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Based on policy and procedure review, medical record review, CARE Event review and staff interview, leadership failed to develop a plan to monitor improvement following a hospital acquired pressure injury (Patient #5).

The findings included:

Review of a policy on 02/28/2019 titled "CARE EVENT REPORTING" last reviewed/revised 05/2017 revealed "...(Facility ) recognizes the importance of early identification and expects its employees to complete a CARE Event (Incident Report) for any occurrence which occurs in the facility or on its premises that is not consistent with routine patient care or operation of the facility that either did or could directly result in injury to a patient or visitor...A. The person discovering, directly involved, or closest to the event should complete an online CARE Event Report within 24 hours..."

Review of a policy on 02/28/2019 titled "SENTINEL EVENTS" last reviewed/revised 08/2015 revealed "...(Facility) is committed to providing quality care to the patients it serves. This commitment is reflected in facility-wide Performance Improvement/Quality Improvement plans...H. A patient safety event is an event, incident, or condition that could have resulted or did result in harm to a patient...H. A 'Compact Cause Analysis (CCA)' is a tool that provides structure for investigations of harm, near misses and no harm events that do not rise to the level of a sentinel event and/or serious safety event and do not require an RCA (root cause analysis)...D. If the event is NOT determined to be a sentinel event, it must still be determined if further follow-up on the issue is required...The SERT (Sentinel Event Reporting Team) determines the appropriate level of cause analysis investigation needed...The SERT may, at its discretion, assign the issue to a performance improvement/quality/peer committee for further evaluation..."

Open medical record review from 02/26/2019 to 02/28/2019 of Patient #5 revealed a 43 year old patient admitted from another acute care hospital on 09/21/2018 intubated, for acute respiratory failure and stroke. Review of the nursing admission assessment on 09/21/2018 at 2000 revealed a Braden score of 11 (at high risk for skin breakdown) and the integumentary (skin) assessment was within defined limits with no integumentary symptoms reported. Review of the nursing assessment on 09/27/2018 revealed at 2000 the nurse documented a stage I pressure ulcer on the right buttock. Review revealed from 09/27/2018 to 11/21/2018 no change in pressure ulcer staging. Review of the skin assessment on 11/26/2018 at 0500 revealed documentation of a midline anterior perianal wound. Review revealed the wound care nurse saw Patient #5 on 11/26/2018 at 0940 and wrote "...Patient has a small tear that is...to the inferior portion of the anus with scant serious drainage. The wound was cleaned with wound cleanser, packed lightly with Aquacel Ag Rope and left a tail for easy dressing change. Dressing changes should be done daily and PRN (as needed)...The buttock/perineum area is erythematous and moist with moisture associated skin damage...Turn clock posted in room, patient should be turned q2h (every 2 hours)..." Review revealed on 12/9/2018 a stage II pressure ulcer was documented. Review revealed on 01/24/2019 a stage IV pressure ulcer was documented on the anterior sacrum. Review revealed on 02/01/2019 Patient #5 underwent surgical debridement of two sacral decubitus ulcer. Review revealed Patient #5 underwent surgery on 02/19/2019 for a "laproscopic formation of end sigmoid colostomy" for fecal diversion from the wound area. Review of the nursing flowsheet dated 02/25/2019 at 2000 revealed documentation of Patient #5's midline anterior sacrum wound as a stage IV.

Review of CARE Events on 02/27/2019 revealed no CARE Events for Patient #9.

Interview on 02/27/2019 at 0945 and on 02/28/2019 at 0855 with the Wound Care Nurse revealed she had seen Patient #5 multiple times since his admission. Interview revealed Patient #5 had a hospital acquired pressure ulcer. Interview revealed currently Patient #5 had an unstagable wound on his sacrum and two Stage III wounds on each buttock. Interview revealed normally if the wound care nurse saw a patient with a hospital acquired pressure ulcer that was Stage III or greater she would put a CARE event in and the Patient Safety Coordinator would be notified. Then the manager on the floor the patient was on would be notified and there would be a chart audit with the manager and staff nurse. A Compact Cause Analysis would be done on pressure ulcers Stage III or above. Interview revealed a CARE event had not been done for Patient #5.

Interview on 02/28/2019 at 1235 with the Patient Safety Coordinator revealed normally the Wound Care Nurse puts a CARE event in and that was how she was notified to do a Compact Cause Analysis to see if the process for pressure ulcer prevention was being followed, then based on that changes would be made. Interview revealed a Compact Cause Analysis should be done on patients with hospital acquired pressure ulcers of Stage III or greater. Interview revealed the Patient Safety Coordinator did not see a CARE event for Patient #5 and a Compact Causes Analysis had not been done.

Based on policy and procedure review, medical record review, and staff interviews facility staff failed to provide consistent evidence of turning every two hours for 3 of 3 patients (#4, #5 and #9) at high risk for skin breakdown and wound dressing changes for 1 of 3 patients with a pressure ulcer wound (Patient #5).

