confirmed MR6 developed a hospital acquired unstageable pressure sore to the sacral area on November 2, 2021, with sacral sloughing, dark black tissue with yellow edges.

Cross reference
482.13(c)(2) Patient Rights: Care In Safe Setting
482.23(b)(3) Rn Supervision Of Nursing Care
482.23(b)(4) Nursing Care Plan
482.23(b)(6) Supervision of Contract Staff