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Based on policy review, medical record review and interview, nursing staff did not monitor and/or implement measures to prevent patient skin breakdown and did not notify the provider of worsening skin integrity for three of three patients (Patient # 1, #14, and #16). Failure to monitor skin integrity has the potential for an adverse patient event.

Findings include:

Review on 02/21/24 of policy "Pressure Injury Prevention and Management" last revised 03/20/23 revealed an evaluation of skin integrity, from head to toe, anterior and posterior surfaces, skin temperature, edema, change in tissue consistency in relation to surrounding tissue and the presence of pressure injuries would be completed and documented on upon admission and discharge, once every shift and with any significant change in patient condition. Without any prevention an at-risk patient can develop skin breakdown within one to two hours. Prevention methods include support surface that meets the patient's needs, elevation of heels completely off surfaces, turning and reposition at least every two hours in bed, use the 30 degree tilted side-lying position (alternating from right side to back to left side) or the prone position, reposition every hour when a patient is in a chair, reposition tubes throughout the shift, manage friction, shear, and excessive moisture, provide nutritional support, and apply prophylactic dressings to bony prominences. Continue to turn and reposition the individual regardless of the support surface in use. Assess a pressure injury when changing the dressing for wound bed type, amount and consistency of exudate, odor, tunneling/undermining, surrounding skin and pain. Measure length, width, depth, tunnels (passageways formed underneath the surface of the skin) or undermining (erosion occurring underneath the visible wound resulting in more extensive damage beneath the skin surface) weekly and document in the medical record. Send a wound enterostomal therapy nurse referral if a pressure injury is present for staging and recommendations. The provider must prescribe all wound care for stage three and stage four pressure injuries, unstageable and suspected deep tissue injuries or wounds that require packing. Report the following situations to the provider: the presence of any and/or additional pressure injury incidence, any injury that has deteriorated in appearance, stage, or presence of necrotic (dead) tissue, signs, and symptoms of a wound or systemic infection, or poor response to the current treatment following two weeks of consistent therapy.

Review of Patient #1 medical record from 08/25/23 thru 10/04/23 revealed the following:
-On 08/25/23 at 05:35 PM, the nurse's initial admission skin assessment stated that Patient #1 did not have any pressure ulcers on admission. At 05:37 PM, the physician's history and physical stated that Patient #1's skin had an occipital chronic non-healing wound and an open left frontal cranial wound.
-From 08/26/23 through 08/27/23, daily (every 12 hours) nursing documentation revealed no indication that Patient #1 had pressure ulcers.
-On 08/28/23 at 02:08 PM, the registered nurse requested a wound and skin referral for a sacral pressure ulcer (a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) however, there is no evidence that the nurse communicated to the provider regarding the sacral pressure ulcer or for treatment orders.
-From 08/29/23 to 09/01/23, daily (every 12 hours) nursing documentation noted the sacral wound was present. There is no evidence that the nurse communicated to the provider regarding the pressure ulcer. The daily provider notes lacked documentation of a sacral pressure ulcer.
-On 09/02/23 at 05:47 PM, a wound care consult was conducted. Patient #1 had a right lower buttock deep tissue injury that was not present on admission. Venelex ointment (an ointment that is used on the skin to cover wounds) was recommended three times a day for skin protection and to leave the wound open to air. The provider was notified, and the care recommendations were approved. The consult was completed. The wound was to be managed by the primary team on an ongoing basis.
-From 09/03/23 to 09/12/23, the nursing shift documentation noted the sacral ulcer as a deep tissue injury. There was no documented evidence that the ulcer had evolved to an unstageable ulcer.
-On 09/12/23 at 05:01 PM, a wound care consult was conducted. A sacral ulcer was not present on admission had evolved to an unstageable ulcer. The primary team was notified, and the wound was to be managed by the primary team on an ongoing basis.
-From 08/25/23 to 10/03/23 the nurse's documentation every shift (every 12 hours) included skin assessments. Patient #1 sacrum was intact until 08/28/23. Patient #1 was repositioned every two hours and was on an alternating air mattress with pillows to assist with body position.

