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Based on record review and interview, the nursing staff failed to implement preventive interventions according to their policies and procedures for 6 of 7 patients at risk for pressure injury (Patient # 1, #4, #6, #7, #8, and #9), nursing staff failed to monitor staff assisting with patient hygiene in 2 of 10 patient's receiving hygiene care (Patient #3 and #8), failed to perform skin and wound assessments according to the facilities policies and procedures for nursing care in 5 of 7 patients receiving wound care (Patient #1, #4, #6, #8 and #9) and failed to perform reassessments to manage pain in 3 of 4 patients experiencing pain (Patient #3, #4 and #5.) in a total of 10 medical records reviewed.

Findings include:

The nursing staff failed to implement preventive interventions for patients at risk for pressure injury and failed to monitor staff assisting with patient hygiene. (See Tag A-0392)

The nursing staff failed to perform skin and wound assessments in patients receiving wound care. (See Tag A-0395)

The nursing staff failed to perform reassessments to manage pain. (See Tag A-0405 )

These deficient practices resulted in new or worsening pressure ulcers in Patients #1, #4, #6, #8, and #9 and lack of appropriate pain control in Patients #3, #4 and #5.

37419


Based on record review and interview, the nursing staff failed to implement preventive interventions according to their policies and procedures for 6 of 7 patients at risk for pressure injury (Patient # 1, #4, #6, #7, #8, and #9) and nursing staff failed to monitor staff assisting with patient hygiene in 2 of 10 patient's receiving hygiene care (Patient #3 and #8) in a total of 10 medical records reviewed.

Findings include:

Record review of policy titled "Skin and Wound; Assessment/Reassessment and Care" #4301308 last approved 5/2019 under policy revealed "The RN (registered nurse) will complete a skin assessment according to the biological systems assessment ...All patients admitted to inpatient units will have a skin/wound assessment and a risk assessment [using Braden scale] by a registered nurse (RN) on admission, daily and with change of condition. A score of 18 or less indicates risk for pressure related to breakdown... E. Inpatients found at risk will have a plan of care implemented with appropriate interventions documented to prevent pressure related to breakdown." Under III Prevention Interventions revealed " A. Use of pressure relieving or pressure reducing measures for patients at risk for skin breakdown such as off loading heels, pressure reducing sleep surface, pressure reducing chair cushions, turn and reposition, use of pillows or other devices to protect bony prominence from direct contact with each and/or unrelieved pressure ... B. Use of measures to minimize friction and shear such as keep skin clean and dry, overhead trapeze bar, use of life sheet, lubricant, skin barrier creams or dressings. VI. Interventions revealed "The RN (Registered Nurse) will implement... interventions as appropriate. Under VIII. Patient/Family Education revealed "A. Instruct patient and/or caregiver regarding prevention measures such as the importance of frequent position changes, use of pressure reducing measures, management of incontinence, measures to minimize friction and shear."

Record review of "Mattress Guideline Quick Reference" indicated that patient's having a Braden score of less than 18 with 2 or more additional risk factors, qualify for a "Low Air Loss Mattress" (special mattress designed to prevent and treat pressure wounds). Risk factors revealed "Cannot be adequately positioned off existing pressure injury. Developed new pressure injury on EHOB (elevate head of bed) waffle overlay. Multiple stage 2, 3, 4, unstageable" pressure points.

Record review of email to Vice President O dated 4/01/2021 at 11:20 AM revealed ""What is the standard for hygiene (specifically bathing)". Response back from Vice President O on 4/01/2021 at 11:24 AM, revealed "We do not have this stated in a policy, but the general nursing standard of care is daily".

Review of Patient #1's medical record revealed Patient #1 is a 81-year-old who presented to the Emergency Department (ED) 12/02/2020 post COVID-19 11/10/2020, with weakness, garbled speech, unable to walk, and was admitted 12/03/2020 to the 2nd floor COVID unit, due to severe weakness. COVID-19 test was negative. Nursing skin assessment 12/02/2020 at 7:20 PM revealed "Red, Intact, Right and Left Medial Buttocks." with a Braden score of 17 (high risk of pressure injury) with no nursing, plan of care, interventions for risk for skin pressure injury, initiated. Nursing plan of care interventions for intact skin-sensory perception risk and intact skin-moisture exposure risk were initiated 12/08/2020 (6 days after admission) which included "Turn every 2 hours," "suspend float heels with pillows," "do not reposition on back," "Apply barrier cream" and "Low air loss mattress." Mobility flow sheet under "Activity" with no position changes documented every 2 hours. No order for low air loss mattress. Review of Patient #1's skin assessment and nursing pressure ulcer flow chart 12/02/2020 through 12/07/2020 with no barrier cream to sacral pressure ulcer documented. The last skin care assessment prior to transfer was completed 12/11/2020 at 7:34 AM. Patient #1 was transferred to the Inpatient Rehabilitation Unit 12/11/2020 at 1:53 PM. No pressure ulcers were noted on heels prior to transfer to Inpatient Rehabilitation Unit.

