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Based on policy review, medical record review, and interview, the hospital failed to have an organized nursing service which provided ongoing assessments of patients needs, failed to identify and implement measures to prevent skin breakdown, failed to identify skin breakdown before excessive tissue damage had occurred, and failed to follow physician orders for 1 of 3 (Patient #1) sampled patients who developed pressure injuries while hospitalized.

The hospital's failure to perform skin assessments on patients identified at risk for pressure injuries and to perform treatments as ordered by physicians placed all bedbound patients at an IMMEDIATE AND SERIOUS THREAT of their health and safety.

The findings included:

1. Review of the facility's policy titled, "Pressure Ulcer Prevention and Management" with last review date of 3/2020 revealed a Braden Skin Assessment was to be performed upon admission and every 12 hours after that.

Review of the facility's policy titled, "Assessment & Reassessment - Patient Guidelines" with last review date of 1/2022 revealed a nursing reassessment of the patient should occur at least every 12 hours with includes reassessment of patient wounds.

2. Patient #1 was transferred and admitted to the hospital from a Skilled Nursing Facility (SNF #1) on 12/19/2020 with complaints of possible dehydration. The patient was admitted to the hospital with diagnoses of Dehydration and Hypernatremia. There was no documentation Patient #1 had pressure injuries upon admission to the hospital.

Review of the nursing Braden Assessments, nursing Integument-System Review Assessments, and the nursing Integument Assessments revealed Patient #1 was at risk for skin breakdown; however, interventions were not consistently put in place to prevent the development of avoidable pressure injuries and the assessments that were completed inconsistently and inaccurately documented the actual status of the patient's skin.

During the patient's hospitalization, Patient #1 developed multiple pressure ulcers on her body that were not identified and/or documented by the nursing staff until excessive tissue damage had occurred. After the pressure injuries were identified, the nursing staff failed to consistently follow wound care orders.

Patient #1's nutritional needs were not based on an assessment of her numerous pressure injuries.

Patient #1 expired while hospitalized on 2/8/2022. There was no documentation of Patient #1's wounds noted on the discharge summary.
Refer to A-392

3. Review of Patient #1's Interdisciplinary Care Plan did not reveal documentation that Patient #1 was identified at risk for skin breakdown and/or pressure injuries or documentation of interventions developed and implemented to prevent skin breakdown and/or pressure injuries. After nursing had been made aware of the numerous hospital-acquired pressure injuries for Patient #1 there was no documentation the care plan had been reviewed or revised with interventions to treat the pressure injures and to prevent further breakdown.
Refer to A-396.

Based on policy review, medical record review, and interview, the hospital failed to ensure nursing services performed skin assessments, developed and implemented measures to prevent the development of preventable pressure injuries, and failed to identify actual skin breakdown until severe tissue injury occurred for 1 of 3 (Patient #1) patients who developed hospital acquired pressure injuries.

The findings included:

