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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation, §482.23 NURSING SERVICES, was out of compliance.

A-0395 A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and document reviews, the facility failed to ensure registered nurses supervised and evaluated the nursing care for each patient. Specifically, the facility failed to ensure nursing staff conducted assessments, reassessments, and vital signs monitoring in accordance with facility policy. This failure was identified in seven of twenty patients who received care in the emergency department (ED) (Patients #1, #8, #9, #10, #11, #12, and #13). Additionally, the facility failed to ensure alterations to patients' skin integrity were appropriately assessed and documented in two of six inpatient medical records reviewed (Patient #1 and Patient #6). Furthermore, the facility failed to ensure a patient who was at-risk for pressure injuries received interventions to prevent skin breakdown in one of six inpatient medical records reviewed. (Patient #6)

Based on interviews and document reviews, the facility failed to ensure registered nurses supervised and evaluated the nursing care for each patient. Specifically, the facility failed to ensure nursing staff conducted assessments, reassessments, and vital signs monitoring in accordance with facility policy. This failure was identified in seven of twenty patients who received care in the emergency department (ED) (Patients #1, #8, #9, #10, #11, #12, and #13). Additionally, the facility failed to ensure alterations to patients' skin integrity were appropriately assessed and documented in two of six inpatient medical records reviewed (Patient #1 and Patient #6). Furthermore, the facility failed to ensure a patient who was at-risk for pressure injuries received interventions to prevent skin breakdown in one of six inpatient medical records reviewed. (Patient #6)

Findings include:

Facility policies:

The Nursing Standards of Practice - Emergency Department policy read, the emergency registered nurse develops a plan that prescribes strategies to attain expected, measurable outcomes. "Develops a plan" starts with documenting the chief complaint, history, vital signs and clinical presentations. This continues with the patient assessments and reassessments. These standards of practice do not replace clinical judgment but represent minimal, safe standards. All ED patients will have a focused assessment appropriate to the reason for visit. All patients in the ED are reassessed as warranted by Emergency Severity Index (ESI) acuity and presentation, including a complete set of vital signs and pain assessment.

The Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy read, the purpose is to outline the standards of care for assessment, reassessment, vital signs and procedures to document and maintain an accurate record of the patients' assessments, progress, treatments, medications, and condition. Reassessment of the hospitalized patient is a continuous, ongoing process. Patient condition and ongoing changes in status warrant more frequent reassessment and documentation of specific system changes as determined by the caregiver. For ESI Level 1 - Life Threatening patients, an initial physical assessment is completed within 30 minutes and vitals are taken every 5-15 minutes based on patient condition, minimum every hour times four, then every two if clinically stable. For ESI Level 2 - Emergency patients, an initial physical assessment is completed within 30 minutes and ongoing vital signs are completed at minimum every hour times four, then every two hours if clinically stable. For ESI Level 3 - Urgent patients, an initial assessment will be completed within one hour and ongoing vital signs will be completed as follows: patients with normal vital signs at minimum every four hours. Patients with abnormal vital signs at minimum every two hours times four, then every four hours if clinically stable. For ESI Level 4 - Nonurgent patients, ongoing vital signs are completed at minimum every 4 hours & as needed (PRN) based on patient condition 1 hour prior to transfer or discharge from the unit.

The Pain Management policy read, the provision and documentation of pain assessment and reassessment is driven by the scope of care, treatment, services provided and is based on individual patient assessment and interventions. Assess pain upon admission, during and after any known pain producing event, with each new pain producing event, and per unit protocol. Pain reassessment timeframe and/or interval is based on patient assessment and knowledge of the onset and peak effect of the intervention provided. Documentation of reassessment will be within 2 hours of pain interventions. Monitor for side effects of opioid medications including constipation, nausea, vomiting, and pruritus. Monitor for adverse effects of opioid medication including sedation and respiratory depression.