Review of Patient #14 medical record from 01/13/24 thru 02/02/24 revealed the following:
-On 1/13/24 at 10:46 AM, the nurse's initial admission skin assessment stated that Patient #14's skin was pink, warm, and dry, and intact. At 12:11 PM, the physician's history and physical stated that Patient #14's skin was intact, warm, and dry, and no rashes.
-From 01/13/24-01/24/24, the nursing shift documentation noted Patient #14's skin was pink, warm, dry, and intact.
-On 01/25/24 at 09:51 AM, the registered nurse requested a wound and skin referral for a sacral pressure ulcer (a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis). The nurse documentation noted the pressure ulcer however, there is no evidence that the nurse communicated to the provider regarding the sacral pressure ulcer or for treatment orders.
-From 01/25/24 to 01/26/25 the nursing documentation noted that the sacral wound was present. There was no evidence that the nurse notified the provider of the pressure ulcer. The daily provider notes lacked documentation of a sacral pressure ulcer.
-On 01/27/24 at 11:42 AM, a wound care consult was conducted. Patient #14 had one sacral unstageable pressure ulcer and a stage one sacral pressure ulcer that were not present on admission. Recommendations for treatment included to cleanse the sacrum with Vashe (wound cleanser), apply Calmoseptine lotion (protects and heals skin irritation) twice a day as needed, and place an abdominal pad (thick gauze pad used to treat large wounds or wounds with drainage) for added comfort and protection without tape. Recommendations to nursing were to turn and position Patient #14 every two hours and as needed, and to offload pressure to sacrum with wedges and pillows. The wound care consult was completed. The wounds were to be managed by the primary team on an ongoing basis. Reconsult the wound team as needed. The primary team and nurse were notified of the recommendations. The wound recommendation orders were co-signed by the provider.
-From 01/25/24 to 02/02/24, the daily provider notes state skin is intact. There was no evidence that the provider was aware of the sacral pressure injury.
-From 01/13/24 to 02/02/24 the nurse's documentation every shift (every 12 hours) included skin assessments. Patient #14's skin was intact until 01/25/24. After this the nurses documented treatments completed to the ulcers in their shift assessments. Patient #14 was repositioned every two hours and was on an alternating air mattress.

