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Based on review of medical records, policies and procedures, and staff interviews, it was determined that the facility failed to provide adequate content of medical record when five patients (P) (P#1, P#2, P#3, P#4, and P#5) of five patients (P#1, P#2, P#3, P#4 and P#5) failed to have turning/repositioning interventions documented.

Findings:

A review of the incident report log from April 2023 till date, October 2023 revealed that there were three patients (P#2, P#3, and P#4) who had skin/wound related incidents, one patient P#1 had an incident where the tracheostomy was found on the floor, and one patient's family (P#5) had a concern/complaint about staff's communication.

1. A review of P#1's medical record revealed that P#1 was admitted to the facility on 2/28/23 at 6:01 p.m. with the chief complaint of acute cerebrovascular accident (stroke), respiratory failure, and hypertension (when the pressure in your blood vessels is too high). P#1 had a past medical history of acute stroke, pontine hemorrhage (bleeding in the brain), acute respiratory failure, physical deconditioning, critical illness polyneuropathy (malfunction of the nerves throughout the body).

A review of the physical exam under the History and Physical (H&P) revealed that P#1's general appearance was ill appearing, and the skin had no rashes and no jaundice. P#1 was put on two hourly turning and repositioning because he was at risk of developing pressure related injuries due to his immobility associated with P#1's critical illness polyneuropathy. Wound care was to follow P#1 weekly and as required to monitor his skin integrity.

A review of the wound care consult notes dated 3/1/23 at 2:11 p.m. revealed that P#1 had a previous abrasion to his right buttocks on 2/13/23 (from a previous admission in another facility). Recommendation was to apply Mepilex (foam absorbent) dressings every three days and to reconsult wound care if there was any new issue. No other wounds or skin problems were reported by the wound care team.

A review of the wound care progress notes revealed the following:
" 3/6/23 at 10:08 a.m. revealed that P#1's skin was warm and dry with no rashes or lesions. Mepilex dressing was over the sacral/coccyx area for protection. The skin was documented to be intact, and no areas of concern were noted.
" 3/15/23 at 12:59 p.m. revealed that there were no new complaints at the time of reassessment.
" 3/20/23 at 10:26 a.m. revealed that P#1 does not have any wound present on examination.
" 3/27/23 at 9:26 a.m. revealed that P#1 did not have any wound present on examination. Documentation also revealed that P#1 would need routine turning and offloading, heel protectors, and an air mattress to aid in the prevention of pressure related injuries.
" 4/10/23 at 10:29 a.m. revealed that P#1 had no wounds present on examination.

Documentation failed to reveal that P#1 was turned every two hours as ordered as the facility did not have any turning/repositioning charts to document the intervention.

P#1 was transferred to a rehabilitation hospital on 4/13/23 at 3:35 p.m.

2. A review of P#2's medical record revealed that P#2 was admitted to the facility on 6/23/23 at 10:38 a.m. with the chief complaint of respiratory failure, end stage renal dialysis (when kidneys no longer function well enough to meet a body's needs, treatment involves kidney dialysis), diabetes (high blood sugar levels), and paraplegia (inability to voluntarily move the lower parts of the body).
A review of the History and Physical (H&P) dated 6/29/23 at 6:45 p.m. revealed that P#2 had a past medical history of Type 2 diabetes mellitus, Hypertension, Paraplegia, End stage renal disease, Decubitus ulcers, Left Below Knee Amputation, and Right Above Knee Amputation.

A review of the wound care progress notes dated 6/28/23 at 1:35 p.m. under the physical exam revealed that P#2's skin was warm and dry, no rashes noted. P#2 had pressure injury of skin of multiple topographic sites present on admission. Maggots were found during skin assessment on the left hip, and treatment done as per order.

Documentation revealed that P#2 had moisture associated skin damage on the buttocks. P#2 had a large full thickness ulcer with small amount of slough (to lose a dead layer of (skin) 80% granulation tissue with moderate amount of greenish white drainage with slight odor.

A review of the wound care progress notes dated 7/3/23 at 8:52 a.m. under the physical exam revealed a plan of derma blue (a dressing foam indicated for moderately to heavily exuding, partial to full thickness wounds) to area daily; keep area clean, turn every one to two hours, air mattress and offloading.

