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Based on interviews and records reviewed, the Hospital failed to ensure a new wound was measured by nursing staff and was staged (a classification system used to identify the severity of tissue damage caused by a pressure injury) by a Certified Wound Specialist (CWS) or designee in accordance with Hospital policies and procedures for 1 Patient (#1) out of a total sample of 10 patients.

Findings include:

Review of the Hospital ' s Skin Integrity Standard of Care Policy, revised 10/2022, indicated that the:

I. Purpose is to accurately identify patients at risk for skin breakdown and development of pressure ulcers and to provide an environment which promotes to maintenance of intact skin or allows for the restoration of tissue integrity.

II. The policy further indicates that skin will be inspected every shift and documented in the electronic medical record (EMR). In addition, any areas of altered skin integrity will be documented in the shift assessment and/or the wound assessment. A plan of care will be developed which promotes restoration of maintenance of skin integrity. Reassessment of wounds will be performed at every dressing change with a minimum of once a week with accurate measurements.

IV. Standards of Clinical Practice indicates that:

2. Skin impairments will be identified by location, a description of the area and if indicated by measurement in centimeters.

5. pressure injures will be classified by depth (never back stage):

Definitions:

a. Partial Thickness Ulcer: Involving loss of epidermis and dermis.

b. Full Thickness Ulcer: Involving loss of Epidermis, Dermis, and deeper layers.

*Only CWS or designee will stage wounds as appropriate.

6. All wounds will be reevaluated a minimum of weekly by CWS.

VIII. Responsibilities indicates that:

1. Rehabilitation Physican will be responsible for initial and ongoing assessment and evaluation in collaboration with the Clinical Wound Specialist Nurse and for ordering appropriate treatments.

Review of Patient #1's medical records, indicated that he/she presented to the Hospital on 7/17/25 for rehabilitation after experiencing increased weakness and paresthesia (tingling and numbness) after an Anterior Cervical Discectomy and Fusion (a surgical procedure to alleviate pressure on the spinal cord or nerve roots).

Review of Patient #1's History and Physical dated 7/17/25 indicated Patient #1 was experiencing numbness and tingling in both hands and both feet. On 7/17/25 the Provider ordered a wound nurse consult. Review of Patient #1's medical record indicated that on 7/18/25, the Nurse Practitioner (NP#1) discontinued the order placed by the Physician for a wound nurse consult for Patient #1. Further review of Patient #1 ' s medical record failed to indicate Patient #1 was seen by the CWS during his/her hospitalization.

Review of the Rehabilitation Physician's daily progress notes throughout Patient #1's admission indicated skin intact with the plan for follow up by NP #1 for the management of medical issues and for medical care.

Review of Patient #1's Nursing Shift Assessments indicated:

7/24/25 at 3:04 A.M., Patient #1's coccyx was red, intact, and non-blanchable (an area that doesn ' t turn white or fade when pressed which could indicate bleeding under the skin or a lack of blood flow to the area).

7/25/25 at 4:10 P.M.: Patient #1's bilateral buttocks were poorly blanchable, and a new left upper buttock superficial opening was identified. Further review failed to indicate the new open area was measured by nursing staff and was staged by a CWS or designee.

7/29/25 at 9:45 P.M., Patient #1's sacral area documented as being red. Further review failed to provide a description of the area by nursing staff.

During an interview on 9/19/25 at 12:22 P.M., NP #1 said Patient #1 had a small open area to the buttocks and he believes it was a stage 1 or 2 pressure injury. NP #1 said he thought Patient #1 had a wound care consult and the wound nurse was seeing the Patient. NP #1 said he is wound certified and generally will visualize wounds weekly at a minimum. NP #1 said a treatment had been implemented for Patient #1 's buttock wound. NP #1 said that he will see wounds after the wound nurse performs an assessment. He further said that a wound care consult will be ordered when a new wound is identified. NP #1 was unable to say the last time he saw Patient #1's wound.

Review of the medical record failed to indicate a wound care consult was performed or documented for Patient #1.

During an Interview on 9/19/25 at 1:41 P.M., the CWS said she didn't work with Patient #1. She said she was on vacation when Patient #1 was admitted and doesn't remember ever being consulted as she would have written a note. She said NP #1 has his own wound certification and will look at surgical wounds and rarely consults her. She said patients with pressure injuries are followed by the wound nurse.

During an interview on 9/23/25 at 9:10 A.M., and throughout the survey, the Director of Nurses (DON) said he had investigated a complaint from Patient #1's family member regarding concerns about a wound on Patient #1's bottom. The DON said when Patient #1 was admitted his/her coccyx was red, and he was unclear if it progressed to an open area. He said NP #1 will sometimes discontinue wound consults as he has wound care certification and that he had started a protective dressing to the area. The DON said the expectation is that nurses will describe wounds in the skin assessments as an open area with partial thickness or full thickness. The DON said the NP or the wound nurse would do staging, and that certain nursing supervisors are cross trained and can also document staging. He said he is unsure if staging ever occurred. He said the nurses should measure and describe any new open areas once identified, and notify the provider. He said nursing would document every shift in the skin assessment and if there is an open wound it is measured weekly. The DON said a more comprehensive assessment will be completed by the wound care nurse or NP. He said there is no evidence in the medical record indicating that Patient #1's wounds were staged by the CWS or NP.

Review of the Wound Ostomy Note from the receiving Outside Hospital (OSH), dated 7/30/25 at 3:04 P.M., indicated that Patient #1 was admitted from an Outside Facility (OSF) today. Upon initial assessment, the patient was noted to have Mepilex border (foam dressing) to the sacrum. The note further indicates the Coccyx area as having red, denuded (a condition where the outer layer of the skin (epidermis) is lost or stripped away, exposing the underlying layers (dermis and subcutaneous tissue) open area with unattached but distinct edges. A follow-up wound consult note dated 8/1/25 at 1:29 P.M., indicated Stage 2 pressure injuries to left and right buttocks previously assessed prior to the patient being taken to the operating room (OR) on 7/31/25.