According to the Hospital-Acquired Pressure Injury (HAPI) Prevention, Assessment and Documentation policy, the Braden Scale for Predicting Pressure Injury Risk was a validated and reliable tool that assessed the patient's level of risk for skin breakdown based on the following six categories: sensory perception, skin exposure to moisture, activity level, mobility, nutritional intake, and exposure to friction and shear. The lower the score, the higher the risk for skin breakdown. The subscales measured functional capabilities of the patient that contributed to either higher intensity and duration of pressure, or lower tissue tolerance for pressure. A Braden Score of less than or equal to 18 indicated a risk for pressure injury development. Pressure injury prevention strategies were implemented for adult patients with a Braden Scale score of less than or equal to 18, or a subscale component less than or equal to two. All Registered Nurses (RNs) on inpatient nursing units initiated the HAPI protocol and requested a consult for wound care for any patient with a Braden Score less than or equal to 18.

A pressure injury was localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury could be present as intact skin or an open ulcer and may be painful. The injury occurred as a result of intense and/or prolonged pressure 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.

The RN assessed risk factors for development of pressure injuries and performed the Braden Scale and a head-to-toe skin assessment within four hours of admission, within four hours of the start of each shift, upon transfer from another unit or department, upon discovery of a suspected pressure injury, and with a change in patient condition. Integumentary assessment included color, temperature, texture/turgor, integrity, moisture, and edema.

The RN implemented prevention strategies for patients identified to be at risk for pressure injury development based on risk factors and the risk assessment tool. Prevention strategies included skin care to maintain skin integrity, such as the application of moisture barrier products and the use of silicone multi-layer foam dressings on areas of high risk (e.g., sacrum, heels and other bony prominences). If Braden mobility subscale score less than or equal to two, the RN repositioned the patient at least every four hours or more frequently based on patient risk factors (e.g., skin and tissue tolerance, medical condition, comfort and pain), level of activity, and ability to independently reposition.

The RN completed documentation to include a Braden Scale risk assessment and head-to-toe skin assessment. Photography, which included visible patient identifiers (e.g., medical record number, identification number, name), measurement device, and date captured for each photograph of a pressure injury or wound, was to be included in documentation upon discovery of a pressure injury or wound, weekly, with any change in patient or wound status, and prior to discharge.

According to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy, nursing staff in the intensive care unit (ICU) performed a focus reassessment of systems every four hours and as needed per patient condition.

1. The facility failed to ensure nursing staff performed assessments, reassessments, and monitored vital signs for ED patients.

A. Document Review

i. A review of Patient #1's medical record revealed Patient #1 presented to the ED on 4/15/25 at 10:19 a.m. with a chief complaint of a fall. Nursing staff triaged Patient #1 as an ESI Level 4. The provider's note filed on 4/15/25 at 1:23 p.m. revealed Patient #1 took the medication Eliquis (used to reduce the risk of forming a blood clot, which increases a patient's risk for bleeding). In the ED, Patient #1 was diagnosed with multiple left-sided rib fractures (broken bones) and a hemothorax (a condition where blood collects between the chest wall and the lungs and can cause respiratory failure).

The ED Care Timeline revealed nursing staff assessed Patient #1's vital signs on 4/15/25 at 10:28 a.m., as part of the triage process. Patient #1's vital signs were not re-assessed until 3:50 p.m., five hours and twenty-two minutes later.

This was in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, vital signs should have been assessed at a minimum of every four hours and PRN, based on patient condition.

The ED Care Timeline also revealed Patient #1 rated their pain level in triage as an eight out of 10. Tylenol 650 milligrams (mg) was administered at 12:07 p.m. Nursing staff did not reevaluate Patient #1's pain level in the ED after pain medication had been administered. Patient #1 was transferred to the Med Surg Trauma unit at 4:24 p.m.