1. Review of the facility's policy titled, "Pressure Ulcer Prevention and Management" with last review date of 3/2020 revealed, "...The purpose of this policy is to establish guidelines for the identification, prevention, and care of patients at risk or with existing alteration in skin integrity...The Braden Risk Assessment Tool is used to evaluate and manage patients at risk for pressure ulcers. The Braden Risk Assessment is performed on all inpatients to evaluate the risk for pressure ulcer development...An initial Braden Risk Assessment is to be completed by a registered nurse on all patients in the Emergency Department for greater than 2 hours and by a licensed nurse once every 12 hours thereafter...Acute care & Critical Care units...A Braden Risk Assessment is to be completed by a registered nurse on admission, and then at each shift (no more than 12 hours between assessments), at transfer and with a change in status or medical condition...Definitions...Pressure Ulcer Staging...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. May also present as an intact or open/ruptured serum-filled blister...Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling...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. Often includes undermining and tunneling...Suspected Deep Tissue Injury - Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue...Unstageable - full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the wound bed...The purpose of Staging Pressure Ulcers is to describe the amount of tissue destroyed...Procedure...Admission Assessment (performed by a registered nurse)...Braden Risk Assessment will be performed and a risk assessment score determined...Risk Assessment scores 1) 19-23 indicates not risk for skin breakdown 2) Score of 18 and below indicates risk for skin breakdown...A skin assessment will be performed. This will include, but is not limited to: Skin tears, pressure ulcers, scars, incisions, rashes, and other alterations in skin integrity...Reassessment...A Braden Risk reassessment will be performed and documented at each shift (no more than 12 hours between assessments), at transfer, and with a change in status or medical condition by the RN caring for the patient...The skin assessment will be performed on admission and no less than every 12 hours...Pressure ulcer prevention may include but not limited to the following interventions determined by the patient's condition and physician's orders...Turn and position at least every 2 hours...Offload heels using pillows under legs or don offloading heel protectors...Head of bed up at 30 degrees or less as tolerated...Apply skin protectant/barrier and provide frequent garment/linen changes...Avoid use of non-breathable moisture retaining pads...Avoid use of adult incontinent briefs (diapers)...Consult the Wound Nurse, Physical Therapist, and Clinical Nutrition for added Pressure Ulcer recommendations...For patients identified as having pressure ulcers and other wounds regardless of the Braden Risk Assessment Tool score, the following minimal interventions are initiated...Notify the physician and consult wound care nurse, physical therapy, nutrition, and case manager to determine the interdisciplinary treatment and discharge plan...Photograph pressure ulcers using hospital approved digital camera, print images, and document on the medical record...The physician may use established clinical practice guidelines or may choose alternative method of treatment based on individual patient needs...Once a hospital acquired stage 3 or 4 pressure ulcer is identified, a hospital occurrence report (2SRM Report) is completed and forwarded to the appropriate manager or director for investigation and filing with the Risk Manager...Once a pressure ulcer is identified, the appropriate clinical practice guideline may be implemented with a physician's order or a wound specialist's order...Once a pressure ulcer is identified, the patient's individual plan of care is updated to reflect this condition...Documentation...All wounds present on admission will be documented as present on admission...The Braden Risk Assessment Score will be documented on the Nursing Admission/Nursing Assessment...The skin assessment will be documented on the Nursing Admission/Assessment...Prevention interventions will be documented...Treatment measures will be documented...The pressure ulcer will be assessed at a minimum for...Exudate...Presence for necrotic tissue...Appearance of wound bed...Odor...Appearance of surrounding skin...Pain level with pressure ulcer dressing change...Stage...Size in centimeters...Location..."

2. Review of the facility's policy titled, "Assessment & Reassessment - Patient Guidelines" with last review date of 1/2022 revealed, "...An admission assessment will be performed by the RN within twelve (12) hours...The history must be completed within the first twenty-four (24) hours admission. The admission assessment and history data will be documented...Included in the admission assessment are Braden skin assessment, Morse Falls Risk assessment, Pain and Venous Thromboembolilsm (VTE) prevention assessment...The RN, after review of the history and assessment data, will identify problems utilizing the nursing process based on individual patient needs. Identified problems will be listed on the patient's interdisciplinary plan of care. Patient problems are revised as needed utilizing all available data...Reassessment is completed by a nurse every 12 hour shift in inpatient areas or more frequently as indicated by patient condition or unit specific parameters...The scope and intensity of further assessment is based on the patient's diagnosis, the care setting, the patient's desire for care, the patient's response to any previous care and the patient's consent...Braden skin assessment, morse Falls Risk and pain assessments are performed on every 12 hour shift) and as patient condition warrants...The care plan is revised as needed to reflect status changes and subsequent assessment data...Reassessment includes but is not limited to review of the following parameters...Wounds, dressings...Skin integrity..."

3. Review of the facility's Job Description for "RN" (Registered Nurse) revealed, "Develops plan of care for newly admitted patients and modifies as condition/needs change. Delivers designated nursing interventions to assigned patients that are consistent with the stated medical plan of care...Notifies appropriate nursing and medical staff of changes in the patient's status...Documents nursing care accurately and completely in all assigned patient records. all patient related information is documented completely on appropriate forms...Evaluates care given including the patient responses. Reassesses and documents the proposed revision of interventions and desired outcomes..."

4. Review of the facility's "Core Skills Competencies & Accountabilities..." for RNs revealed, "...Performs head-to-toe assessment on all patients; assessment and reassessment of the patient is clearly and concisely communicated in charting...Documentation meets current standards, policies and procedures and is completed per policy...Provides direct patient care and ongoing patient assessment through communication with and observation of patients, consults with family and interdisciplinary team and ongoing review of records...Reports occurrences which are detrimental to patient or to the effective functioning of the unit, to the appropriate supervisor in a timely manner...Keeps physicians, Nurse Manager and other members of the care team informed of patient's needs or changes in a timely manner...Provides care appropriate to disease condition and age of patient; coordinates and supervises patient as necessary..."

