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Based on interview and record review, the facility failed to ensure one individual was designated as the director of nursing services, failed to ensure that registered nurses supervised and evaluated the nursing care for 3 patients (P-1, 6, 9) of 10 patients reviewed, and failed to implement and document interventions in the plan of care for 1 patient (P-1) of 10 patients reviewed, resulting in the potential for negative outcomes to all patients served by the facility, including preventable physical decline. Findings include:

See Tags:
A0386 - Failure to designate a Director of Nursing.
A0395 - Failure of nursing staff to supervise and evaluate nursing care.
A0396 - Failure to maintain a nursing care plan.

Based on interview and record review, the facility failed to ensure that one individual was clearly designated as the director of nursing services with a plan of administrative authority and delineation of responsibilities for nursing services, resulting in the potential for poor outcomes for all patients served by this facility. Findings include:

During the entrance conference on 2/10/25 at 1015, the director of operations (Staff B) stated the Chief Nursing Officer (CNO) position "has been vacant for some time" and they have a nurse manager at the facility that oversees nursing services. Staff B provided an organizational chart dated June 2024 that indicated nurse managers reported to the director of operations. The organizational chart did not list a CNO position or indicate the position as vacant.

The CNO job description (no date) states the CNO "actively participates in the oversight and establishment of best practices and standards for hospital clinical services." The nurse manager job description (dated revised 5/7/21) states the manager reports to the CNO and "leads nursing staff in delivering excellent care."

The nurse manager (Staff C) was queried on her job description and if her role includes CNO duties during an interview on 2/11/25 at 1330. Staff C responded that her role does not include CNO duties.

Based on interview and record review, the facility failed to ensure that registered nurses supervised and evaluated the nursing care for 3 (P-1, P-6, P-9) of 10 patients reviewed, resulting in the lack of assessment and monitoring for P-1, 6, 9 and the potential for poor outcomes. Findings include:

On 2/10/25 at 1400 record review revealed P-1 was ventilator dependent and paraplegic as a result of a trauma accident. P-1 required total assistance for bed mobility. P-1 was admitted to the facility from a skilled facility with a documented stage 2 pressure injury to the coccyx. The coccyx wound progressed during stay, and a new pressure injury developed on mid back, that also progressed during stay.

Review of the nursing flow records revealed that documentation of P-1 being turned and repositioned per wound care protocol every two hours, was inconsistent, including but not limited to the following.

11/25/24 - no documentation of turning and repositioning found between the hours of 1200 -1800.
12/06/24 - no documentation of turning and repositioning found between the hours of 1100 -1800.
12/11/24 - no documentation of turning and repositioning found between the hours of 0800 -1800.
12/15/24 - no documentation of turning and repositioning found between the hours of 0800 -1800.
12/16/24 - no documentation of turning and repositioning found between the hours of 0800 -1300.

On 12/16/24 at 1450, a new wound care protocol order to position patient from side to side every 1 hour was entered into record. None of the flow sheets from 12/17/24 - 1/22/25 had turns documented every hour.

In addition, review of nursing daily flow records for P-1 revealed wound assessment, (required once a shift) was inconsistently documented, including but not limited to:
12/16/24 - no documentation of wound assessment on 7PM - 7 AM shift.
12/18/24 - no documentation of wound assessment on 7PM - 7 AM shift.
12/24/24 - no documentation of mid back wound found on 7 AM-7PM shift or 7PM shift - 7 AM shift.
12/31/24 - only location of wounds documented (7 AM- 7PM shift) site assessments/treatments not documented, no documentation of wound assessment 7PM - 7 AM shift.
01/03/25 - no documentation of wound assessment on 7PM - 7 AM shift
01/04/25 - no documentation of wound assessment on 7 AM - 7PM shift.


48772

P-6: This 38-year-old female was admitted to the facility on 1/25/25 with diagnoses of necrotizing fasciitis, bilateral polynephritis, and peritonitis. The patient was on a ventilator and expired on 2/8/25 after being placed on comfort care. P-6 had extensive wounds on her gluteal, ischial, and sacral regions as well as on her abdomen and left upper extremity.

During record review on 2/11/25, it was noted that the daily nursing assessment flowsheets that indicated documentation of repositioning every two hours was inconsistent, including but not limited to the following:
1/22/25-no documentation of turning and repositioning from 2400 to 0600
1/23/25-no documentation of turning and repositioning for entire day

It was also noted that the daily nursing assessment flowsheets that indicated wound documentation two times daily was inconsistent, including but not limited to the following:
1/13/25-(7PM-7AM)-no documentation of wound
1/29/25-(7PM-7AM)-no documentation of wound
1/30/25-(7PM-7AM)-no documentation of wound

P-9: This 39-year-old female was admitted to the facility on 10/1/24 with diagnoses of adrenal insufficiency, anoxic encephalopathy, cerebrovascular accident, and ventilator dependent respiratory failure. P-9 had a stage 3 pressure injury on the left thumb and a stage 4 pressure injury on the sacrum. The patient expired on 11/15/24.

During record review on 2/11/25, it was noted that the daily nursing assessment flowsheets that indicated documentation of repositioning every two hours was inconsistent, including but not limited to the following:
11/14/24-no documentation of turning and repositioning from 1000 to 1800 and 0200 to 0600
11/15/24-no documentation of turning and repositioning from 1400 to 0600

It was also noted that the daily nursing assessment flowsheets that indicated wound documentation two times daily was inconsistent, including but not limited to the following:
11/9/24-(7PM-7AM)-no documentation of wound
11/15/24-(7PM-7AM)-no documentation of wound

These findings were reviewed and acknowledged by the nursing manager (Staff C) during an interview on 2/11/25 at 1330. Staff C stated nursing staff should be evaluating the wound every shift.

*Policy-Management of Pressure Ulcers Overview Flowchart, Ref 2117 (Revised 8/2023). "Pressure ulcer should be evaluated each shift. Evaluate the dressing if present, dressing intact, drainage present. Evaluate the area surrounding the pressure ulcer."

Based on interview and record review, it was determined that the hospital failed to ensure that nursing staff completely and accurately established nursing treatment protocols to prevent avoidable decline and initiated appropriate actions to facilitate a nursing response to address skin breakdown in 1 (P-1) of 3 sampled patients with pressure ulcers. This resulted in nursing care plans that lacked the necessary therapeutic intervention detail to limit reasonable preventable tissue breakdown and to facilitate healing. Findings include:

Review of form titled, 24 Hour Patient Record and Plan on Care for P- 1 revealed the following:

11/24/25 and 1/08/24, section titled "Wound Documentation, Interventions" had no documentation (Blank)

On 12/16/24 turning and repositioning for P-1 was ordered to be increased to every 1 hour. Daily care plans reviewed for 12/17/24, 12/18/24 12/20/24, and 1/8/25 did not reflect the increase for changing P-1's position.

On 2/11/25 at 1150, interview with Staff RN revealed the wound care section of the form on the 24-Hour Care Record and Plan of Care monitors patient progress toward goals, all applicable sections should be completed daily.

Record review of policy titled, "Assessment Daily Flowsheet", revised 8/2024, revealed, "The Nursing Flow Sheet provides data to support the nursing diagnosis and process. It utilizes a systemic approach to identifying patient problems. It is legal document that supports and guides nursing action within 24-hour period ...Proper documentation is essential to patient care."

Review of policy titled, "Interdisciplinary Plan of Care", dated last reviewed 8/24, revealed, "Care, treatment and services are planned to ensure that they are individualized to the patient's needs ... All staff should be responsible for interdisciplinary collaboration to establish goals and appropriate interventions".