This was in contrast to the Pain Management policy which read, documentation of reassessment should have been within 2 hours of pain interventions.

ii. A review of Patient #8's medical record revealed Patient #8 presented to the ED on 7/9/25 at 7:57 p.m. with a chief complaint of left sided facial numbness and weakness. Nursing staff triaged Patient #8 as an ESI level 2 (emergency). At 8:16 p.m., the provider ordered vital signs to be assessed every 15 minutes for one hour, and then every hour once stable, with continuous pulse oximetry monitoring, continuous cardiac monitoring, and neurological assessments every 30 minutes for one hour, and then hourly. Patient #8 was diagnosed with a transient ischemic attack (a temporary blockage of blood flow to the brain).

The ED Care Timeline revealed nursing staff performed a neurological assessment and an assessment with the National Institutes of Health (NIH) stroke scale (a tool to determine neurological deficits) on 7/9/25 at 8:06 p.m. There were no further neurological assessments completed in the ED until 7/10/25 5:15 a.m., nine hours and nine minutes later. This was in contrast to the provider's order which instructed staff to perform neurological assessments every 30 minutes for one hour, and then hourly.

The ED Care Timeline revealed nursing staff assessed Patient #8's vital signs on 7/9/25 at 8:30 p.m., 9:00 p.m.,10:50 p.m., and 11:00 p.m. There were no additional vital signs assessed until 7/10/25 at 3:00 a.m., four hours later. There was no evidence in the ED Care Timeline of continuous pulse oximetry and cardiac monitoring for Patient #8. This was in contrast to the provider's order for vital signs to be assessed every 15 minutes for one hour, and then every hour once stable, with continuous pulse oximetry monitoring, and continuous cardiac monitoring.

This was also in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, for ESI Level 2 - Emergency patients ongoing vital signs should have been completed at a minimum of every hour times four, and then every two hours if clinically stable.

iii. A review of Patient #9's medical record revealed Patient #9 presented to the ED on 6/13/25 at 3:00 a.m. with a chief complaint of vomiting blood and syncope (a temporary loss of consciousness that follows a drop in blood flow to the brain). The provider's note revealed Patient #9 had vomited an estimated two units of blood prior to arrival. Patient #9 had a history of esophageal varices (swollen veins in the esophagus that can rupture and cause massive bleeding) and portal hypertension (high blood pressure in the portal vein that runs through the liver). Nursing staff assessed Patient #9's heart rate of 88 (normal is 60-100) beats per minute at 3:06 a.m., and assessed Patient #9's blood pressure of 77/55 (normal is 120/80) at 3:10 a.m. Nursing staff triaged Patient #9 as an ESI level 1 (life threatening) at 3:11 a.m. No additional vital signs were assessed until 4:00 a.m., 50 minutes later.

At 3:53 a.m. nursing staff administered 500 milliliters (ml) of packed red blood cells via Massive Transfusion Protocol (a rapid blood administration protocol used in cases of massive bleeding). Nursing staff assessed vital signs every five to 10 minutes from 4:00 a.m. until 4:50 a.m. At 4:50 a.m., Patient #9's blood pressure reading was 83/54. Vital signs were next assessed at 5:30 a.m., 40 minutes later. At 5:30 a.m., Patient #9's blood pressure was 74/52.

From 5:30 a.m. to 6:51 a.m., when Patient #9 was transferred to the intensive care unit (ICU), there was a period of one hour and 21 minutes with no additional vital signs assessed in the ED.

These gaps in vital signs assessments were in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, for ESI Level 1 patients, vital signs should have been assessed every 5-15 minutes.

iv. A review of Patient #10's medical record revealed Patient #10 presented to the ED on 6/21/25 at 3:12 a.m. with a chief complaint of a gunshot wound to the right shoulder. The provider diagnosed Patient #10 with a fracture of the right humerus (the upper arm bone). Nursing staff triaged Patient #10 as an ESI level 1.

The ED Care Timeline revealed Patient #10's vital signs were assessed at 3:19 a.m., 3:20 a.m. and 3:25 a.m. No additional vital signs were assessed until 5:35 a.m., two hours and five minutes later.

This gap in vital signs monitoring was in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, for ESI Level 1 patients, vital signs should have been assessed every 5-15 minutes based on patient condition, and if clinically stable, at minimum every hour times four.

