The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

MARSHFIELD MEDICAL CENTER - WESTON 3400 MINISTRY PARKWAY WESTON, WI 54476 March 25, 2019
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record review and interview, the hospital failed to ensure it provided patients/patient representatives with a written grievance response containing the required regulatory elements, in 1 of 1 patients ( Patient #1) in a total sample of 16 patients.

Findings include:

On 2/28/19 at 2:00 PM reviewed hospital policy "Patient Complaints and Grievances" dated 9/5/2017 revealed "2. Response of Grievance Process. A. The department leader or designee will inform the patient of the specific time frame for review and response during initial contact with the patient. Most grievances should be reviewed and resolved with a final grievance response letter mailed to the patient or patient's representative within 7 days. If the grievance is not resolved, or if the investigation is not or will not be completed within 7 days, the patient shall be informed of the process of the investigation, and given a reasonable timeframe for completion. The department leader or designee will document in the ERS ticket the estimated timeframe to complete the review, this is not to exceed 30 days if possible."

On 2/28/19 at 1:30 PM reviewed grievance file for Patient #1. Grievance was filed on 1/25/19 via email. No resolution letter has been sent to the patient or patient's representative.

An interview was conducted with Director of Quality B on 2/28/19 at 4:00 PM. Director of Quality B stated the facility offered the family (of Patient #1) a meeting to better understand the concerns. Director B was asked if the facility sent the resolution letter and Director B stated "we know we are over the deadline."
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record review and interview, nursing staff failed to report skin pressure injuries on the date the injury was identified in 3 of 3 patients with skin pressure injuries (Patient #1, 2, and 3) out of a total universe of 16 patients.

Findings include:

On 2/28/19 at 12:00 PM, facility policy titled "Event Reporting" dated 9/8/2017 was reviewed and revealed "B. The Organizational Associate that first identifies that an Event has occurred, or who first is notified that an Event has occurred, must initiate completion of an Event Report by the end of the shift during which the Event occurred or one was notified of an event occurring."

On 2/28/19 at 1:30 PM, facility Event Reporting Logs were reviewed and revealed three events of skin pressure injuries between 11/6/2018 and 1/11/2019.
Patient #1's Event Report revealed, "When did the event occur: 12/18/18." This skin pressure injury was not reported until 1/14/2019.
Patient # 2's Event Report revealed, "When did the event occur: 1/9/2018." This skin pressure injury was not reported until 1/30/2019.
Patient #3's Event Report revealed, "When did the event occur: 11/6/2018." This skin pressure injury was not reported until 11/13/2018.

During an interview on 2/28/2019 at 4:02PM, Director B confirmed for Patients #1, 2, and 3 that neither nursing staff nor wound clinic nurses completed incident reports upon identification of the acquired pressure injury during the inpatient stay per facility policy. Patients #1, 2, and 3's pressure injuries were "discovered" in the medical record by quality or documentation review staff upon retrospective review. Director B stated, "we have identified a lack of education on who should be entering incident reports. We expect the nursing staff to do this."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record review and interview, facility staff failed to develop skin integrity care plans for 10 of 10 at risk patients (Patients #1, 2, 3, 5, 11, 12, 13, 14, 15, 16) and failed to perform preventive interventions for 8 of 10 patients at risk for impaired skin integrity (Patients #1, 2, 3, 5, 11, 12, 13, 15), in a total sample of 16.

Findings include:

Facility staff failed to implement protective interventions and prevent skin breakdown for patients at risk. See tag A395.

Facility staff failed to develop care plans with measurable goals and interventions for at risk patients. See tag A396.

These deficient practices have the potential to affect all patients at risk for impaired skin integrity admitted to the facility and has resulted in new pressure ulcers for 3 of 10 at risk patients (Patients #1, 2, 3).

An immediate jeopardy (IJ) was identified on 3/25/2019 at 3:11 PM under Nursing Services (A-385), when the facility failed to document interventions for the prevention of new or worsening pressure injuries in patients identified as at risk for skin breakdown per facility policy in 8 of 10 (Patients # 1, 2, 3, 5, 11, 12, 13, 15) patients identified as at risk for skin breakdown, out of a total universe of 16 patients. Patients # 1, 2, and 3 did not present with pressure injuries upon admission and developed preventable pressure ulcers while in the care of this facility.

Quality Director B, Vice President of Patient Care Services D, Quality Coordinator G, and Risk Manager K were notified of the immediate jeopardy on 3/25/2019 at 3:40 PM. The immediate jeopardy was not removed by the exit of the survey on 3/25/2019 at 5:20 PM.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the facility failed to document repositioning for the prevention of new or worsening pressure injuries in patients identified as at risk for skin breakdown per facility policy in 8 of 10 (Patients # 1, 2, 3, 5, 11, 12, 13, 15); failed to notify the physician of new and changing wound status for 2 of 3 patients (Patients #1, #3); failed to measure wounds per policy for 4 of 4 patients (#1, #2, #3, #12); failed to follow wound consult recommendations for 2 of 2 patients (Patients #1, #3); failed to provide pressure relieving interventions per policy for 8 of 8 patients (Patients #1, 2, 3, 5, 11, 12, 13, 15); and failed to provide incontinence care per policy for 4 of 4 patients (Patients #3, #5, #12, #15), out of a total universe of 16 patients. Patients #1, 2, and 3 were admitted with no pressure injuries upon admission and developed preventable pressure ulcers while in the care of this facility.

