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Based on interview and record review, the facility failed to ensure a registered nurse consistently implemented their policy and procedure for the prevention and care of skin integrity management for one patient (#1) of 5 patients reviewed for nursing services resulting in the increased potential for the development of altered skin integrity for patient #1.

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(A-0395) Based on interview and record review the facility failed to ensure that a Registered Nurse assessed, evaluated and performed wound care treatments as prescribed for 1 (#1) of 5 patients reviewed for wound conditions.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) consistently implemented their policy and procedure for preventing and treating changes in skin integrity for one patient (#1) of 5 patients reviewed for nursing services resulting in the increased potential for alterations in skin integrity for patient #1.
Findings include:

On 5/4/2022 at 1130, review of the medical record for patient #1 was conducted with the Assistant Chief Nursing Officer (Staff D) and Patient Care Services RN (Staff L) and revealed the following:

Patient #1 was a 52-year-old male who was admitted to the facility on 1/18/2022 for complaints of shortness of breath and chest pain. The patient's location remained in the Emergency Department (ED), admitted to the Medical Intensive Care unit (MICU) overflow from 1/18/2022-1/26/2022. The patient's skin integrity was described as clean, dry, and intact on 1/18/2022.

On 1/19/2022, the patient's Braden Scale (tool for predicting the risk for developing pressure injury) revealed the patient was coded a "22" on a scale of no risk (19-23), to severe risk (less than 9). There were no further updates or changes noted for the patient's Braden Scale risk assessment documented after 1/19/2022.

On 1/20/2022, the patient's skin was noted to be "within defined limits" (w/d/l). The patient remained on a stretcher in the ED per nursing notes.

On 1/21/2022, the patient's buttocks were noted to be "excoriated". The nurse documented the medical doctor was paged, an order for Wound Care consultation was obtained, and a foam dressing was applied to the patient's buttocks. The patient continued to remain on a stretcher in the ED per nursing notes.

Review of physician's orders dated 1/21/2022, revealed an order to "Consult Wound Care."

Further review of nursing notes dated 1/22/2022, and 1/23/2022 revealed nursing staff documented; "skin w/d/l". There was no further documentation that the patient's foam dressing was in place or changed after 1/21/2022, after nursing documented a foam dressing was applied to the patient's buttocks due to the changes in his skin integrity.

On 5/5/2022 at 0930 an interview and review of a "Wound Management" note dated 1/24/2022, was conducted with Wound Ostomy Continence Nurse (Staff N).

She confirmed, she saw the patient on 1/24/2022. Staff N said she was consulted to evaluate the patient's sacrococcyx/buttock condition. She noted the patient was in the ED at the time of her evaluation. She noted the patient was awake, verbal and needed repositioning with one person assist during her assessment. At that time, Staff N was asked if the patient only required her assistance with turning she replied, "No, I should have written 2 person assist."

Review of the "Wound Management" note dated 1/24/2022 revealed the patient (#1), remained on a stretcher. She recommended for the patient to be transferred to a (name of type of advanced pressure reducing support surface bed/mattress). She documented the last Braden Score per EMR was not available. She noted, "Pressure injury to the patient's sacrococcyx/buttock was most likely complicated by incontinence. She measured the wound at 15 centimeters (cm) x (by) 21 cm. She staged the wound as Deep tissue pressure injury evolving."

She described the wound bed as follows: Epidural blistering with hyperpigmentation noted. She noted the wound bed was open with dark discoloration, some areas with dull pink to viable tissue. She noted there was a moderate amount of serosanguineous (bloody) drainage. She noted the patient was soiled with urine and she performed incontinence care at that time.

Her wound care recommendations at that time included:
a. Cleanse wound with normal saline
b. Pat dry with gauze.
c. Apply a double layer of non-adherent dressing
d. Cover with a silicone border foam dressing
e. Every (Q) shift assessment and Q day/as needed dressing changes.

She noted the following interventions at that time that included:
1. Initiate pressure injury management order set and continue pressure injury protocol.
2. Complete wound care education, and document integumentary Q shift plan of care per (name of health system) policy...7. Maintain skin hygiene: cleanse skin with pH balanced no rinse foam cleanser...8. Apply barrier cream to peri area for incontinence. Apply barrier cream in a nickel thickness layer. Perform surface cleansing only after each incontinence episode, and reapply protectant barrier cream. 9. Continue moisture management, recommend use of condom catheter, as well as use of one layer moisture wicking underpad.
Wound care will sign off. Nurse to monitor progression towards healing, and complete wound care per order...reconsult wound care services as needed, if area becomes necrotic, or if area deteriorates.

