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Based on record review and interview the facility failed to meet the Condition of Participation to ensure all nursing services were being provided by a registered nurse as evidenced by prevention measures not being done to stop the development or progression (the process of developing or moving gradually towards a more advanced state) of pressure injuries.

The findings are:

A. The facility failed to turn patients and did not perform a thorough skin assessment on admission. Refer to tag A-0395

B. The facility failed to adhere to the procedure of reporting new pressure ulcers. Refer to tag A-0398

Based on record review and interview the facility failed to have a clear policy and process for identifying when a patient needs to be turned and how frequently. The facility failed to promptly identify and prevent the possible progression of pressure injuries (damage to skin and underlying tissue caused by pressure) for 6 (P[patient]2, P3, P7, P8, P9, and P12) out of 13 (P1-P13) patients reviewed for pressure injury prevention by:

1. Not turning 3 (P[patient]2, P3, and P12)

2. Not performing a thorough skin assessment on admission for 4 (P2, P7, P8, and P9)

This deficient practice could lead to poor outcomes for patients by increasing their risk for pressure injuries.

The findings for not turning patients are:

A. Record Review of facility policy titled, "Pressure Injury Prevention and Wound Care (Adult)" dated 02/28/2023 on page 1 under purpose it is stated, "To outline guidelines for the care of patients with actual or potential skin or tissue breakdown, and/or a Braden [tool used to help predict pressure injury risk] score of 18 or less in adults. Skin or tissue breakdown may be related to wounds of any type. - These guidelines and resources are to assist staff to provide pressure ulcer prevention and management. These guidelines are not meant to be a substitute for nursing or medical clinical judgement." On page 2 under "Wound Care Interventions" it is stated "Relieve pressure to the affected area." No further explanation on when a patient should be repositioned and how often they should be repositioned to prevent skin breakdown was found in this policy.

B. Record review of facility document titled, "Care Plan Guide Skin Injury Risk Increased (Adult, Obstetrics Inpatient)" updated 01/28/2022 on page 1, under "Key Information" the last bullet point stated: "Repositioning frequency should be individualized for the patient considering general condition, treatment, objectives, comfort, skin and tissue tolerance. . ." On page 4, under "Optimize Skin Protection" the 8th bullet point stated, "Relieve and redistribute pressure (e.g., scheduled position changes, weight shifts, use of support surface. . .) based on individual risk factors and condition." Braden scoring was not found to be mentioned in this document.

C. Record review of facility training titled, "Pressure Injury Prevention 2023-2024", page 49 is titled "Pressure Injury Prevention Intervention Guidelines", under the header "Area of Risk" it is stated "Reduce Pressure (for decreased sensation, activity, or mobility) and under the header "Interventions" it is stated ". . . Turn patient Q 2 Hours (every 2 hours)."

D. Record review of a National Quality Forum article titled "National Voluntary Consensus Standards for Developing a Framework for Measuring Quality for Prevention and Management of Pressure Ulcers" dated 04/30/2022 by Ahmad M. Al Aboud states "Proper repositioning is essential in maintaining skin integrity and is needed in patients who are unable to do this for themselves. Pressure, friction, and shear forces should be avoided during positioning. The most effective way of repositioning is to move the patient every 2 hours so that the ischemic areas can recover."

E. Record review of a provider note for P2 dated 02/11/2023 states, ". . . presents to the ED with a failure to thrive [loss of appetite, loss of weight, and low activity level] which started 3 days ago. Patient states that [they were] supposed to have a caregiver come to [their] home, and was supposed to have a friend come and help [them], but neither came." Under past medical history it states, "T6-7 paraplegia [loss of function and sensation from mid-chest down]. . ."

F. Record review of P2's flowsheets for admission from 02/11/2023-02/15/2023 revealed that patient was given a Braden score of 13 (meaning patient was at moderate risk for developing pressure injuries).

G. Record review of P2's "Other Orders" revealed that no order was entered for patient to be turned every 2 hours.

H. Review of P2's flowsheets revealed gaps in patient being turned as evidenced under "Body Position" in the flowsheets. No evidence of "Body Position" charted on 02/11/2023 or 02/12/2023. On 02/13/2023 at 8:39 AM it is charted "turned"; a position is charted at 10:50 AM, 11:22 AM, 3:00 PM, 4:45 PM, and 6:32 PM; and at 8:14 PM it is charted "weight shifting." On 02/14/2023 a position is charted at 8:40 AM, 10:39 AM, 12:05 PM, 2:17 PM, 3:10 PM, 4:38 PM, 6:40 PM, and 9:00 PM. On 2/15/2023 at 8:32 AM it is charted "Position changed independently"

I. Record review of a provider note for P12 dated 02/14/2023 states. ". . . hx [history] of spina bifida [birth defect that can cause damage to the spinal cord resulting in paralysis] who presents to the ED [Emergency Department] with c/o [complaints of] spasms. . ."

