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Based on document review and interview the facility failed to ensure a patient's wound was measured upon admission; failed to consult a wound care nurse in a timely manner; failed to obtain a urine culture in a timely manner; failed to obtain a therapeutic blood level (Depakote) test per provider order; failed to initiate skin prevention interventions (specialty bed/mattress & turning repositioning every two hours); failed to document intake in the medical record; failed to initiate treatment/care plan related to wound/skin integrity and nutrition upon admission; and failed to complete an incident report related to a new hospital acquired wound for 1 of 10 patient medical records reviewed. (Patient # 10)

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, the registered nurse failed to ensure a patient's wound was measured upon admission in one (1) instance, failed to order a wound care nurse consult in a timely manner in one (1) instance, failed to collect a urine sample in a timely manner in one (1) instance, failed to obtain a physician order to collect a urine sample by strainght catheterization in one (1) instance, failed to collect a therapeutic blood test in one (1) instance, failed to initiate skin prevention interventions (specialty bed/mattress & turning repositioning every two hours), failed to ensure a ring was returned after being in the facilities safe in one (1) instance, and failed to document a patient's intake in the medical record (MR) in one (1) instance. (Patient # 10)

Findings include:

1. The facility policy titled, Physician Orders/Receipt and Notation, no policy number, indicated on page 1 - Policy - There shall be Provider's Orders written for all medical and functional management for each patient specific to their individual needs. In circumstances when a delay in care could result in a negative patient outcome, a telephone or verbal order may be received. This policy was last revised in 09/2020.

2. The facility policy titled, Laboratory Process, PolicyStat ID 12197196, indicated on page 1 - Policy - To obtain laboratory results and place them on the cart for provider review in a timely manner. Procedure - number 1. Provider orders lab, number 4. Nurses obtains specimen for ordered tests, and number 10. Lab refusals shall be documented on the lab sheet in the patient's medical record. This policy was last revised in 05/2021.

4. The facility policy titled, Intake & Output Monitoring, PolicyStat ID 12386133, on page 1 - Purpose - To assure that each patient receives sufficient amount of fluids based on individual needs. This policy was last revised in 09/2022.

5. The facility policy titled, Skin-Pressure Ulcer Assessment and Prevention, PolicyStat ID 12197143, on page 1 - Policy - The hospital shall ensure consistent, accurate assessment for the risk for skin breakdown is completed upon admission. Patients determined to be at risk for skin breakdown shall receive the necessary care and services to prevent skin breakdown. Procedure - Initial Assessment - Upon admission, all patients will be assessed for the risk of skin impairment using the Braden Pressure Ulcer Risk Assessment, which is part of the Nursing Admission form. The Braden Pressure Ulcer Risk Assessment is a scored scale that predicts a hospitalized patient's risk for skin impairment. Scoring - High Risk 12 or below. The nurse will identify all applicable nursing interventions to assist in achieving the expected outcomes and goals, including but not limited to - Recording intake to ensure adequate nutrition and hydration, implementing low air loss mattress in bed, and turning and repositioning the patient at a minimum of every two (2) hours. This policy was last revised in 01/2020.

6. The facility policy titled, Management of Patient Belongings, PolicyStat ID 13950524, on page 1 - Discharge - letter c - Delivering the items to the skilled or assisted living facility, and/or referring facility of the patient. This policy was last revised in 07/2023.

7. The facility policy titled, Wound Care and Treatment, PolicyStat ID 12385988, on page 1 - Purpose - To ensure consistent, accurate identification and assessment of all wounds, and to ensure appropriate treatment is implemented timely in accordance with professional standards of practice for wound treatment. Policy - letter A - Wounds will be measured on admission (length, height, width), on page 3 - Procedure for Wound Treatment - number 1 - A treatment order will be obtained upon identification of a wound. This policy was last revised in 09/2022.