Review of Patient #1 History and Physical dated 12/11/2020 revealed Patient #1 was admitted to the Inpatient Rehabilitation (Rehab) Unit 12/11/2020 with a diagnosis including myopathy (disease that affects the muscles that control voluntary movement in the body), hypertension, and bilateral foot-drop. The first skin assessment documented by the registered nurse (RN) on the Inpatient Rehab Unit was dated 12/11/2020 at 2:25 PM, noting the unstageable pressure ulcer on the sacrum. Braden score was 15. On 12/11/2020 at 9:22 PM right and left heel stage 3 pressure ulcers were documentation by the RN. 12/13/2020 low air loss mattress was ordered (5 days after nursing intervention identified). Wound Care Note dated 12/14/2020 at 12:00 PM by Certified Wound Ostomy Nurse (CWON) K (5 days after first wound care consult, 3 days after Inpatient Rehab admission) under Plan for pressure ulcers revealed "Reposition every 2 hours. Heel suspension with pillows/heel suspension boots at all times while in bed... low air loss mattress," "cleanse with soap and water, rinse well and pat dry" daily, " Nursing care Mobility flowsheet under "Activity" revealed the following: 12/19/1010 at 6:15 AM "Repositioned, 12/20/2020 at 2:40 AM "Repositioned" (20 hours and 45 minutes later); 12/20/20 at 3:50 AM "Repositioned" 12/23/20 at 1 AM "Repositioned" (2 days, 22 hours, and 10 minutes later). There was no documented evidence of staff consistently repositioning Patient #1 every 2 hours. Patient #1 was discharged 12/29/2020 with home health for wound care, physical and occupational therapies.

On 3/31/2021 at 9:12 AM during interview with Unit Lead Supervisor P, Supervisor P stated interventions to prevent pressure injury should be documented and Supervisor P confirmed repositioning should be documented "every 2 hours during the day" and at a minimum, "every 4 hours" during the night on the Inpatient Rehabilitation Unit.

On 3/31/2021 at 3:31 PM during interview with 2nd Floor Manager D, when questioned about skin assessments related to Patient #1 care, Manager D stated "I can't speak to that" we had a high volume of patients at the time.

Review of Patient #3's medical record was started on 03/31/2021 at 4:40 PM. History and Physical dated 3/29/2021 revealed Patient #3 was admitted 03/29/21 at 1:20 PM for a right knee replacement surgery and is currently an inpatient at the time of this review. Review of Patient #3's "Hygiene" nursing assessments revealed there was no documented evidence of hygiene or oral cares being done (2 days after after admission).

On 3/31/2021 at 12:00 PM during interview with Registered Nurse H , H stated that patients should be offered hygiene and oral interventions at least daily.

On 3/31/2021 at 4:40 PM during interview with Director of Acute Care G, Director G confirmed there was no evidence of hygiene or oral cares documented in Patient #3's medical record.

Per interview with Chief Nursing Officer K on 3/31/2021 at 5:30 PM, the facility does not have a policy and procedure regarding patient hygiene and oral care.