5. Review of the facility's Job Description for "Wound and Ostomy RN" revealed, "...Delivers designated nursing interventions to assigned patients that are consistent with the stated medical plan of care. Performs assessment, evaluation and management for skin, wound and ostomy patients. Assists others with patient's activities and care. Executes physician's orders for assigned patients; safely and properly administers medications and treatments related to skin, wound and ostomy care. Notifies appropriate nursing and medical staff to changes in the patient's status. Independently performs duties and assumes responsibility for skin, wound and ostomy care of assigned patients...Evaluates care given including the patient response. Documents reassessment and modification of skin, wound and ostomy plan of care..."

6. Medical record review revealed Patient #1 presented to the facility's Emergency Department (ED) from a Skilled Nursing Facility (SNF #1) on 12/19/2021 with complaints of possible dehydration.

The ED Physician's note dated 12/19/2021 at 7:48 PM revealed Patient #1 had a past medical history of Hypertension (high blood pressure), Myocardial Infarction (heart attack), and a Cerebro-vascular Accident (stroke). A Basic Metabolic Panel and Complete Blood Count was completed and the patient was started on IV fluids and medications to increase her appetite and treat her Hypertension.

A physician's order dated 12/19/2021 at 10:51 PM revealed a Braden Scale Assessment was to be performed upon admission and every 12 hour shift thereafter.

Patient #1 was admitted to the hospital's telemetry unit for observation on 12/20/2021 with diagnoses which included Dehydration and Hypernatremia. (A condition in which the sodium level in the blood is elevated.)

Review of the initial Braden Assessment performed on 12/19/2020 at 7:27 PM revealed Patient #1 had the potential for problems with friction and shear and a Braden score of 15 indicating the patient was at risk for skin breakdown. There was no documentation interventions were put into place to decrease the risk for skin breakdown.

Review of the Braden Assessments from the day of admission on 12/19/2021 at 11:38 PM through 1/28/2022 at 8:39 PM revealed there were no Braden Assessments performed on the night shift on 12/20/2021, 12/21/2021, 12/22/2021, and 12/23/2021. There were no Braden Assessments performed on any shift on 12/24/2021. There were no Braden Assessments performed on the night shift on 12/25/2021, 12/27/2021.

Patient #1 was transferred from the hospital's observation unit to the hospital's inpatient unit on 12/28/2021. There were no Braden Assessments performed on the night shift on 12/30/2021, and 12/31/2021. There was no Braden Assessment performed on the day shift on 1/14/2022 and no Braden Assessments performed on the night shift on 1/15/2022, 1/16/2022, 1/19/2022, 1/20/2022, 1/22/2022, and 1/29/2022.

The Braden Assessments that were performed on 12/19/2021 at 11:38 PM through 1/28/2022 at 8:39 PM, revealed Patient #1 was at risk for skin breakdown with Braden Scores ranging from 8 to 15 and had the "Potential problem" with Friction and Shear. There was no documentation of interventions to prevent skin breakdown noted from 12/25/2021 through 1/4/2022; 1/7/2022; 1/10/2022; 1/15/2022 through 1/17/2022; and 1/19/2022 through 1/22/2022.

Review of the Integumentary Assessments and the Integumentary Assessment-System Reviews dated 12/19/2021 at 11:32 PM through 1/6/2022 at 8:00 AM revealed the facility failed to ensure Integumentary Assessments and/or Integumentary Assessment-System Reviews were performed on 12/24/2021 and 1/3/2022. All Integumentary Assessment-System Reviews that were performed from 12/19/2021 at 11:32 PM through 1/6/2022 at 8:00 PM revealed Patient #1's integumentary system was "WDL...Integumentary Assessment Within Normal Limits Definition...Adult: Skin is warm, dry, intact and elastic. Mucous membranes are moist and pink. Skin color is acceptable for ethnicity..."

There were no Integumentary Assessments performed on 1/7/2022; the night shift on 1/8/2022 and 1/9/2022; the day shift on 1/14/2022; and the night shift on 1/15/2022, 1/16/2022, and 1/17/2022.

All Integumentary Assessments performed from 1/8/2022 at 8:00 AM through 1/20/2022 at 8:00 AM revealed an "Oral Assessment Description." There was no other documentation regarding the status of Patient #2's skin on the Integumentary Assessments reviewed.

Review of a physical therapy treatment note dated 1/14/2022 at 4:01 PM, revealed Patient #1 "has skin tears, weeping, and edema noted on LUE [left upper extremity]..." There was no documentation the nursing staff or physicians were notified of the findings, and no documentation interventions were put in place to treat the wounds, and no documentation the wound care nurse was consulted.