At 3:38 a.m., nursing staff administered 4mg of Morphine (an opioid medicine used for severe pain) intravenously (IV). Nursing staff administered a second dose of 4mg of Morphine IV at 6:03 a.m. There were no nursing assessments for pain prior to administrations of Morphine, or pain reassessments after Morphine had been administered.

Nursing staff administered a third dose of 4mg of Morphine IV at 6:47 a.m., and documented Patient #10's pain was an eight out of 10 at the time of medication administration. ED nurses discharged Patient #10 from the facility at 6:59 a.m. and did not reassess Patient #10's pain prior to discharge.

This lack of pain assessment and reassessment was in contrast to the Pain Management policy which read, the pain reassessment timeframe and/or interval should have been based on the knowledge of the onset and peak effect of the intervention provided. Documentation of reassessment should have been within 2 hours of pain interventions. Staff should have monitored for adverse effects of opioid medication including sedation and respiratory depression.

The lack of pain assessment and reassessment was also in contrast to the Nursing Standards of Practice - Emergency Department policy which read, the emergency registered nurse should have developed a plan that prescribed strategies to attain expected, measurable outcomes. This should have continued with patient assessments and reassessments. All patients in the ED should have been reassessed, including a complete set of vital signs and pain assessment.

v. A review of Patient #11's medical record revealed Patient #11 presented to the ED on 5/7/25 at 9:24 p.m. with a chief complaint of a seizure. The ED Care Timeline revealed nursing staff triaged Patient #11 as an ESI level 2. The provider diagnosed Patient #11 with a breakthrough seizure.

Nursing staff assessed Patient #11's vital signs at 9:30 p.m. No additional vital signs were taken until 11:45 p.m., two hours and 15 minutes later.

This was in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, for ESI Level 2 - Emergency patients ongoing vital signs should have been completed at minimum every hour times four, and then every two hours if clinically stable.

vi. A review of Patient #12's medical record revealed Patient #12 presented to the ED on 6/21/25 at 2:10 p.m. with a chief complaint of a sore throat after sinus surgery. Nursing staff triaged Patient #12 as an ESI level 3 (urgent). Patient #12 complained of difficulty breathing, talking, and swallowing. The provider's note revealed Patient #12 appeared to be in distress with difficulty speaking.

The provider diagnosed Patient #12 with a retropharyngeal abscess (a severe infection that can pose a threat to life by obstructing the airway) and tracheal perforation (tear or break in the windpipe that affects the airway).

The ED Care Timeline revealed nurses assessed Patient #12's vital signs at 2:26 p.m. in triage and they were within the normal range. No additional vital signs were obtained in the emergency department. Patient #12 was admitted to the operating room at 7:16 p.m for intubation (a lifesaving medical procedure that uses a tube to keep the airway open). The gap in vital signs from triage to Patient #12's transfer to the operating room was a period of four hours and 50 minutes.

This was in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read for ESI Level 3 - Urgent patients, vital signs should have been completed at a minimum of every four hours.

vii. A review of Patient #13's medical record revealed Patient #13 presented to the ED by ambulance on 5/9/25 at 11:16 p.m. with a chief complaint of left sided facial paralysis and facial drooping. Nursing staff triaged Patient #13 as an ESI level 2 on arrival and completed a stroke assessment using the NIH Stroke Scale.

At 11:19 p.m., the provider placed a nursing order for neurological assessments to be performed every 30 minutes for one hour, and then hourly. Nursing staff did not perform a primary assessment or any neuro assessments while Patient #13 was in the ED.

This was in contrast to the provider's order for neurological assessments to be performed every 30 minutes for one hour, and then hourly. This was also in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, for ESI Level 2 - Emergency patients, an initial physical assessment should have been completed within 30 minutes.