J. Record review of P12's flowsheets for admission from 02/14/2023-03/17/2023 revealed that patient was given a Braden score of 10 - 12 throughout her admission (meaning patient was at high risk for developing pressure injuries).

K. Record review of P12's "Other Orders" revealed that no order was entered for patient be turned every 2 hours.

L. Record review of P12's flowsheets revealed gaps in patient being turned as evidenced under "Body Position" in the flowsheets for 02/16/2023 which were charted as follows:
12:00 AM "turned",
2:00 AM "weight shifting; upper extremity elevated; neutral head position; neutral body alignment; lower extremity elevated",
8:00 AM "weight shifting",
10:00 AM "weight shifting",
12:00 AM "weight shifting",
2:00 PM "weight shifting",
4:00 PM "weight shifting",
8:00 PM "turned",
10:00 PM "weight shifting; upper extremity elevated; neutral head position; neutral body alignment".

M. Record review of a provider note dated 05/01/2023 states, ". . . past medical history of. . . quadriplegia [paralysis of all 4 limbs]. . . who was brought in by [ambulance company] for evaluation of a pressure wound. . ."

N. Record review of P3's flowsheets for admission from 05/01/2023 (patient was admitted at time of survey) revealed that patient was given a Braden score of 12 throughout admission (meaning patient was at high risk for developing pressure injuries).

O. Record review of P3's "Other Orders" revealed an order dated 05/02/23 at 11:50 AM that stated, "INSTRUCTIONS FROM WOUND CARE TEAM TO BEDSIDE STAFF: 1. Please turn patient q 2 hrs [every 2 hours], offload pressure points with pillows. Thank you." Ordering user was S(staff)14, RN (Registered Nurse), authorized by S13, MD [Medical Doctor].

P. Record review of P3's flowsheets revealed gaps in patient being turned as evidenced under "Body Position" in the flowsheets for 05/02/2023 were charted as follows:
4:05 AM "supine",
8:40 AM "Refused to be turned",
12:00 PM "Refused",
7:35 PM "weight shifting",
11:20 PM "weight shifting."

Q. During an interview on 05/10/2023 at 8:30 AM with S(staff)3, Nurse Manager and S12, DON (Director of Nursing) it was asked if there were orders when patients are to be turned every 2 hours and what the process was for someone to be considered a turn every 2-hour patient? It was answered that no there is not an order placed and to determine if a patient is to be turned every 2-hour staff would go off the Braden score. When asked what Braden score would qualify someone as a turn every 2-hour patient it was answered that they would refer to the care practice guidelines.

R. During an interview on 05/10/2023 at 11:00 AM with S3, Nurse Manager and S12, DON it was asked if weight shifting was the same as turning. The staff demonstrated a "weight shift" in their chair showing a slight shift in either direction then settling back to original position. It was asked if there was a policy or protocol that defined all the options under "Body Position" in Epic [facility charting system] i.e., weight shift, tilt, turned? It was stated, "No, we don't."

Not performing a thorough skin assessment on admission:

S. Record review of facility policy titled, "Pressure Injury Prevention and Wound Care (Adult) dated 02/28/2023 on page 2, under "Assessment: Skin/Tissue Management" it stated "An assessment of the skin for signs and symptoms of skin and/or tissue breakdown is performed at admission and every shift. The following components are required. . . Four eyes [two nurses perform skin assessment] on assessment is completed on admission to the unit."

T. Record review of P8's flowsheet for admission date 08/02/2022 did not reveal a "4 Eyes Skin Assessment documented.

U. During an interview on 05/10/2023 at 8:30 AM with S3, Nurse Manager and S12, DON it was asked if there was a four eyes assessment done for P8. It was confirmed there was no documented four eyes assessment on admission.

V. Record review of P7's flowsheets for admission date 11/21/2022 did not reveal a "4 Eyes Skin Assessment" documented.

W. During an interview on 05/10/2023 at 8:30 AM with S3, Nurse Manager and S12, DON it was asked if there was a four eyes assessment done for P7. It was confirmed there was no documented four eyes assessment on admission.

X. Record review of P9's flowsheets for admission date 01/30/2023 did not reveal a "4 Eyes Skin Assessment" documented.

Y. Record review of P2's flowsheets for admission date 03/01/2023 revealed a "4 Eyes Skin Assessment" charted on 03/26/2023 at 4:49 AM.