8. Review of the closed MR for patient # 10 indicated the patient was an 86 y/o (year/old) admitted to H # 2's (Psychiatric Hospital) inpatient unit on 12/24/2024 and was discharged on 01/02/2025 to H # 3 (Long Term Care Facility). The patient's diagnoses included, but were not limited to, unspecified dementia (confusion), multiple falls, severe depression, aggression, anxiety, and recent history of UTI (urinary tract infection).
a. Patient Personal Effects Inventory dated 12/24/2025, indicated no jewelry listed/described.
b. Security Patient Belongings dated 12/24/2024, indicated a gold ring was placed in the patient valuables envelope security bag, receipt number 3722769.
c. Nursing Admission Assessment, no date, indicated the Braden Risk Assessment Scale was completed at time of admission - patient's score was an eleven (11) which indicated the patient was at High Risk (12 or below).
d. Nursing Admission Assessment dated 12/24/2024 at 2:31 pm, indicated the patient had redness (slight open red area) on the sacrum/coccyx area. No measurements documented.
e. Daily Nursing Narrative dated 12/24/2024 at 3:00 pm, indicated patient had redness in groin area and coccyx
f. Admission Orders dated 12/24/2024 at 4:00 pm, indicated urinalysis with culture & sensitivity (C&S), and Depakote level.
g. Medication Administration Reconciliation dated 12/29/2024 indicated a urine sample was collected by straight catheterization.
h. Provider Order dated 01/01/2025 at 7:00 pm, indicated to cleanse wound to left hand dorsal 3rd finger, and apply skin prep to 3rd/4th fingers, TARP (turn and reposition patient) while in bed to offload pressure from sacrum, cleanse wound to midline sacrum with wound cleaner and apply skin prep to peri wound, apply medihoney to wound bed and cover with optifoam dressing.
i. Weekly Skin Assessment dated 01/01/2025, indicated the patient had two (2) areas of concern. Number one (1) - pressure sore on third finger was open, drainage, area red, moist and foul odor, length 2.5 cm (centimeters) x width 1 cm. Number two (2) - open pressure ulcer, red, moist, coccyx with no measurements.
j. Daily Nursing Narrative dated 01/01/2025 at 6:30 pm, by wound care, indicated wound noted to midline sacrum, measures 4.6 cm x 0.7 cm x 0.1 cm.
k. Patient Observation Rounds dated 01/01/2025 from 7:00 pm until 01/02/2025 at 12:55 pm, indicated the patient was in his/her room, and lacking any documentation the patient was being turned every two (2) hours (8 times).
l. Daily Nursing Narrative dated 01/01/2025 at 8:40 pm, indicated patient resting quietly in his/her bed for all evening/night so far.
m. Labcorp patient report - Urine Culture - date collected 12/29/2024 - date received 12/29/2024 - date reported 01/03/2025, indicated the urine culture was abnormal resulting Citrobacter Koseri - greater than 100,000 colony forming units per mL (milliliter), and Proteus Mirabilis - greater than 100,000 colony forming units per mL of urine. Cefazolin (Antibiotic) recommended.
n. The MR lacked appropriate documentation related to the patient being discharged with his/her ring from the safe.
o. The MR lacked documented oral intake data. Measurements in cc's (cubic centimeters) per policy.
p. The MR lacked a Depakote level which should have been collected per provider order.
q. The MR lacked initial measurements for the sacrum/coccyx wound discovered on admission and lacked an order for wound nurse consultation upon admission.
r. The MR lacked documentation the patient was on any kind of specialty bed.

9. In interview on 02/21/2025 at approximately 11:30 am with administrative staff member A # 2 (Licensed Practical Nurse-LPN/Chief Executive Officer-CEO), confirmed patient # 10's belongings bag was signed out from the safe and taken to the unit on 01/02/2025 at 9:04 am, but was unsure where the bag went.

10. In interview on 02/21/2025 at approximately 11:45 am with staff member M # 1 (Maintenance/Security), confirmed he/she removed the security bag from the safe, walked it to the 200 unit, told an employee, and left it at the unit.

11. In interview on 02/21/2025 at approximately 1:30 pm with administrative staff member A # 1 (Registered Nurse-RN/Director of Nursing-DON), confirmed if the patient was turned every two (2) hours it should be documented in the medical record. If the patient refused a straight catheter (techniques used to collect a urine sample), it should be documented in the patient's medical record.

12. In interview on 02/21/2025 at approximately 2:20 pm with administrative staff member A # 2, confirmed that after reviewing the video camera footage, it appeared that M # 1 notified B # 1 (Behavioral Health Assistant-BHA) that the patient's belongings security bag was on the rack. He/she placed the security bag on the rack. A # 2 was unable to confirm where the security bag went. The footage doesn't show anything. I checked the unit and was unable to locate the security bag. B # 1 has been terminated since then.