A review of the wound care progress notes dated 7/7/23 at 10:41 a.m. revealed that P#2 had multiple wounds on admission, and no changes in wound care treatment. P#2 was educated on the importance of appropriate wound care as P#2 refused dressing changes sometimes.

A review of the nursing progress notes reveal the following:
On 6/23/23 dressings were clean, dry, and intact.
On 6/24/23 dressing was intact, elbows padded, and P#2 was on a pressure redistribution mattress/bed.
On 6/25/23 dressing was clean, dry, and intact.
On 6/26/23 elbows padded, lift sheet.
On 6/27/23 lift sheet, pressure redistribution mattress/bed, commercial moisture barrier applied.
On 6/28/23 dressing saturated with drainage. Wound was cleaned with gauze sponge scrub, Dakin's solution (used to kill germs and prevent germ growth in wounds), and dressings applied.
On 6/29/23 wound cleaned and redressed.
On 6/30/23 dressing clean, dry, and intact, moisture barrier applied.
On 7/1/23 dressing clean, dry, and intact.
On 7/2/23 commercial moisture barrier applied.
On 7/3/23 dressing change was performed.
On 7/4/23 dressing clean, dry, and intact.
On 7/5/23 elbows padded, heels padded, heels floated, bony prominences padded. Pressure redistribution mattress/bed, commercial moisture barrier applied.
On 7/6/23 dressing changed.
On 7/7/23, 7/8/23, 7/9/23, dressing clean, dry, and intact.
On 7/10/23 commercial moisture barrier applied.
On 7/11/23 pressure redistribution mattress/bed
On 7/12/23-7/14/23 dressing dry, clean, and intact; commercial barrier cream applied.
On 7/15/23, and 7/16/23 all dressings intact
On 7/17/23 dressing loosely intact.
On 7/18/23 dressing clean, dry, and intact.
On 7/19/23,dressing clean, dry, and intact.

Documentation failed to reveal the frequency of P#2's turning/repositioning as the facility did not have any turning/repositioning chart documentation.

P#2 was transferred to an acute care center on 7/20/23 at 10:55 a.m.

3. A review of P#3's medical record revealed that P#3 was admitted to the facility on 6/22/23 at 12:52 p.m. with the chief complaint of sepsis (a serious condition in which the body responds improperly to an infection), respiratory failure, and multiple wounds.

A review of the History and physical (H&P) dated 6/23/23 at 2:06 p.m. revealed that P#3 had a past medical history of acute kidney injury, stroke, Gastroesophageal reflux disease (GERD) (a common condition in which the stomach contents move up into the esophagus), hypertension, hyperlipidemia (your blood has too many lipids (or fats), Methicillin-resistant staphylococcus aureus (MRSA) (infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used), respiratory failure, seizure disorder, hypothyroid (happens when the thyroid gland doesn't make enough thyroid hormone), and Clostridium difficile (C. Diff) (a bacterium that causes an infection of the colon).

A review of the wound care consult notes dated 6/25/23 at 1:35 p.m. revealed a consultation of multiple wounds present on admission. P#3 had a stage III sacral ulcer, and the plan was to start with Dakins wet to moist dressing daily; side to side turning every one to two hours. Documentation revealed P#3 had moisture associated skin damage (MASD) to the tracheostomy, and the plan was to apply barrier cream for protection, clean dressing, and monitor drainage.

A review of the nursing progress notes dated 6/30/23 at 2:26 p.m. revealed that P#3's sacral wound was debrided with a pre-debridement measurement of 9x7x4 undermining throughout, deepest at 5:00 - 4.5 cm. Documentation revealed post debridement measurements of 9x7x4.4.

Documentation revealed P#3 was seen by the wound care nurse as required as there was no evidence of wound deterioration.

Documentation failed to reveal that P#3 was turned/repositioned as per order as the facility did not have a turning/repositioning documentation.

P#3 was transferred to a skilled nursing facility on 8/14/23 at 5:56 p.m.