Findings include:

Review of facility policy titled, "Skin Integrity Management Clinical Practice Guidelines for Inpatients", approved 1/29/2019 (no policy #) revealed the hospital uses the Braden Scale to determine patient risk of skin breakdown:
Very High Risk: Total Score 6-9
High Risk: Total Score 10-12
Moderate Risk: Total Score 13-14
At Risk: Total Score 15-18
No Identified Risk: Total Score 19-23
Policy revealed, "2. Braden risk assessment should be done on admission and daily for all inpatient units ... 3. Skin assessment should be performed on admission and every shift thereafter. Initiate a skin integrity care plan appropriate for the patient based on Braden Score result (Braden score of 18 or lower) ...Notify the provider with presence of skin alterations upon admission or throughout the course of hospitalization ...Further descriptions of the wounds or ulcers will be documented in a narrative note as needed."

Review of facility policy # 58 titled, "Routine Skin Care and Prevention", last revised 7/19/2018 revealed, "2. Interventions B. Positioning...Pressure redistribution surface as needed for chair and/or bed...If patient is at risk for skin breakdown change position every 2 hours when in bed [12 times in a 24 hour period]. Limit sitting to no more than 1 hour at a time. Encourage patient to shift weight every 15 minutes if able. NO Rings or DONUTS!...4. Document Assessment findings and interventions".

Review of facility policy # 47 titled, "Skin Tear Assessment and Treatment", last revised 2/23/2018 revealed, "3. Document ...A. Initial wound documentation to include wound type, location, wound history, measurement, odor, drainage, wound bed (tissue type), peri-wound skin, signs/symptoms of [DIAGNOSES REDACTED]. D. Dressings used and any other interventions performed (culture, pressure relief measures, patient and caregiver education)."

Review of facility policy # 80 titled, "Pressure Injury - Stage 1 and Deep Tissue Pressure Injury Assessment and Treatment", last revised 2/23/2018 revealed, "Document ...A. Initial wound documentation to include location, wound history, stage of injury, measurement, temperature variations, color, tissue consistency (boggy, mushy, firm), peri-wound skin, signs/symptoms of [DIAGNOSES REDACTED]"

Review of facility policy # 02 titled, "Pressure Injury - Stage 2 Assessment and Treatment", last revised 2/23/2018 revealed, "1. Physician Notification ...A. Notify patient's physician and/or designee of: 1. Presence of pressure injury/injuries upon admission. 2. Development of pressure injury during patient's stay. 3. Progression of pressure injury stage ...B. Relieve pressure to site of injury...4. Document ...A. Initial wound documentation to include location, wound history, stage of pressure injury, measurement, odor, drainage, wound bed, peri-wound skin, signs/symptoms of [DIAGNOSES REDACTED]. D. Physician notification: presence of pressure injury, stage and progression."

Review of facility policy # 29 titled, "Pressure Injury - Stage 3 Assessment and Treatment", last revised 7/19/2018 and facility policy # 15 titled, "Pressure Injury - Stage 4 and Unstageable Assessment and Treatment", last revised 2/23/2018 revealed, "1. Physician Notification ...A. Notify patient's physician and/or designee of: 1. Presence of pressure injury/injuries upon admission. 2. Development of pressure injury during patient's stay. 3. Progression of pressure injury stage ...B. Relieve pressure to site of injury...3. Management ...E. Consider appropriate support surface and/or devices. F. Consult physician or wound care specialist/team ...4. Document ...A. Initial wound documentation to include location, wound history, stage of injury, measurement, odor, drainage, wound bed with % of granulation versus necrotic tissue, presence of undermining tunneling, appearance of wound edge (curled or rolled), peri-wound skin, signs/symptoms of [DIAGNOSES REDACTED]. Provider notification: presence of pressure injury, stage and progression. E. Interventions."

Review of facility policy # 20 titled, "Incontinence Skin Care Urinary and Fecal", last revised 3/15/2018 revealed, "Gently cleanse perineal area from front to back using a pH balanced skin cleanser after each incontinence epsiode...Pat area dry...Assess skin after each cleansing...Protect intact skin...Apply a protective ointment to intact skin after each cleansing...Document... Assessment findings and interventions."

Patient #1

Patient #1 was admitted [DATE] at 2:40 PM for a hip fracture and had a history of the following comorbidities: congestive heart failure (CHF), end-stage kidney disease requiring dialysis, diabetes, prostate and renal (kidney) cell cancer, hematuria (blood in urine), radiation cystitis (inflammation of the bladder as a result of radiation treatments for [DIAGNOSES REDACTED]), pulmonary hypertension (high blood pressure affecting arteries in the lungs and heart), [DIAGNOSES REDACTED](irregular, rapid heart rate), and generalized weakness (per "Hosp (sic) [Hospital] History and Physical").

Further review of Patient #1's nursing documentation titled, "Multi-Disciplinary Charting" and wound care documentation titled, "Nurses Notes (Clinic Non-Appt (sic) [Appointment] Document", "Wound Healing Photographic Record", and "Progress Note" revealed:

Review of the admission nursing assessment in "Multi-Disciplinary Charting" on 12/10/2018 revealed "Mobility: repositions with assistance" and "Integumentary Assessment: Within Normal Limits." Braden risk assessments on 12/10/2018 revealed Patient #1 was "at risk" for skin breakdown with an assessment score of 17 at 3:20 PM and 15 at 8:00 PM.

Patient #1 was admitted with no documented evidence of skin breakdown in the "Multi-Disciplinary Charting" record. No interventions to reposition every 2 hours were implemented in response to Patient #1's Braden scores and in accordance with facility policy.

No turning or repositioning was documented in "Multi-Disciplinary Charting" for Patient #1 from 12/11/18 at 8:00 AM until 13 hours later, on 12/22/18 at 8:45 AM. The next documented repositioning was nearly 7 days later, on 12/19/2018 at 7:25 AM.