Z. During an interview on 05/10/2023 at 8:30 AM with S3, Nurse Manager and S12, DON Vascular it was asked when a four eyes assessment should be completed? They explained it should be done within 24 hours of admission.

Based on record review and interview the facility failed to adhere to the procedure of reporting new pressure ulcers for 3 (P (patient) 2, P3, P12) of 13 (P1 - P13) patients reviewed for pressure ulcers. This failed practice can lead to patient harm and neglect for all patients.

The findings are:

A. Record review of facility clinical training titled "Pressure Ulcer Prevention 2023-2024" undated showed: 1. Untitled Scene, 1.15 Skin Assessment Documentation: It is everyone's [bolded in document] responsibility for ensuring that a MIDAS [bolded in training] (Medical Information Data and Analysis System) report is completed within 24 hours of identifying a pressure injury. Choose incident from the available risk forms. Choose Pressure Ulcer Risk Event Category dropdown. Follow each prompt and fill in all necessary information."

B. Record review of patient chart for P 2 admitted on 02/28/2023 showed wound was identified upon admission and no MIDAS report was entered into system.

C. Record review of patient chart for P3 admitted on 05/01/2023 showed wound was identified upon admission and no MIDAS report was entered into system.

D. Record review of patient chart for P12 admitted on 02/14/2023 showed wound was identified on 02/17/2023 and no MIDAS report was entered into system.

E. Record review of facility document titled "MIDAS Incident Report" dated 01/02/2023 to 05/02/2023 showed all pressure ulcer reports filed by staff. No report was located for P2, P3, and P12.

F. During interview on 05/04/2023 at 12:15 pm with S10, Wound Care Nurse, when asked, "Do you always put a MIDAS [report] in, even if the floor nurse may have?", S10 answered, "Yes I do, it's part of my process." No report was identified for above patients.

G. During interview on 05/04/2023 at 4:23 pm with Staff (S)7, Wound Care Nurse, when asked if a MIDAS report was placed upon identification of a new pressure ulcer, S7 responded, "Yes, and usually the floor nurse has already done that as well." No report identified for above patients.


47302

Based on record review and interview the facility failed to ensure that the medical record contained complete information to aide in the patient's care planning for 1 (P [patient]12) out of 13 (P1-P13) patients reviewed for documentation. This deficient practice could lead to inadequate care for patients related to lack of documentation.

The findings are:

A. Record review of facility policy titled "Pressure Injury Prevention and Wound Care (Adult)" dated 02/28/2023 on page 4 under "Referrals" it is stated, "4. Notify the provider if any signs or symptoms of infection are noted (i.e. an increase in wound pain, an increase in drainage, peri wound erythema or induration, decline in wound appearance, fever, or wound odor if present after cleansing)."

B. Record review of P12's electronic health record revealed:
1. In a care plan note dated 03/09/2023 at 3:09 PM it is charted, ". . . pressure injury to sacrum (barrier cream applied, specialty mattress in use, heels floated . . . WC [wound care] consult placed due to new wounds to sacrum noted. . ."

2. Progress note dated 03/10/2023 at 3:05 PM by S15, MD revealed, "Physical Exam Skin: Warm, no diaphoresis [sweating]". There is no evidence that wounds were documented in this progress note.

3. Physician order dated 03/15/2023 at 9:59 PM that stated, "Pressure injury to sacrum [lower back/pelvis]: Cleanse with Aloe Vesta Foam [no-rinse cleanser] or soap and water PRN [as needed]. Apply Aloe Vesta ointment [protective ointment] to reddened areas BID [twice a day] and PRN. Offload and continue PUPP [pressure ulcer prevention program]." Signed by S15, MD.

4. Discharge Summary dated 03/17/2023 at 1:29 PM by S16, MD revealed, "Disposition/Instructions Wound Care: Keep wound clean and dry." No further explanation of wound or instructions were found in this note.

C. During an interview on 05/04/2023 at 12:15 PM with S10, Registered Nurse it was asked if they expect to find wounds documented in the provider's notes? They stated, "Yes, and when I find a wound I will send a message to the attending listed on the chart."

Based on record review and interview the facility failed to properly execute consent forms for inpatient treatment for 12 (P (patients) 1, P2, P3, P4, P5, P6, P8, P9, P10, P11, P12 & P13) of 13 (P1 - P13) reviewed for properly executed consent forms. This failed practice is likely to cause harm or diminish the quality of care for all patients receiving treatment in the facility.