Review of a nursing note dated 1/18/2022 at 8:12 PM, revealed, "...pt blisters on left arm peeling skin elbow forearm. but pressure ulcer open to air. RN apply new foam with medi honey / cream. RN apply barrier cream to pt right hip. Place pillow between knees..." There was no documentation describing the wounds further, no documentation the physician was notified of the findings, and no documentation the wound care nurse was consulted.

The Integumentary Assessment performed on 1/21/2022 at 8:22 AM revealed Patient #1's "Left arm has open wound from where arm had blisters", a "right hip wound" and a "wound to coccyx." There was no documentation describing the wounds further, no documentation the physician was notified of the findings, and no documentation interventions were put in place to treat the wounds, and no documentation of interventions for the treatment of the wounds identified.

There was no Integumentary Assessment performed on 1/22/2021.

The Integumentary Assessment performed on 1/23/2022 at 9:50 PM revealed Patient #1 had "draining sacral wound, generalized skin tears with peeling." There was no documentation describing the wounds further, no documentation the physician was notified of the findings, and no documentation interventions were put in place to treat the wounds, and no documentation the wound care nurse was consulted.

A physician's order dated 1/24/2022 at 8:42 AM revealed, "...Wound Care Consult...draining sacral wound..."

The Integumentary Assessment performed on 1/24/2022 at 9:00 PM revealed Patient #1 had "Tenderness...draining sacral wound, generalized skin tears...skin tears on elbow; sacral wound." There was no documentation describing the wounds further and no documentation interventions were put in place to treat the wounds.

The Integumentary Assessment performed on 1/25/2022 at 8:00 AM revealed Patient #1 had "generalized wounds, skin ear [tear] on left arm multiple popped blisters, right hip discoloration, sacral pressure injury" and her coccyx was described as "Erythema, Fragile, Moist, Pink, Red, Thick."

Review of a Communication/Notification note dated 1/25/2022 at 8:22 AM revealed, "family concerned pt skin break down left arm wound, not changed since 1/22, sacral wound, multiple wounds on body..."

Review of a Communication/Notification note dated 1/25/2022 at 11:49 AM revealed, "NP [nurse practitioner] call RN back use lavuse to wash pt wounds, petroleum dressing and foam..."

A physician's order dated 1/25/2022 at 2:18 PM revealed Dakins 1/4 strength topical solution, 1 application for irrigation twice daily for dressing changes. The order did not specify which wound (s) the solution was to be used on.

Review of a Communication/Notification note dated 1/25/2022 at 2:34 PM revealed "RN speak with wound care nurse about pt wounds "no one has documented her wounds all hospital acquired, pt needed wound care consult" dressing changed left knee, right thigh, right hip, sacrum, left arm..."

A physician's order dated 1/25/2022 at 2:19 PM revealed, "Wound Care by Nursing...Cleanse area with Vashe' - skin prep periwound - Zinnnnnc [zinc] Paste to wound edge - Pack wound with Dakins Moistened gauze/Kerlix - Cover with a Sacral Foam Dressing. BID [twice a day] and PRN [as needed] if soiled., Sacrum..."

