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Based on the records reviewed, policies reviewed and interviews, the facility failed to ensure that staff reviewed and revised the patient care plan in regard to Tissue Integrity for 1 of 1 patient (patient#1) reviewed with Nursing Services allegation.
The nursing staff failed to consistently assess, document and communicate assessment findings to providers. This failure to assess, document and relay findings cause a skin breakdown on patient #1 at the time of discharge.

Findings;
Medical Record review:
Patient #1 was admitted to this facility on 12/15/2020 for Respiratory Failure with Hypoxemia, Chronic Obstructive Pulmonary Disease, Pneumonia, Atrial Fibrillation, Chronic Anticoagulation, Dementia with delirium, Type 2 Diabetes and Coronary Artery Disease.
The patient was admitted to a Progressive Cardiac Care unit (PCCU) but had to be transferred to an ICU 12 hours after his admission due to worsening condition.
Patient #1 was in ICU care from 12/16/2020 until 12/25/2020. Deficient documentation of skin assessments and interventions were corroborated by administration and unit managers. While in this unit, pictures were taken on 12/21/2020 and 12/25/2020 demonstrating that the patient had redness to his sacral area, no evidence present in the record that a provider was notified. The nursing staff used a foam product as a nursing intervention to prevent worsening of the skin sore.
Patient #1 was transferred back to PCCU on 12/25/2020 until 1/6/2021. During the stay in this unit the patient encountered the same failure of inconsistent assessments and lack of documentation of skin assessments. It was not clear in the medical record if a provider was made aware of Tissue integrity issues. There was no evidence found that the patient had a skin assessment upon his arrival to this unit.
Patient #1 was then transferred to a Med/Surg unit from 1/6/2020 until discharge on 1/11/2021. No consistent skin assessments were recorded. Also, no photos were taken when the patient arrived to the unit as per protocol. It was validated that a provider was notified of the sacral skin integrity issues on 1/8/2021. Orders for treatment were initiated as well as a Wound care assessment by the Wound Care nurse.

Interviews:
Interview with administration team member; staff 1 stated that in their internal review it was confirmed that the nursing staff did not follow policy/protocols regarding skin assessments. Staff #1 reported that a peer review had been scheduled to review the failures. Staff #1 also confirmed that the patient did not have decubitus ulcers upon his admission to the facility as per the medical record. Staff #1 stated that a plan of correction was already on draft form and that immediate initiatives were already implemented to prevent this type of situation. The preliminary actions include; All nursing unit directors will do daily audits. All nursing unit directors will report out results of audits at daily (m-F) loop closure meeting. All nursing unit directors will report status of patient's with active wounds and status of treatment at morning administrative safety huddle (m-f).
Interview with unit manager; staff 6 stated that patient #1 was on the unit from 12/15/2020 with a stay of 12 hours due to a transfer to ICU due to the patient's condition. The patient returned to the unit on 12/25/2020 until 1/6/2021. Staff 6 stated that pictures were not taken of present wounds recorded in ICU on 12/21/2020. No evidence of assessment nor communication to provider team obtained. It was documented that a skin barrier was utilized by the nursing staff as a nursing intervention. Patient #1 was then transferred to a med/surg unit on 1/6/2021.
Interview with unit manager; staff 4 stated that the patient was on the unit from 1/6/2021 until 1/11/2021. Staff 4 stated that based on their protocol the staff takes weekly pictures of any wounds present on patients, yet pictures were not taken on patient #1. It was also noted that patient #1 did not have any pictures taken upon his admission to the unit. Staff #1 stated that a provider was alerted to patient #1's pressure ulcers on 1/8/2021 with subsequent orders obtained to treatment the skin issues. A wound care nurse consultation was also scheduled on 1/8/2021.
Interview with Wound Care Nurse provider; Staff 3. Staff 3 stated that nursing staff is to complete a shift skin assessment of patients. That any changes in the skin assessment require adequate documentation as well as provider notification. Staff 3 confirmed that pictures were taken of the sacral redness on 12/21/2020 and that later pictures were taken on 12/25/2021 but no evidence of subsequent photographic documentation was found on the medical record.

Policy:
Tissue Integrity policy and Pressure Injury Prevention and Management No. NURS-GEN-032 Effective 2/01/2017. Policy purpose; "is to establish guidelines for the identification, prevention and care of a patient at risk for or with existing alteration in tissue integrity.". The policy states, under the protocol title, that the facility uses the Braden Risk Assessment scale to assess for skin integrity risks. It also states that a skin assessment is required to be completed by a registered nurse within 12 hours of admission. This policy states that reassessment of pressure ulcer risk is performed in the following circumstances;
a) Change of shift with no greater than 12-hour between assessments
b) Change of primary nurse
c) Significant change in the patient's condition
d) Transfer to higher level of care

The policy states that "staff must remain alert for changes in mobility, incontinence or nutrition which will alter the patient's risk of developing tissue integrity issues.
Regarding photography the policy states that photographic documentation is required on admission, after admission and weekly during the patient's stay.

These items were not consistently followed by the nursing staff at this facility in the care of patient #1.