B. Interviews

i. An interview was conducted on 7/14/25 at 9:30 a.m. with registered nurse (RN) #8. RN #8 stated patients who were classified as a lower ESI were considered high acuity (the severity of an illness or medical condition) patients. RN #8 stated it was important for ED nurses to assess and reassess patients in the emergency department. RN #8 stated at minimum, nurses should have conducted a primary assessment and a focused assessment based on the chief complaint of the patient. This was in contrast to Patient #13's medical record review which revealed nurses did not perform a primary or neurological assessment of Patient #13 while they were in the ED.

RN #8 also stated at minimum, vital signs should have been assessed every two hours on all patients. RN #8 stated if a patient had abnormal vital signs, vital signs should have been assessed at a minimum of every hour.

This was in contrast to Patient #1's medical record review which revealed a gap of five hours and twenty-two minutes in the assessment of vital signs.

ii. An interview was conducted on 7/16/25 at 9:26 a.m. with RN #7. RN #7 stated ED nurses were expected to document an assessment and a focused assessment addressing the patient's chief complaint. RN #7 stated reassessments of patients were completed based on length of stay in the ED, any medications they received, and if any changes in condition occurred. RN #7 reassessments should have been conducted if pain medication was given. RN #7 stated ED providers relied on nurses to observe and report changes in patient condition. RN #7 stated ED patient's vital signs were checked more frequently based on their ESI level. A patient who was assigned an ESI level 2 should have had vital signs assessed every 15 minutes to every 30 minutes depending on the chief complaint.

This was in contrast to Patient #11's medical record review which revealed they were scored as an ESI level 2 and had a two hour and 15 minute gap in the assessment of vital signs.

RN #7 also stated a patient who was evaluated in the ED for stroke-like symptoms should have had a neurological assessment and vital signs at a minimum of every hour to determine if there were any neurological status changes. RN #7 stated the risk of not reassessing a patient with stroke-like symptoms included a worsening neurological status and abnormal vital signs.

This was in contrast to Patient #8's medical record review which revealed a neurological reassessment did not occur, and vital signs were not assessed every hour while they were in the ED. This was also in contrast to Patient #13's medical record review which revealed nurses did not perform a neurological assessment when the patient presented with left sided facial paralysis and facial drooping.

Additionally, RN #7 stated a patient with a retropharyngeal abscess with tracheal perforation should have been monitored closely and assessed frequently for airway status and changes in vital signs. RN #7 stated vital signs should have been documented every five minutes for a patient with retropharyngeal abscess with tracheal perforation. RN #7 stated the risk of not reassessing a patient with retropharyngeal abscess with tracheal perforation included a loss of airway and death.

This was in contrast to Patient #12's medical record review which revealed nurses did not assess Patient #12's vital signs for four hours and 50 minutes.

RN #7 stated a patient with a chief complaint of vomiting blood and syncopal episodes should have been reassessed frequently for changes in vital signs, cardiac monitoring, mental status, labs, and airway. RN #7 stated a blood pressure in the 70s/50s was dangerously low, required frequent monitoring, and provider notification.

This was in contrast to Patient #9's medical record review which revealed multiple gaps in vital signs assessments, which included gaps of 50 minutes, 40 minutes, and one hour and 21 minutes. Additionally, nursing staff documented multiple episodes of low blood pressure readings and there was no evidence of provider notification regarding the abnormal vital signs.

Furthermore, RN #7 stated patients who received IV Morphine should have been monitored for blood pressure, pain control, and vomiting for at least one hour after administration. RN #7 stated it was important to reassess blood pressure because pain medication, such as Morphine, had a risk of lowering blood pressure to a dangerous level. RN #7 stated it was important to reassess a patient's pain level after administering any pain medication to determine if the pain medication had effectively reduced a patient's pain level.

This was in contrast to Patient #10's medical record review which revealed nurses administered two doses of Morphine without completing a pain assessment, and no pain reassessments were performed. Additionally, Patient #10 was discharged from the ED twelve minutes after a third dose of IV Morphine had been administered.