Patient #1's "Integumentary assessment" in "Multi-Disciplinary Charting"on 12/18/2018 at 1:40 PM revealed the first documentation of the presence of a pressure ulcer. "Location #1: Sacral; Etiology #1: pressure ulcer; Type/Stage #1: Stage 2 - break in skin, blisters or abrasions; Size #1: measured; Dressing #1: Dressing changed; Drainage #1: Old drainage; Peri-wound #1: Pink."

Review of Patient #1's "Multi-Disciplinary Charting" revealed no documentation that the physician was notified of Patient #1's change in condition upon identification of the pressure injury on 12/18/2018 per policy, or that the wound measurements were documented upon initial identification of the pressure injury on 12/18/2018 per policy.

Patient #1's "RN Inpatient Wound Care Consult" in the document titled, "Nurses Notes (Clinic Non-Appt Document)" on 12/18/2018 at 5:09 PM revealed sacral wound documented as "Stage: 3." Wound measurement, "3.6 cm x 2.3 cm x 0.1 cm." Recommendations from the wound care nurse included dressing change "every day right after HBOT [hyperbaric therapy] and in the HS [before bed] and prn [as needed]."

There was no documentation of a daily wound dressing change in "Multi-Disciplinary Charting" on 12/19/2018. Review of Patient #1's "Multi-Disciplinary Charting" revealed Patient #1 was repositioned on 12/19/2018 at 7:25 AM, 12:27 PM, and 5:30 PM. Patient #1 was not repositioned every 2 hours per policy.

Patient #1's "Wound RN Inpatient Consult" in the document titled, "Progress Note" dated 12/21/18 at 11:30 AM revealed no change in staging. No signs or symptoms of [DIAGNOSES REDACTED].Dressing Change Schedule: Change daily and PRN [as needed] when soiled."

There was no documentation in "Multi-Disciplinary Charting" of a daily wound dressing change on 12/23/2019.

No turning or repositioning was documented in "Multi-Disciplinary Charting" for Patient #1 from 12/19/18 at 5:30 PM until 82 hours later, on 12/23/18 at 3:03 AM. The next documented repositioning was nearly 24 hours later, on 12/24/2018 at 2:23 AM.

On 12/24/2018 at 1:41 PM "Wound RN Inpatient Wound Care" in the document titled, "Progress Note" revealed no change in staging. Light debridement, cleansing, and dressing change completed. Wound measurement, "3.5 cm x 1.4 cm x 0.2 cm. Cover Dressing ...to be changed MWF [Monday, Wednesday, Friday] in the wound clinic and PRN [as needed] if soiled on the floors. Continue to have patient roll from side to side to avoid pressure on [Patient #1]'s coccyx."

Patient #1's "Integumentary assessment" in "Multi-Disciplinary Charting" on 12/24/2018 at 8:30 PM revealed a pressure ulcer staging of "Stage 3 - Break in skin to subcutaneous tissue." Nursing did not document physician notification or document wound measurements in "Multi-Disciplinary Charting" per policy. Nursing interventions to prevent further breakdown of skin were not documented in "Multi-Disciplinary Charting," 6 days after the initial identification of the pressure ulcer.

Patient #1 was next repositioned on 12/25/2018 at 4:00 PM, more than 36 hours after the previously documented reposition. There was no documentation in "Multi-Disciplinary Charting" that Patient #1 was turned or repositioned again for more than 48 hours, on 12/27/2018 at 7:40 PM.

Patient #1's "Integumentary assessment" in "Multi-Disciplinary Charting" on 12/28/2018 at 5:59 AM revealed "pt (sic) refused additional air mattress. [R]emoved from bed." Review of Patient #1's "Mulit-Disciplinary Charting" revealed Patient #1 was repositioned next more than 14 hours later at 8:01 PM.

Per "Multi-Disciplinary Charting," Patient #1 was repositioned on 12/29/2018 at 3:46 AM, then again more than 16 hours later at 8:00 PM, Patient #1 was next repositioned on 12/30/2018 at 2:12 AM, then more than 17 hours later at 8:47 PM. Patient #1 was only repositioned once on 12/31/2018 at 1:02 AM. There was not another reposition documented for 5 days, on 1/5/2019 at 1:24 AM.

Review of Patient #1's "Integumentary assessment" in "Multi-Disciplinary Charting" revealed there was no daily dressing change documented by nursing on 1/2/2019.

On 1/3/2019 at 4:02PM "Wound RN Inpatient Wound Care" in the document titled, "Progress Note" revealed no change in staging and wound measurement, "1.7 cm x 1.2 cm x 0.2 cm."

Review of Patient #1's "RN Inpatient Wound Care Consult" in the document titled, "Nurses Notes (Clinic Non-Appt Document)" on 1/8/2019 at 3:03 PM revealed no change in staging. Documentation revealed wound measurement "10.4 cm x 9.3 cm x 0.1 cm." This was an increase from the wound measurement of 1.7 cm x 1.2 cm x 0.2 cm on 1/3/2019. There was no documentation of the significant increase in wound size from the previous assessment, and no documentation of physician notification per facility policy.

Review of a wound assessment documented in "Multi-Disciplinary Charting." on 1/14/2019 at 5:25 PM revealed no change in staging. "Size #1 - Measured 7.5 cm x 9.0 cm x 0.4 cm."

"RN Inpatient Wound Care Follow Up" documented in "Nurses Notes (Clinic Non-Appt Document)" completed on 1/14/2019, not electronically signed until 1/18/2019 at 9:26 AM, revealed "Stage: Unstageable". Wound cleaned and dressed. Wound measurement, "7.9 cm x 9.0 cm x 0.2 cm". "Wound care education performed however patient continues to have low blood pressure when placed on [Patient #1] side or sitting up. Patient has been refusing to roll or stay off coccyx due to condition. Wound continues to increase in size due to the inability to roll from side to side. Patient also has an inflatable pad for use to help with pressure, however patient does not like this mattress and will requests (sic) it be removed. Floor nurse was able to get patient to agree to air mattress and it was again placed under [Patient #1]." There was no documentation regarding pressure relieving mattress interventions in the "Multi-Disciplinary Charting" in Patient #1's record until 1/19/2019.

