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Based on the review of policy and procedures, medical records, and staff interviews, it was determined that the facility failed to ensure that nursing staff and other personnel adhered to the facility's policy, procedures and protocols when it was determined that four (P#2, P#3, P#4, and P#6) of eight sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, and P#8) were not turned and repositioned every two hours.

Findings included:

A review of the facility's "Wound, Ostomy, Continence Nursing Consultation, Assessment, and Evaluation policy", Policy #PS-22, last reviewed December 2021, stated that the purpose of the policy was to define a process for initiation of wound care assessment and treatment by a wound, ostomy, and continence registered nurse (WOC RN). The WOC RN develops a plan of care and initiates wound treatment as appropriate; consults the provider if the plan of care (POC) extends beyond the usual nursing scope of practice; May place photographs of a wound in the patient's progress notes with other WOC RN documentation; Assess patient and develop patient plan of care; Discuss patient concerns, recommendations and/or orders with provider as needed prior to implementation of POC; Implement nursing interventions as needed for Pressure Injury Prevention and/or Treatment; Review plan of care with nurse caring for patient.


A review of the facility's "Prevention of Pressure Injuries policy", Policy #PS-48, last revised 12/29/2021 stated that the purpose of the policy was to define a process for the promotion and maintenance of skin integrity.
Assess all skin surfaces (including skeletal prominences) on admission and every shift. Utilize the appropriate Skin Assessment Form or Pressure Injury Assessment Form.
Assess patient risk for developing pressure injury using Braden or Braden QD Scale depending on the patient population.
Implement interventions for low-risk patients. See PS-48-03 Maintenance of Skin Integrity
" Braden Score greater than or equal to 18
" Braden QD Score less than 13.
" Implement interventions for high-risk patients.
" Refer to the computerized nursing plan of care for Impaired Skin Integrity.
" Braden Score less than or equal to 17 or other clinical indicators of high risk of impaired skin integrity.
" Braden QD Score greater than or equal to 13 or other clinical indicators of high risk of impaired skin integrity.
" Clinical indicators of high risk of impaired skin integrity include (but are not limited to): the use of 2 or more vasopressors, prone positioning, prematurity, and utilization of medical devices.


A review of the facility's "Maintenance of Skin Integrity Job Aid policy", Policy #PS-48-03, last reviewed 12/29/2021 stated that:
" Provide care to patients as listed below to prevent skin breakdown:
" Assess for reddened areas over bony prominences
" Reposition patient in bed or chair every two hours if unable to reposition self
" Instruct patient on causes and prevention of skin breakdown
" Keep skin clean, dry, and moisturized
" Use skin protective wipes or skin sealant under tape with dressing changes
" Use moisturizers or emollient lotions for dry skin
" Maintain the head of the bed at the lowest degree of elevation consistent with a medical condition.
" Use proper positioning, transferring, and turning techniques to prevent injury or friction
" Limit the use of adhesive products on thin, fragile skin
" Avoid the use of donut devices; may use pressure reduction chair cushion
" Avoid massage over skeletal prominences and discolored/hyperemic areas
" Minimize skin exposure to moisture from incontinence, perspiration, or wound drainage
" Document areas of redness that do not disappear within 30 minutes or any breaks in the skin.
" Notify Wound Care when assistance is needed.


A review of the facility's "Treatment of Pressure Injuries policy", Policy #PS-49, last reviewed 12/09/2021 stated that the purpose of the policy was to define a process for treatment of pressure injuries and prevention of further impairment of skin integrity.
Interventions include:
Assess all skin surfaces (including skeletal prominences, skin folds, and under medical devices) on admission and every shift.
Implement Wound Care Treatment Guidelines
Initiate Nurse-driven wound treatment protocol in Electronic Medical Record (EMR) as applicable.
Consult Wound, Ostomy, Continence (WOC) Nurse regarding altered skin integrity or for additional assistance.
Contact the Medical Doctor (MD) if the WOC Nurse is unavailable.

A review of Patient (P)#2's medical record revealed that P#2 was admitted to the facility on 4/11/2023 at 1:51 p.m. via the Emergency Department (ED) with the chief complaint of Shortness of Breath.