The findings included:

Review on 02/27/2019 of a policy titled "Pressure Ulcer Prevention and Treatment Guidelines" no reviewed/revised date listed did not reveal specifically how frequently a patient should be turned. Review revealed "Universal Skin Care Practices (All Patients)...Braden Scale (a 23-point scale used to predict a patient's risk for skin breakdown, where a lower score indicates greater risk) predicting pressure ulcer risk assessment on admission and daily. Schedule frequent repositioning and turning for bed bound and chair bound patients...Prevention practices for at risk patient (Braden Scale 18 or less): Continue Universal Skin Care Practices Maintain adequate hydration and dietary intake of protein and calories..."

1. Open medical record review from 02/26/2019 to 02/28/2019 of Patient #5 revealed a 43 year old patient admitted from another acute care hospital on 09/21/2018 intubated, for acute respiratory failure and stroke. Review of the nursing admission assessment on 09/21/2018 at 2000 revealed a Braden score of 11 (at high risk for skin breakdown) and the integumentary (skin) assessment was within defined limits with no integumentary symptoms reported. Review revealed no available evidence of turning and repositioning on 09/23/2018 at 0600 until 2000 (14 hours later). Review revealed no evidence of turning and repositioning from 09/26/2018 at 0500 until 1900 (14 hours later). Review of the nursing assessment on 09/27/2018 revealed at 2000 the nurse documented a stage I pressure ulcer on the right buttock. Review revealed from 09/27/2018 to 11/21/2018 no change in pressure ulcer staging. Review of the skin assessment on 11/26/2018 at 0500 revealed documentation of a midline anterior perianal wound. Review revealed the wound care nurse saw Patient #5 on 11/26/2018 at 0940 and wrote "...Patient has a small tear that is...to the inferior portion of the anus with scant serious drainage. The wound was cleaned with wound cleanser, packed lightly with Aquacel Ag Rope and left a tail for easy dressing change. Dressing changes should be done daily and PRN (as needed)...The buttock/perineum area is erythematous and moist with moisture associated skin damage...Turn clock posted in room, patient should be turned q2h (every 2 hours)..." Review of the orders on 11/26/2018 revealed an order for dressing changes daily with Aquacel. Review of the flowsheet for dressing changes revealed no documentation of dressing changes on 11/28/2018 or 11/29/2018. Review revealed on 12/9/2018 a stage II pressure ulcer was documented. Review revealed wound care saw Patient #5 again on 01/15/2019 at the request of staff. Review revealed "...He continues to have a small laceration in the perianal area which is cleaner but bigger than last assessment and a challenge due to the location in the perianal area, frequently contaminated with stool...The skin breakdown on the buttocks is all superficial...The sacral area is a progression of the MASD (moisture associated skin damage) and pressure on the sacrum-this area measures 2x2cm...orders for wound care updated..." Review of the orders on 01/15/2019 revealed orders for triad paste three times a day and as needed dressing changes with wound cleanser to the perianal area. Review of the wound flow sheet revealed no documented evidence that triad paste was applied on 01/16/2019 and 01/17/2019. Review revealed on 02/01/2019 Patient #5 underwent surgical debridement of two sacral decubitus ulcer. Review revealed no available evidence of turning and repositioning on 02/07/2019 at 0500, until 02/07/2019 at 1700 (12 hours later). Review revealed no available evidence of turning and repositioning on 02/07/2019 at 1700 until 02/08/2019 at 0700 (14 hours later). Review of the orders on 02/14/2019 revealed orders to change wound dressing daily. Review revealed Patient #5 underwent surgery on 02/19/2019 for a "laproscopic formation of end sigmoid colostomy" for fecal diversion from the wound area. Review revealed wound care saw Patient #5 on 02/20/2019 and wrote "...discussion with ICU and (unit) nursing regarding bed surface-dressing changes etc..." Review revealed no documented dressing changes on 02/21/2019 and 02/22/2019. Review revealed no available documentation of turning and repositioning on 02/22/2019 at 1534 until 02/24/2019 at 1000 (42 hours and 18 minutes). Review revealed no available documentation of turning and repositioning on 02/24/2019 at 1000 until 02/25/2019 at 1004 (24 hours and 4 minutes), when Patient #5 was supine. Review of the nursing flowsheet dated 02/25/2019 at 2000 revealed documentation of Patient #5's midline anterior sacrum wound as a stage IV.

Interview on 02/27/2019 at 0945 and on 02/28/2019 at 0855 with the Wound Care Nurse revealed she had seen Patient #5 multiple times since his admission. Interview revealed Patient #5 had a hospital acquired pressure ulcer. Interview revealed after the Wound Care Nurse saw patients she discussed the care of the patient with the bedside nurses taking care of the patient about new orders and dressing changes. Interview revealed Patient #5 had low Braden scores since admission and should be turned every two hours. Interview revealed currently Patient #5 had an unstagable wound on his sacrum and two Stage III wounds on each buttock. Interview revealed the wound care nurse could not say if Patient #5's wounds were preventable. Interview while reviewing Patient #5's medical record revealed in hindsight the Wound Care Nurse could see inconsistency in turning, repositioning and dressing changes in documentation for Patient #5.