4. A review of P#4's medical record revealed that P#4 was admitted to the facility on 9/15/23 at 11:50 a.m. with the chief complaint of acute sepsis, Chronic Obstructive Pulmonary Disease (COPD) (refers to a group of diseases that cause airflow blockage and breathing-related problems), End Stage Renal Disease (ESRD- on Hemodialysis), and bacteremia (presence of bacteria in the bloodstream).

A review of the History and Physical (H&P) dated 9/16/23 at 1:15 p.m. revealed that P#4 had a past medical history of cataracts, congestive heart failure, End Stage Renal Disease (on dialysis), history of deep vein thrombosis (occurs when a blood clot forms in a deep vein), fatty liver disease, gout (common form of inflammatory arthritis that is very painful; usually affects one joint at a time (often the big toe joint)), hypertension, hyperlipidemia, and peripheral vascular disease (the narrowing or blockage of the vessels that carry blood from the heart to the legs).

A review of the initial wound care consult notes dated 9/18/23 at 9:42 a.m. revealed that P#4 did not have any skin breakdown, and P#4 denied any problems with his skin. Documentation revealed that P#4 reported some swelling to his bilateral lower extremities when P#4 sat down for prolonged times. Documentation also revealed two hourly turning and repositioning for P#4 due to the risk of developing pressure related injuries. Heels remained intact.

A review of the wound care consult notes dated 9/25/23 at 10:01 a.m. revealed no skin breakdown on admission. Wound care to follow up weekly and as necessary to monitor skin integrity.

A review of the wound care progress notes dated 10/2/23 at 9:07 a.m. and 10/9/23 at 9:28 a.m. revealed that P#4 had no new complaints.

Documentation failed to reveal that P#4 was turned/repositioned as per order as the facility did not have any turning/repositioning documentation.

P#4 was discharged home with Home Health on 10/12/23 at 2:47 p.m.

5. A review of P#5's medical record revealed that P#5 was admitted to the facility on 9/12/23 at 11:35 a.m. with the chief complaint of acute resp failure, cardiac arrest, chronic kidney disease - CKD-Not on dialysis (a disease characterized by progressive damage and loss of function in the kidneys ), and Diabetes Mellitus.

A review of the History and Physical (H&P) dated 9/13/23 at 1:13 p.m. revealed that P#5 had a past medical history of acute respiratory failure, history of cardiac arrest, chronic kidney disease stage 3, fatty liver, critical illness polyneuropathy, physical deconditioning, Type 2 diabetes mellitus, epilepsy, right below knee amputation.

A review of the wound care consult notes dated 9/13/23 at 3:36 p.m. revealed a wound to the left heel present on admission. The plan was to offload, apply betadine with the goal to keep dry, and monitor for complications. Two hourly turning.

A review of the wound care nursing notes dated 9/14/23 at 1:45 p.m. and 9/15/23 at 11:14 a.m. revealed no new complaints.

A review of the wound care progress notes revealed the following:
" On 9/18/23 at 11:06 a.m. revealed no distress noted and heels offloaded.
" On 9/20/23 at 9:31 a.m. revealed that P#5 had some inflammation due to incontinence to the perineum and groin area. Barrier cream applied. The left heel was darkened with intact skin. No signs of infection.
" On 9/21/23 at 9:49 a.m. revealed no new issues reported.
" On 9/22/23 at 8:51 a.m. revealed that P#5's heels were not offloaded.
" On 9/25/23 at 12:34 p.m. revealed P#5's heels were floated. Left heel, no changes, remained stable. Documentation revealed the groin/perineum/inner thighs redness and inflammation associated with moisture from incontinence had improved.
" Progress notes from 9/26/23 at 9:01 a.m. through 10/3/23 at 8:42 a.m. revealed that the left heel was floated with intact skin, and no signs of infection. The redness and inflammation on the groin/perineum/inner thighs had reduced and was resolving.
" On 10/4/23 at 9:15 a.m. revealed that P#5's skin was warm and dry, the groin and thigh area moisture was controlled and Triad paste (zinc-oxide based paste used on broken skin in the presence of incontinence or maceration of the peri-wound skin) to be used as needed. Documentation revealed the left heel was unstageable.
" On 10/5/23 at 8:52 a.m., and 10/6/23 at 10:38 a.m. revealed that P#5's left heel was firm with dry eschar (dark scab), peri-wound skin was dry and callused (hardened skin). No changes and remained stable. Wound care was done with Betadine (an antiseptic used for skin disinfection).
" 10/9/23 at 10:20 a.m. through 10/17/23 at 8:40 a.m., revealed no changes to P#5's left heel wound.
" On 10/16/23 at 9:24 a.m. revealed that P#5's left heel was firm dry, eschar moist but intact. Border foam dressing was applied for protection.
" On 10/18/23 at 9:36 a.m. revealed that P#5's left heel eschar and peri wound was dry with decreased moisture.
" On 10/19/23 at 9:13 a.m. revealed the plan to continue betadine to left heel with the goal of keeping the wound dry and stable.