A review of the History and Physical (H&P) on 4/11/23 at 10:13 p.m. revealed that P#2 had a past surgical history of sacral wound debridement (a procedure that involves removing dead or infected tissue from the area around the lower back and buttocks) on 3/17/23. A review of the Plan of Care in the H&P notes revealed: falls/aspiration precautions, supplemental oxygen, intravenous antibiotics, telemetry monitoring, consider palliative care, and wound/dietician evaluation.

A review of the wound care nursing notes on 4/12/23 at 8:44 a.m. revealed that multiple pressure ulcers were present on admission on the sacrum, right back, right hip, right chest, and right arm. Staples were present on AKA site.

A review of the wound care consult notes on 4/13/23 at 5:46 p.m. revealed a Braden score (an assessment tool used to assess a patient's risk of developing a pressure ulcer) of 11. Documentation revealed a Wound Pressure Injury Sacrum, which was first assessed on 2/28/23, at a previous admission with a measurement of 10 cm in length by 8 cm in width, and a depth of 3.2 cm. Documentation revealed a site assessment of Brown; Black; Eschar; Nongranular; Pink; Red; Slough; and Tan with exposed structures of Adipose and muscle. Documentation revealed that drainage amount was moderate, and wound dressing was done with foam, moist to moist temporary dressing. Continued review of the wound care consult notes revealed that P#2 should be turned every two hours due to the Braden score.

Continued review of P#2's medical record revealed that wound care routine per protocol was ordered on 4/13/23 at 6:00 p.m.

An electronic medical record revealed that P#2 was not turned on:
4/13/23, from 4:23 a.m. to 8:00 a.m.
4/14/23, from 8:00 p.m. to 5:00 a.m.
4/15/23, from 5:00 p.m. to 9:00 p.m.
4/16/23, from 9:00 p.m. to 7:00 a.m.
4/16/23, from 11:30 a.m. to 4:30 p.m.
4/17/23, from 12:00 a.m. to 8:00 a.m.
4/17/23, from 9:00 p.m. to 8:00 a.m., 4/18/23
4/18/23, from 12:00 p.m. to 4:00 p.m.
4/20/23, from 12:00 p.m. to 4:00 p.m., and then from 4:00 p.m. to 9:00 p.m.
4/21/23, from 12:00 p.m. to 5:00 a.m.
4/22/23, from 4:00 a.m. to 9:30 a.m., and then 9:30 a.m. to 10:00 p.m.
4/22/23, from 10:00 p.m. to 8:00 a.m. on 4/23/23
4/23/23, from 1:00 p.m. to 5:00 p.m.
4/23/23, from 9:00 p.m. to 8:00 a.m., 4/24/23
4/24/23, from 8:00 a.m. to 12:00 p.m.
4/24/23, from 12:00 p.m. to 4:00 p.m.
4/25/23, from 4:00 a.m. to 8:00 a.m., and from 8:00 a.m. to 1:00 p.m.
4/26/23, from 8:00 p.m. to 6:00 a.m., 4/27/23
4/27/23, from 5:00 p.m. to 7:55 a.m., 4/28/23
4/28/23, from 9:00 p.m. to 8:00 p.m., 4/29/23
4/30/23, from 4:00 a.m. to 9:00 a.m.
4/30/23, from 9:00 a.m. to 6:39 a.m., 5/1/23
5/1/23, from 12:00 p.m. to 4:00 p.m.
5/1/23, from 9:00 p.m. to 6:00 a.m., 5/2/23
5/2/23, from 12:00 p.m. to 4:00 p.m., and from 4:00 p.m. to 8:00 p.m.
5/2/23, from 8:00 p.m. to 4:00 a.m. 5/3/23
5/3/23, from 4:00 p.m. to 8:00 p.m.
5/3/23, from 8:30 p.m. to 6:00 a.m., 5/4/23
5/4/23, from 4:00 p.m. to 8:30 p.m.
5/5/23, from 12:00 a.m. to 4:45 a.m.
5/5/23, from 4:00 p.m. to 8:00 p.m.
5/6/23, from 3:50 a.m. to 8:00 a.m., and from 10:00 a.m. to 4:00 p.m., and from 4:00 p.m. to 9:00 p.m.
5/6/23, from 9:00 p.m. to 8:00 a.m., 5/7/23

A review of Patient (P)#3 's record revealed that P#3 was admitted to the facility on 10/08/23 at 3:48 p.m. via the Emergency Department (ED) with the diagnosis of Acute Kidney Injury (sudden episode of kidney failure or kidney damage that happens within a few hours or a few days). Documentation revealed that P#3 had multiple wounds present on admission.

