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Based on medical record review, staff interview, and policy review, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient (A395).

Based on medical record review, staff interview, and policy review, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for two of ten patients reveiewed (Patient #2 and #3). The active census was 274.

Findings include:

Review of the hospital policy titled, Skin Assessment Wound and Pressure Injury, last reviewed on 08/23/21 revealed the nurse is responsible for documenting and reporting skin integrity. The registered nurse is to complete a Head-To-Toe assessment every shift. A wound care consult should be put in for wounds staged at III, IV, unstageable or wounds that progress to an advanced stage. A four eye assessment is to be completed within four hours of admission. Wound interventions included notification of the doctor. Further review of the policy revealed, "if the Braden scale is 18 or less and the nurse feels the patient is at risk for developing pressure injuries, activate the careplan, "Pressure Injury Actual or Risk of."

1. Review of the medical record for Patient #2 revealed the patient arrived to the emergency department on 02/20/22 at 3:08 AM from a skilled nursing facility (SNF) due to a worsening sacral wound and altered mental status changes. Review of the emergency department physician documentation revealed a moderate sized deep sacral decubitus ulcer with evidence of purulent fluid overlying the subcutaneous tissue. The physician also noted the patient had what appeared to be a recently drained abscess to the mid thoracic back with packing still in place. There was concern for sepsis and intravenous Zosyn and Vancomycin antibiotics were prescribed and administered. The emergency room/admitting diagnoses included an altered mental status and a stage four pressure injury to the sacral region. On 02/20/22 at 8:50 AM the physician ordered wound care, infectious disease, and surgical consults for further evaluation and management of the sacral decubitus ulcer.

Review of the initial wound care consult completed on 02/21/22 at 2:29 PM noted a stage four (a deep wound that reaches the muscles, ligaments, or even bone) sacral wound that measured 5 centimeters (cm) x 5.1cm x 4cm with tan drainage and a foul odor. The medial back wound measured 0.5cm x 0.3cm x 0.5cm with tan purulent drainage and was reported as a cyst that required incision and drainage, and a stage three (full thickness of the skin and may extend into the subcutaneous tissue layer) left buttocks wound was identified measuring 4.9cm x 3.5cm x 0.2 cm depth with serosanguineous drainage. Per the wound care assessment the patient was to be turned and repositioned every two hours to prevent further skin breakdown. Per the physician documentation a bedside surgical debridement was completed on 02/21/22 at 4:12 PM with sharp excisional debridement of the skin and subcutaneous tissue measuring 5cm x 10cm.

The nursing flowsheets lacked evidence the patient was turned and repositioned every two hours on 02/21/22 and 02/22/22 as ordered. On 02/23/22 a pressure alternating mattress was provided to the patient to relieve pressure areas. Per Staff F the specialty mattress was set to alternate pressures every ten minutes and to provide pressure redistribution to prevent further skin breakdown.

Staff F confirmed in an interview on 04/20/22 at 9:00 AM the patient was not turned and repositioned every two hours on 02/21/22 and 02/22/22 and was not provided the specialty mattress until 02/23/22.

Review of the intravenous lines included a left antecubital placed on 02/20/22 at 3:34 AM, left posterior forearm placed on 02/21/22 at 10:21 PM, and a left anterior forearm placed on 02/23/22 at 7:29 PM. The intravenous lines were all noted to have been discontinued on 02/24/22 with no time documented. Review of the nursing flowsheets revealed the nurses continued to document on the intravenous lines on 02/25/22, 02/26/22, and 02/27/22.

An interview was conducted with Staff B on 04/20/22 at 11:32 AM who stated per standard practice the expectation was the nurse documented the time of removal of a peripheral intravenous line.

Further review of the medical record revealed the patient arrived back to the emergency department on 04/03/22 at 12:19 PM due to blood tinged urine in the foley catheter. The patient was admitted on 04/03/22 at 6:36 PM with continued diagnoses of stage three and four pressure injuries to the right and left sacrum region. Review of the nursing flowsheets revealed on 04/13/22 at 4:32 AM the nurse noted deep tissue injures to the bilateral heels.

An interview was conducted with Staff J on 04/20/22 at 10:29 AM who reported being unable to identify any documentation of a wound consult and/or wound assessment for the skin integrity of the bilateral heels.


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2. Review of the medical record for Patient #3 revealed the patient arrived to the emergency department on 02/13/22 at 9:24 AM with altered mental status, hypoglycemia and was diagnosed with acute respiratory failure and admitted to the intensive care unit. On 02/14/22 at 12:14 AM the initial skin assessment was completed and there were no wounds or skin issues noted. Review of the flow sheets revealed on 02/15/22 at 4:00 PM the nurse noted a small, unblanchable breakdown to the left buttock. On 02/17/22 at 8:00 AM the left buttock wound was noted as coccyx breakdown. On 02/20/22 at 8:00 AM the nurse noted breakdown to the patient's bilateral buttocks. There was no documentation any treatment was provided.

On 02/17/22 the flow sheets revealed the nurse identified unstageable wounds to the patient's bilateral heels. The nurse noted a barrier cream was applied to the heels and they were left open to air. There was no wound care consult in the medical record for any of the wounds. There was no complete wound assessment to include size, drainage, color or staging for the coccyx wound that was initially identified as "left buttock small break down." There were no new interventions or any treatment orders put into place for the coccyx wound. There was no documentation the physician was notified of the coccyx wound.

Review of the Discharge Summary dated 02/25/22 revealed there was no mention of the coccyx wound, only the two unstageable heel wounds. The patient's Braden scale score ranged from 11 to 15 throughout the stay. The patient was discharged on 02/25/22.

Interview on 04/21/22 at 10:55 AM with Staff K and Staff B revealed the nurses should consult wound care when the wound is a stage 3, 4 or unstageable. Staff B and Staff K verified the wound assessments for Patient #3 were incomplete and did not include measurements, if there was any drainage noted or the appearance of the wound bed. In addition, they verified that the coccyx wound got bigger and that there was no wound care consult and/or wound care orders to treat the wound.

This deficiency substantiates Substantial Allegation OH00130756.