Review of Patient #16 medical record from 12/18/23 thru 02/21/24 revealed the following:
-On 12/18/23 at 07:37 PM, the provider's history and physical stated that Patient #16's skin was not intact. Patient #16 had wounds on both hands and multiple healing ulcers on both lower extremities.
-On 12/18/23 at 09:56 PM, the provider ordered a wound and skin referral due to wounds on both hands.
-On 12/19/24 at 12:00 PM, the nurse's initial admission skin assessment stated that Patient #16's had wounds on both hands.
-On 12/20/23 at 04:18 PM, the nurse requested a wound and skin referral due to wounds on both hands.
-From 12/20/23-01/01/24, the nursing shift documentation noted non-pressure abscesses (swollen area within the body tissue containing an accumulation of pus) and all other skin was intact.
-On 12/23/23 at 09:52 AM, wound care consult was conducted. Recommendations were provided for treatment of hand wounds. Patient #16 was noted to have intact skin on heels and sacrum and no redness.
-On 01/02/23 the nurse documented the redness to the sacrum and a foam protective dressing was applied. There was no evidence that the nurse notified the provider of the pressure ulcer. The provider notes lacked documentation of a sacral pressure ulcer.
-On 01/03/23 the nurse documented a deep tissue injury on the sacrum and foam protective dressing intact that the sacral wound was present. There was no evidence that the nurse notified the provider of the pressure ulcer. The provider notes lacked documentation of a sacral pressure ulcer.
-From 01/04/23 to 01/10/23 the nursing shift documentation noted a deep tissue injury on the sacrum with a foam protective dressing intact. There was no evidence that the nurse notified the provider of the pressure ulcer. The provider notes lacked documentation of a sacral pressure ulcer.
-On 01/06/24 at 11:30 PM, the registered nurse requested a wound and skin referral due to a deep tissue injury on the sacrum.
-On 01/10/24 at 06:51 PM, wound care consult conducted. There was an unstageable pressure ulcer on the sacrum that was not present on admission. Recommendations for treatment were to clean with Vashe (cleansing solution) and apply a nickel thick layer of Santyl (ointment that removes dead tissue from wounds) to scattered tan slough (dead tissue). The ulcer was to be covered with Vashe (cleansing solution) moistened gauze and covered with an abdominal pad twice a day and as needed for drainage. Bilateral heels were intact with boggy (abnormal texture of tissue) blanchable pink. While in bed heel protection boots were to be applied. The wound care consult was completed. The wound was to be managed by the primary team on an ongoing basis. Reconsult the wound team as needed. The recommendations were communicated to the nurse and the primary team. The wound recommendation orders were co-signed by the provider.
-From 01/10/24 to 01/19/24 the nursing shift documentation noted the sacral ulcer. The documentation lacked evidence of the pressure injury to Patient #16's heels.
-On 01/17/23 at 06:00 PM, the provider requested a wound and skin referral due to pressure ulcers.
-On 01/19/24 at 03:29 PM, the wound care consult was conducted. Two heel pressure ulcers were noted that were not present on admission. The left heel had a stage two (a shallow open ulcer with a red or pink wound bed) pressure ulcer, and the right heel had a stage one (pressure-related alteration of skin with non-blanchable redness over a bony area) pressure ulcer. No treatment plan or interventions were documented. No documentation related to the sacral pressure ulcers was noted. The wound care consult was complete. The wound was to be managed by the primary team.
-From 01/19/24 at 08:00 PM, the nursing shift documentation noted the bilateral heel ulcers for the first time.
-From 01/06/23 to 01/20/24, the daily provider notes did not document the sacral pressure injury or heel pressure injuries.
- From 12/19/23 to 02/21/24 the nurse's documentation every shift (every 12 hours) included skin assessments. Nurses documented treatments completed to the wounds and ulcers in their shift assessments. Patient #16 was repositioned every two hours and was on an alternating air mattress. Pillows and foam wedges were used to keep Patient #16 in desired body position. Patient #16's heels were floated off the bed.

Interview on 02/21/24 at 04:35 PM with Staff (W), Wound Registered Nurse, revealed the wound care team follow the care of patients that have a wound vacuum in place. The wound care team would not follow the care of a patient that had an unstageable wound. During a consult, the wound care team would recommend treatments for the care of the wound to the provider. The wound care team would then sign off and have the primary team follow the care of the wound. A 0.7 cm by 1 cm by 0 cm wound may be able to heal within a month of time. When providing a wound consult, if a nutrition consult was not ordered Staff (W) would request the consult.

Interview on 02/22/24 at 11:56 AM with Staff (A), Chief Nursing Officer and Staff (PP), Director of Regulatory Affairs, confirmed these findings and revealed there is no formal policy for a wound nurse consult. The expectation is that the wound nurse would complete the wound consult within 24 hours.

Interview on 02/22/24 at 12:00 PM with Staff (B), Chief Quality and Patient Safety, confirmed these findings and revealed the wound nurse consult is to provide recommendations to the primary provider. The wound nurse would then turn care of the patient over to the primary provider to follow through on the care. The wound nurse is not expected to follow up with care on a wound. When another wound consult is ordered, the wound nurse would provide another consult. The wound nurse follows the care of patients that have wound vacs in place. There is not a policy for a wound nurse consult.

Based on observations, policy review, medical record review, document review, and interviews, the facility failed to adhere to facility policies.

1. The facility failed to implement policies to ensure expired supplies are not utilized in the ED.
2. The facility failed to make an incident report for the transfer of Patient #2 to the unintended facility.
3. The facility failed to document the appropriate receiving facility on the transfer document.

Findings #1:

Review of the policy "Non-Conforming Product/ Services Document Procedure," last revised 08/08/12 indicated that all hospital personnel are responsible for identifying nonconforming services and notifying management of nonconformance. Examples of nonconforming product is out of date shelf-life materials.

Observations on 02/21/24 at 10:14 AM in the emergency department supply room revealed four (4) 1000 ml bags of 5% Dextrose and 0.45% Sodium Chloride Injection solution with an expiration date of January 2024.

