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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES, was out of compliance.

A-0395 RN SUPERVISION OF NURSING CARE A registered nurse must supervise and evaluate the nursing care for each patient. Based on document review and interviews the facility failed to complete and document the nursing admission assessments for patients upon admission to the facility. Based on interviews and document review, the facility failed to ensure nursing care was provided which met the continuous care needs of patients. Specifically, nursing staff failed to implement preventive measures in order to prevent a new pressure injury or monitor and prevent further pressure injury once it was identified.

Based on interviews and document review, the facility failed to ensure nursing care was provided which met the continuous care needs of patients. Specifically, nursing staff failed to implement preventive measures in order to prevent a new pressure injury or monitor and prevent further pressure injury once it was identified.

Findings include:

Facility policies:

The Pressure Injury Prevention, Management and Treatment policy read, Pressure Injury: Localized damage to the skin and underlying soft tissue can occur as a result of intense or prolonged pressure. An individualized prevention and treatment plan for patients with pressure injuries or assessed to be at risk will be initiated, with interventions based on physical assessment findings, the Braden Score (a valid and reliable risk assessment for predicting a patient's pressure injury risk) and individual patient needs. A patient is considered to be at risk with a total Braden Score of 18 or less. A skin assessment at least once per shift, including the Braden Score and weekly pressure injury measurement documented.

Nursing Wound Assessment policy dated 11/2019 read, all nursing staff are responsible for the monitoring and management of preventative measures and wound treatment interventions on their assigned patients. All nursing staff providing wound treatments are responsible for performing wound assessment with each dressing change to evaluate wound healing and determine if treatment indicated or contraindicated based on the assessment of the wound. The nurse will complete a head to toe assessment on admission and each shift in the patient's electronic health record (EHR) under Integumentary (skin) Assessment. The nurse will complete a Braden Score Assessment on admission and every shift minimally.

1. The facility failed to ensure nursing staff implemented measures to prevent skin breakdown, or prevent continued injury to an existing pressure wound.

A. Documents were reviewed.

a. According to the Pressure Injury Prevention policy, an individualized prevention and treatment plan for patients with pressure injuries or assessed to be at risk for developing pressure injuries were to have interventions initiated. A skin assessment and interventions were to be documented once every shift.

b. The medical record for Patient #1 was reviewed. The record lacked evidence of patient repositioning, pressure sore prevention precautions or interventions done after a pressure sore was discovered on 6/21/21.

i. Review of Patient #1's History and Physical revealed she was admitted on 6/17/21. Patient #1 was on hospice and had a history of diabetes, ischemic vascular disease with a gangrenous foot. Due to the pain, Patient #1 underwent a BKA (below the knee amputation) on 6/17/21. The initial Skin Integrity Assessment was performed on 6/17/21 at 1:49 p.m., and noted the only skin related issue was the surgical site, specifically the right lower leg. There was no documentation of a pressure injury to the coccyx or sacrum upon admission.

ii. Review of Patient #1's medical record revealed her Braden Scores ranged from 14 to 18 on 6/17/21 to 7/2/21. According to the pressure injury prevention, management and treatment policy, a patient was considered to be at risk of skin breakdown with a Braden Score of 18 or less. Patient #1's medical record revealed no evidence of interventions implemented such as two hour turns, sacrum offloaded or barrier cream applied.

iii. Patient #1 was hospitalized from 6/17/21 to 7/2/21, a total of 15 days. On 6/21/21 at 1:25 p.m., four days after admission, medical record revealed Occupational Therapy (OT) discovered a small skin tear on Patient #1's buttocks area.

iv. On 6/23/21 at 4:38 p.m., a physician ordered Patient #1 to be turned every two hours. The flow sheet, where patient care, including if the patient was repositioned or turned, was reviewed and revealed no evidence Patient #1 was turned as ordered.

v. On 6/30/21 at 1:00 p.m., (nine days after the discovery of a pressure injury) a wound care consult was performed. The wound care nurse recommended staff to keep Patient #1's coccyx offloaded (to minimize or remove weight placed on an area). The medical record for Patient #1 was reviewed and revealed no evidence staff followed the wound care nurse's recommendation to minimize or remove the pressure from Patient #1s coccyx.

B. Interviews with staff were conducted and revealed no evidence nursing staff followed physician orders to turn Patient #1 every two hours or wound care recommendations to offload coccyx.

a. On 8/12/21 at 10:55 a.m., an interview was conducted with Registered Nurse (RN) #2. RN #2 stated each shift, the RN performed an assessment which included a skin assessment. RN #2 reviewed Patient #1's medical record and stated she was not able to find evidence where Patient #1 was repositioned or turned every two hours as ordered by the physician. RN #2 stated patients were at risk of infection or increased skin breakdown if preventative measures were not implemented.

b. On 8/12/21 at 11:47 a.m., an interview was conducted with Wound Care Nurse (WCN) #3. WCN #3 stated wound care was important because wounds could be debilitating to a patient. WCN #3 stated patients with pressure wounds were at risk of infection, pain, and a potential decreased quality of life.

WCN #3 stated RNs completed a Braden Score assessment every shift and the score showed the risk assessment with interventions to follow. WCN #3 reviewed Patient #1's medical record, and stated the Braden score for this patient was high risk. WCN #3 stated it was up to the nurse which interventions to implement. WCN #3 stated a doctor placed an order for two hour turns and stated when she reviewed the record, there was no evidence or documentation the ordered turning had occurred.

c. On 8/12/21 at 1:00 p.m., an interview was conducted with RN #4. RN #4 stated when a patient was turned it was to be documented in the flow sheets. RN #4 stated nurses were responsible to make sure patients were turned as ordered. RN #4 stated patients on a turn schedule were turned every two hours. She stated if a patient turned themselves, staff documented the position change as well as the position they were in.

d. On 8/12/21 at 2:24 p.m., an interview was conducted with Nurse Manager (Manager) #5. Manager #5 reviewed Patient #1's medical record and stated documentation was sporadic and not completed every two hours. Manager #5 stated her expectation was for RNs to follow physician orders to turn a patient every two hours and document each time a patient was turned. Manager #5 stated if a patient was scored high risk on the Braden Scale, the RN was to follow intervention instructions that are part of the Braden Scale such as: apply barrier cream, turn every two hours and/or prevent shearing (when the skin sticks to a surface while muscles slide in the direction the body moved). Manager #5 stated Patient #1's Braden scale scores had been 18 or less for the duration of her hospital stay. She stated a Braden score of 18 or less was high risk.

Manager #5 stated there was a risk of infection, osteomyelitis (inflammation or swelling which occurs in the bone) and possible death if they were not turned every two hours as ordered.