Review of the Wound Care Note dated 1/25/2021 at 3:46 PM revealed, "Pt [Patient] was seen today per request for sacral wound...The pt was examined and the wounds are as follows:
L [left] Elbow: 6 x 9 x 0.01...elbow has an open shallow wound with small...drainage - no odor - the wound appears to be a skin tear with a significant amount of epilifting that has pulled away from the wound and hardened. There is no s/s [signs and symptoms] of pressure - rather a result of the pts condition of Covid with microvascular damage and sheering of the skin. The wound was cleansed with Vashe' - then Xeroform Gauze was placed over the wound and then a Foam Dressing - change QOD [every other day] and PRN [as needed] if dislodged.
L - Hip/Trochanter - PI [Pressure Injury] Stage 3 - 2 x 2 x 0.1 -- Wound edge is attached - 100 % [percent] thin yellow slough - slight..drainage - no periwound involvement with breakdown or darkening. Area was cleansed with Vashe' - Xeroform gauxe [gauze] and a dab of Medihoney Gel to wound bed - covered with Foam Dressing. QOD and PRN.
L- Hip Posterior Trochanter - 8.5 x 9.5 x 0.01 -- Area is a presentation that also represents as result of the pts condition of Covid with microvascular damage and a sheering of the skin and associated pressure. The area is covered with a thin epilifting of skin that has also hardened - the wound bed underneath is red/pink and appears as a shallow wound. The wound was cleansed with Vashe' - then Xeroform Gauze was placed over the wound and then a Foam Dressing - change QOD and PRN if dislodged.
L Buttock: 9 x 5 x 0.01 -- Area is a presentation that also represents as result of the pts condition of Covid with microvascular damage and sheering of the skin and associated pressure. The area is covered with a thin epilifting of skin that has also hardened - the wound bed underneath is red/pink and appears as a shallow wound. The wound was cleansed with Vashe' - the Xeroform Gauze was placed over the wound and then a Foam Dressing - change QOD and PRN if dislodged.
L Foot - Lat [lateral] 5th Met [metatarsal] head - Combination of pressure and Covid related skin condition - closed area of dark purple/blackened 1.7 x 2 -- skin prepped and then allowed to dry - Daily and PRN - needs Heel Boots.
L Great Toe Distal tip: 1.5 x 1.5 -- Reddened area that is closed - combination of pressure and covid related condition. Skin prepped and allowed to dry. Daily and PRN - needs Heel Boots.
L Ankle PI/U [pressure injury/ulcer] -- 4 x 2 -- Pt with PI to ankle with attached and closed eschar - the periwound is darkened and the area is intact. There is a distinct Covid and pressure combination of skin breakdown in this area. Area was cleansed with Vashe' - skin prepped liberally and allowed to dry - Daily and PRN -needs Heel Boots.
L Knee: 6 x 1.5 x 0.01 -- Area with epilifting and wound bed appears shallow - slight...drainage - wb [wound bed] is darker pink and may have a small area of combination Covid and pressure that is from the pt's contractures. Cleansed with Vashe' - then Xeroform Gauze was placed over the wound and then a Foam Dressing - change QOD and PRN if dislodged.
R Shin: 3.5 x 2 -- Area is a presentation that also represents as result of the pts condition of Covid with microvascular damage and sheering of the skin and associated pressure. The area is covered with a thin epilifting of skin that has also hardened - the wound be underneath is red/pink and appears as shallow wound. The wound was cleansed with Vashe' - then Xeroform Gauze was placed over the wound and then a Foam Dressing - change QOD and PRN if dislodged.
R Hip: PI/Unstageable -- R hip has an area of darkened eschar that is attached with pink red wound edge...drainage - no periwound involvement - no odor - the wound edge has some epilifting and the wound appears to have the combination Covid and Pressure mix. The wound was cleansed with Vashe' - then Xeroform Gauze was placed over the wound and then a Foam Dressing - change QOD and PRN if dislodged.
Sacral Wound - PI - 9 x 9 x 3 - Unstageable wound that has an odor - has mod [moderate] tan...drainage - the wound edge is attached with the wound covering of light brown thickened slough/eschar 80%. The wound and Covid related skin issues with some pressure - edges do have some pink tissue - but over all anemic looking. The periwound is intact and the wound does have some maceration noted to the distal edge. Etiology of the wound appears to be a combination of MASD [moisture associated skin damage]. The wound was lavaged [washed out] with Vashe' - then zinc paste to wound edge and then Vashe' moistened gauze packed lightly in the wound bed - covered with Foam Dressing. Change BID [twice a day] and PRN if strik thru. Will order Dakins' Sol [solution] to be using instead of the Vashe'. Pt's sacral wound would benefit from debridement - possible SX [surgical] Consult - however family will need to be involved in decision for either Palliative care or aggressive measures towards healing. REC [recommend] See wound treatments above - will be reflective in the nursing orders. Turn Q [every] 2 [hours] and PRN using Pillows and a wedge to support side lying. Freq [frequent] incontinent care as needed using Barrier Creams and Foams for skin protection. Heel boots to be worn at all times. P500 bed..."

The nursing Integumentary Assessment completed on 1/25/2022 at 9:50 PM revealed Patient #1 had "Tenderness...draining sacral wound, generalized skin tears" and her right hip was described as "Black, Red, Thin, Warm."

The nursing Integumentary Assessment completed on 1/26/2022 at 8:00 AM revealed Patient #1 had a "sacral wound," her left arm was "Pink" and her right hip was "Red." There was no documentation wound care was completed.

The nursing Integumentary Assessment completed on 1/26/2022 at 9:38 PM revealed Patient #1 had "sacral wound, left arm healing blisters." There was no documentation wound care was completed.

