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Based on medical record review, staff interview, and review of the intake tier system, the facility failed to ensure a registered nurse (RN) supervised and evaluated patients (A395).

Based on medical record review, staff interview, and review of the intake tier system, the facility failed to ensure a registered nurse (RN) supervised and evaluated one of one patients reviewed for wound care (Patient #1). The total sample was ten records. The active census was 90.

Findings include:

Review of the policy and procedure titled, "Skin Assessment and Integrity," reviewed/revised 03/23, revealed to notify the practitioner of need for wound consult, follow practitioner's recommendations for treatment, the RN will reassess skin and any wounds condition daily on the nursing reassessment form, utilizing a progress note or alternative document for additional information. Impaired skin integrity is to be addressed on the patient's treatment plan, as either an active medical problem or a deferred problem if it will not be treated during the hospitalization.

Review of the medical record for Patient #1 revealed the patient had a history of confusion and who had three mechanical falls within three days in December 2022. The patient was found to be septic at that time requiring his left great toe to be amputated. The patient was then discharged from the hospital to a skilled nursing facility on 01/09/23 for rehabilitation and intravenous antibiotic therapy. The patient became increasingly confused at the skilled nursing facility and was attempting to climb out of windows, making excessive late night calls to his daughter with abnormal/unusual behaviors that included cursing, stating he was put in a dark room alone, and that staff were playing a joke on him and he felt the daughter was involved. During the visit the patient exhibited paranoia with a bizarre delusional thought process and was involuntarily transferred to the inpatient psychiatric facility on 01/28/23 at 3:39 AM with an estimated length of stay of five to seven days.

Review of the initial nursing assessment on 01/28/23 at 3:50 AM revealed the skin was intact however the skin diagram and documentation noted a stage two wound to the coccyx area. The medical record did include pictures that were obtained of the wound(s) to the buttocks and perineal area on 01/28/23 which appeared to show the patient had multiple open areas.

Review of the initial psychiatric evaluation on 01/28/23 at 2:15 PM revealed the patient appeared to have delirium and had multiple medical issues including a stage three to four decubitus ulcer on the coccyx that was tunneling. There was a large ecchymotic area from the right buttocks over the left buttocks around the inner thighs to the perineum. It was described as deep purple and reddish and part of the coccyx appeared to be infected. The patient was initially sent to the emergency room as it was believed his behaviors were psychiatric in nature, although does not appear the patient has a previous psychiatric history. Per the psychiatric documentation it appeared the patient had multiple medical issues and likely delirium caused by the multiple medical issues. The medical team diagnosed him with tunneling stage three decubitus ulcer to the coccyx and was unsure of how deep the tunneling goes. The area is red and purple to the surrounding tissue with small open areas that are yellow with serosanguineous fluid noted on the dressing. The patient should be watched closely for any signs of sepsis and will need to be send out for medical stability if identified.

Review of the history and physical dated 01/28/23 at 3:14 PM revealed the patient was wearing a diaper with a history of incontinence. The skin assessment noted the patient had a tunneling stage three decubitus ulcer to the coccyx and it was unclear how deep the tunneling goes. Excoriation was noted to surrounding tissue along with multiple small open areas that were present. A small amount of serosanguineous fluid was noted on the dressing from these open areas. Excoriation is also present on the patient's bilateral buttocks and perineal area. The plan included to pack the tunneling coccyx wound with iodoform gauze (antimicrobial gauze) strips once a day and cover open areas with mepilex border (absorbent foam dressing) and change as needed.

Review of a coccyx wound follow up medical progress note dated 02/02/23 at 1:15 PM revealed that after consultation with nursing staff it was reported they were unable to pack what originally appeared to be a tunneling wound to the coccyx. A stage three pressure ulcer with surrounding stage two ulcers still remained with multiple open areas noted to coccyx and the bilateral buttocks. There was a small amount of bright red blood noted from one of the wounds on the left lower buttock.

Review of the medical progress note dated 02/07/23 (no time) revealed the skin assessment showed a stage three pressure ulcer with numerous open areas to the coccyx and bilateral buttocks. There did appear to be an area of eschar (dead tissue) on the left side of the ulcer. There was no tunneling and a scant amount of active drainage to the left lower part of the ulcer that was seroanguinous, but after it was wiped away was no longer oozing. The mepilex that was removed prior to exam had a scant amount of serosanguineous drainage on it. There was excoriation present on the periarea as well as bilateral buttocks, the tissue surrounding this area is purplish in color.

Further review revealed the patient was not seen again by the medical team until 02/14/23 (no time). The progress note revealed the medical team had been trying to manage the stage three pressure ulcer to the coccyx that the patient arrived with. It did not appear the wound was healing and was slightly getting worse. The patient had no border dressing in place and stated it falls off frequently related to incontinence. The patient denied ever seeing a wound care specialist and denied pain and/or any feeling to the area. The skin assessment noted a stage three pressure ulcer to the coccyx region with a moderate amount of yellow and white tissue present that did not appear to be tunneling. There was a foul odor and redness noted to the surrounding area and edges are well-demarcated. It was approximately eight to ten inches in length just for this particular wound. There was a similar area noted superior to this and was approximately four to six inches in length. There was a scant amount of oozing of serosanguineous drainage throughout. There was a significant amount of excoriation that was black, light pink, and blue in color to the surrounding area of this wound on the buttocks down to the perineal area. An order was placed on 02/14/23 at 10:00 AM to transfer the patient to a local hospital for a wound care consultation as the wound was not healing and was worsening. The patient was transferred and did not return to the inpatient psychiatric facility.

Review of the Ohio Hospital for Psychiatry, Intake Tier System revealed the capabilities of the facility to manage medical conditions related to each body system. Tier 4 includes active stage three and four wounds. This tier further states patients in this category have been determined by the medical staff to be outside the capability to provide care for the facility.

This finding was confirmed in an interview with Staff A and C on 04/03/23 at 2:52 PM.

Review of the initial nursing treatment plan dated 01/28/23 at 4:31 AM revealed it was documented that the patient's skin was a problem area however it did not include any interventions. Further review revealed the nursing treatment plan was implemented on 01/28/23 at 4:30 PM by a certified nurse practitioner which noted a stage three tunneling decubitus ulcer with no interventions listed. The impaired skin integrity treatment plan was not implemented until 02/02/23.

This finding was confirmed with Staff L in an interview on 04/04/23 at 10:19 AM who reported the expectation was that treatment plans were completed timely.

Review of the twelve hour nursing shift documentation from admission through discharge revealed no evidence of wound characteristics such as length, width, depth, color, odor, or drainage amount. The following was identified on the nursing notes: On 01/28/23 no PM skin assessment was completed; 01/29/23 the PM skin assessment noted no issues; 01/30/23 the AM skin assessment lacked documentation of the coccyx wound and the PM skin assessment noted no issues; 01/31/23 no AM skin assessment and the PM skin assessment noted no issues; 02/01/23 the PM skin assessment noted no issues; 02/02/23 the PM skin assessment noted no issues; 02/03/23 the PM skin assessment noted no issues; 02/04/23 the PM skin assessment noted no issues; 02/05/23 the PM skin assessment noted no issues; 02/08/23 the PM skin assessment noted no issues; 02/09/22 there was no AM or PM shift assessments noted; 02/10/23 the AM and PM skin assessments noted no issues; and on 02/11/23 the PM skin assessment noted no issues.

These findings were confirmed with Staff L in an interview on 04/04/23 at 10:23 AM who reported nursing shift assessments should be completed accurately.

This deficiency represents non-compliance investigated under Substantial Allegation OH00140512.