Review of Patient #4's medical record revealed Patient #4 was admitted through the Emergency Department (ED) 2/26/2021 for a fall, which resulted in a closed right hip fracture and s/he underwent a right hip hemiarthroplasty (surgical procedure where half of the hip is replaced) on 2/27/2021 and Patient #4 was transferred to Inpatient Rehabilitation Unit on 3/04/2021. On 2/26/2021 at 5:21 AM initial nursing skin assessment revealed skin tear left buttock with a Braden score of 16 which dropped to 13 (indicating more risk for skin injury) on 3/04/2021 with documentation of a new "unstageble" pressure ulcer left buttocks. On 3/04/2021 at 10:57 AM wound care orders for buttocks/sacrum were put in by RN and revealed "Wound care to buttocks and sacrum twice daily and as needed; cleanse with soap and water ... apply clear barrier ointment and leave open to air." Review of Patient #4's nursing care flowsheet for skin care revealed no skin care documented 2/26/2021 through 3/04/2021. Nursing plan of care interventions for intact skin-mobility limitation risk were initiated 3/04/2021 (6 days after admission) which included "Turn every 2 hours," "suspend float heels with pillows," and "heel suspension boots," "do not reposition on back," "do not reposition on right," and "Use lift for boosting." Nursing care, Mobility flow sheet under "Activity" with no documentation of position changes every 2 hours, no use of heel suspension boots or use of a lift for boosting. Nursing plan of care interventions for intact skin-moisture exposure risk were initiated 3/04/2021 (6 days after admission) which included "Apply barrier cream" "Low air loss mattress." Nursing skin care flow sheet with no documentation of barrier cream being applied. Low air loss mattress was not ordered. Patient #4 was transferred 3/04/21 to the Inpatient Rehabilitation Unit. Patient's position is not documented, there was no documented evidence of staff consistently repositioning Patient #4 every 2 hours.

On 3/31/2021 at 4:55 PM during interview with Unit Lead Supervisor P, Supervisor P stated interventions to prevent pressure injury should be documented and Supervisor P confirmed reposition was not documented every 2 hours, barrier cream application was not documented, and a low air loss mattress was not ordered.

On 4/01/2021 at 11:07 AM during telephone interview with Director of Acute Care G, Director G confirmed the "floor nurses" are responsible for doing the skin assessments and making sure the nursing plan of care is being followed.

Review of Patient #6's medical record revealed Patient #6 was admitted as an inpatient on 12/11/2020 at 10:46 PM and discharged on 12/16/20 at 2:08 PM with a diagnosis of Shortness of Breath, Pneumonia, Chronic Obstructive Pulmonary Disease, and Dementia. Patient #6's initial nursing admission assessment dated 12/11/2020 at 11:11 PM, revealed unstageable wounds on the Left Dorsal 2nd toe, Right dorsal toe, and left medial foot present on admission with a Braden score of 13 on admission. 12/12/2020 at 1:20 AM nursing note revealed "Patient has skin concerns, wound care consulted, Meplix (dressing) placed on areas with Nursing Plan of Care intervention to "turn every 2 hours" and reposition as needed. Review of Physical Therapy note dated 12/12/2020 at 9:20 AM revealed that Patient #6 is a "total assist" for bed mobility requiring "assist of 2". Nursing note on 12/12/2020 at 11:49 AM revealed patient (pt) "is not able to make needs known at this time so pt is repositioned every 2 hours and checked for incontinence." Wound Care Ostomy Nurse (WCON) note dated 12/14/20 at 3:07 PM plan of care interventions listed: Reposition "every 2 hours", and "heel suspension" with pillows or heel suspension boots. Keep buttocks clean and dry, apply clear barrier ointment twice daily and as needed. Review of Patient #6 skin nursing assessment and interventions dated 12/14/2020 through 12/16/2020 revealed no documented evidence of nursing staff applying barrier ointment twice daily. Review of Patient #6's "Mobility" nursing assessment flowsheet under the category of "Activity" revealed the following: Staff documented "Repositioned" on 12/12/20 at 4:49 PM, nursing staff did not document repositioning again until 12/13/20 at 12:26 AM (7 hours and 36 minutes later). Staff documented "Repositioned" on 12/13/12 at 9:32 AM, nursing staff did not document repositioning again until 6:17 PM (8 hours and 45 minutes later). Staff documented "Repositioned" on 12/15/20 at 9:17 PM, nursing staff did not document repositioning again until 12/16/20 at 8:45 AM (11 hours and 28 minutes later). There was no documented evidence of staff consistently repositioning Patient #6 every 2 hours or application of barrier ointment twice daily.

On 3/30/2021 beginning at 4:00 PM, during interview with Registered Nurse H while doing medical record review, Registered Nurse H stated nursing staff should document application of barrier ointment and repositioning every 2 hours reflecting when the nursing interventions were completed.