Documentation failed to reveal that P#5 was turned every two hours as the facility did not have a turning/repositioning documentation.

P#5 was transferred to a rehabilitation facility on 10/19/23 at 3:15 p.m.

A review of the facility policy titled, "Wound Care Program", Policy No: WC-05, effective date March 2022, stated that the purpose and scope of the policy was to ensure the optimization of all wounds, and to monitor high risk patients for skin breakdown.
III Procedures
7. Daily dressings are done by the wound care team unless otherwise indicated by the provider and/or team.
8. When nursing staff performs wound care, it will be documented on MAR. (Weekends and after hours).

A review of the facility policy titled, "Plan of Care - Patient", Policy No: P-18, effective March 2022 stated that the purpose of the policy was to provide a standardized method of documentation of the patient plan of care at the facility. To provide a collaborative approach in planning the care for patients utilizing an interdisciplinary approach. The form was to be initiated by the Registered Nurse at the time of admission and continued in the weekly interdisciplinary patient care meeting.

A review of the facility policy titled, "Nursing Care Delivery Model", Policy No: N-10, effective March 2022, stated that the resource nurses use the nursing process of assessment, planning, implementation, and evaluation of patient needs. Assumed responsibility for documenting nursing process activities and findings.

A review of the facility policy titled, "Patient Care Documentation", Policy No: P-09, effective March 2022, stated that daily nursing documentation was noted in the nurses' notes. Patients were reassessed at a minimum of every eight hours and as necessary based on the patient's status. Narrative documentation was charted in the nurses' notes, respiratory, physical therapy, occupation therapy, and speech therapy notes: date/time and focused on each entry charted. Focus pertains to the identified patient problem or issues to their care. Responses to treatment interventions were also noted.

An interview took place in the office on 10/30/23 at 1:38 p.m. with Director of Nursing (DON) AA revealed that the facility did not have any documentation of how often patients were being turned/repositioned as the facility only utilized verbal communication to ensure patients were turned/repositioned as per order. DON AA also stated that the facility did not have any policy on turning/repositioning of patients as had been incorporated into the Nursing care delivery model policy.

An interview took place in the conference room on 10/31/23 at 9:30 a.m. with Nurse Practitioner (NP) BB who revealed that the staff usually communicated verbally to ensure patients were being turned/repositioned, and there was no formal chart of documenting the turning/repositioning.

An interview took place in the conference room on 10/31/23 at 9:50 a.m. with Nurse Practitioner (NP) CC revealed that patients who were at high risk were placed on air mattress to offload the pressure, and dressing changes were documented on the Medication administration record (MAR). NP CC further revealed that the staff used 'word of mouth' to make sure patients were being turned/repositioned as the facility did not have any actual chart to document the turning/repositioning.

An interview took place in the conference room on 10/31/23 at 10:10 a.m. with Certified Nurse Assistant (CNA) DD revealed she usually documented patients' care on the Certified Nurse Assistant (CNA) flowsheet under physical activity.

An interview took place in the conference room on 10/31/23 at 10:25 a.m. with Licensed Practical Nurse (LPN) EE revealed that wound care was always done as per order, and patients were also turned as per order, but the facility did not have a specific chart that they documented turning/repositioning of patients.

A telephone interview took place in the conference room on 10/31/23 at 10:40 a.m. with Registered Nurse (RN) FF revealed that a skin assessment was usually done for all patients on admission, and dressings were done as per order. RN FF also revealed that patients were always turned every two hours, but the facility did not have a chart to document the turning/repositioning.