No turning or repositioning was documented, per policy, in Patient #1's "Multi-Disciplinary Charting" from 1/5/2019 at 1:02 AM until 9 days later on 1/14/2019 at 10:30 AM. Review of Patient #1's "Independence level" in "Multi-Disciplinary Charting" on 1/14/2019 at 8:30 PM revealed "Fully dependent repo. (sic) [reposition] every 2 hours." There was no documented evidence in "Multi-Disciplinary Charting" that Patient #1 was repositioned every 2 hours. On 1/15/2019, Patient #1 was repositioned at 8:51 AM, then again 8 hours later at 4:58 PM. Patient #1 was repositioned only once on 1/16/2019, at 7:49 AM, then again over 24 hours later on 1/17/2019 at 9:30 AM. Review of Patient #1's "Multi-Disciplinary Charting" revealed Patient #1 was not consistently turned and repositioned every 2 hours until 1/19/2019, more than a month after Patient #1's pressure ulcer was initially assessed and after the ulcer had progressed to a Stage 4 pressure ulcer.

"RN Inpatient Wound Care Follow Up" documented in "Nurses Notes (Clinic Non-Appt Document)" on 1/17/2019, electronically signed at 12:03 PM, revealed wound remained unstageable. Documentation revealed wound measurement, "8.2 cm x 11.6 cm x 2 cm...Deep hole area in the center is 5 cm x 2.6 cm x 2 cm."

Review of Patient #1's "Multi-Disciplinary Charting" revealed pressure relief interventions were not initiated until 1/18/2019, a full month after Patient #1 developed a pressure ulcer. Per Patient #1's "Multi-Disciplinary Charting" interventions for "Pressure Relief" were first documented on 1/18/2019 at 9:50 AM: "Head Pillows ...Heels Pillows ...Specialty Bed - Waffle mat."

"Integumentary assessment" in "Multi-Disciplinary Charting" revealed on 1/19/2019 at 3:35 PM documentation of the wound type/stage was changed to "Stage 4 - Break in skin down to muscle, tendon, bone", indicating an increase in the extent of the wound as compared to the initial identification of the wound on 12/18/2018. Review of Patient #1's "Multi-Disciplinary Charting" revealed no documentation that the physician was notified of Patient #1's change in condition on 1/19/2019 regarding the progressed wound stage per policy, or that the wound measurements were documented upon change in wound stage on 1/19/2019 per policy.

On 1/24/2019, Patient #1's "Wound Healing Photographic Record" (time not documented) revealed wound size measured as "6 cm x 6.8 cm x 2.2 cm."

Patient #1 was discharged [DATE] with a stage 4 pressure ulcer.

Patient #1's incident report titled "Event Details" (no date) revealed the facility's investigation of Patient #1's pressure injury was completed on 2/4/2019 and concluded "Event was preventable."

During an interview with Supervisor E on 2/28/2019 at 12:10 PM, when asked about Patient #1's pressure injury, Supervisor E stated, "During our investigation, we noticed differences between what the nurses were telling us they did and what was documented. There was limited charting of repositioning, and nothing was documented related to pressure prevention measures. [Patient #1] had multiple comorbidities and [Patient #1] was bedridden. [Patient #1] was placed on a specialty mattress and overlay eventually. There was no documentation of redness prior to the wound staging on 12/18/2018."

Patient #2

Patient #2 was admitted [DATE] at 3:58 PM for altered mental status and STEMI (ST-elevated myocardial infarction) [heart attack], and had a history of the following comorbidities: congestive heart failure, diabetes, respiratory failure, and peripheral neuropathy (per Patient #2's demographic record and "Problem" list documented in "Care Plan Charting" record).

Patient #2's closed nursing record titled, "Multi-Disciplinary Charting" was reviewed with Supervisor C and revealed the following:

Review of the admission nursing assessment in "Multi-Disciplinary Charting" on 1/5/2019 revealed "Independence Level: Fully dependent" and "Integumentary Assessment: Not within Normal Limits...Ecchymosis [bruising] scattered." Braden risk assessment on 1/5/2019 revealed Patient #2 was "at risk" for skin breakdown with an assessment score of 17 at 4:58 PM. "Mobility" assessment at 8:00 PM revealed, "Needs assistance with all activity."

Patient #2 was admitted with no documented evidence of skin breakdown in "Multi-Disciplinary Charting." No interventions to reposition every 2 hours were implemented in response to Patient #2's Braden scores and in accordance with facility policy.

No turning or repositioning was documented in "Multi-Disciplinary Charting" for Patient #2 from 1/9/2019 at 4:00 AM until 10 hours later, at 2:00 PM. The next documented repositioning was 10 hours later, on 1/10/2019 at 12:02 AM. Review of Patient #2's flowsheets revealed Patient #2 was repositioned on 12/10/2018 at 4:00 AM, 7:59 AM, 10:00 AM, 11:59 AM, and 3:59 PM. The next documented repositioning was 8 hours later, on 1/11/2019 at 12:05 AM. Patient #2 was not repositioned every 2 hours per policy.