Interview on 02/21/24 at 10:14 AM with Staff (H), Emergency Department Nurse Manager, verified the findings.

Findings #2:

Review of the policy "Corporate Event Reporting," last revised 12/22/99 indicated that when an event occurs that did result or could have resulted in an adverse development in a patient's condition, whether an inpatient or outpatient, the web-based event reporting system (STARS) must be accessed, and a report entered.

Review of the Buffalo General Hospital medical record for Patient #2 revealed the following:
-On 8/18/23 at 08:12 PM Patient #2 presented to the emergency department for status post left ventricular assistive device (pumps blood from the lower left heart chamber) site with oozing. At 08:16 PM, Patient #2 was triaged. At 09:15 PM a medical screening examination was conducted and concluded that review of Patient' #2's cat scan (image of body tissues) chest noting asymmetric enlargement with large acute intramuscular hematoma, Case discussed with left ventricular assistive device (pumps blood from the lower left heart chamber) team and emergency room physician at Rochester General Dr. Higgins excepts transfer of Patient #2. Patient #2will be transferred to Rochester General
-On 08/19/23 at 05:39 AM, the acute transfer form indicated Patient #2 was stable and was to be transferred due to an "infection," and transferred via ambulance for a higher level of care to the left ventricular device (pumps blood from the lower left heart chamber) team treating Patient #2. A physician from Rochester General Hospital was listed as the accepting provider. Report between the sending and receiving registered nurses was documented listing a phone number for the Rochester General Hospital triage registered nurse. Patient #2 consented to the transfer.
-On 08/19/23 at 10:38 AM, Staff (DD), Registered Nurse was given report by the night registered nurse that the transfer of Patient #2 to "Rochester Strong" was set up. The paperwork indicated that Patient #2 was going to Strong Memorial Hospital. At 07:50 AM, emergency medical services arrived (at Buffalo General Hospital) to transport Patient #2. Emergency medical services arrived at Strong Memorial Hospital and noted that the transfer was supposed to go to Rochester General Hospital instead. The emergency medical services supervisor came back to the hospital to obtain a new physician certification statement of medical necessity form for the ambulance transportation to Rochester General Hospital. Staff (DD), spoke to "Cindy" at Rochester General Hospital when Patient #2 arrived. The charge nurse was made aware of the situation. (Patient #2 was initially brought to Strong Memorial Hospital instead of Rochester General Hospital as ordered).
-On 08/19/23 (no time), the "Physician Certification Statement of Medical Necessity" form for ambulance transportation revealed the transfer destination as "Rochester- Strong" for left ventricular assistive device services not available at the hospital. Patient #2 required cardiac and hemodynamic monitoring during the transport. The form was signed by Staff (GG), Physician. (This form was documented for the initial transfer and indicates "Rochester-Strong" as the transfer destination. The intended destination was Rochester General Hospital. Emergency medical services brought Patient #2 to Strong Memorial Hospital instead of Rochester General Hospital).
-On 08/19/23 (no time), the "Physician Certification Statement of Medical Necessity" form for ambulance transportation revealed the transfer destination as Rochester General Hospital for left ventricular assistive device services not available at the facility. Patient #2 required cardiac and hemodynamic monitoring during the transport. The form was signed by Staff (DD), Registered Nurse. (This form was documented to change the destination from Strong Memorial Hospital to the intended Rochester General Hospital after Patient #2 was initially taken to Strong Memorial Hospital)

Review of the incident report log from August 2023 to January 2024 revealed no incident reports pertaining to Patient #2.

Interview on 02/22/24 at 09:59 AM with Staff (DD), Registered Nurse revealed the paperwork for Patient #2 was filled out and ready. Staff (DD) called Rochester General Hospital to confirm Patient #2 had arrived but was informed that emergency medical services brought Patient #2 to Strong Memorial Hospital instead. Patient #2 refused to get out of the ambulance indicating that they were being treated at Rochester General Hospital for the left ventricular assistive device. Patient #2 was taken to Rochester General Hospital. The emergency medical services supervisor was notified, and a new transfer form was completed by Buffalo General Hospital staff and handed to the supervisor. Staff (DD) indicated that this appeared to be a documentation issue, as all reports were with Rochester General Hospital, where Patient #2 was accepted.

