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Based on policy review, medical record review and interview, nursing services failed to provide necessary care and services to prevent the occurrence of healthcare-associated pressure injuries.

The findings included:

1. Nursing services failed to perform ongoing accurate assessments of patients in order to prevent healthcare-associated pressure injuries.

Refer to A 392.

Based on policy review, medical record review and interview, nursing services failed to provide accurate assessments and interventions to prevent the occurrence of healthcare-associated pressure injuries for 1 of 1 (Patient #1) sampled patients with pressure injuries.

The findings included:

1. Review of the facility's "PRESSURE INJURY AND WOUND TREATMENT GUIDELINES" policy revealed, "...Each patient is assessed for potential and actual skin breakdown on admission, daily, and as needed if patient's condition changes. Once assessed, prevention/treatment begins in a timely manner...1. Skin assessment is performed from head to toe with particular attention to the bony prominences...b. heels...2. Skin inspection includes warning signs for pressure injury development (e.g. redness, warmth, edema, induration)...".

2. Medical record review revealed Patient #1 presented to the facility's Emergency Department (ED) on 7/21/2020, after falling at home. The patient was found to have a right hip fracture that required surgical repair on 7/23/2020. Patient #1 was also noted to have diagnoses that included Gastritis, and Acute on Chronic Renal Failure. The patient was admitted to the swingbed unit of the facility on 7/26/2020 for rehabilitation services.

Review of the admission skin assessment on 7/21/2020 revealed no wounds or open areas to the patient's heels.

Review of daily flowsheets from 7/21/2020 through 8/16/2020 revealed skin assessments were performed every shift. There was no documentation of skin breakdown or injury to the patient's heels.

On 8/17/2020 at 11:46 AM, a note on the daily flowsheet, documented by RN #1, revealed an unstageable pressure injury to the right heel and left heel of Patient #1. The right heel wound was 7 centimeters (cm) in length by 4 cm in width. The left heel wound was 7 cm in length by 3 cm in width. The skin to both heels was described as black, burgundy and closed.

In an interview on 9/14/2020 at 10:00 AM in the conference room, the Quality Director and Chief Nursing Officer verified the skin assessments could not have been accurate. The Quality Director verified the unstageable wounds could not have occurred within one day.

The facility failed to ensure nursing staff performed accurate assessments to prevent the formation of unstageable wounds.