Review of Patient #2's "Multi-Disciplinary Charting" revealed pressure relief not being consistently provided. On 1/6/2019, "Pressure Relief" was documented at 4:00 AM and again 16 hours later at 8:00 PM. There was no documentation of pressure relief interventions in Patient #2's "Multi-Disciplinary Charting" from 1/8/2019 at 7:35 AM until nearly 41 hours later on 1/9/2019 at 12:05 AM, and there was no documentation of pressure relief interventions in Patient #2's "Multi-Disciplinary Charting" from 1/10/2019 at 12:02 AM until nearly 44 hours later on 1/11/2019 at 8:00 PM and again at 10:00 PM. No additional documentation of pressure relief found in "Multi-Disciplinary Charting" until 1/13/2019 at 12:10 AM, over 50 hours later.

Patient #2's "Integumentary assessment" in "Multi-Disciplinary Charting" on 1/11/2019 at 8:00 PM revealed the first documentation of the presence of a pressure ulcer. "Skin Integrity - Weeping midline buttocks (sic) around pressure sites...Location #1 - Coccyx AICU [attending physician] notified; Etiology #1 - Pressure Ulcer; Type/Stage #1 - Stage 2 - Break in Skin, Blisters or Abrasions; Size #1 - Not Measured (sic); Dressing #1 - Dressing dry and intact; Drainage #1 - Minimal Drainage Bright Red."

Review of Patient #2's "Multi-Disciplinary Charting" revealed no evidence that wound measurements were documented upon initial identification of the pressure injury on 1/11/2019 per facility policy.

Review of Patient #2's "Multi-Disciplinary Charting" revealed from the initial pressure injury identification on 1/11/2019 at 8:00 PM until the time of Patient #2's death while inpatient on 1/16/2019 at 6:10 PM, nearly 5 days later, no changes in wound staging was documented and no measurements of the pressure injury were documented per facility policy. Patient #2 died with a stage 2 pressure ulcer.

Patient #2's incident report titled, "Event Details" (no date) revealed the facility's investigation of Patient #2's pressure injury was completed on 2/11/2019 and concluded "Event was preventable."

Patient #3

Patient #3 was admitted [DATE] at 7:50 AM for chest pain and CHF (congestive heart failure) and a Coronary Artery Bypass Graft (open heart surgery) and and had a history of the following comorbidities: coronary artery (heart) disease, acute renal (kidney) failure, respiratory failure, and peripheral vascular disease (per history documented in "Nurses Notes (Clinic Non-Appt (sic) [appointment] Document)" and "Problem" list documented in "Care Plan Charting" record).

Patient #3's closed nursing record titled, "Multi-Disciplinary Charting" and wound care notes documented in "Nurses Notes (Clinic Non-Appt (sic) [appointment] Document" were reviewed with Supervisor C and revealed the following:

Review of Patient #3's nursing assessment in "Multi-Disciplinary Charting" on 11/1/2018 revealed "Mobility: Needs assistance with all activity" and "Integumentary Assessment: "Not within normal limits...No wound; Incision Presence - Yes." Braden risk assessment on 11/1/2018 at 8:00 PM revealed Patient #3 was "at risk" for skin breakdown with an assessment score of 16.

Patient #3 was admitted with no documented evidence of skin breakdown in "Multi-Disciplinary Charting." No interventions to reposition every 2 hours were implemented in response to Patient #3's Braden scores and in accordance with facility policy.

No turning or repositioning was documented in "Multi-Disciplinary Charting" for Patient #3 from 11/2/2019 at 6:00 AM until 14 hours later, at 8:00 PM. Review of "Multi-Disciplinary Charting" revealed Patient #3 was repositioned on 11/3/2018 at 6:00 AM, then again 26 hours later on 11/4/2018 at 8:00 AM.

Review of Patient #3's "Multi-Disciplinary Charting" revealed Patient #3 was repositioned on 11/4/2018 at 7:57 PM, then again 24 hours later on 11/5/2018 at 8:00 PM. On 11/6/2018, Patient #3 was repositioned at 6:00 AM, then again 14 hours later at 8:00 PM.

Patient #3's "Integumentary assessment" in "Multi-Disciplinary Charting" on 11/6/2018 at 2:02 AM revealed the first documentation of the presence of a pressure ulcer. "Skin Integrity 3 - Wound...Location #1 - Coccyx; Etiology #1 - Pressure Ulcer; Type/Stage #1 - Stage 2 - Break in Skin, Blisters or Abrasions; Size #1 - Not measured (sic); Dressing #1 - Applied; Drainage #1 - No Drainage; Peri-Wound #1 - Pink; Tunnel/Undermine #1 -None."

Review of Patient #3's "Multi-Disciplinary Charting" revealed there was no documentation that the physician was notified of initial identification of the pressure injury on 11/6/2018 per policy, or that wound measurements were documented upon initial identification of the pressure injury on 11/6/2018 per policy.

No turning or repositioning was documented in "Multi-Disciplinary Charting" for Patient #3 from 11/12/2019 at 4:00 AM until 14 hours later, at 8:00 PM.

Patient #3's "Inpatient RN Wound Care consult (sic)" documented in "Nurses Notes (Clinic Non-Appt Document)" on 11/13/2018 at 6:30 PM revealed "Type of wound: pressure injury; Wound location: buttock/coccyx/sacrum; Stage: Suspected deep tissue; Dimensions (L X W X D) in cm: 10.7 cm x 12.8 cm x <0.1 cm (136.96 cm 2)...Recommendations and wound care performed:...Offload, turn, and reposition patient every q (sic) 1 hour."

Review of Patient #3's "Multi-Disciplinary Charting" revealed Patient #3 was not turned or repositioned every hour per wound care recommendation. No documentation was found in Patient #3's "Multi-Disciplinary Charting" that wound care recommendations were communicated to nursing.

On 11/15/2018, "Multi-Disciplinary Charting" revealed Patient #3 was incontinent of urine and stool at 2:00 PM. No documentation of perineal care or skin care interventions were documented per facility policy.