Review of Patient #7's medical record, History and Physical dated 1/19/2021 revealed that Patient #7 was admitted on 1/19/2021 with the diagnosis of Acute Respiratory Failure and Chronic Obstructive Pulmonary Disease and discharged 1/22/21. Review of Patient #7's Physical Therapy note dated 1/20/21 at 4:15 PM revealed that Patient #7's "Bed Mobility" requires "Moderate assist," s/he needs "A lot" of help when turning from back to side while in a flat bed without using bed rails. There was no required documentation of Braden score obtained on admission or daily with skin assessments until 1/21/2021 at 9:29 AM, Braden score was 15 (high risk for pressure sores). Review of Patient #7's nursing "Plan of Care" documentation dated 1/19/2021 through 1/21/2021 showed no evidence of specific pressure ulcer prevention measures implemented. Review of Patient #7's nursing "Plan of Care" documentation dated 1/22/2021 at 6:48 am stated that Patient #7 was "Repositioned q (every) 2 hours". Per review of Patient #7's "Mobility" nursing assessment under the category of "Activity," flowsheet documentation revealed the following: Staff documented "Repositioned" on 1/21/2021 at 9:30 PM, nursing staff did not document repositioning again until 1/22/20 at 8:20 AM (10 hours and 50 minutes later). Staff documented "Repositioned" on 1/22/2021 at 10:50 AM, nursing staff did not document repositioning again until 5:00 PM (6 hours and 10 minute later). There was no documented evidence of staff consistently repositioning Patient #7 every 2 hours.

On 3/31/2021 at 10:30 AM during interview with Registered Nurse H, Registered Nurse H stated that s/he was unable to find evidence of a risk for impaired skin integrity plan of care implemented from 1/19/2021 to 1/21/2021 including interventions and patient education. Registered Nurse H confirmed staff did not document repositioning of Patient #7 every 2 hours.

Patient #8's medical record revealed Patient #8 was admitted as an inpatient on 12/18/2020 with the diagnosis of shortness of breath, atrial fibrillation, hypertension, and Covid-19 virus infection and discharged 12/22/2021. Admission nursing skin assessment 12/18/2020 at 8:00 AM revealed an open pressure wound to posterior right lower leg measuring 2 cm x 2 cm with a Braden score of 17. History and Physical dated 12/18/2020 at 11:27 AM under "Physical Exam" revealed "Bilateral lower extremity lymphedema. No evidence of open wounds or cellulitis... [s/he] moves lower extremities with some difficulty bilaterally." Review of Patient #8's Physical Therapy note dated 12/19/2020 at 4:26 PM revealed that Patient #8's "Bed Mobility" required "Moderate assist" and is "non-ambulatory at baseline". Review of the Physical Therapy notes "Problem list" stated that Patient #8 has decreased strength, decreased endurance, decreased mobility, impaired sensation, and decreased skin integrity. On 12/20/2020 at 10:45 PM, nursing skin assessment documented an "unstageable" wound/blister to right upper thigh with a decreased Braden score of 14 (increased risk for skin injury). Review of Patient #8's nursing "Plan of Care" note dated 12/21/2020 at 1:56 AM (3 days after admission) revealed to, "Repo (reposition) q (every) 2 hours. Review of Patient #8's nursing "Plan of Care" documentation from 12/18/2020 through 12/20/2021 showed no evidence of specific pressure ulcer prevention measures implemented or any evidence of staff educating and instructing Patient #8 on pressure wound prevention measures. Per review of Patient #8's "Mobility" nursing assessment under the category of "Activity" documentation revealed the following: Staff did not document repositioning of Patient #8 from 12/18/2020 7:00 AM until 12/20/2020 at 12:00 AM (41 hours later). Staff documented "Repositioned" on 12/20/2020 at 4:00 pm, nursing staff did not document repositioning again until 12/20/2020 at 10:45 pm (6 hours and 45 minutes later). Staff documented "Repositioned" on 12/22/2020 at 8:45 AM, nursing staff did not document repositioning again until 1:35 PM (4 hours and 50 minutes later). There was no documented evidence of staff consistently repositioning Patient #8 every 2 hours.

Review of Patient #8's "Hygiene" documentation in the nursing assessments revealed the following: Perineal care completed on 12/20/2020 at 10:45 PM (2 days after admission). Bath completed on 12/21/2020 at 12:00 PM (3 days after admission). Oral care completed on 12/22/2020 at 8:45 AM (4 days after admission).

On 3/31/2021 at 12:00 PM during interview with Registered Nurse H, Registered Nurse H stated that s/he was unable to find evidence of a nursing plan of care related to risk of impaired skin integrity, to included interventions and patient education, from 12/18/2020 to 12/21/2020. Registered Nurse H confirmed staff did not document repositioning of Patient #8 every 2 hours or educate patient on high risk for skin injury.

On 3/31/2021 at 12:00 PM during interview with Registered Nurse H , H stated that patients should be offered hygiene and oral interventions at least daily.

