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Based on interviews and document review, the facility failed to ensure nursing care was provided that 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 in one of three patients reviewed. (Patient #2)

Findings include:

Facility policies:

The Skin Integrity Assessment policy read, a complete head to toe, visual assessment of the skin of each patient is done upon admission to the hospital and reassessed each shift with documentation. Determination of risk for developing pressure injuries is the responsibility of the RN. Assessments with the nursing skin risk assessment scale are performed by RNs every shift. Pressure injuries present on admission or discovered during hospital care are to be photographed. Sequential photographs will be made following any surgical debridement, weekly, and prior to discharge. Physician and Wound/Ostomy Department will be notified whenever there is worsening of wound condition.

The Wound Assessment, Management, and Documentation policy read, all wounds, including pressure injuries, will be assessed upon admission or discovery, and with significant changes and upon discharge. Skin assessments are done every shift, or with change in patient's condition to identify any new wounds in a timely manner. Hospital acquired pressure injuries are reported to physician and wound nurse.

The Pressure Injury Prevention policy read, all patients will be assessed for risk of pressure injury on admission, every shift, and with significant change in condition. Appropriate preventive interventions will be implemented. General pressure injury prevention interventions are: Place silicon-coated foam border dressing over sacrum prophylactically. If patient declines to be turned, determine and address issues. Instruct patient and family how lack of repositioning can contribute to skin breakdown, continue to offer to reposition every two hours and document patient's response every time.

The Pressure Ulcer and Prevention And Management policy read, this policy is to identify patients at risk for pressure ulcer development and reduce the incidence of pressure ulcers. To utilize appropriate treatment methodologies in order to resolve and/or prevent further tissue breakdown. A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.

Definitions of pressure ulcers: Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (tissue material made up of dead tissue, pus, and other debris that accumulates on a wound's surface). Stage III: Full thickness tissue loss. Subcutaneous fat may be visible. Slough may be present but does not obscure the depth of tissue loss. Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (a hardened layer of dead tissue that can impede healing) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined.

All patients are assessed for their risk of developing pressure ulcers utilizing the Braden Scale upon admission and during each shift throughout their hospital stay. A total Braden Scale score of 18 or below in an adult patient is considered predictive for development of a pressure ulcer unless preventative measures are taken. Braden Scores will be classified as: Generally not at risk- Greater than 18, At Risk- 15 to 18, Moderate Risk- 13 to 14, High Risk- 10 to 12, Very High Risk- 9 or below.

1. The facility failed to ensure patients at risk of pressure injuries were monitored and had implemented interventions to protect patients' skin integrity.

A. Record review

i. The medical record for Patient #2 was reviewed. Patient #2 presented to the hospital on 4/29/24 with shortness of breath, became hypotensive (low blood pressure), and briefly lost pulses. Patient #2 was intubated (insertion of a breathing tube) and admitted to the intensive care unit (ICU) with a diagnosis of sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection).

ii. Patient #2 was hospitalized from 4/29/24 to 5/19/24, a total of 21 days. On admission to 5/3/24 Patient #2's skin was noted as intact. On 5/3/24, documentation revealed Patient #2 had a stage 1 pressure injury to the coccyx (the last bone at the bottom of the spine), and a Mepilex (foam dressing) was applied. There was no evidence a Mepilex dressing was applied prior to 5/3/24.

This was in contrast to the Pressure Injury Prevention policy which read, appropriate preventive interventions will be implemented. Place silicon-coated foam border dressing over sacrum prophylactically.

iii. Review of Patient #2's medical record revealed the skin risk assessment was not completed for the day shifts on 5/4/24, 5/8/24 and 5/18/24. Patient #2's skin risk assessment Braden score ranged from 8 (very high) to 18 (at risk) from 4/29/24 to 5/19/24.

This was in contrast to the Pressure Ulcer and Prevention And Management policy which read, all patients are assessed for their risk of developing pressure ulcers utilizing the Braden Scale during each shift throughout their hospital stay.

iv. Review of Patient #2's medical record revealed a skin assessment was not performed for the day shifts on 5/5/24 and 5/9/24, or the night shift on 5/15/24.

This was in contrast to the Skin Integrity Assessment policy which read, a complete head to toe, visual assessment of the skin of each patient is done each shift with documentation.

This was also in contrast to the Pressure Injury Prevention policy which read, all patients will be assessed for risk of pressure injury every shift.

v. Review of Patient #2's medical record revealed on 5/10/24 the pressure injury to the coccyx had advanced to a stage 2. A wound care consult was ordered on 5/17/24 at 6:10 p.m., seven days after the pressure injury had worsened. Medical records revealed the wound care consult did not occur as Patient #2 was discharged on 5/19/24. On 5/19/24 at 11:40 a.m., just prior to discharge, Patient #2's pressure injury to the coccyx was noted as stage 2 with eschar (hardened, dry, dead tissue), fat, and slough (yellow to white material in a wound bed) with purulent (thick wound drainage) brown drainage noted.

This was in contrast to the Wound Assessment, Management, and Documentation policy which read, hospital acquired pressure injuries are reported to physician and wound nurse.

This was also in contrast to the Skin Integrity Assessment policy which read, Physician and Wound/Ostomy Department will be notified whenever there is worsening of wound condition.

vi. Review of Patient #2's medical record revealed two photographs were taken of the pressure injury on 5/17/24 and 5/19/24. Patient #2's stage 1 pressure wound was discovered on 5/3/24 and had advanced to a stage 2 on 5/10/24. The first photograph was taken 14 days after the pressure wound was discovered.

This was in contrast to the Skin Integrity Assessment policy which read, Pressure injuries discovered during hospital care are to be photographed. Sequential photographs will be made weekly, and prior to discharge.

B. Interviews

i. On 10/14/24 at 1:33 p.m., an interview was conducted with wound care nurse (WCN) #1. WCN #1. WCN #1 stated the WCN could be consulted by nurses at any time for pressure wounds of any stage. WCN #1 stated a Mepilex dressing was to be placed on the patient's coccyx as a preventative measure if the patient's risk score was high. WCN #1 stated skin assessments were important because there was a risk of infection, sepsis, and death.

WCN #1's interview was in contrast with Patient #2's medical record which showed the patient did not have a Mepilex dressing applied until a pressure injury was identified, although they scored high risk.

ii. On 10/14/24 at 1:51 p.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated a patient's skin was to be assessed every shift by the RN which included all bony prominence areas such as the shoulders, heels, and coccyx. RN #2 stated risk scores were to be performed every shift. RN #2 stated high risk patients were turned every 2 hours, a Mepilex dressing was to be placed on the coccyx to prevent pressure injuries. RN #2 stated it was important to prevent pressure injuries because it could cause sepsis and death.

iii. On 10/14/24 at 2:09 p.m., an interview was conducted with RN #3. RN #3 stated every patient's skin was to be assessed, and a risk score was to be performed by the nurse each shift. RN #3 stated if a patient scored high risk on the Braden Scale, the RN was to follow interventions such as applying barrier cream, turning the patient every two hours, and applying a Mepilex dressing to the coccyx. RN #3 stated a wound care consult could be ordered if a pressure wound was present on admission, if a wound had advanced to stage 3, or at any time the nurse felt a consult was necessary. RN #3 stated patients were at risk of infection, organ failure, and death or increased skin breakdown if preventative measures were not implemented.