Review of "Inpatient RN Wound Care Follow Up" documented in "Nurses Notes (Clinic Non-Appt Document)" on 11/19/2018 at 6:43 PM revealed no change in wound type, location, or stage. "Dimensions (L X W X D) in cm: 9.7 cm x 13.2 cm x <0.1 cm (128.04 cm2)."

Review of Patient #3's "Multi-Disciplinary Charting" revealed no documentation of coccyx pressure relief interventions from 11/24/2018 at 4:00 PM until nearly 41 hours later on 11/26/2018 at 8:30 AM.

"Wound RN Inpatient Consult," documented in "Nurse Notes (Clinic Non-Appt Document)" on 11/26/2018, electronically signed at 8:29 PM, revealed, "Location and Type: Pressure Ulcer Unstageable; Size: Coccyx 13.5 cm x 14.5 x Unstageable." This was an increase from the wound measurement of 9.7 cm x 13.2 cm x <0.1 cm on 11/19/2018. There was no documentation in "Nurse Notes (Clinic Non-Appt Document)" or "Multi-Disciplinary Charting" of physician notification of Patient #3's change in condition per policy.

Review of Patient #3's "Multi-Disciplinary Charting" revealed Patient #3 was not consistently turned and repositioned every 1 hour per wound care recommendation. Review of "Multi-Disciplinary Charting" between 11/13/18 at 9:00 PM and 11/30/18 revealed Patient #3 was not turned or repositioned a total of 274 times out of 408 opportunities, and between 12/1/2018 and discharge 12/6/2018, Patient #3 was not turned or repositioned a total of 101 times out of 144 opportunities.

Review of Patient #3's "Multi-Disciplinary Charting" revealed coccyx pressure relief interventions were not documented from 12/1/2018 at 6:00 AM until 40 hours later on 12/2/2018 at 10:00 PM.

"Inpatient RN Wound Care Follow Up" documented in "Nurses Notes (Clinic Non-Appt Document)" on 12/3/2018 revealed "Type of wound: Kennedy ulcer [a dark sore that develops during the final stages of a person's life]; Wound location: buttock/coccyx/sacrum; Dimensions (L X W X D) in cm: 12.8 cm x 14.7 cm x 0.2 cm (188.16 cm2)", indicating a progression in size from initial measurement of 10.7 cm x 12.8 cm x <0.1 cm on 11/13/2018. No physician notification of Patient #3's change in condition was documented in "Multi-Disciplinary Charting" or "Nurses Notes (Clinic Non-Appt Document)" per policy. Review of Patient #3's "Multi-Disciplinary Charting" and "Nurses Notes (Clinic Non-Appt Document)" revealed this was the only documentation found identifying the injury as a Kennedy ulcer rather than a pressure ulcer. There was no documentation in "Multi-Disciplinary Charting" or "Nurses Notes (Clinic Non-Appt Document)" that Patient #3 was on hospice care during the inpatient hospitalization .

Patient #3's incident report titled "Event Details" (no date) revealed the facility's investigation of Patient #3's pressure injury was completed on 12/18/2018 and concluded "Event was preventable" and was classified as "Pressure Injury."

During an interview conducted on 2/28/2019 at 12:10 PM, Supervisor C stated Patient #3 "was in the ICU (Intensive Care Unit), critical with hemodynamic instability (not enough pressure to keep blood flowing throughout the body). The nurse reported to the doctor [Patient #3] was already showing signs [of skin breakdown]," No documentation of physician notification regarding Patient #3's pressure injury was found in Patient #3's medical record from admission on 11/1/2018 until discharge on 12/6/2018.

During an interview with Supervisor E and Director J on 3/25/2019 at 4:11 PM, when asked how nursing staff know when a wound nurse sees a patient and makes recommendations, Supervisor E stated the wound nurse "can do a verbal report or enter a nursing order, but those tend to get lost and buried in the active orders." When asked if nurse to nurse verbal reports of wound nurse recommendations are expected to be documented, Supervisor E stated, "no, verbal reports don't have to be documented." This was confirmed by Director J.

Patient #5

Patient #5 was admitted to facility on 2/15/2019 at 5:08 PM for abdominal pain, weakness, and sepsis and had a history of the following comorbidities: end-stage, chronic kidney disease, peripheral neuropathy, and cirrhosis (liver disease) (per review of Patient #5's demographic record, "Problem" list documented in "Care Plan Charting" record, and history documented in "Nurses Notes (Clinic Non-Appt (sic) [appointment] Document)." Patient #5's nursing documentation titled, "Multi-Disciplinary Charting" was reviewed and revealed the following:

Review of the admission nursing assessment in "Multi-Disciplinary Charting" on 2/15/2019 revealed "Independence Level: Bedrest" and "Integumentary assessment: Not Within Normal Limits" with non-pressure related wounds on the right abdomen and left ankle. Braden risk assessment score on 2/15/2019 revealed Patient #5 was "at risk" for skin breakdown with an assessment score of 17 at 5:20 PM.

Review of Patient #5's "Multi-Disciplinary Charting" revealed no interventions to reposition every 2 hours were implemented in response to Patient #5's Braden scores and in accordance with facility policy.

Patient #5's nursing assessment in "Multi-Disciplinary Charting" on 2/16/2019 at 7:52 AM revealed "Mobility: Repositions with assistance w/2" (sic) [with 2]" and "Independence Level: Fully dependent w/2" (sic) [with 2]."