On 3/31/2021 at 5:30 PM, during interview with Chief Nursing Officer (CNO) K, CNO K stated the facility does not have a policy and procedure regarding patient hygiene and oral care.

Review of Patient #9's medical record revealed Patient #9 was admitted 10/17/2020 with the diagnosis of sepsis and altered mental status and discharged 10/27/2020. History and Physical revealed Patient #9 is wheelchair bound and is full assist with transfers. Nursing admission assessment 10/17/2020 at 11:30 PM revealed skin was "WDL" (within defined limits), warm, dry with no additional findings, and a Braden score of 12 (high risk for pressure injury). Review of Patient #9's Plan of Care daily nursing documentation from 10/18/2020 through 10/27/2020 revealed Patient #9 was identified as having problems associated with "skin integrity impairment risk", "intact skin-moisture exposure risk", intact skin-mobility limitation risk", and "intact skin-activity limitation risk". Review of Patient #9's Plan of Care nursing interventions revealed staff will reposition Patient #9 "every 2 hours", apply condom catheter to maintain skin, and apply heel boots. Per review of Patient #9's "Mobility" nursing assessment in the category of "Activity" documentation revealed the following: Staff did not document evidence of repositioning until 10/19/2020 at 4:00 AM (2 days after admission). Staff documented "Repositioned" on 10/19/2020 at 4:00 AM, nursing staff did not document repositioning again until 10/19/2020 at 9:01 AM (5 hours later). Staff documented "Repositioned" on 10/19/2020 at 11:00 AM, nursing staff did not document repositioning again until 10/19/2020 at 6:01 PM (7 hours later). Staff documented "Repositioned" on 10/19/2020 at 9:55 PM, nursing staff did not document repositioning again until 10/20/2020 at 8:55 PM (23 hours later). Staff documented "Repositioned" on 10/20/2020 at 8:55 PM, nursing staff did not document repositioning again until 10/21/2020 at 8:46 AM (12 hours later). Staff documented "Repositioned" on 10/21/2020 at 8:35 PM, nursing staff did not document repositioning again until 10/22/2020 at 9:00 AM (12 hours later). There was no documented evidence of staff consistently repositioning Patient #9 every 2 hours."

On 3/31/2021 at 3:00 PM during interview with Registered Nurse H, Registered Nurse H confirmed staff did not document repositioning every 2 hours.

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Based on record review and interview, the facility failed to perform skin and wound assessments according to the facilities policies and procedures for nursing care in 5 of 7 patients receiving wound care (Patient #1, #4, #6, #8 and #9) in a total of 10 medical records reviewed.

Findings include:

Record review of policy titled "Assessment/Reassessment of Patients, an Interdisciplinary Approach" #4268523, last approved 5/2019, Attachment A titled "Summary of Each Disciplines Scope of Assessment & Reassessment" revealed the time frame to assess Inpatient and Observation patients on admission is "within 4 hours of admission", Inpatient Rehabilitation revealed "Within 8 hours of admission." Reassessment Time Frame of Inpatient or Observation patients revealed "Minimally 3 times in a 24 hour period," Inpatient Rehabilitation "At least 2 times in 24 hours."

Record review of policy titled "Providing Basic Wound Care and Pressure injury treatment (sic)" #6990422 last revised 9/2019 under Shallow Wounds revealed "Cleanse with normal saline or wound cleanser ... Apply foam border dressing. Under Key Reminders revealed "Wound assessment should be performed on admission and with each dressing change (location, type/stage, wound base appearance, wound edge, surrounding skin, drainage/odor, measurement, undermining/tunneling). Wound measurements (LxWxD) (length, width, depth) should be performed on admission, weekly... and at discharge... Note: CWOCN (Certified Wound, Ostomy and Continence Nurse) consult must be initiated for any hospital acquired pressure injury." Under Stage I revealed " Initiate MD order for CWOCN consult." Under Deep Tissue Injury revealed "Intact or non-intact skin... non-blanchable deep red maroon, purple discoloration...dark wound bed or blood filled blister... Provide pressure relief and repositioning. Evaluate if upgrade in mattress is needed. If skin is intact, cleanse with soap and water... apply foam boarder dressing for protection. Lift dressing daily to inspect skin beneath... Change every 3 days and as needed ... Initiate MD order for CWOCN consult."

