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Based on policy review, record review, and interview, nursing services failed to provide appropriate interventions and assessments, follow physician orders and adhere to policies and procedures in the prevention and treatment of hospital-acquired pressure injuries for 1 of 3 (Patient #1) sampled patients who developed hospital acquired pressure injuries.

The findings included:

1. Patient #1 was directly admitted to the hospital on 4/3/2021 with diagnoses including Acute Thalamic Bleed and an Acute Pontine Infarct (Stroke). The patient's skin assessment on 4/3/2021 was "intact", and the 4/4/2021 Braden skin assessment documented to turn and re-position the patient every 2 hours. There was no documentation the patient was turned and repositioned every 2 hours from 4/12/2021- 4/14/2021 at 4:00 PM.
Refer to A392.

2. Review of the Braden Assessment dated 4/15/2021 included interventions to initiate a turning schedule; turn and position patient at least every 2 hours, position with pillows to offload bony prominences, use pillows, offload heels, and involve patient/family in turning schedule. Review of the physician's orders dated 4/16/2021 revealed wound care ordered for "breakdown on bottom and testicles".
Refer to A392.

3. Review of the Wound Care note dated 4/19/2021 revealed the patient had a pressure injury/deep tissue injury on his sacrum and an unstageable pressure injury on his right ischial tuberosity. There was no documentation of the wounds by the nursing staff prior to 4/19/2021. There was no documentation the patient was turned and repositioned consistently every 2 hours and a Braden skin assessment conducted every 12 hours. The patient's heels were intact bilaterally.
Refer to A392.

3. On 4/20/21 the physician ordered Collagenase topical daily to Patient #1's sacral wound. There was no documentation provided by the hospital the Collagenase was applied to the patient's wound for 3 days from 4/24/2021 - 4/26/2021.
Refer to A405.

4. On 4/27/2021 Patient #1 developed a deep tissue pressure injury to the right heel measuring 11 x 10.5 centimeters.
Refer to A392.

5. Patient #1 was discharged from the hospital to a skilled nursing facility on 5/4/2021 with an unstageable pressure injury to the sacrum and a deep tissue pressure injury to the right heel.
Refer to A392.

Based on policy review, medical record review and interview, nursing services failed to ensure patients were turned and re-positioned every 2 hours and ongoing skin assessments were conducted to ensure the patient's needs were met in the treatment and prevention of hospital-acquired pressure injuries for 1 of 3 (Patient #1) sampled patients who developed hospital-acquired pressure injuries.

The findings included:

1. Review of the hospital's Pressure Ulcer Prevention And Management policy revealed, "...Braden Risk Assessment will be performed and a risk assessment score determined...Score 18 and below indicates risk for skin breakdown...A Braden Risk Assessment will be performed and documented at each shift (no more than 12 hours between assessments)...the skin assessment will be performed on admission and no less then every 12 hours...General Preventative Measures...Turn and position patient at least every 2 hours...position patient at 30 degree angle...use pillows or positioning devices...Documentation...The skin assessment will be documented on the Nursing Admission/Assessment...Prevention interventions will be documented..."

2. Medical record review for Patient #1 revealed an admission date of 4/3/2021 with diagnoses which included Acute Thalamic Bleed, Acute Pontine Infarct (Stroke), Hypertensive Emergency, Acute Kidney Injury, Cardiomegaly, and Medical Non-Compliance.

The Braden Assessment dated 4/3/2021 at 11:00 PM revealed a score of 15 indicating Patient #1 was at risk for skin breakdown. Patient #1's skin was intact at admission to the hospital.

The Braden Assessment dated 4/4/2021 at 8:03 AM revealed, "...Turn and position patient at least every 2 hours. Position with pillows to offload bony prominences. Use pillows to avoid skin to skin contact..."

There was no documentation provided by the hospital that Patient #1 was turned and repositioned every 2 hours from 4/12/2021- 4/14/2021 at 4:00 PM.

The Braden Assessment dated 4/15/2021 at 11:00 PM revealed a score of 11. Interventions included initiate a turning schedule; turn and position patient at least every 2 hours, position with pillows to offload bony prominences, use pillows, offload heels, and involve patient/family in turning schedule.

The physician's order dated 4/16/2021 at 4:40 PM revealed, "...Wound Care Consult...Consult Reason breakdown...breakdown on bottom and testicles..."

There was no documentation provided by the hospital that nursing staff assessed Patient #1's skin breakdown on the patient's bottom (sacral and right ischial) and testicles prior to 4/19/2021.

