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Based on document review and interview, Nursing services failed to turn and reposition patients as ordered in 5 of 10 MRs (Medical Records) reviewed (P1, P2, P3, P4, P6); failed to perform daily dressing changes and/or apply daily barrier cream to patients in 3 of 10 MRs reviewed (P1, P2, P10); failed to document wound measurements in 5 of 10 MRs reviewed (P1, P4, P7, P8, P9); failed to document wound photographs in 5 of 10 MRs reviewed. ( P1, P3, P7, P8, P9). (tag 0395) and failed to document follow up and education to staff involved in missed dressing changes for 1 of 10 MRs (Medical Records) reviewed. (P10) (tag 0398).

The cumulative effects of this systemic problem resulted in the facilities inability to provide nursing services in a safe manner.

Based on document review and interview, the facility failed to provide documentation of a RCA (Root Cause Analysis) for 1 of 1 Adverse Events reviewed. (P10)

Findings include:

1. Facility policy titled Electronic Event Reporting, Policy # 600, Last Reviewed Date 05/16/2024, Page 2, under Policy, An event report is to be completed for every occurance which meets the following definition: any happening not consistent with the routine care or operation of the facility, or the desired routine care of the patient and/or operation of the facility, which places our patients and visitors at increased risk for harm. The Quality Committee has delegated the task of investigation of adverse events to the DQR (Director of Quality Risk), and the DQR may designate individuals to assist with these investigations as needed. Page 4, under II. Response to Sentinel Event: The Governing Board/Quality Committee has delegated the task of investigation of adverse events determining if an adverse event meets the definition of a sentinel event and if so, completing a Root Cause Analysis to the Director of Quality/Risk (DQR)

2. Facility policy titled Sentinel Events, Policy # 692, Last Reviewed Date: 5/16/2024, Page 1, under Definitions: Sentinel Event: For the purpose of this policy, A Sentinel Event is defined as a patient safety event (not primarily related to the natural course of the patient's illness or underlying condition) that reaches a patient and is considered "sentinel" because it signals a need for immediate investigation and response. Page 4, under II. Response to Sentinel Event: The Governing Board/Quality Committee has delegated the task of investigation of adverse events determining if an adverse event meets the definition of a sentinel event and if so, completing a Root Cause Analysis to the Director of Quality/Risk (DQR), and the DQR may designate individuals to assist with investigation as needed. Under Non-Reviewable Root Cause Analysis, Page 5, 1. Upon determination or suspicion that a Non-Reviewable Sentinel Event has occurred, the DQR may choose to do a Modified Root Cause Analysis and Action Plan form.

3. Event dated 1/7/25, Entered date 1/8/25, P10 admitted to facility on 12/27/24, indicated a patient care advocate noted a bad odor in patients room and requested surgical incision to be checked. Nurse entered room, noticed bad smell, removed dressing and noted wound to be dehisced and infected. Wound cleansed, redressed and physician notified. Later that evening the physician assessed wound and ordered antibiotics. An order was previously written for daily dressing changes on 12/30/24 due to patient having excess drainage, multiple nurses ignored the order, and the dressing change only completed a couple of times since 12/20/24.Security level D. No harm-Reached patient monitoring required. Sentinel Event: yes, No outcome actions or subsequent actions listed. Event lacked documentation of a Root Cause Analysis.

4. In interview on 3/12/25 at approximately 1120 hours with A3, he/she confirmed that there was no follow up education with employees involved in the incident reported on 1/7/25 of missed dressing changes on dates 12/31/24, 1/3/25 and 1/4/25 for P10 and event lacked documentation of Root Cause Analysis.

Based on document review and interview, Nursing services failed to turn and reposition patients as ordered in 5 of 10 MRs (Medical Records) reviewed (P1, P2, P3, P4, P6); failed to perform daily dressing changes and/or apply daily barrier cream to patients in 3 of 10 MRs reviewed (P1, P2, P10); failed to document wound measurements in 5 of 10 MRs reviewed (P1, P4, P7, P8, P9); failed to document wound photographs in 5 of 10 MRs reviewed. ( P1, P3, P7, P8, P9)

Findings include:


1. Facility policy titled Wound Assessment and Documentation, Policy #2, Last reviewed Date: 08/15/2024, indicated on Page 2, under Policy: All patients admitted to the hospital will be screened within 8 hours for risk of skin breakdown and for alteration in skin integrity by a registered nurse. For a Braden score of 18 or less, the Pressure Injury Prevention Protocol will be initiated and incorporated into the plan of care. I. Assessment: An RN (Registered Nurse) will inspect each patient's skin daily and as often as indicated. 1. The Braden Scale is used to assess all patients for risk of skin breakdown. Findings are recorded upon admission and weekly at a minimum. A. A full skin assessment is completed within 8 hours of admission (or discovery of a new wound) to include descriptions, measurements, and physician notification if applicable. D. Pressure injuries/ulcers will be staged, measured, and photographed in accordance with the wound treatment plan, but no less than weekly. E. Within 2 days before discharge a final complete assessment is conducted, including descriptions, staging, measuring, and photography as appropriate. 3. Skin tears, procedure-related wounds, or lower extremity ulcers (arterial, venous, or neuropathic) are not staged unless pressure is a primary factor. These types of alterations in skin integrity should be described, measured and photographed as addressed further in this policy. Page 4, under III. Documentation: 2. Daily documentation of skin and wound inspection completed by an RN will include the following, if present: A. skin condition, B. dressing integrity, C. description of wound drainage, odor, pain, signs of inflammation or infection, if present. Page 5, IV. Wound Photography: 2. The following wounds are to be photographed within 24 hours of discovery, weekly, and within 2 days of discharge as below: A. all pressure injuries/ulcers Stage 2 or above, B. any procedure-related wound that is not proceeding on an expected healing course, C. any other alterations in skin integrity with significant clinical characteristics such as drainage or signs of infection, D. any wound that would trigger the completion of a Skin/Tissue Electronic Event Report.

2. Review of P1 MR indicated:
a. P1 admitted to the facility on 1/15/25 with Diagnosis of Acute metabolic encephalopathy. Braden Scale Score 14. (Moderate risk for pressure ulcer development)
b. Patient admitted to facility with traumatic wound to top of Left foot, MR lacked documentation of wound measurements of left foot from 1/15/25 through 1/29/25, MR lacked documentation of photograph within two days of discharge.
c. Wounds to Right Posterior Lower Leg and Right Anterior Lower Leg were measured on 1/17/25, MR lacked documentation of wound measurements from 1/18/25 through 1/29/25.
d. On 1/17/25 wound to coccyx noted and wound care nurse ordered barrier cream to apply as needed and with each incontinent episode as a preventative measure, lacked documentation of barrier cream applied to coccyx from 1/17/25 through 1/24/25.
e. Nursing flowsheets lacked documentation of turning and repositioning patient including, but not limited to 1/15/25 at 2100 hours through 1/16/25 at 1400 hours. Patient required assistance to turn and reposition.

3. Review of P2 MR indicated:
a. P2 admitted to the facility on 12/27/24 with Diagnosis of Encephalopathy. Braden Scale Score 16. (Mild risk for pressure ulcer development)
b. Patient was on dialysis, diabetic with a surgical incision and abscess on left thigh. Patient unable to reposition self.
c. On 12/27/24 initial assessment indicated skin to buttock red and blanchable, on 12/30/24 wound care nurse ordered Remedy Protect: apply to buttock area as needed and with incontinent episodes, cream applied to area on 12/30/24 and 1/2/25 through 1/6/25. Lacked documentation of preventative cream applied on 12/31/24, 1/1/25 and 1/7/25.
d. On 12/31/24 orders for repositioning with pillow support, off-load heels, Reposition per patients' needs.
e. MR lacked documentation of turning and repositioning patient per order including, but not limited from 12/28/24 at 0600 hours through 12/28/24 at 1700 hours. Patient dependent on repositioning.

4. Event dated 1/8/25, P2 admitted to facility on 12/27/24, indicated a deep tissue pressure to gluteal cleft discovered by nursing staff. Two areas were still dark purple and non-blanchable, the rest was 100% adherent slough tissue. P2 is a Hoyer lift/slide board transfer. P2 incontinent of urine and stool. Wound is most likely a pressure injury to contributing factors of shearing and moisture.

5. Review of P3 MR indicated:
a. Patient was admitted to the facility on 2/7/25 with Diagnosis of Femur fracture. Braden Scale Score 16. (Mild risk for pressure ulcer development)
b. Patient admitted with surgical incision to left hip. Patient incontinent of bowel and bladder.
c. MR lacked documentation of turning and repositioning patient including, but not limited to, from 2/7/25 from 1200 hours through 2/7/25 at 2000 hours, 2/8/25 at 0500 hours through 2/8/25 at 2300 hours, 2/8/25 at 0200 hours through 2/9/25 at 1200 hours. Patient dependent for repositioning.
d. On 2/10/25 wound care order placed to cleanse sacral area with soap and water, apply skin prep and Optiview dressing every 5 nights, pressure relief when up in chair with specialty cushion, reposition with pillow support in bed, off-load heels.
e. On 2/13/25 wound care nurse notified of DTPI (Deep Traumatic Pressure Injury) and wound care orders placed to cleanse wound with soap and water and apply Plurogel and foam dressing to sacral area.
f. Lacked documentation of photograph of sacral wound within 2 days of discharge on 2/28/25.