Documentation revealed that P#3 had the following wounds present on admission:
- Wound Pressure Injury, Coccyx, first assessed on 4/13/21 on a previous admission.
- Wound Skin Tear, Shoulder left, first assessed 10/9/23, present on original admission.
- Wound Skin Tear, Shoulder right, first assessed 10/9/23, present on original admission.
- Wound pressure Injury, Heel right, first assessed 10/9/23, present on original admission.
- Wound pressure injury, left, first assessed 10/9/23, present on original admission.

An electronic medical record review of the record revealed that P#3 was not turned and repositioned:
On 10/14/23 from midnight to 7:47 a.m., and from 8:00 p.m. to 7:55 a.m. on 10/15/23
On 10/15/23, from 8:40 p.m. to 4:00 a.m. on 10/16/23
On 10/16/23, from 10:16 p.m. to 3:39 a.m. on 10/17/23

A review of Patient (P)#4's medical record revealed that P#4 was admitted to the facility on 1/6/24 at 12:21 a.m. via the Emergency Department (ED) post-fall with Altered Mental Status.

A review of the skin assessment on admission revealed that P#4 had a wound, pedal anterior right, first assessed on 1/6/24 at 2:30 p.m.; Wound Ankle Anterior, left, first assessed on 1/6/24 at 2:30 p.m.; Wound skin tear knee left, lateral, first assessed 1/6/24 at 2:30 p.m.; Wound Leg anterior, distal, right, first assessed 1/6/24 at 2:30 p.m., and Wound Leg anterior, distal right upper, first assessed 1/6/24 at 2:30 p.m.

A review of the nursing notes on 1/9/2024 at 9:22 a.m. revealed a wound consult for multiple sores to bilateral lower extremities was ordered for P#4. Continued review of the nursing notes
revealed a wound pressure injury on the left heel, first assessed on 1/9/24 at 9:22 a.m. Documentation revealed that the site assessment was purple with a measurement of 3.5 cm in length, and 2 cm in width. Documentation revealed a wound pressure injury, to the right heel, first assessed 1/9/24 at 9:22 a.m. with a measurement of 6 cm by 5 cm and a purple site assessment. Continued review of the nursing notes on 1/9/2024 at 9:22 a.m. revealed the plan was to continue skin pressure injury preventive measures, turn the patient every two hours, and PRN (as required).

An electronic medical record review of the nursing progress notes revealed that P#4 was not turned as per order on the following days:
1/6/24, from 11:00 p.m. to 8:00 a.m. on 1/7/24
1/7/24, from 4:00 p.m. to 8:10 p.m.
1/8/24, from 6:02 a.m. to 2:00 p.m. and at 6:00 p.m.
1/8/24, from 10:00 p.m. to 8:00 a.m. on 1/9/24
1/10/24, turnings were missed at 10:00 a.m., 12:00 p.m., and 3:00 p.m.
1/12/24, from 2:00 p.m. to 9:16 p.m.
1/13/24, turnings were missed at 2:00 a.m. and 8:00 a.m.
1/13/24, from 10:00 a.m. to 9:30 p.m.
1/15/24, turning was missed at 6:00 p.m.
1/20/24, turning was missed at 6:00 a.m.
1/22/24, from 4:00 p.m. to 10:28 p.m.

A review of P#6's medical record revealed that P#6 was admitted to the facility on 1/15/24 at 3:12 p.m. via the Emergency Department (ED) with the diagnosis of Peripheral Artery Disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).