A physician's orders dated 1/27/2022 at 10:01 AM revealed, "...Wound Care by Nursing...Cleanse areas with Vashe' - apply skin prep and then reapply Heel Boots. Daily and PRN, Bilat [bilateral] feet darkened areas. L Ankle...Check wound site daily..."

A physician's order dated 1/27/2022 at 10:03 AM revealed, "...Wound Care by Nursing...Q [every] Other Day, PRN...Cleanse area with Vashe' - place cut piece of Xeroform gauze - Cover with Foam Dressing., R Hip - R shin..."

A physician's orders dated 1/27/2022 at 10:05 AM revealed, "...Wound Care by Nursing...Q Other Day, PRN...Cleanse with Vashe' - cut and place Xeroform Gauze over area - Cover with Foam Dressing...L Knee/L Hip/L Elbow..."

A physician's orders dated 1/27/2022 at 10:07 AM revealed, "...Pressure Relieving Device...Bilat Heel Boots - For relief of heel pressure..."

A physician's orders dated 1/27/2022 at 10:08 AM revealed, "...P500 Bed - Pressure..."

There was no Integumentary Assessment performed on the night shift on 1/27/2022 or the day shift on 1/28/2022. The Integumentary Assessments performed on 1/27/2022 at 7:50 AM and on 1/28/2022 at 8:39 PM revealed an "Oral Assessment Description." There was no other documentation regarding the status of Patient #1's skin on either one of the Integumentary Assessments. There was no documentation wound care was provided as ordered.

Review of the Nutrition Services assessments performed 12/21/2022 at 1:11 PM through 1/24/2022 at 12:09 PM revealed Patient #1's skin was "Intact" and had Braden scores of 11 and 12. There was no documentation Nutrition Services was consulted to evaluate if there were any additional nutritional interventions recommended to promote wound healing after Patient #1's wounds were identified.

Review of a physician's Discharge Summary dated 1/30/2022 revealed Patient #1 "...initially presented to the hospital on 12/20 from [SNF #1] with suspected dehydration...found to be hyponatremic ["hypernatremic" admitting diagnosis] and was started on IV fluids. Megace [a medication used to increase appetite] was added and family requested information on a PEG [percutaneous endoscopic gastrostomy tube]" (A PEG tube is a medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate.) Patient #1 "was evaluated by GI [gastro-intestinal physician], however ended up refusing the PEG. She also had persistent tachycardia [rapid heart rate] and was evaluated by cardiology. Throughout her hospital stay she continued to have poor p.o. [per oral] intake. She was medically cleared for discharge and her family refused a PEG. The day discharge was planned, her family agreed upon PEG placement, therefore her discharge was canceled and PEG was ordered. Overnight, she had a respiratory decline. Work-up revealed that she had suspected pneumoperitoneum. [the presence of air in the area surrounding the abdominal cavity]. Due to her decline, family was agreeable to GIP [general inpatient] hospice..." Patient #1 was transferred to the hospital's hospice floor on 1/29/2022 in "grave" condition with diagnoses which included Dehydration, Hypernatremia, Moderate protein-calorie malnutrition, Tachycardia, Essential Hypertension, History of Deep Vein Thrombosis, Gastroesophageal Reflux Disease, Covid - 19, and Pneumoperitoneum (Patient #1 developed Covid -19 while hospitalized).

Patient #1 expired in the hospital on 2/8/2022 with diagnoses which included Covid-19 viral syndrome, Acute Hypoxic Respiratory failure secondary to Bilateral Pneumonia, Dehydration, Hypernatremia secondary to Dehydration, Hypertension, and Pneumoperitoneum. There was no mention of Patient #1's numerous pressure ulcers in the discharge summary.

The facility failed to provide appropriate care and services to prevent skin breakdown for Patient #1 whom they determined was at risk for skin breakdown. The facility further failed to accurately and consistently assess the patient's skin status, and failed to identify hospital acquired pressure injuries and wounds until they were Stage 3, 4, and/or unstageable. There was no documentation wound care was provided after the initial wound care assessments and treatments were performed by the wound care nurse on 1/25/2022 at 3:46 PM. There was no documentation noted to reveal why orders for wound care were not written until 1/27/2022, two days after the wound care nurse consult occurred.

During an interview on 3/1/2022 at 12:30 PM, the Director of Nursing Inpatient Services (DONIPS) verified Braden Assessments and Integumentary Assessments should have been completed "once a shift."