This was also in contrast to the medical record review for Patient #1 which revealed a pain reassessment had not been completed by nursing staff after Tylenol 650mg had been administered for a pain level of eight out of 10.

iii. An interview was conducted on 7/16/25 at 1:57 p.m. with the ED director (Director) #6. Director #6 stated the requirement varied for nursing assessments and rounding on patients based on patient acuity. Director #6 stated it was important to assess patients in the ED because medical conditions and acuity levels could change. Director #6 stated all ED patients should have received a primary assessment by nursing staff, and a focused assessment based on their chief complaint. Director #6 stated nurses should have re-assessed patients after interventions, or with any patient changes in patients' conditions. Director #6 stated nurses would have identified changes in patient condition by being present in the patient's room, talking with patients, administering medication, and assessing vital signs.

Director #6 also stated pain levels should have been reassessed after pain medications were administered in the ED. Director #6 stated abnormal vital signs should have been reassessed more frequently. Director #6 stated it was important to reassess patients with neurological complaints because if a neurological condition, such as a stroke, was not quickly treated, irreversible damage to brain tissue could have occurred. Director #6 stated assessment was the only way to determine if a patient's condition had worsened.

Additionally, Director #6 stated the risk of not monitoring a patient who had received a rapid blood transfusion could have been a blood transfusion reaction. Director #6 stated it was important for nurses to communicate abnormal blood pressure readings, including low blood pressure, to providers. Director #6 stated it was concerning if patients had gaps of several hours in vital signs monitoring or assessments. Director #6 stated patients were at risk for deterioration if they were not assessed, reassessed, or if their vitals signs were not monitored.

2. The facility failed to ensure alterations to patients' skin integrity were appropriately assessed and documented.

A. Document Review

i. A review of Patient #1's medical record revealed Patient #1 presented to the hospital on 4/15/25 after an unwitnessed fall at home which resulted in left rib cage bruising and tenderness, pain with passive movement of the left arm, and shallow breathing. The patient was diagnosed with multiple rib fractures and a hemothorax (collection of blood in the space between the chest wall and the lung).

Patient #1 arrived to the inpatient unit on 4/15/25 at 4:24 p.m. On 4/15/25 at 4:30 p.m., Patient #1's initial Braden Scale score was 16. The initial skin assessment, documented on 4/15/25 at 8:30 p.m., revealed the patient's skin to be intact. Subsequent nursing assessments revealed Patient #1 had bruising to the left posterior hip. However, the record failed to reveal documentation of a wound care consult or images of the wound uploaded into the patient's chart.

This was in contrast to the HAPI Prevention, Assessment and Documentation policy which read, nurses on all inpatient units were to document photographs of pressure injuries or wounds upon discovery. A Braden Scale score of less than 18 indicated a risk for pressure injury development, and the RN should have requested a wound care consult.

ii. A review of Patient #6's medical record revealed Patient #6 presented to the facility on 6/8/25 with necrotizing fasciitis (a bacterial infection that rapidly destroys tissue under the skin) which required emergent surgery. The patient's hospitalization was complicated by duodenal perforations (a life-threatening condition where there are holes or tears in the wall of part of the small intestine), which required multiple surgeries, and an acute kidney injury requiring continuous renal replacement therapy (continuous dialysis treatment that helps filter waste and excess fluid from the bloodstream).

Patient #6 was transferred to the ICU on 6/13/25 at 1:13 a.m. The initial skin assessment, documented on 6/13/25 at 3:53 a.m., revealed disruptions in skin integrity to include surgical incisions to the abdomen and right lower extremity, and bruising to an unspecified location; no pressure injury was identified at that time. Five days later, on 6/18/25 at 11:28 a.m., a skin assessment revealed the presence of a pressure injury. Documentation thereafter revealed the wound bed to be unapproximated (the edges of the wound were separated), until 6/22/25 at 4:00 p.m., at which point documentation revealed the wound bed to be pink and friable. This was in contrast to the wound care RN's assessment on 6/25/25 at 2:30 p.m. which revealed the wound bed to be black and purple with areas of necrosis (dead or dying tissue).

