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Based on medical record, policy review and interview, the facility did not ensure the implementation of falls precautions in 1 of 2 patients.(Patient #5).

Findings include:

Review on 09/17/21 of the medical record revealed Patient #5 was admitted on 03/17/21 for a right hip replacement. Patient #5 has a history of Vascular Dementia, is alert with pleasant confusion, and requires verbal cues and re-direction at times to complete ADL's (Activities of Daily Living).

Review on 09/17/21 of the nursing care plan for Patient #5 dated 03/16/21 revealed a "Falls Care Plan" that included the use of a bed/chair alarm.

Review on 09/17/21 of the nurses note dated 03/17/21 at 09:30 AM revealed Patient #5 experienced an unwitnessed fall while out of bed in the chair. He was found sitting in a "W" position on the floor. The provider was notified, and an x-ray was obtained. Due to injuries sustained in the fall, Patient #5 was returned to surgery the same day for a closed reduction of the newly replaced right hip replacement. There is no evidence in the medical record to indicate a chair alarm, as identified in the nursing care plan, was in use at the time of the fall.

Interview on 09/17/21 with Staff (QQQ), RN- Clinical Nurse Specialist, verified these findings.

Based on medical record review, document review, photographic review and interview, the facility failed to ensure nursing staff are conducting ongoing patient assessment and monitoring consistent with the patient's condition. Lack of patient assessment and monitoring has the potential to negatively impact the patient's condition.

Findings include:

See Tag # 395.

Based on medical record review, document review, photographic review, and interview, the registered nursing staff did not ensure the ongoing assessment and treatment of wounds in accordance with acceptable nursing practice and provider order for 3 of 8 patients. (Patient #1, #2 and #50). Failure to assess and treat wounds can result in a worsening of the patients condition.

Findings Include:

Review of policy "Skin Integrity: Risk Assessment, Prevention of Skin Breakdown and Treatment" effective 4/17 indicates staff are to implement interventions to protect patient from skin breakdown if Braden score is 18 or below for adult. Pressure injuries will be documented to include interventions, status of wound, location, size, description of wound base (necrotic tissue, eschar, slough, etc.), exudate, and odor. Wounds shall be staged using guidelines and patients and caregivers shall be educated about cause and risk factors for pressure injury.

Review on 09/17/21 of the medical record for Patient #1 revealed the following:
-Nursing wound care order dated 01/31/21 indicates to apply medihoney to wound bed, cover with Allevyn and change daily and as needed.
-Flow sheet from 02/01/21 to 02/28/21 revealed the Braden score was less than 18 daily and skin care interventions were indicated.
-Nursing documentation from 02/01/21 to 02/28/21 revealed nursing staff applied medihoney to wound bed, covered the area with Allevyn and changed the dressing daily only 16 of the 28 days reviewed.

Interview on 09/17/21 at 10:00 AM with Staff (A), RN- Senior Director of Clinical Regulatory Compliance confirmed these findings.

Review on 09/17/21 of the medical record for Patient #2 revealed the following:
-Nursing documentation from 02/03/21 to 03/17/21 revealed Patient #2 had a stage 2 decubitus on the sacrum.
-Discharge documentation written on 03/16/21 for 3/17/21 discharge indicated Patient #2 had a Stage 2 on the sacrum. No treatment instructions were included in the discharge documentation.
-Patient #2 was readmitted on 03/23/21 for the treatment of infected sacral decubiti.
-Photographs dated 03/18/21 (taken by the nursing home) reveal a large decubitus on the buttocks/sacrum that is open, and excoriated. The central area of the wound is unstageable with black eschar, green and yellow drainage present.
-Operative note dated 03/26/21 indicates a surgical debridement of a sacral decubitus was performed for a wound that was through the muscle and down to the bone. The measurements of the decubitus were 15 cm wide x 15 cm in length and 4.0 cm deep.
-Death note dated 04/11/21 lists the primary cause of death was sepsis secondary to a sacral decubitus ulcer.
-No documented assessments throughout the first hospitalization revealed the progression of the sacral decubitus to an unstageable necrotic decubitus.

Review on 09/17/21 of the Quality Assurance Patient Safety Indicators (PSI) Review form dated 03/22/21 revealed the following: On 03/18/21 Patient #2 was identified having a major sacral decubitus after being discharged to a local rehab center on 03/17/21. The wound was an undocumented, unstageable decubitus. Discharge paperwork only documented a Stage 2 decubitus on the sacrum.

Review on 09/17/21 of the medical record for Patient #50 revealed the following:
-Patient #50 was admitted on 07/26/21 with abraided areas of the buttocks and knee.
-Nursing documentation from 07/26/21 to 08/18/21 notes abraided areas to left buttocks and knees secondary to fall at home upon admission.
-Review of the discharge documentation dated 8/17/21 for 8/18/21 discharge indicate Patient #50 had a Stage 2 decubitus on the sacrum.
-Photographs sent to the hospital from the rehabilitation center dated 08/19/21 revealed a decubitus on the left buttocks/sacrum that is approximately 7cm x4 cm with necrotic tissue present at proximal and distal ends with surrounding sloughing and excoriation.
-No documented assessments throughout hospitalization revealed the progression of the buttock's decubitus to an unstageable necrotic decubitus.

Interview on 09/16/21 at 02:00 PM with Staff (QQQ), RN, Clinical Nurse Specialist verified these findings.