Record review of policy titled "Skin and Wound; Assessment/Reassessment and Care" #4301308 last approved 5/2019 under policy revealed "The RN (registered nurse) will complete a skin assessment according to the biological systems assessment ...All patients admitted to inpatient units will have a skin/wound assessment and a risk assessment [using Braden scale] by a registered nurse (RN) on admission, daily and with change of condition. A score of 18 or less indicates risk for pressure related to breakdown... E. Inpatients found at risk will have a plan of care implemented with appropriate interventions documented to prevent pressure related to breakdown." Under VII. Referral revealed "A Wound/Ostomy written referral is completed by the RN for any patients with a deep tissue injury, Stage III, Stage IV, or unstageable pressure ulcer, multiple areas of skin breakdown... or wound with necrotic tissue or slough. B. A wound/Ostomy referral should be ordered and/or reordered for pressure related breakdown in the presence of pressure reducing interventions and any signs of deterioration of a wound indicated by increased size, drainage odor or sign of infection."

Review of Patient #1's medical record revealed Patient #1 is a 81-year-old who presented to the Emergency Department (ED) 12/02/2020 post COVID-19 11/10/2020, with weakness, garbled speech, unable to walk. Patient #1 was admitted 12/03/2020 at 10:31 AM to the 2nd floor COVID unit, due to severe weakness, COVID-19 test was negative. Admission skin assessment 12/02/2020 at 7:20 PM revealed "Red, Intact, Right and Left Medial Buttocks" with no documentation of measurements. On 12/07/2020 at 8:10 AM, documentation of unstageable pressure ulcer sacrum was initiated by the registered nurse, (5 days after admission). No wound care consult was ordered. On 12/09/2020 at 1:08 PM wound care consult was ordered by Registered Nurse L (2 days after pressure wound sacrum was determined to be unstageable). The last skin care assessment prior to transfer to the Inpatient Rehabilitation Unit was completed 12/11/2020 at 7:34 AM. Measurements of sacral pressure ulcer was never documented. No pressure ulcers were noted on heels during this hospital admission. Patient #1 was discharged 12/11/2020 at 1:53 PM from the 2nd floor Medical Unit and admitted to the Inpatient Rehabilitation Unit. Discharge Summary by Doctor M 12/11/2020 at 8:59 AM, under Discharge Instructions and Follow-Up, revealed "Wound Care: none needed."

Review of Patient #1 History and Physical dated 12/11/2020 at 8:52 PM revealed Patient #1 was admitted to the Inpatient Rehabilitation Unit and discharged 12/29/2020. Under History of Presenting Illness revealed "with pressure also overlying the gluteal area bilateral noted on December 7th, 2020 currently slowly resolving." There was no skin assessment documented by the provider. A wound care consult order was entered by Registered Nurse (RN) N, 12/11/20 at 1:53 PM. The first skin assessment documented by the RN on the Inpatient Rehab Unit was dated 12/11/2020 at 2:25 PM, noting the unstageable pressure ulcer on sacrum. On 12/11/2020 at 9:22 PM right and left heel stage 3 pressure ulcers were documented by the RN. Wound care consult by Certified Wound Ostomy Nurse (CWON) K was completed 12/14/2020 at 11:58 AM (5 days after the first order for wound care was entered). Skin assessment performed 12/14/2020 by CWON K revealed 3 pressure ulcers (sacrum, left, and right heels) with the first measurements taken of the pressure ulcers. On 12/14/2020, CWON K's plan included wound care RN to follow patient weekly, and referral to Physical Therapy for pulsed lavage and debridement sacral wound (fluid flushed to clean the wound), pulse lavage recommended 2-3 times a week. Pressure ulcer measurements were not documented by nursing. Next wound care nurse visit note by CWON K was dated 12/23/2020 at 1:59 PM (9 days after the first assessment). Assessment "continues to have a deep undermining at noon to 2 ... will benefit from a wound VAC" (Vacuum-Assisted Closure), (decreases air pressure on wound to help heal wound more quickly). Wound VAC was applied 12/24/2020 at 9:57 AM. Pulse lavage of the sacral pressure ulcer was completed by physical therapy 4 times (12/17/20, 12/21/20, 12/23/20 and 12/28/2020) in the 15 days prior to discharge 12/29/2020. (less than recommended by CWON K on 12/14/2020). Patient #1 was discharged home 12/29/2020.