The findings are:

A. Record review of facility policy titled "Access - General Consent for Inpatient Treatment" dated 06/07/2021, stated "Policy:
[Facility Name Health System] will obtain general consent for treatment for all inpatients to confirm patients' general consent to their admission and routine treatments that may occur during their inpatient stay (i.e. blood draw, administration of medication, etc.) and the fact that charges will be incurred. It is the responsibility of the Patient Access Representative to document such consent by having the patient or their legal representative (i.e., patient's surrogate, parent, custodian, guardian or Health Care Agent) sign the General Consent form.
It is the responsibility of the Patient Access representative to obtain these signatures during the registration process.
Procedure:
3. When the patient or his or her legal representative indicates he or she understands the general consent form, he or she should sign the form, via electronic signature pad or on a hardcopy form, and indicate the date and time of signature.
5. The Patient Access Representative shall label the general consent form with the patient's name and medical record number, if the form used is a hardcopy form.
7. The Patient Access Representative shall provide the document for scanning of the original general consent form into the electronic medical record immediately after obtaining consent when scanning technology is reasonably available, if a hardcopy of the form was signed. The form will automatically flow into the document imaging system.
8. If the hardcopy form is signed, the Patient Access Representative, the document will be placed for scanning the general consent form. The form will then be placed in the patient's chart and forwarded to Medical Records.

B. Record review of consent form "Consent for Hospital/Physician Medical Services" for P1 dated 04/30/2023 showed on page 1, missing identifier specific to location patient was treated at out of 11 facility locations listed on form and on page 2, Relationship to Patient is blank.

C. Record review for P2, when asked to provide consent form, facility could not provide a completed consent form for patient.

D. Record review of consent form "Consent for Hospital/Physician Medical Services" for P3 dated 05/01/2023 showed page 1, missing identifier specific to location patient was treated at out of 11 facility locations listed on form and on page 2 time is missing.

E. Record review of consent form "Consent for Hospital/Physician Medical Services [facility name] Healthcare Services Facilities" for P4 dated 04/28/2023 showed at end of form relationship to patient is blank.

F. Record review of consent form "Consent for Hospital/Physician Medical Services [facility name] Healthcare Services Facilities" for P5 dated 04/14/2023 showed at end of form relationship to patient is blank.

G. Record review for P6, when asked to provide consent form, facility could not provide a completed consent form for patient.

H. Record review of consent form "Hospital General Consent [facility name] Healthcare Services Facilities" for P8 dated 08/02/2022 showed at end of form relationship to patient is blank.

I. Record review of consent form "Consent for Hospital/Physician Medical Services" for P9, dated 01/14/2023 for first admission, showed page 1 missing identifier specific to location patient was treated at out of 11 facility locations listed on form, page 2 missing time and patient identifier. Record review of "Consent for Hospital/Physician Medical Services" for P9 dated 01/30/2023 for second admission, showed page 1 missing identifier specific to location patient was treated at out of 11 facility locations listed on form , page 2 is missing patients name and relationship to patient is blank.

J. Record review of consent form "Consent for Hospital/Physician Medical Services" for P10 dated 03/24/2023 showed page 1 missing identifier specific to location patient was treated at out of 11 facility locations listed on form .

K. Record review of consent form "Consent for Hospital/Physician Medical Services" for P11 dated 04/29/2023 showed page 1 missing identifier specific to location patient was treated at out of 11 facility locations listed on form, page 2 missing patient name and relationship to patient is blank.

L. Record review of consent form "Consent for Hospital/Physician Medical Services [facility name] Healthcare Services Facilities" for P12 showed at end of form relationship to patient is blank.

M. Record review of consent form "Consent for Hospital/Physician Medical Services [facility name] Healthcare Services Facilities" for P13 showed at end of form relationship to patient is blank.

N. During an interview with S1, Director of Regulatory on 05/04/2023 at 11:32 am when asked to provide a consent form for P2 and P6, per S1 one could not be found.

O. During an interview with S4, Patient Access Manager on 05/04/2023 at 3:34 pm, when asked who is responsible for filling out the relationship to patient field, S4 replied, "Patient access is responsible for all blank fields except the signature."

P. During an interview with S9, Patient Access Supervisor on 05/05/2023 at 10:51 am, when asked if a page is double sided do you require patient identifiers on both sides, S9 answered, "yes." When asked who is responsible for making sure relationship to patient is filled in, S9 answered, "the patient access staff is." When asked who is responsible for making sure time the patient signed is on the form, S9 answered, "That should have been our staff [patient access staff]."