6. Review of P4 MR indicated:
a. Patient was admitted to the facility on 1/28/25 with Diagnosis of CVA with left side affected. Colon Cancer with status post colostomy and Chronic kidney Disease stage 3. PEG (Percutaneous Endoscopic Gastrostomy) tube placement. Braden Score 15. (Mild risk for pressure ulcer development)
b. Patient admitted to the facility with a sacral deep tissue pressure injury measuring 4.8 cm (centimeters) long x 3.5 cm wide x 0.2 cm depth. Maceration noted to scrotum and groin area. Photographs taken of wounds on admission.
c. On 1/29/25 wound care orders for groin, sacral area and scrotum: Cleanse with Anacept wound cleanser, pat dry, do not scrub. Apply skin prep to peri wound, apply Anacept gel to wound bed and apply sacral foam at bedtime daily and as needed with soiling, saturation or dislodgement.
d. Orders on 1/29/25 Advanced boot to stroke affected side (Left side), Blue boot to right foot, Float heels while in bed. Reposition patient as needed when up in chair. Reposition with pillow support in bed, check for toileting incontinence. Order comments: Reposition per patients' needs, Evolving DTPI to sacrum, incontinent and dependent for mobility.
e. On 2/11/25 a blister to the abdomen was noted, MR lacked documentation of measurements of wound from 2/11/25 through 2/19/25.
f. On 2/18/25 wound noted to end of penis, lacked documentation of measurements.
g. On 2/18/25 deep tissue injury noted to left heel measuring 5 cm x 6 cm x 0 cm. Off-loading boots were not on patient as ordered at the time the wound was discovered. Order placed to paint heel with betadine every 3 days and place optiview dressing. Daily head to toe skin assessment from 1/28/25 through 2/17/25 lacked documentation of any skin alterations to left heel.
h. Nursing flowsheets lacked documentation of turning and repositioning patient including, but not limited to, from 1/28/25 at 1900 hours through 1/29/25 at 0600 hours. Patient dependent on repositioning and transfers with Hoyer lift.
i. Sacral wound on 2/18/25 measured 12.5 cm x 15 cm x 1 cm.
j. Patient discharged to skilled nursing facility on 2/19/25.

7. Event dated 2/18/25, P4 admitted to facility on 1/28/25, indicated wound care nurse making routine rounds and discovered P4 in bed without off-loading heel boots. Blood blister to left heel noted. Wound care completed and off-loading boots applied, and patient repositioned to right side with pillow support.

8. Review of P6 MR indicated:
a. Patient admitted to the facility on 2/19/25 for Diagnosis of UTI (Urinary Tract Infection). Braden Scale Score 17 (Mild risk for pressure ulcer development)
b. On 2/20/25 orders written per wound nurse to Float heels in bed, reposition as needed when up in chair, reposition with pillow support in bed, check every 2 hours, if area of skin is not red may increase the time patient stays on that side, if patient is red reduce the time the patient needs to be turned. Wheelchair cushion.
c. Nursing flowsheets lacked documentation of turning and repositioning patient every 2-3 hours per order including, but not limited to, from 2/19/25 at 1300 hours through 2/20/25 at 1300 hours. Patient required moderate assist to turn and reposition.

9. Review of P7 MR indicated:
a. Patient admitted to the facility on 1/29/25 with Diagnosis of Hip fracture. Braden Scale Score 14. (Moderate risk for pressure ulcer development)
b. Patient admitted with wounds: left lower leg venous ulcer, right lower leg venous ulcer, left heel pressure injury and left lateral leg incision.
c. MR lacked wound measurements to Left lower leg venous ulcer and right lower leg venous ulcer from 1/29/25 through 2/11/25. MR lacked photograph of wounds within 2 days prior to discharge.
d. MR lacked documentation of measurements to right heel wound from 1/30/25 through 2/11/25. Lacked photograph of wound from 1/30/25 through 2/11/25.

10. Review of P8 MR indicated:
a. Patient admitted to the facility on 1/27/25 with Diagnosis of Wound Dehiscence. Braden Scale Score 16. (Mild risk for pressure ulcer development)
b. Patient admitted with right hip skin tear, right breast skin tear, buttock skin damage and right chest surgical incision.
c. MR lacked documentation of right hip skin tear measurements and photographs from 1/27/25 through 2/9/25.
d. MR lacked documentation of right breast skin tear measurements from 1/27/25 through 2/9/25. Lacked documentation of wound photographs from 1/28/25 through 2/9/25.
e. MR lacked documentation of right chest surgical incision measurements from 1/27/25 through 2/9/25. Lacked documentation of wound photographs from 1/28/25 through 2/9/25.

11. Review of P9 MR indicated:
a. Patient admitted to the facility on 2/12/25 with Diagnosis of 7-9 Posterior rib fracture. Braden Scale Score 18. (Mild risk for pressure ulcer development)
b. Admitted with left heel fissure. Lacked documentation of measurements to wound from 2/12/25 through 2/19/25. MR lacked documentation of wound photographs from 2/13/25 through 2/19/25.