The record failed to reveal images of the pressure injury uploaded into the patient's chart by the primary nurses until the wound care RN's assessment, seven days after the wound was discovered. The record also failed to reveal consults for wound care regarding the newly acquired pressure injury. This was in contrast to the HAPI Prevention, Assessment and Documentation policy which read, nurses on all inpatient units were supposed to document photographs of pressure injuries upon discovery, weekly, and with any change in patient or wound status.

Additionally, the medical record review revealed lapses between skin assessments, which included a 12 hour gap between assessments from 6/24/25 at 8:00 p.m. until 6/25/25 at 8:00 a.m. An eight hour gap was identified between assessments from 6/20/25 at 12:00 p.m. until 8:00 p.m. Additionally, a seven hour gap was identified between assessments from 6/14/25 at 4:00 p.m. until 11:00 p.m. This was in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, focused reassessments were to be performed by ICU nursing staff every four hours.

Furthermore, skin assessments in Patient #6's medical record lacked key characteristics including skin color, temperature, texture/turgor, and integrity. At least two out of six characteristics were absent from skin assessments on 6/15/25 at 8:00 p.m., 6/16/25 at 12:00 a.m. and 4:00 a.m., and 6/19/25 at 8:00 a.m., 12:00 p.m. and 4:00 p.m. This was in contrast to the HAPI Prevention, Assessment and Documentation policy which read, integumentary assessments should have included documentation of skin color, temperature, texture/turgor and integrity, moisture, and edema.

B. Interviews

i. On 7/14/25 at 9:35 a.m., an interview was conducted with ICU RN #1. ICU RN #1 stated two nurses performed an assessment of patients' skin upon admission to the ICU. If skin breakdown was noted, the RN should take a photograph of the breakdown and consult the wound care nurse for further evaluation and care recommendations. RN #1 also stated skin assessments should be performed every four hours. This was in contrast to the medical record review for Patient #6, which failed to reveal skin assessments performed every four hours.

ii. On 7/14/25 at 10:32 a.m., an interview was conducted with the medical/surgical clinical coordinator (Clinical Coordinator) #2. Clinical Coordinator #2 stated RNs should obtain a photograph of wounds upon discovery and consult the wound care team. Clinical Coordinator #2 also stated a bruise may be differentiated from a deep tissue injury or pressure injury based on whether or not it was near a bony prominence or pressure point. If there was any uncertainty regarding whether or not discoloration was a bruise or injury, then the RN should have uploaded a photograph into the medical record and consulted wound care.

iii. On 7/15/25 at 3:11 p.m., an interview was conducted with RN #3. RN #3 stated the primary RN should have consulted wound care any time there was skin discoloration noted on assessment in order to distinguish between pressure injury, deep tissue injury, and bruising.

iv. On 7/16/25 at 3:11 p.m., an interview was conducted with wound care RN #4. RN #4 stated the primary RN should take a photograph of patients' wounds upon discovery and consult the wound care nurse for further evaluation.

These interviews were in contrast to the medical record review, which failed to reveal images of Patient #1's wound at any point during their hospitalization. These interviews were also in contrast to the medical record review, which failed to reveal images of Patient #6's wound captured by the primary RNs in the seven days between initial discovery and assessment by the wound care RN. Furthermore, these interviews were in contrast to the medical record reviews, which failed to reveal consultation to the wound care RN upon discovery of the wounds for both Patient #1 and Patient #6.

3. The facility failed to ensure a patient who was at-risk for pressure injuries received interventions to prevent skin breakdown.

a. Medical record review revealed Patient #6's Braden Scale score upon arrival to the ICU on 6/13/25 at 1:31 a.m. was 12 (high risk). Patient #6's mobility subscale score was two (very limited mobility); their mobility subscale score ranged from one (completely immobile) to two for the duration of their hospitalization.

Patient #6's pressure injury was discovered on 6/18/25 at 11:28 a.m. Howev