On 3/31/2021 at 9:12 AM during interview with Unit Lead Supervisor P, Supervisor P stated a full head to toe skin assessment must be completed on admission and three times daily on the general inpatient units, and twice a day in the Inpatient Rehab Unit "once every 12 hour shift." Supervisor P confirmed when a wound care consult is ordered, the goal is to have it completed within 24 hours. Supervisor P confirmed that Patient #1's bilateral heel pressure ulcers were not documented as being present on admission.

On 3/31/2021 at 3:31 PM during interview with 2nd Floor Manager D, when questioned about skin assessments and wound care related to Patient #1's care, Manager D stated "I can't speak to that" we had a high volume of patients at the time.

Review of Patient #4's medical record revealed Patient #4 was admitted through the Emergency Department (ED) 2/26/2021 for a fall, which resulted in a closed right hip fracture and s/he underwent a right hip hemiarthroplasty (surgical procedure where half of the hip is replaced) on 2/27/2021. Admission diagnoses included atrial fibrillation, renal failure, and bilateral interstitial pneumonia. Patient #4 was transferred to the Inpatient Rehab Unit on 3/04/2021. On 2/26/2021 at 5:21 AM initial nursing skin assessment documented skin tear left buttock. On 3/01/2021, no time noted, nursing documented deep tissue injury sacrum wound "unstageable," with no measurements documented. Nursing skin assessment flowsheet revealed no skin care of sacral wound documented, 2/26/2021 through 3/04/2021. On 3/04/2021 at 8:59 AM, RN documented new pressure ulcer left buttocks "unstageable." On 3/04/2021 at 10:46 AM, last documentation of sacral pressure ulcer prior to transfer revealed "Staging-Suspected deep tissue.. Purple;Red" No wound care consult was ordered. Patient #4 was transferred 3/04/21 to the Inpatient Rehabilitation Unit.

On 3/31/2021 at 4:55 PM during interview with Unit Lead Supervisor P, Supervisor P stated wound measurements should be documented or a notation that the wound was not measurable. Supervisor P confirmed that Patient #4's unstageable pressure ulcer left buttocks was not documented as being present on admission.

Review of Patient #6's medical record revealed Patient #6 was admitted as an inpatient on 12/11/2020 at 10:46 PM and discharged on 12/16/20 with a diagnosis of Shortness of Breath, Pneumonia, Chronic Obstructive Pulmonary Disease, and Dementia. On 12/11/2020 at 11:11 PM, initial nursing skin assessment revealed unstageable wounds on the Left Dorsal 2nd toe, Right dorsal toe, and left medial foot. On 12/12/2020 at 1:20 AM nursing note under Nursing Plan of Care revealed "Patient has skin concerns, wound care consulted, Mepilex (dressing) placed on areas." On 12/13/2020 at 1:28 AM nursing note revealed "Mepilex in place over stage II ulcerations on coccyx: Mepilex on heels bilateral; ecchymosis (bruising) right forearm." None of the pressure ulcerations were measured. Patient #6's nursing admission assessment showed no documented evidence of a coccyx stage II wound present on admission.

On 3/30/2021 at 4:00 PM, during interview with Registered Nurse H while doing medical record review, Registered Nurse H stated that skin and wound assessments should be performed and documented by a nurse 3 times in a 24 hour period and confirmed there was no documentation of the coccyx stage II wound on admission.

Review of Patient #8's medical record revealed that Patient #8 was admitted on 12/18/2020 and discharged on 12/22/20 with the diagnosis of shortness of breath, atrial fibrillation, hypertension, and Covid-19 virus infection. History and Physical dated 12/18/2020 at 11:27 AM under "Physical Exam" revealed "Bilateral lower extremity lymphedema. No evidence of open wounds or cellulitis...She moves lower extremities with some difficulty bilaterally." On 12/18/2020 at 8:00 AM initial nursing skin assessment revealed an open pressure wound posterior right lower leg measuring 2 cm x 2 cm. On 12/20/2020 at 10:45 PM, nursing skin assessment revealed an "unstageable" wound/blister to right upper thigh. No wound care consult was ordered. On 12/21/2020 at 9:30 PM, nursing staff documented redness to medial buttocks.

On 3/31/2021 at 12:00 PM during interview with Registered Nurse (RN) H, RN H confirmed there was no wound care consult completed for Patient #8. Registered Nurse H confirmed that Patient #8's right upper thigh wound/blister and redness to buttocks was not documented as being present on admission.