12. Review of P10 MR indicated:
a. Patient admitted to the facility on 12/27/24 with Diagnosis of Right hip fracture. Braden Scale Score 18. (Mild risk for pressure ulcer development)
b. Patient admitted with an abdominal incision. MR lacked measurement of incision on admission. Incision open to air.
c. On 12/30/24 order written for daily dressing change to abdominal incision due to increased drainage.
d. MR lacked documentation of daily dressing change to abdomen on 12/31/24, 1/3/25 and 1/4/25.

13. In interview on 3/12/25 at approximately 1200 hours with A4 (Wound Program Coordinator), he/she indicated they do not measure every wound that comes into the facility. A4 indicated the wounds that are measured are pressure wounds, or those wounds that require a Wound Vacuum. A4 or N1 (Wound Care Nurse) write the wound care orders for patients, precautionary measures to prevent further skin breakdown including but not limited to turning and repositioning patients, and off-loading measures including but not limited to air mattress and heel protectors. A4 confirmed P1's MR lacked documentation of wound measurements, photographs, turning and repositioning of patient, and no barrier cream applied to coccyx as ordered on 1/17/25 through 1/24/25; P2's MR lacked documentation of turning and repositioning patient and applying barrier cream to patients coccyx on 12/3/24, 1/1/25 and 1/7/25 as ordered; P3's MR lacked documentation of photograph of sacral wound within 2 days prior to discharge and turning and repositioning patient as ordered; P4's MR lacked documentation of turning and repositioning patient as ordered and wound measurements of abdomen, penis and groin; P6's MR lacked documentation of turning and repositioning patient as ordered; P7's MR lacked documentation of wound measurements of right and left leg venous ulcers from 1/29/25 through 2/11/25, lacked wound measurements and photograph of right heel from 1/30/25 through 2/11/25, and turning and repositioning patient as ordered; P8's MR lacked documentation of right hip skin tear measurements and photographs from 1/27/25 through 2/9/25, right breast skin tear measurements from 1/27/25 through 2/9/25 and wound photographs from 1/28/25 through 2/9/25, right chest surgical incision measurements from 1/27/25 through 2/9/25 and photographs from 1/28/25 through 2/9/25; P9's MR lacked documentation of left heel fissure measurements from 2/12/25 through 2/19/25 and lacked documentation of wound photographs from 2/13/25 through 2/19/25; P10's MR lacked documentation of daily dressing change to abdomen per order on 12/31/24, 1/3/25 and 1/4/25. A4 also confirmed if repositioning of patients is ordered, it is per patients' needs. If the patient is dependent on turning and repositioning it is every 2 hours.

Based on document review and interview Nursing Services failed to document follow up and education to staff involved in missed dressing changes for 1 of 10 MRs (Medical Records) reviewed. (P10)

Findings include:

1. Facility policy titled Electronic Event Reporting, Policy # 600, Last Reviewed Date 05/16/2024, Page 2, under Policy, An event report is to be completed for every occurance which meets the following definition: any happening not consistent with the routine care or operation of the facility, or the desired routine care of the patient and/or operation of the facility, which places our patients and visitors at increased risk for harm. The Quality Committee has delegated the task of investigation of adverse events to the DQR (Director of Quality Risk), and the DQR may designate individuals to assist with these investigations as needed.

2. Review of P10 MR indicated:
a. a. Patient admitted to the facility on 12/27/24 with Diagnosis of Right hip fracture. Braden Scale Score 18. (Mild risk for pressure ulcer development)
b. On 12/30/24 order written for daily dressing change to abdominal incision due to increased drainage.
c. MR lacked documentation of daily dressing change to abdomen on 12/31/24, 1/3/25 and 1/4/25.

3. Event dated 1/7/25, Entered date 1/8/25, P10 admitted to facility on 12/27/24, indicated a patient care advocate noted a bad odor in patients room and requested surgical incision to be checked. Nurse entered room, noticed bad smell, removed dressing and noted wound to be dehisced and infected. Wound cleansed, redressed and physician notified. Later that evening the physician assessed wound and ordered antibiotics. An order was previously written for daily dressing changes on 12/30/24 due to patient having excess drainage, multiple nurses ignored the order, and the dressing change only completed a couple of times since 12/20/24.Security level D. No harm-Reached patient monitoring required. Sentinel Event: yes, No outcome actions or subsequent actions listed.

4. In interview on 3/12/25 at approximately 1120 hours with A3, he/she confirmed that there was no follow up education with employees involved in the incident reported on 1/7/25 of missed dressing changes on dates 12/31/24, 1/3/25 and 1/4/25 for P10.