Interview on 02/27/2019 at 1605 with CNA #1 (Certified Nursing Assistant) revealed Patient #5 had a wound and should be turned every two hours. Interview revealed she worked with Patient #5 on 02/23/2019 and 02/24/2019. Interview revealed she remembered turning Patient #5 because you usually needed two people. Interview revealed she did not document turning patients because she was not aware of a place to document turns.

Interview on 02/27/2019 at 1620 with RN #1 (Registered Nurse) revealed she worked with Patient #5 on 02/23/2019. Interview revealed usually the nurse aide documents turns but ultimately it was "my responsibility to make sure it was charted." Interview revealed RN #1 recalled turning Patient #5 but it might not have been documented. Interview revealed RN #1 believed Patient #5 was receiving proper care but she was "overwhelmed" with the amount of charting for him because she was not always able to chart in real time.

Interview on 02/29/2019 at 1125 with NP #1 (Nurse Practitioner) revealed he took care of Patient #5 in the ICU. Interview revealed from admission to the last time he took care of Patient #5 in January his wound had worsened.

Interview on 02/27/2019 at 1231 with NM #1 (Nurse Manager) revealed the expectation was that Patient #5 should be turned every two hours and it should be documented.


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2. Open medical record review for Patient #4 on 02/26/2019 revealed, a 78 year old male admitted on 02/18/2019 at 1554 for sepsis (bacterial infection). Review of the H&P (History and Physical) revealed he had a history of multiple co-morbidities including most recent esophageal cancer, with worsening weakness, fluctuating cognition. Record review revealed he was admitted to the facility with a stage IV (pressure injury is very deep, reaching into muscle and bone and causing extensive damage) pressure ulcer. Review revealed during Patient #4's admission the Braden score was between 12 - 16 (high risk for skin breakdown). Review revealed no available evidence of turning and repositioning on 02/21/2019 at 2320 until 02/23/2019 at 2140 (46 hours and 20 minutes). Review revealed no available evidence of turning and repositioning on 02/23/2019 at 2140 until 02/24/2019 at 0210 (4 hours and 30 minutes). Review revealed no evidence of every two hour turning and repositioning of Patient #4.

Telephone interview with RN #7 on 02/28/2019 at 0850 revealed, she thought the patient was able to turn himself. RN #7 was under the impression that " ...Typically if the Braden score was <16 as per policy, the patient would be placed on an air mattress bed and required to turn and reposition every 2 hours if they are not able to move themselves." RN #7 was not sure if staff were required to document patient position (left side lying, right side lying or supine) due to the patient lying on an air mattress.

Interview with the Wound Care Nurse on 02/28/2019 at 1015 revealed, nursing staff were expected to implement measures for pressure prevention protocol for patients with Braden score less than 18. Interview revealed, Patient #4 despite the use of the "Sport" ICU specialty bed, still required to be turned, repositioned and heels elevated every 2 hours.

3. Open medical record review for Patient #9 revealed,an 84 year old male admitted from a Skilled Nursing Facility on 02/23/2019 at 0526 for pneumonia on a 40% Tracheostomy collar (breathing forced air through an opening in his neck). Review of his History and Physical (H&P) revealed, he was nonverbal with multiple medical issues which included status post CVA (stroke) in 2014, and multiple decubitus ulcers prior to admission. Review revealed during Patient #9's admission the Braden score was between 7 - 12 (high risk for skin breakdown). Review revealed no available evidence of turning and repositioning on 02/24/2019 at 1249 until 2210 (9 hours and 21 minutes). Review revealed no available evidence of turning and repositioning on 02/24/2019 at 2210 until 02/26/2019 at 1920 (45 hours and 10 minutes). Review revealed no available evidence of turning and repositioning on 02/26/2019 at 1920 until 02/27/2019 at 0812 (12 hours and 52 minutes). Review revealed no evidence of every two hour turning and repositioning of Patient #9.

Telephone interview with RN #8 on 02/27/2019 at 0945 revealed, she provided nursing care for Patient #9 and performed dressing changes on his wounds. RN #8 revealed the facility utilized signs on the doors to alert staff of the scheduled every two hour turn and reposition needed as part of patient care. RN #8 revealed it was expected of the CNA (Certified Nurse Assistant) to perform patient turn and reposition task, document completion and the patient's position in the computer.

Interview with CNA #3 on 02/28/2019 at 1015 revealed, she did rounding on the odd hours and the RN did rounding on the even hours. Rounding tasks include assisting the patient with position change, bathroom or other assistance the patient may need. Interview revealed CNA #3 explained a patient's turning and repositioning was a shared responsibility between the nurse and CNA. CNA #3 revealed, she "Relied on the RN to document in the computer of turn and repositioning (the) patient."

Interview with Wound Care Nurse on 02/28/2019 at 1015 revealed, nursing staff were expected to implement measures for pressure prevention protocol for patients with Braden score less than 18. Interview revealed, patients were required to be turned, repositioned and heels elevated every 2 hours.

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