A review of the nursing notes on 1/22/24 at 10:15 a.m. revealed that P#6 had a wound pressure injury coccyx, first assessed 1/21/24 at 1:11 p.m. Documentation revealed a wound measurement of 6 cm in length, 5 cm in width, and 0.3 cm in depth. Documentation revealed that the wound was cleansed, and dressing applied.

A review of the nursing progress notes on 1/24/24 at 11:57 a.m. revealed a wound care consult for 1/23/24 at 12:09 p.m. for pressure injury to the sacrum/coccyx. Documentation revealed the dressing on the sacrum was saturated with bloody stool; cleansed, peri care was provided, and pads were changed. Documentation revealed that zinc oxide was applied on Vaseline gauze as the wound was wet and Z-guard ointment (medication to treat and prevent skin irritations) was not sticking well. Documentation revealed a plan to continue skin preventive measures; turn the patient every two hours and PRN (as required).

An electronic medical record review revealed that P#6's Braden Score on 1/15/24 at 7:30 p.m. was 17.
On 1/16/24 at 7:15 p.m., documentation revealed a Braden score of 15 with Redness on Sacrum.

Continued review revealed P#6 was not turned on:
1/16/24 from 8:00 a.m. to 7:15 p.m.
1/17/24, from 8:30 a.m. to 7:05 p.m. Documentation revealed a foam dressing was applied on the sacrum.
On 1/18/24 at 9:15 a.m., Documentation revealed that P#6's Braden score was 18.
On 1/19/24 at 11:07 a.m., turning was missed.

During the electronic medical record review, CC SS stated that patients are not required to be turned/repositioned by the facility's staff every two hours if they have a Braden score of 18 and above. CC SS stated that such patients are expected to turn and reposition themselves.

A review of the nursing progress notes on 1/31/24 at 11:20 a.m. revealed a Wound Pressure Injury, Coccyx, first assessed 1/21/24 at 1:11 p.m. now measuring 8 cm by 4.7 cm, and a depth of 0.3 cm. Documentation revealed to continue 2 hourly turns.

An interview took place in the conference room on 3/26/24 at 12:06 p.m. with Nurse Manager (NM) RR (Burn Unit/Inpatient Wound Care) who stated that clinical Coordinator (CC) SS was the first point of contact if there were any concerns regarding pressure injuries/ulcers, or wound care. NM RR stated that part of her duties is to educate staff, round on patients, and address any concerns about wound care. NM RR also stated that each unit leader is responsible for the chart audits.

An interview took place in the conference room on 3/26/24 at 12:15 p.m. with Clinical Coordinator (CC) SS, Wound Care who stated that she coordinated inpatient wound care and checked back on rounding for wound care. CS SS stated that she could only remember P#2 vaguely and could recall P#2's family did not want her (P#2) to have a colostomy, and the family was informed the wound might not heal.

An interview took place in the conference room on 3/26/24 at 1:10 p.m. with Assistant Nurse Manager (ANM) OO for the 2-North Unit who stated that the Care Partners do the turning and documented it every two hours. ANM OO stated that if the patient required the assistance of two staff, a care partner would go in with a buddy, which could either be another care partner or a Registered Nurse. ANM OO also stated that each patient's room had a turn clock, which helped to remind staff to strictly follow the two-hourly turn.

An interview took place in the conference room on 3/26/24 at 1:18 p.m. with Nursing Director (ND) PP, for the 2-North and 2-South units, who stated that processes are in place for audits for patients at high risk for skin breakdown. ND PP stated that a readiness meeting took place every morning to discuss patients at high risk for skin breakdown and to put necessary interventions in place.

An interview took place in the conference room on 3/26/24 at 1:43 p.m. with Registered Nurse (RN) QQ who stated that she personally worked with care partners to get things done. RN QQ stated that she usually reminded the care partners about turning/repositioning patients as she (RN QQ) did her hourly rounds on patients. RN QQ also stated that there are set parameters to follow as per wound care on the electronic medical record system.

A telephone interview took place on 3/28/24 at 9:30 a.m. with Care Partner (CP) VV who stated that there are "turn teams" on the units who specifically assist in turning patients with Braden scores of 17 or less. CP VV stated that the care partners do not work on weekends, and turning could be missed sometimes, especially if they are short-staffed.