Review of Patient #5's "Multi-Disciplinary Charting" revealed no documentation of pressure relief interventions from 2/16/2019 at 7:52 PM until nearly 20 hours later, on 2/17/2019 at 3:58 PM, and then not again until 16 hours later on 2/18/2019 at 8:00 AM, and then again 8 hours later at 4:00 PM and 6:00 PM. From 2/18/2019 at 6:00 PM until 2/24/2019 at 7:15 AM, there was no documentation of pressure relieving interventions for Patient #5.

On 2/17/2019 at 8:00 PM, "Multi-Disciplinary Charting" revealed "pt (sic) refusing writer to assess skin areas of concern, refuses repositioning despite risk of skin break down." No education was documented and no additional attempts at repositioning every 2 hours were documented in "Multi-Disciplinary Charting," per policy, until 10 hours later on 12/18/2019 at 6:00 AM.

Review of Patient #5's "Multi-Disciplinary Charting" revealed Patient #5 was repositioned on 2/18/2019 at 8:12 PM, then again nearly 14 hours later on 2/19/2019 at 9:47 AM. Patient #5 was only repositioned once on 2/20/2019 at 2:00 PM, then 16 hours later on 2/21/2019 at 8:00 AM.

Patient #5's "Multi-Disciplinary Charting" on 2/20/2019 at 8:12 AM revealed, "Mobility: Needs assistance with all activity."

On 2/20/2019, "Multi-Disciplinary Charting" revealed Patient #5 was incontinent of stool at 8:12 AM, 4:08 PM, and 7:00 PM. Patient #5 was incontinent of stool on 2/21/2019 at 8:00 AM, on 2/22/2019 at 7:43 AM, on 2/23/2019 at 10:25 AM, and on 2/24/2019 at 1:00 PM. No pericare or skin care interventions were documented in "Multi-Disciplinary Charting" per facility policy.

Patient #5's "Multi-Disciplinary Charting" revealed no documentation of pressure relieving or specialty bed interventions from 2/25/2019 at 2:10 AM until nearly 45 hours later on 2/26/2019 at 11:00 PM.

Patient #5's "Multi-Disciplinary Charting" revealed between 2/25/2019 and 3/4/2019, turns and repositioning were not documented a total of 64 times, out of 108 opportunities (12 opportunities every 24 hours). Between 3/5/2019 and 3/13/2019, turns and repositioning were not documented a total of 79 times, out of 108 opportunities (12 opportunities every 24 hours).

Patient #5's "Multi-Disciplinary Charting" revealed no documentation of pressure relieving specialty bed intervention from 3/2/2019 at 12:0
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, facility staff failed to develop skin integrity plans of care for patients identified as at risk for skin breakdown in 2 of 10 patients (Patients #11, 13) and failed to implement interventions to achieve care plan goals per facility policy in 8 of 8 patients (Patients #1, 2, 3, 5, 12, 14, 15 and 16) with skin integrity care plans, out of a total universe of 16 patients.

Findings include:

Review of facility policy "Skin Integrity Management Clinical Practice Guidelines for Inpatients", approved 1/29/2019 (no policy #) revealed, " ...Initiate a skin integrity care plan appropriate for the patient based on Braden Scale result (Braden score of 18 or lower) ..."

Review of facility policy # 5 titled, "Patient Centered Documentation and the Nursing Process", last revised 6/29/2017 revealed, " ...1. An individualized plan of care is initiated by the RN (sic) [Registered Nurse] within eight hours of admission ...3. The plan includes the patient's primary problems or areas of focus, identified outcomes, interventions, and the evaluation of progress towards outcomes ...4. The Registered Nurse, along with the multidisciplinary team, will review and update each patient's plan of care ...as the patient's condition, diagnosis, and needs change."

Review of Patient #11's open medical record revealed Patient #11 was admitted on [DATE] at 1:00 AM for chest pain. Patient #11's open medical record reviewed with Supervisor C and Supervisor E who confirmed the following: On 3/23/2019 at 12:22 AM, Patient #11's Braden risk assessment score revealed "15" (at risk). No skin integrity care plan had been initiated per policy for Patient #11.

Review of Patient #13's open medical record revealed Patient #13 was admitted on [DATE] for a fall and right anterior lower leg [DIAGNOSES REDACTED]. Per medical record review, Patient #13's Braden risk assessment score revealed "13" (moderate risk) upon admission on 3/18/2019 at 11:11 PM. No skin integrity care plan was initiated per facility policy for Patient #13 at the time of the review on 3/25/2019.

During an interview on 3/25/2019 at 1:05 PM, Supervisor C stated care plans, goals and interventions are expected to be implemented for all patients with a Braden score less than 18.

Patient #2 was admitted [DATE] at 3:58 PM for altered mental status and STEMI (ST-elevated myocardial infarction) [heart attack]. Review of Patient #2's medical record revealed Braden risk assessment score "17" (at risk) on 1/5/2019 at 4:58 PM. No skin integrity care plan was initiated, per policy, for Patient #2 until 1/8/2019 (3 days after admission). Patient #2's Care Plan revealed "Braden Score" care plan was initiated on 1/8/2019 at 7:09 PM. Goal descriptions titled, "Minimize friction and shear; No areas of redness or breakdown; Skin integrity maintained/improved; Skin moisture balance maintained; Skin pink, warm, dry." Nursing evaluation of Patient #2's progress was documented as "In Progress" from 1/9/2019 through discharge 1/16/2019. Per review of nursing assessment notes, Patient #2 developed a pressure ulcer on 1/11/2019. The progress was not measurable, no nursing interventions were included in Patient #2's care plan, and no changes to the plan of care were documented for Patient #2's change in condition.

