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Based on review of the facility policy and procedures, medical record review, and staff interviews, the nursing staff failed to conduct a full skin assessment; and failed to identify changes in a patient's skin condition resulting in a stage 3 pressure ulcer in 1 of 3 sampled patients (Patient #3).

Findings include:

Review on 07/29/2020 of the facility policy titled "Skin and Wound Program Overview" with a release date of 06/2017 revealed "... e. Skin assessment/inspection at time of admission and each shift ..."

Review on 07/28/2020 of the facility policy titled "CORE: Clinical Guidelines for Pressure Injury" with a release date of 06/2019 revealed "... 3. Each patient should have an individualized plan of care created around the identified risk level ..."

Medical record review on 07/28/2020 of Patient #3 revealed a 72-year-old male admitted on 03/06/2020 at 2348 with a diagnosis of "Respiratory Failure". Review of the "Skin Assessment Flowsheet" revealed documentation of skin breakdown and wounds on Patient #3's lower extremities on admission. Review of the skin assessment flowsheets revealed no evidence of further skin breakdown on admission. Review of a physician order revealed "Reposition, Inspect skin, monitor, record report reddened area; apply skin barrier/protection (critic-aid clear [type of barrier cream]) Start 03/07/2020 0200, q2h (every 2 hours) ..." Review of a wound care nursing note on 03/25/2020 at 1816 revealed a wound to the left lateral lower leg. Review of a physician's (surgeon) progress note dated 04/14/2020 (not timed) revealed the patient had bilateral lower extremity pressure ulcers that were failing to heal. Review revealed the wound on the left lower leg showed no signs of healing and recorded there was not adequate blood flow to heal the wounds. Review of the patient's primary physician dated 04/14/2020 (no time) revealed the patient had a surgical debridement of the left lower leg pressure ulcer on 03/31/2020. Review revealed a phone discussion with the patient's family on 04/14/2020 to discuss possible amputation and prognosis of wounds. Review of a nursing note recorded by the wound care nurse on 04/15/2020 at 1543 revealed the patient had a left lateral leg wound that measured 21 cm (8.4 inches) by 5.5 cm (2.2 inches), unable to determine depth, with necrotic tissue present. Review of the daily skin assessments for 03/06/2020 through 04/14/2020 revealed no documentation of skin breakdown on the sacrum area. Review of a nursing note dated 04/15/2020 at 0921 by the patient's primary nurse revealed "... skin appearance: ashen (pale gray color), warm, dry, smooth, well hydrated, Skin integrity: skin not intact, wound related ..." Review of the wound documentation recorded by the patient's primary nurse on 04/15/2020 at 0921 revealed wounds were present on the patient's right lateral leg. Review of the nursing note failed to document any wounds to the patient left leg. Review of the note did not show documentation of skin breakdown on Patient #3's sacrum. Review of the medical record revealed Patient #3 was being seen by the wound care nurse on Monday, Wednesday, and Fridays for wound care. Review of "Nurses Note" documented by the wound care nurse dated 04/15/2020 at 1552 revealed "Weekly wound care - Pressure injury: sacrum ... Wound onset type: acquired after admission Stage: stage 3 Wound length: 4 cm [centimeters] (1.6 in [inch]) Wound width: 1 cm (0.4 in) Wound depth: 0.2 cm (0.1 in) ..." Review of the medical record revealed the wound care nurse provided wound care as ordered by the physician orders. Review of the medical record revealed Patient #3 was discharged on 05/22/2020 to Facility F per Patient #3's daughter's request for second opinion on wounds.

Interview on 07/30/2020 at 1052 with Staff #15 revealed she was the wound nurse when Patient #3 was admitted to the facility. Interview revealed Patient #3 was admitted with multiple vascular wounds on his right lower leg. Interview revealed there was no break down on Patient #3's sacrum or left leg on admission.

Interview on 07/30/2020 at 1330 with Staff #16 revealed she was the primary nurse who provided care for Patient #3 on 04/14/2020. Interview revealed she did not recall seeing a pressure ulcer on Patient 3's sacrum. Interview revealed Staff #16 recalled the wounds on the right and left lower extremity. Interview revealed Staff #16 had given Patient #3 a Braden score (a tool used to predict pressure ulcer risk) of 12 (high risk for pressure sore). Interview revealed a Stage III pressure ulcer would not develop overnight on a patient.

An interview was attempted with Staff #25 who was the primary nurse that documented the skin assessment on 04/15/2020 at 0921. The staff member was not available for interview.

Interview on 07/28/2020 at 1620 with Staff #17 revealed she was the wound care nurse for the facility and documented the Stage III pressure ulcer on the sacrum on 04/15/2020 at 1552. Interview revealed Patient #3 had a Stage III Pressure Ulcer identified over his sacrum area on 04/15/2020. Interview revealed there was no documentation of a pressure ulcer identified on 04/14/2020 or during the prior week skin assessments. Interview revealed a Stage III pressure ulcer would not develop overnight.

In summary, facility nursing staff failed to conduct a complete skin assessment by failing to document left leg wounds on 04/15/2020 at 0921; and failing to identify a pressure ulcer that had progressed to a Stage III pressure ulcer on Patient #3's sacrum when found by the wound care nurse on 04/15/2020 at 1552.

NC00165074, NC00166178