During an interview on 3/1/2022 at 4:05 PM, the Wound Care Nurse (WCN) was questioned about measures put in place to prevent skin breakdown for patients identified at risk. The WCN stated pericare and incontinence care were always ongoing and the "nurses and CNAs [Certified Nursing Assistants] always consult me." The WCN then stated the standard of care is to put foam dressings on the sacrum or areas that are compromised and those dressings should be changed daily and as needed if soiled. The WCN then stated if foam dressings weren't used, barrier creams were used to protect the skin; other times, the areas were left open to air depending on the status of the wound. The WCN nurse was asked how she knew which patients should be seen. The WCN stated, "the nurses know if they see something, they know to put a foam dressing on the sacrum and alert me if something has changed."

During a interview on 3/2/2022 at 4:10 PM, the Chief Nursing Officer and the Director of Quality Improvement (DQI) verified nursing staff should have identified the patient's wounds before they were Stage 3, 4, or unstageable.

During an interview on 3/3/2022 at 1:35 PM, the DQI informed this surveyor no hospital occurrence report was completed when the pressure ulcers were identified as required by the facility's "Pressure Ulcer Prevention and Management" policy.

During an interview on 3/7/2022 at 1:50 PM, the Chief Medical Officer for the Midsouth Region stated, "We dropped the ball and now we have to fix it."

Based on policy review, medical record review, and interview, nursing services failed to ensure each patient's interdisciplinary care plan was developed with appropriate interventions to promote skin integrity, and failed to update or revise the care plan with appropriate interventions to promote healing of wounds once alterations in skin integrity were identified for 1 of 3 (Patient #1) patients at risk for skin breakdown reviewed.

The findings included:

1. Review of the facility's policy titled, "Pressure Ulcer Prevention and Management" with last review date of 3/2020 revealed, "...The purpose of this policy is to establish guidelines for the identification, prevention, and care of patients at risk or with existing alteration in skin integrity...The Braden Risk Assessment Tool is used to evaluate and manage patients at risk for pressure ulcers. The Braden Risk Assessment is performed on all inpatients to evaluate the risk for pressure ulcer development...An initial Braden Risk Assessment is to be completed by a registered nurse on all patients in the Emergency Department for greater than 2 hours and by a licensed nurse once every 12 hours thereafter...Acute care & Critical Care units...A Braden Risk Assessment is to be completed by a registered nurse on admission, and then at each shift (no more than 12 hours between assessments), at transfer and with a change in status or medical condition...Risk Assessment scores 1) 19-23 indicates not risk for skin breakdown 2) Score of 18 and below indicates risk for skin breakdown...A Braden Risk reassessment will be performed and documented at each shift (no more than 12 hours between assessments), at transfer, and with a change in status or medical condition by the RN caring for the patient...The skin assessment will be performed on admission and no less than every 12 hours...Pressure ulcer prevention may include but not limited to the following interventions determined by the patient's condition and physician's orders...Turn and position at least every 2 hours...Offload heels using pillows under legs or don offloading heel protectors...Head of bed up at 30 degrees or less as tolerated...Apply skin protectant/barrier and provide frequent garment/linen changes...Avoid use of non-breathable moisture retaining pads...Avoid use of adult incontinent briefs (diapers)...Consult the Wound Nurse, Physical Therapist, and Clinical Nutrition for added Pressure Ulcer recommendations...For patients identified as having pressure ulcers and other wounds regardless of the Braden Risk Assessment Tool score, the following minimal interventions are initiated...Notify the physician and consult wound care nurse, physical therapy, nutrition, and case manager to determine the interdisciplinary treatment and discharge plan...Once a pressure ulcer is identified, the patient's individual plan of care is updated to reflect this condition..."

2. Review of the facility's policy titled, "Assessment & Reassessment - Patient Guidelines" with last review date of 1/2022 revealed, "...An admission assessment will be performed by the RN within twelve (12) hours...The RN, after review of the history and assessment data, will identify problems utilizing the nursing process based on individual patient needs. Identified problems will be listed on the patient's interdisciplinary plan of care. Patient problems are revised as needed utilizing all available data...Reassessment is completed by a nurse every 12 hour shift in inpatient areas or more frequently as indicated by patient condition or unit specific parameters...The care plan is revised as needed to reflect status changes and subsequent assessment data...Reassessment includes but is not limited to review of the following parameters...Wounds, dressings...Skin integrity..."