Review of Patient #9's medical record revealed Patient #9 was admitted on 10/17/2020 with the diagnosis of sepsis and altered mental status and discharged 10/27/2020. History and Physical, dated 10/17/2020 at 9:26 PM revealed Patient #9 is wheelchair bound and is full assist with transfers. Per review of Patient #9's Integumentary (skin) nursing assessment documentation dated 10/17/2020 at 11:30 PM, Patient #9's skin was "WDL" (within defined limits), warm, dry, and "No" was documented for "Integumentary Additional Assessments". Review of Patient #9's skin risk assessment/Braden score of 12 (indicating high risk for skin injury). On 10/23/2020 at 9:17 AM skin and wound assessment documentation revealed a "Stage 1" heel wound, "Wound Assessment" documentation showed heel wound was, "Intact,Red,Purple". On 10/23/2020 at 7:30 PM nursing wound assessment documentation identified a "Stage II" pressure injury to the "Buttocks," no measurements were documented. No wound care consult was ordered.

On 3/31/2021 at 3:00 PM during interview with Registered Nurse (RN) H , RN H stated there was no wound care consult ordered for Patient #9's hospital acquired pressure injury and RN H confirmed nursing staff did not document Patient #9's heel and buttocks pressure wounds as being present on admission.

Per interview 3/30/2021 at 1:45 PM with 2nd floor Manager D, Manager D stated the expectation for a wound consult to be completed after it is ordered, is within 24 hours "if possible."

On 4/01/2021 at 11:07 AM during telephone interview with Director of Acute Care G, Director G confirmed the wound care nurse does not always get to the wound consults within 24 hours and stated "the floor nurses" are responsible for doing the skin assessments and wound care.

37419


Based on record review and interview, the facility failed to follow their policies and procedures by failing to perform reassessments to manage pain in 3 of 4 patients experiencing pain (Patient #3, #4 and #5.) in a total of 10 medical records reviewed.

Findings include:

Record review of policy titled "Pain Management Resource" #8069523, last approved 5/2020 under Reassessment revealed "reassessment is 15-30 minutes after IV (intravenous) administration and 60-120 minutes after oral administration."

Patient #3's medical record was reviewed on 03/31/2021 at 4:40 PM. History and Physical dated 3/29/2021 revealed Patient #3 was admitted 03/29/21 at 1:20 PM for a right knee replacement surgery and is currently an inpatient at the time of this review. During review of Patient #3's medical record with Registered Nurse Lead H, Patient #3's Medication Administration Record revealed Patient #3 was given Oxycodone for pain on 03/30/21 at 2:12 PM. Review of Patient #3's "Pain Assessments" flowsheet showed no documented evidence of pain reassessments being done.

Patient #4's medical record was reviewed and revealed Patient #4 was admitted through the Emergency Department (ED) 2/26/2021 for a fall, which resulted in a closed right hip fracture and s/he underwent a right hip hemiarthroplasty (replacement of half of the hip) on 2/27/2021. Review of Patient #4's pain assessment flow sheet on 2/26/2021 at 5:46 PM revealed Patient #4 was medicated with Tramadol 50 mg (pain medication) one tablet and pain was reassessed at 11:00 PM (3 hours and 14 minutes later). 2/27/2021 at 6:30 PM Tramadol 50 mg tablet was given and pain was reassessed 2/28/2021 at 11:32 AM (15 hrs. late). On 2/28/2021 at 11:25 PM Tramadol 50 mg tablet was given, pain was reassessed 3/01/2021 at 9:30 AM (7 hours and 55 minutes late).

Review of Patient #5's medical record revealed Patient #5 was admitted on 2/2/2021 at 11:33AM and received surgery for a below the knee leg amputation on 2/03/2021. Review of Patient #5's Medication Administration Record revealed Patient #5 received intravenous Dilaudid for pain 2/04/2021 at 1:14 AM, 7:05 AM, and 12:22 PM. Nursing "Pain Assessment" flowsheet showed no evidence of a nurse reassessment of Patient #5's pain within 30 minutes after intravenous medication administration. On 2/05/2021 Patient #5 received intravenous Dilaudid for pain at 1:05 AM and 8:25 PM. Review of nursing "Pain Assessment" flowsheet showed no evidence of reassessment of pain within 30 minutes after intravenous medication administration.

On 3/31/2021 at 4:55 PM during interview with Unit Lead Supervisor P, Supervisor P stated pain is reassessed 1-2 hours after oral medications are given and confirmed, Patient #4's pain should have been reassessed earlier.

On 3/31/2021 at 4:40 PM during interview with Director of Acute Care G, Director G confirmed there were no pain reassessments documented in Patient #3 or Patient #5's medical record.