On 5/5/2022 at 0945 Staff N was asked how often did she expect the foam dressing for patient #1, to be changed and how often were staff required to assess the patient's skin integrity. Staff N replied, "the patient was incontinent so the dressing should have been changed every shift and more if needed to prevent any wound contamination." Staff N explained nursing staff should assess and document skin assessments every shift.

On 1/30/2022, the patient's sacrococcyx/buttock pressure injury measured 13 cm x 10 cm while the patient was on the 4th floor nursing unit. There were no further assessments or wound care dressing changes documented in the medical record after 1/31/2022. The patient was discharged to a Sub-Acute Rehab (SAR) on 2/2/2022.

Review of medical doctor progress notes dated 1/20/2022 through 2/2/2022 revealed there were no mentions that the patient had a sacrococyx/buttock wound.

A phone interview was conducted with medical doctor Staff O was conducted on 5/5/2022 at 1345. She said she was able to sign in remotely and review the patient's medical record.
Staff O explained she was a resident physician who treated the patient during his hospitalization. Staff O said she was not aware of the patient having a wound. She said, "He (#1) never told me he had a wound." Staff O confirmed she saw the patient on the day of his discharge. When asked if she evaluated the patient's wound she reiterated she did not know that she had a wound.

On 5/5/2022 at 1400, Staff D was asked to explain why nursing staff failed to consistently document the patient's (#1's) skin assessments in the patient's medical record on 1/20/2022-1/26/2022 while the patient was in the ED/MICU, and why nursing staff did not consistently document the patient's wound was assessed and the patient's wound care dressing were performed daily and as ordered on 2/1/2022 or 2/2/2022. Staff D was asked to explain why the medical staff were not documenting on the patient's wound condition. At that time, she responded "we recognized we had a problem with documentation". She explained, nursing staff had been inserviced on the requirements and expectations of documentation including wounds. Staff D said she shared the expectations with the "Chiefs". Staff D was asked if she shared the education requirements with the "Residency Program Director or the Residents", she replied, she had not.

A review of the facility's "Pressure Injuries: Prevention and Care" policy dated, August 10, 2021 documented the following:
C. RN responsibilities:

"1. Provide assessment, planning, documentation and evaluation of skin, pressure injuries and wound care with every shift assessment...4. Initiate EMR orders for pressure injury prevention and management based on patient risk assessment and/or either presence of pressure injuries directed toward specific subscale risk factors...7. Document in Altered Tissue Integrity Plan of Care every shift for patients with pressure injuries, healed pressure injuries, or at risk for pressure injuries...9. Assess patient outcomes. Revise plan of care as needed. 10. Assure continuity of care through communication of plan to health care team members."

Documentation:
In EMR I-View:
Wound location...status, cleansing, dressing type/treatment.
However, that was not done.

Based on document review and interview, the facility failed to ensure Social worker (Staff R) was qualified to manage and oversee the department of Discharge Planning Staff, resulting in the potential for less than optimal outcomes for all patients served by the facility.

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(A-809)
Failure to ensure (Staff R), met the qualifications to perform the duties of a Manager according to the facility's job description for the Manager of Social Work.

Based on document review and interview the facility failed to ensure Social Worker (Staff R), met the qualifications to perform the duties of a Manager according to the facility's job description for the Manager of Social Work, resulting in the potential for less than optimal outcomes for all patients served by the facility. Findings include:

An interview was conducted with the Director of Case Management (Staff J) on 5/4/2022 at 1215 and the following was revealed. Staff J was queried regarding Staff R's role, experience and licensure. According to Staff J, Staff R had been recently promoted to the role of "Manager" of Case Management by the previous "Group Case Management Director."

When further queried at that time, regarding Staff R's qualifications she (Staff J) replied, Staff R was a "Limited Licensure Medical Social Worker (LLMSW)", who had worked at the facility for 2 years and was due to test for full Licensure in July.

On 5/5/2021 at 1230 a review of Staff R's personnel file revealed she was hired on 8/10/2020. She held a "Limited License Medical Social Worker (LLMSW)". Her license was documented as issued on 7/14/2020.

On 5/5/2022 at 1700 Staff A was made aware of the findings. At that time, she (Staff A), replied she was not aware of the concern.

A review of the facility's job description titled "Manager, Social Work", Job Code: 0SA15. Date: 5/2019 documented the following:
Minimum Qualifications:
"... 2. Current license as a Licensed Master's Social Worker in the State of Michigan."
However, that was not done.