3. Review of the facility's Job Description for "RN" (Registered Nurse) revealed, "Develops plan of care for newly admitted patients and modifies as condition/needs change..."

4. Medical record review revealed Patient #1 presented to the facility's Emergency Department (ED) from Skilled Nursing Facility (SNF #1) on 12/19/2021 with complaints of possible dehydration. Patient #1 was admitted to the hospital's telemetry unit for observation on 12/20/2021 with diagnoses which included Dehydration and Hypernatremia. (A condition in which the sodium level in the blood is elevated.) The patient was transferred from the facility's observation unit to an inpatient unit on 12/28/2021.

The Braden Assessments performed on 12/19/2021 at 11:38 PM through 1/28/2022 at 8:39 PM revealed Patient #1 was at risk for skin breakdown with Braden Scores ranging from 8 to 15 and had the "Potential problem" with Friction and Shear. There was no documentation of interventions to prevent skin breakdown noted from 12/25/2021 through 1/4/2022; 1/7/2022; 1/10/2022; 1/15/2022 through 1/17/2022; and 1/19/2022 through 1/22/2022.

A physical therapy note dated 1/14/2022 revealed Patient #1 had edema and skin tears that were weeping on her left upper arm. There was no documentation the nursing staff or physicians were notified of the findings, and no documentation interventions were put in place to treat the wounds, and no documentation the wound care nurse was consulted.

A nursing note dated 1/18/2022, revealed blisters and peeling skin were noted on Patient #1's left arm, elbow and forearm. The RN dressed the wound, and applied barrier cream to the patient's right hip; however; there was no documentation describing the wounds further, no documentation the physician was notified of the findings, and no documentation the wound care nurse was consulted.

The nursing Integumentary Assessments performed on 1/21/2022 at 8:22 AM through 1/23/2022 at 9:50 revealed Patient #1 had skin breakdown on right hip, left arm, coccyx, as well as blisters and skin tears. There was no documentation describing the wounds further, no documentation the physician was notified of the findings, and no documentation interventions were put in place to treat the wounds, and no documentation the wound care nurse was consulted.

A physician's order dated 1/24/2022 at 8:42 AM revealed, "...Wound Care Consult...draining sacral wound..."

A Communication/Notification note dated 1/25/2022 at 2:34 PM revealed "...no one has documented her wounds all hospital acquired, pt needed wound care consult" dressing changed left knee, right thigh, right hip, sacrum, left arm..."

Patient #1 was evaluated by the Wound Care Nurse (WCN) on 1/25/22 at 3:46 and the patient had an open wounds on the left elbow, a Stage 3 Pressure Injury on the Left hip/trochanter, an open wound on the posterior aspect of the left hip, an open wound on the left buttock, and area of pressure and Covid related skin damage on the 5th toe of the left foot and left big toe, a Pressure Injury on the left ankle, and open wound on the left knee, and open wound on the right shin, an unstageable Pressure Injury on the Right hip, and an unstageable Pressure Injury on the sacrum.

There was no documentation on the Interdisciplinary Care Plan initiated on 12/24/2021 to indicate Patient #1 was at risk for skin breakdown, and no documentation the care plan was updated to reflect the patient's impaired skin integrity once the wounds were identified.

Patient #1 was transferred to the hospital's hospice floor on 1/29/2022.

Review of a physician's Discharge Summary dated 1/30/2022 revealed Patient #1 was transferred to the hospital's hospice floor on 1/29/2022 in "grave" condition with diagnoses which included Dehydration, Hypernatremia, Moderate protein-calorie malnutrition, Tachycardia, Essential Hypertension, History of Deep Vein Thrombosis, Gastroesophageal Reflux Disease, Covid - 19, and Pneumoperitoneum (Patient #1 developed Covid -19 while hospitalized). There was no documentation of the patient's wounds on the Discharge Summary.

Patient #1 expired in the hospital on 2/8/2022 with diagnoses which included Dehydration, Hypernatremia, and Acute Hypoxic Respiratory failure secondary to Bilateral Pneumonia related to acute Covid 19 syndrome. There was no mention of Patient #1's numerous pressure ulcers in the discharge summary.

During a interview on 3/2/2022 at 4:10 PM, the Chief Nursing Officer and the Director of Quality Improvement (DQI) verified nursing staff should have identified the patient's wounds before they were Stages 3, and 4, or unstageable.

During an interview on 3/7/2022 at 1:50 PM, the Chief Medical Officer for the Midsouth Region stated, "We dropped the ball and now we have to fix it."