Review of the Wound Care Note dated 4/19/2021 at 2:33 PM revealed, " ...[Patient #1] able to nod head appropriately to questions...verbalizes pain with movement...Sacral/bilateral buttocks PI [Pressure Injury] 9.1 x [by] 15.3 cm [centimeters] DTI [Deep Tissue Injury] with pink superficial edges 30% [percent] dark brown/yellow adgerenet [adherent] slough L [left] buttock and dark eschar over sacrum/R [right] buttocks...R ischial... PI unstageable, dark peeling skin lifts to visualize pink tissue beneath but unable to fully visualize wound bed...Rec [Recommendations]...Cleanse all with Vashe (wound cleanser)...Cover with Aquacel foam [wound dressing]...need for surgical consult...Apply Zinc barrier paste to R ischial and scrotum q [every] shift and with each incontinent episode...need for P-500 bed [special bed to help keep patient's skin cool, dry and comfortable]...Heels clear and intact but...needs...heel protector boots for prevention...turn q 2 hours from side to side. Keep pressure off sacrum using wedge to support side-lying..." There was no documentation provided by the hospital Patient #1 was turned and repositioned consistently every 2 hours. There was no documentation provided by the hospital that the Braden skin assessments were performed every 12 hours.

The Wound Care note dated 4/27/2021 at 3:35 PM revealed Patient #1's sacral wound had worsened and Patient #1 had developed breakdown to the right heel as, "...Unstageable Sacral PI...10.5 x 13.5 cm with 85% dark brown adherent eschar...R ischial tuberosity...0.5 x 1.2 x 0.05 cm...pink, dry wound bed...R heel DTPI [Deep Tissue Pressure Injury]...11 x 10.5 cm with a boggy wound bed...most of wound bed is an off-white/tan color beneath the surface...Received notification from NP [Nurse Practitioner]...continue current tx [treatment] for sacral wound with the addition of a flexi seal rectal tube...will also need pressure relief boots..."

The Wound Care note dated 5/4/2021 at 4:34 PM revealed, "...Unstageable Sacral PI...10.5 x 13.5 cm with 65% dark brown, tan, and yellow adherent eschar and slough and 35% pink, moist tissue to wound bed...R ischial wound is now closed...R heel DTPI 11 x 10.5 cm...fluid drained from the superior aspect while cleansing leaving a flat surface with no fluctuance...The surface is intact..."

Patient #1 was discharged to a skilled nursing facility on 5/4/2021 with an unstageable pressure injury to the sacrum and a deep tissue pressure injury to the right heel.

3. In an interview on 5/11/2021 at 11:30 AM, the Interim Nurse Manager of the Neurology Specialty Telemetry Unit verified nursing staff were expected to document skin integrity issues when they occurred.

In an interview on 5/11/2021 at 2:00 PM, the Chief Nursing Officer verified nursing staff should document Braden and skin assessments every 12 hours.

Nursing services failed to perform ongoing assessments and interventions for the treatment and prevention of hospital acquired pressure injures for Patient #1.

Based on policy review, medical record review, and interview, the hospital failed to ensure nursing staff administered all drugs and biologicals according to the physician's order for 1 of 3 (Patient #1) sampled patients with hospital-acquired pressure injuries.

The findings included:

1. 1. Review of the hospital's "PRESSURE ULCER PREVENTION AND MANAGEMENT" policy revealed, "...Once a pressure ulcer is identified, the appropriate clinical practice guideline may be implemented with a physician's order or a wound specialist's order...Treatment measures will be documented..."

2. Medical record review for Patient #1 revealed an admission date of 4/3/2021 with diagnoses which included Acute Thalamic Bleed, Acute Pontine Infarct, Hypertensive Emergency, Acute Kidney Injury, Cardiomegaly, and Medical Non-Compliance.

The Wound Care Note dated 4/19/2021 at 2:33 PM revealed, "...Sacral/bilateral buttocks, PI [Pressure Injury], 9.1 x 15.3 cm [centimeters] DTI [Deep Tissue Injury] with pink superficial edges-30% [percent], dark brown/yellow adgerenet [adherent] slough L [left] buttock and dark eschar over sacrum/R [right] buttocks...3)R ischial tuberosity, PI, unstageable, dark peeling skin lifts to visualize pink tissue beneath but unable to fully visualize wound bed...Rec [Recommendation]...Cleanse all with Vashe (wound cleanser)...Pat dry, apply skin prep to periwound. Cover with Aquacel foam...need for surgical consult..."

The Physician Progress note dated 4/20/21 at 1:00 PM revealed, "...No urgent surgical indication at this time...will add collagenase for local wound care daily per nursing...Continue with frequent turns & reposition while in bed..."

The physician's order dated 4/20/21 at 2:00 PM revealed, "...collagenase topical...daily..."

There was no documentation provided by the hospital that collagenase was applied to Patient #1's sacral wound as ordered by the physician for 3 days, from 4/24/2021 through 4/26/2021.

3. In an electronic communication on 5/14/2021, the Director of Risk Management verified she was unable to locate wound care provided from 4/24/2021 through 4/26/2021 for Patient #1.