Based on the review of the facility's policies/procedures, medical record review, and staff interviews, it was determined that the facility failed to safely discharge one (P#1) of eight sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, and P#8) P#1's change in condition was not identified before discharge, which resulted in P#1 being re-admitted immediately after discharge to the facility.


Findings include:

Cross refer to A-0396 as it relates to the nursing staff's failure to follow the plan of care when nursing staff failed to follow the plan of care for P#1.

Cross refer to A-0398 as it relates to nursing staff's failure to follow policies and procedures when P#1's change in condition was not identified prior to discharge.
Cross refer to A-0802 as it relates to the facility's failure to follow the discharge planning process by not identifying and re-evaluating changes in P#1's condition that required modification of the discharge plan.

Based on review of the facility's policies/procedures, medical record review, and staff interviews, the facility's discharge planning process failed to include a re-evaluation for one four (P#1) of eight patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, and P#8) for one (P#1) sampled patients. P#1's temperature on 2/26/24 at 4:02 p.m. 101.2 degrees. P#1 was discharged on 2/26/24 at 8:20 p.m. P#1 arrived back to the facility's ED on 2/26/24 at 9:12 p.m. with hypotension and a temperature of 101.3 degrees. P#1 was re-admitted with sepsis.

Findings:

Review of the "Assessment of the Patient" policy #PE-05-01, revised 11/1/22, revealed that patients would be reassessed after procedures, changes in condition, upon transfer to a different level of care, and at specified times based on the discipline and patient location.

Review of the "Nursing Plan of Care" policy #PS-51, revised 8/27/20, revealed that a Plan of Care (POC) was a process that included nursing assessments, diagnosis, interventions, goals, and evaluation of the patient's progress toward established goals. Patients would be assessed at admission then reassessed at specific times based on the level of care or when there was a significant change in the patient's condition.

Review of the "Disposition Planning" policy CC-15-01, revised 1/2017, revealed that all patients would be screened at the time of initial contact and at regular intervals during the hospitalization to identify continuing healthcare needs. The registered nurse would assess patients for potential post-hospital care needs. The patient's condition and disposition plan would be monitored to ensure the services arranged would meet the patient's healthcare needs at the time of discharge.


A review of an Emergency Department (ED) Report revealed that P#1 arrived at the ED on 1/30/24 at 2:19 p.m. with low blood pressure. P#1 was admitted as inpatient at 7:55 p.m.

A review of a nursing flowsheet on 2/26/24 at 4:02 p.m. by the Care Partner (CP) BB revealed that P#1 had a temperature of 101.2 degrees. Review of nursing documentation failed to reveal that the physician had been notified of the increased temperature.

A review of the Discharge Information revealed that P#1 was discharged with Home Health Services on 2/26/24 at 8:20 p.m.

A review of the Emergency Department (ED) Care Timeline revealed that P#1 arrived at the ED on 2/26/24 at 9:12 p.m. with hypotension (low blood pressure). The Quick Look vital signs at 9:42 p.m. revealed that P#1's temperature was high at 101.3 degrees.

A review of a Discharge Summary Note by MD EE 3/11/24 at 3:42 a.m. revealed that P#1 had sepsis due to recurrent urinary tract infections.


A telephone interview took place with the Registered Nurse (RN) GG on 3/27/24 at 11:10 a.m. RN GG said P#1 was discharged and had already left the unit by the time RN GG discovered the elevated temperature. If a patient was ready for discharge and presented like something was wrong, there would be a complete reassessment prior to letting the patient leave the facility. Patients were routinely assessed every two to four hours depending on their condition, including vital signs. RN GG said P#1 did not have any complaints and her condition seemed satisfactory at the time of discharge. RN GG did not notice the elevated temperature.

A telephone interview took place with RN HH on 3/27/24 at 2:59 p.m. RN HH said she was coming on evening shift and received a report from the previous nurse that P#1 was waiting for transport off the unit. All discharge paperwork had been completed. The charge nurse took over the discharge for P#1 since RN HH was tending to an emergency at the time. RN HH said nobody told her P#1 was running a fever.