Interview on 02/22/24 at 09:29 AM with Staff (B), Chief Quality & Patient Safety Officer verified these findings and revealed that after the discovery of Patient #2 being sent to Strong Memorial Hospital versus the intended facility of Rochester Memorial Hospital, someone should have reviewed it. No investigation or incident report was completed.

Findings #3:

Review of the policy "Patient Transfer and Medical Screening "last revised 04/07/01 indicated that an appropriate transfer must be carried out in an appropriate manner as follows: the transferring hospital must provide treatment to the individual within its capacity which minimizes the risks to the individual's health; the transferring hospital should obtain agreement from a receiving facility that it has available space and qualified personnel to treat the individual and that it will accept the transfer and provide appropriate treatment; all medical records related to the emergency condition with which the individual has presented must be sent with the individual if available at the time of transfer. The written document must indicate the individual has been informed of risks and benefits of the transfer and state the reason for the individual's refusal.

Review of the Buffalo General Hospital medical record for Patient #2 revealed the following:
-On 08/18/23 at 08:12 PM, Patient #2 presented to the emergency department for status post left ventricular assistive device (pumps blood from the lower left heart chamber) site with oozing. At 08:16 PM, Patient #2 was triaged. At 09:15 PM a medical screening examination was conducted and concluded that review of Patient' #2's cat scan (image of body tissues) chest noting asymmetric enlargement with large acute intramuscular hematoma, Case discussed with left ventricular assistive device (pumps blood from the lower left heart chamber) team and emergency room physician at Rochester General Dr. Higgins excepts transfer of Patient #2. Patient #2 will be transferred to Rochester General
-On 08/19/23 at 05:39 AM, the acute transfer form indicated Patient #2 was stable and was to be transferred due to an "infection," via ambulance for a higher level of care to the left ventricular device (pumps blood from the lower left heart chamber) team treating Patient #2. A physician from Rochester General Hospital was listed as the accepting provider. Report between the sending and receiving registered nurses was documented listing a phone number for the Rochester General Hospital triage registered nurse. Patient #2 consented to the transfer.
-On 08/19/23 (no time), the "Physician Certification Statement of Medical Necessity" form for ambulance transportation revealed the transfer destination as "Rochester- Strong" for left ventricular assistive device services not available at the hospital. Patient #2 required cardiac and hemodynamic monitoring during the transport. (This form was documented for the initial transfer and indicates "Rochester-Strong" as the transfer destination. The intended destination was Rochester General Hospital. Emergency medical services brought Patient #2 to Strong Memorial Hospital instead of Rochester General Hospital).
-On 08/19/23 at 10:38 AM, Staff (DD), Registered Nurse was given report by the night registered nurse that the transfer of Patient #2 to "Rochester Strong" was set up. The paperwork indicated that Patient #2 was going to Strong Memorial Hospital. At 07:50 AM, emergency medical services arrived (at Buffalo General Hospital) to transport Patient #2. Emergency medical services arrived at Strong Memorial Hospital and noted that the transfer was supposed to go to Rochester General Hospital instead. The emergency medical services supervisor came back to the hospital to obtain a new physician certification statement of medical necessity form for the ambulance transportation to Rochester General Hospital. Staff (DD), spoke to "Cindy" at Rochester General Hospital when Patient #2 arrived. The charge nurse was made aware of the situation. (Patient #2 was initially brought to Strong Memorial Hospital instead of Rochester General Hospital as ordered).

Interview on 02/22/24 at 09:59 AM with Staff (DD), Registered Nurse revealed the paperwork for Patient #2 was filled out and ready. Staff (DD) called Rochester General Hospital to confirm Patient #2 had arrived but was informed that emergency medical services brought Patient #2 to Strong Memorial Hospital instead. Patient #2 refused to get out of the ambulance at Strong Memorial Hospital indicating that they were being treated at Rochester General Hospital for the left ventricular assistive device. Patient #2 was taken to Rochester General Hospital.

Interview on 02/21/24 at 10:14 AM with Staff (H), Emergency Department Nurse Manager, verified the findings.