HospitalInspections.org

Based on document review and interview, nursing services failed to complete a per shift skin assessment and wound care as ordered for 1 of 10 medical records (MR) reviewed (P1); and failed to document repositioning every 2 hours for 9 of 10 patient medical records reviewed (P1, P2, P4, P5, P6, P7, P8, P9, and P10).

The cumulative effects of these systemic problems resulted in the facility's inability to provide nursing care in a safe manner.

Based on document review and interview, nursing services failed to complete a per shift skin assessment and wound care as ordered for 1 of 10 medical records (MR) reviewed (P1); and failed to document repositioning every 2 hours for 9 of 10 patient medical records reviewed (P1, P2, P4, P5, P6, P7, P8, P9, and P10).


Findings include:

1. Review of policy/procedure titled, "CORE: Clinical Guidelines for Pressure Injury," Policy number: H-PC 10-004, release date 06/2022; indicated under Policy: 1. The skin and wound assessment is conducted per the Registered Nurse (RN) b. Each shift (including the day of discharge). 5. Standard interventions for all patients can include but are not limited to: c. Repositioning orders (minimum every two-hour turns). Under Procedure: 8. Documentation: d. Within the electronic/paper medical record document: ii. Execution of the order.

2. Review of P1's MR indicated:
a. On 04/14/25 wound care nurse completed the admission skin assessment. P1 was noted to have a full thickness stage IV sacral wound that measured 8.7 centimeters (cm) x 8.5 cm x 1.3 cm with exposed fat layer, tan, soft, adherent slough, margin open attached to bare peeling epidermal layer mottled across dark non-blanching.
b. The vital flow sheet & daily ADL's sheet, lacked every two-hour entries for turns on: 05/21/25, 06/12/25, 06/13/25, 06/16/25, and 06/17/25.
c. The MR lacked documentation of every shift skin assessment completed on 04/16/26, 04/27/25, 05/03/25, 05/09/25, 05/24/25, 05/27/25, 06/04/25, 06/05/25, 06/13/25, 06/14/25, and 06/23/25.
d. The MR indicated P1 had wound care orders to be completed on Monday, Wednesday, and Friday starting on Monday, 04/14/25. The MR lacked documentation of wound care provided on 04/18/25, 04/28/25 through 05/26/2025, 05/28/25, 05/30/25, 06/02/25, 06/04/25, 06/11/25, 06/13/25, 06/16/25, 06/20/2025, 06/23/2025, 06/25/25, and 06/30/25.
e. On 6/30/2025 the discharge skin assessment indicated P1's pressure injury to their sacrum had increased in size; the wound had deteriorated to a KTU (Kennedy Terminal Ulcer) to the sacral region included bilateral ischial wounds as all are connected, with a measurement of 22 cm x 26.5 cm x 3.2 cm with eschar, slough, bone, granulation tissue, and muscle noted to wound bed.

3. Review of P2's MR indicated the following:
a. P2 admitted on 04/07/25
b. The vital flow sheet & daily ADL's sheet, lacked every two-hour entries for turns on the following dates:
04/08/25.

4. Review of P4's MR indicated the following:
a. P4 admitted on 04/14/25
b. The vital flow sheet & daily ADL's sheet, lacked every two-hour entries for turns on the following dates:
04/25/25 and 04/26/25.

5. Review of P5's MR indicated the following:
a. P5 admitted on 05/30/25
b. The vital flow sheet & daily ADL's sheet, lacked every two-hour entries for turns on the following dates:
05/31/25 and 06/01/25.

6. Review of P6's MR indicated the following:
a. P6 admitted on 05/17/25
b. The vital flow sheet & daily ADL's sheet, lacked every two-hour entries for turns on the following dates:
05/31/25 and 06/01/25.

7. Review of P7's MR indicated the following:
a. P7 admitted on 05/07/25
b. The vital flow sheet & daily ADL's sheet, lacked every two-hour entries for turns on the following dates:
05/22/25 and 05/23/25.

8. Review of P8's MR indicated the following:
a. P8 admitted on 06/17/25
b. The vital flow sheet & daily ADL's sheet, lacked every two-hour entries for turns on the following dates:
06/29/25.

9. Review of P9's MR indicated the following:
a. P9 admitted on 06/27/25
b. The vital flow sheet & daily ADL's sheet, lacked every two-hour entries for turns on the following dates:
07/05/25.

10. Review of P10's MR indicated the following:
a. P10 admitted on 06/04/25
b. The vital flow sheet & daily ADL's sheet, lacked every two-hour entries for turns on the following dates:
06/22/25 and 06/23/25.

11. Interview with A4 (Nursing Supervisor) on 08/12/25 at approximately 4:17 p.m., confirmed if a wound treatment is completed it is to be signed off on the treatment administration record.

12. Interview with A1(Chief Operating Officer) and A2 (Chief Executive Officer) confirmed P1, P2, P4, P5, P6, P7, P8, P9, and P10 lacked every two-hour turns.