13. In interview on 02/21/2025 at approximately 3:20 pm with staff member B # 4 (BHA) confirmed he/she was hired at H # 2 in 02/2025, and was taught to sign the Patient Belongings sheet upon discharge to ensure all patient belongings were sent with the patient.

14. In interview on 02/21/2025 at approximately 4:10 pm with administrative staff member A # 2, confirmed the nurse should have collected the urine for the urinalysis/urine culture within twenty-four (24) hours, and notified the physician to get an order for straight catheterized if necessary. The medical record lacked an order for the patient to have a straight catheterization. The medical record showed an order for a specialty mattress but lacked documentation that the patient had a specialty mattress. At 4:40 pm, further confirmed the initial admission skin assessment indicated the patient had a sacrum/coccyx area which was red and slightly open (wound), but lacked a wound nurse consult within twenty-four (24) hours.

Based on document review and interview the registered nurse failed to ensure the patient's treatment plan was initiated upon admission related to skin integrity/wound care in one (1) instance. (Patient # 10)

Findings include:

1. The hospital policy titled, Patient Treatment Plan, PolicyStat ID 12386362, indicated on page two (2) - Procedure - Preliminary Treatment Plan: Upon admission, the nurse shall initiate the Interdisciplinary Treatment Plan for the patient's identified nursing care needs as part of the admission assessment. This policy was last revised in 09/2022.

2. The hospital policy titled, Skin Assessment, PolicyStat ID 12385990, indicated on page one (1) - Assessment - number two (2) - letter f - number 1. If a skin condition, wound, pressure ulcer is noted, the wound should be assessed by the nurse and documented on the skin/wound form, and page two (2) - number 3 - Provide any necessary pressure relieving measures. This policy was last revised in 09/2022.

3. The hospital policy titled, Wound Care and Treatment, PolicyStat ID 12385988, indicated on page one (1) - Purpose - to ensure consistent, accurate identification and assessment of all wounds, and to ensure appropriate treatment is implemented timely in accordance with professional standards of practice for wound treatment. This policy was last revised in 09/2022.

4. Review of Patient # 10's medical record indicated the following:
a. Nursing Admission Assessment dated 12/24/2024 at 2:31 pm, indicated on page one (1) - Public Health History & Status - Integumentary - redness (slight open red area) to sacrum/coccyx area. The medical record lacked any initial measurements, and/or initial skin/wound assessment discharge plan within twenty-four (24) hours.
b. Providers Orders dated 01/01/2025 at 7:00 pm by N # 1 (Nurse Practitioner-NP), indicated cleanse wound to midline sacrum (4.6 centimeters-cm x 0.7 cm x 0.1 cm) with wound cleanser and pat dry. Apply Medihoney to wound bed and cover with optifoam dressing.

5. In interview on 02/21/2025 at approximately 4:20 pm with administrative staff member A # 2 (Licensed Practical Nurse-LPN/Chief Executive Officer-CEO), confirmed the nurse should have initiated the skin/wound treatment plan within twenty-four (24) hours of admission.

Based on document review and interview the facility failed to ensure an incident report was completed for a new hospital acquired wound in one (1) instance. (Patient # 10)

Findings include:

1. The hospital policy titled, Incident Reports, PolicyStat ID 13033981, indicated on page one (1) - Purpose - it is the policy of the hospital to support a culture of shared accountability for the identification, reporting and management of patient events that may impact the quality of care provided. An incident is defined as: any event which is not consistent with the routine operation of the hospital and that adversely affects or threatens to affect the well-being of the patients. This policy was last revised on 01/2023.

2. Review of patient # 10's medical record indicated the following:
a. Provider Order dated 01/01/2025 at 10:50 am, indicated a new wound consultation for right third (3rd) and fourth (4th) fingers.
b. Daily Nursing Narrative dated 01/01/2025 at 5:47 pm, indicated patient had a pressure sore to third finger which was open with serous drainage and foul odor.
c. Medical record initial skin assessment lacked documentation related to finger wounds.

3. In interview on 02/21/2025 at approximately 11:30 am by administrative staff member A # 1 (Registered Nurse-RN/Director of Nursing-DON), indicated there were no incident reports completed for patient # 10's hand wound.