Patient #3 was admitted [DATE] at 7:50 AM for chest pain and CHF (congestive heart failure) and a Coronary Artery Bypass Graft (open heart surgery). Review of Patient #3's medical record revealed Braden risk assessment score "16" (at risk) on 11/1/2018 at 8:00 PM. No skin integrity care plan was initiated, per policy, for Patient #3 until 11/6/2018 (5 days after admission). Patient #3's Care Plan revealed "Stage II, III, IV, Skin Breakdown" care plan was initiated on 11/6/2018 at 11:10 PM. Per review of nursing assessment notes, Patient #3 developed a pressure ulcer on 11/6/2018 that grew in size from 11/6/2018 to 12/3/2018. The care plan's goal included "Minimize friction and shear; Skin integrity maintained/improved; Skin moisture balance maintained." Nursing evaluation of Patient #3's progress was documented as "In Progress" from 11/6/2018 through discharge 12/6/2018. The progress was not measurable, no nursing interventions were included in Patient #3's care plan, and no changes to the plan of care were documented as Patient #3's condition changed.

Review of Patient #15's open medical record revealed Patient #15 was admitted on [DATE] for altered mental status. Patient #15's open medical record was reviewed with Supervisor C and Supervisor E on 3/25/2019 who confirmed the following: On 3/23/2019 at 8:00 PM, Braden risk assessment score was changed to "17" (at risk). No skin integrity care plan initiated per policy until 3/25/2019, 2 days after identified as at risk for skin breakdown. Patient #15's care plan goals included "Skin integrity maintained/improved." Nursing evaluation of Patient #15's progress was documented as "In Progress" from 3/23/2019 through 3/25/2019. The progress was not measurable and no nursing interventions were included in Patient #15's care plan.

Patient #1 was admitted [DATE] at 2:40 PM for a hip fracture. Review of Patient #1's medical record revealed Braden risk assessment score"17" (at risk) on 12/10/2018 at 3:20 PM and "15" (at risk) on 12/10/2018 at 8:00 PM. Two skin integrity care plan goals were initiated on 12/10/2018 at 4:03 PM: "Indep. (sic) [independent] mobility or return to baseline;" "Skin color/integrity/temp return to norm (sic)." Additional care plan goals of Skin moisture balance maintained; Minimize friction and shear; and No areas of redness or breakdown were added on 12/15/2018. No interventions to achieve the care plan goals were included in the care plan. Patient #1 developed a pressure ulcer at the facility on 12/18/2018. Nursing evaluation of Patient #1's progress was documented as "In Progress" from 12/10/2018 through discharge 1/25/2019. The progress was not measurable, no interventions were included in Patient #1's care plan, and no changes to the plan of care were documented as Patient #1's condition changed.

Patient #5 was admitted on [DATE] at 5:08 PM for abdominal pain, weakness, and sepsis. Review of Patient #5's medical record revealed Braden risk assessment score "17" (at risk) on 2/15/2019 at 5:20 PM. Patient #5's Care Plan revealed "Braden Score" care plan was initiated on 2/15/2019 at 6:15 PM. Care plan goals included "Skin integrity maintained/improved; Skin pink, warm, dry." Patient #5's nursing assessment revealed a pressure ulcer developed on Patient #5's coccyx on 2/17/2019. Nursing evaluation of Patient #5's progress was documented as "In Progress" from 2/15/2019 through discharge 3/13/2019. The progress was not measurable, no nursing interventions were included in Patient #5's care plan, and no changes to the plan of care were documented as Patient #5's condition changed.

Review of Patient #12's open medical record revealed Patient #12 was admitted on [DATE] for adult neglect or abandonment and sacral decubitus ulcer. Patient #12's open medical record was reviewed on 3/25/2019 with Supervisor C and Supervisor E who confirmed the following: On 3/21/2019 at 10:40 PM, Patient #12's Braden risk assessment score was "14" (moderate risk). Patient #12's care plan, initiated on 3/22/2019, included goals of "No areas of redness or breakdown; Skin moisture balance maintained; Minimize friction and shear." Nursing evaluation of Patient #12's progress was documented as "In Progress" from 3/21/2019 through 3/25/2019. The progress was not measurable and no nursing interventions were included in Patient #12's care plan.

Review of Patient #14's open medical record revealed Patient #14 was admitted on [DATE] for Influenza A and pneumonia. Patient #14's open medical record was reviewed on 3/25/2019 with Supervisor C and Supervisor E who confirmed the following: On 3/20/2019 at 2:31 AM, Patient #14's Braden risk assessment score was "16" (at risk). Patient #14's Care Plan, initiated on 3/20/2019, included goals of "No areas of redness or breakdown; Skin integrity maintained/improved; Skin moisture balance maintained; Minimize friction and shear.".Nursing evaluation of Patient #14's progress was documented as "In Progress" from 3/20/2019 through 3/25/2019. The progress was not measurable and no nursing interventions were included in Patient #14's care plan.

Review of Patient #16's open medical record revealed Patient #16 was admitted on [DATE] for congestive heart failure and hypoxemia (low oxygen). Patient #16's open medical record was reviewed on 3/25/2019 with Supervisor C and Supervisor E who confirmed the following: On 3/22/2019 at 10:15 AM, Patient #16's Braden risk assessment score was "17" (at risk). On 3/22/2019 at 11:34 AM, "Care Plan" revealed "Braden Score" care plan was initiated with goals of "No areas of redness or breakdown; Skin moisture balance maintained; Minimize friction and shear." Nursing evaluation of Patient #16's progress was documented as "In Progress" from admission 3/22/2019 through 3/25/2019. The progress was not measurable and no nursing interventions were included in Patient #16's care plan.

During an interview on 3/25/2019 at 4:11 PM, Supervisor E stated "care plan interventions are documented in the nurse's notes ...interventions are not being documented." Supervisor E stated care plan goals are identified as either in progress or unmet and "if the patient is not continuing to progress toward care plan goals, the goal should be documented as unmet."