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Based on observation, interview, record review and policy review the hospital failed to have an effective skin injury prevention program that prevented new or worsening wounds from occurring for three current patients (#3, #31 and #74) and two discharged patients (#4 and #39), of nine patients with wounds reviewed.

These failures had the potential to lead to poor outcomes for patients with wounds, and those at risk for skin breakdown.

These practices resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation: Nursing Services. The hospital census was 221.

Please see the 2567 for additional information.

Based on observation, interview, record review and policy review the hospital failed to have an effective skin injury prevention program that prevented new or worsening wounds from occurring for three current patients (#3, #31 and #74) and two discharged patient (#4 and #39), of nine patients with wounds reviewed.
These failure had the potential to lead to poor outcomes for patients with wounds, and those at risk for skin breakdown. The hospital census was 221.

Findings included:

Review of the hospital's policy titled, "Wound Photography, Measurement and Documentation," revised 06/22/22, showed the following directives for staff:
- A pressure injury was localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device.
- Pressure wounds were to be photographed upon admission/date of initial physical examination/assessment, upon detection, weekly, within 72 hours prior to discharge and as otherwise requested by the provider/care team.
- Pressure injuries were to be measured when photos were taken. The length and width should be expressed in centimeters (cm).

Review of the hospital's policy titled, "Skin Care for Adults," revised 05/04/23, showed the following directives for staff:
- A head to toe skin assessment was be conducted upon admission and at least every shift if the patient is at risk for skin breakdown or has any alteration in skin integrity.
- A skin risk score was to be completed upon admission and at least daily.
- Risk factors to assess include: sensory perception, moisture, diaphoresis (excessive sweating due to an underlying health condition or a medication), incontinence, activity level, mobility, nutritional status, friction and shear (force generated when the skin is moved against a fixed surface that results in tissue injury).
- Upon admission, all dressings were to be removed to assess each wound.
- Assessment and documentation of all wounds will be completed every shift, with every dressing change.
- Documentation should include integrity of dressings, observation for changes in drainage, foul odor, and tissue necrosis (death of tissue through disease or injury).
- Dressing changes were to be documented.
- Observation and documentation were to include changes in the skin surrounding the wound.
- Monitor patient for systemic signs and symptoms of fever, White blood cells, and increased pain.
- Wounds shall be photographed.
- Any wound condition that is deemed appropriate by the nurse, wound care specialist, or provider shall be photographed.
- Pressure injury (injury to the skin and/or underlying tissue, usually over a bony area) and wound photographs will be taken on admission to include the date of initial physical examination/assessment.
- Pressure injury and wound photographs will be taken upon detection of any new wound.
- All pressure injuries were to be photographed, measured, and documented weekly.
- Pressure injuries needed to be photographed within 72 hours prior to discharge.
- All pressure injuries needed to be measured when photos are taken to include the length and width in centimeters.
- Patient information and measuring guide were to be included with every photo.
- Consent for photography must be included.

Review of the hospital's undated document titled, "Wound Adult and Altered Skin Integrity Standing Orders," showed that staff were to do the following:
- Routine, continuous, and upon admission, all dressings are to be removed and assessment of wound to be completed unless there is direction not to.
- Wound or dressing assessment and documentation will be completed every shift and with dressing changes.
- Patient's with a Braden Scale (an assessment tool for predicting the risk of bed sores or pressure ulcers) of 18 or less, will be at a higher risk for skin breakdown and preventative measures are to be implemented to include routine and continuous head to toe skin assessments to include all skin folds and are to be done daily.
- A skin risk score will be completed daily.
- Patients will be turned and/repositioned frequently with a goal of at least every two hours and at least every hour for those patients that are sitting continuously.
- Patients with an open wound and altered skin integrity should have routine, continuous, and upon admission should have dressings removed unless ordered otherwise.
- Wound or dressing assessment and documentation will be completed every shift and with all dressing changes.
- Observe and document changes in skin surrounding the wound/dressing for inflammation, edema, tenderness, maceration (tissue damage that occurs when skin is in contact with moisture for too long), and erythema (superficial reddening of the skin).

Review of the hospital's policy titled, "Required Elements of Daily Assessment/Reassessment (REDA)," revised 01/12/23, showed the following:
- Assessment of Patients is the accountability of the registered nurse.
- Initial physical assessment consists of a head to toe assessments for acute medical inpatients.
- Shift assessment includes the care provided and any changes of the patient's condition.

Review of the hospital's policy titled, "Attachment C - Required Elements of Daily Assessment of Adult Acute Care," revised 03/2021, is to include the following:
- Skin assessments to be done once per shift with all patients.
- Braden Scale is to be used and if a score is less than or equal to 18, should have appropriate pressure ulcer prevention interventions and assessments once per shift.
- Assessment for musculoskeletal function is to include the determination if the patient is able to move all extremities without limitation of function, joints are without swelling, and steady gait.

1. Review of Patient #4's medical record, from Hospital B, dated 02/07/23 to 02/15/23, showed the following:
- He was a 63-year-old male who presented to the emergency department (ED) with vomiting, diarrhea, and body aches. He was admitted to the hospital for sepsis (life threatening condition when the body's response to infection injures its own tissues and organs) due to pneumonia (infection in the lungs), possible infection of the skin at the trans-metatarsal amputation (TMA) site, and Methicillin-resistant Staphylococcus aureus (MRSA, high contagious bacteria, that causes infections in different parts of the body and is resistant to many common antibiotics) bacteremia.
- On 02/09/23, the patient was diagnosed with acute encephalopathy (inflammation of the brain, caused by infection or an allergic reaction) and left arm weakness. He was transferred to the intensive care unit (ICU, a unit where critically ill patients are cared for), intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose, down into their windpipe when a person is not breathing on their own), went to operating room (OR) for debridement of a wound on the right foot, a wound culture (a test to identify bacteria that may cause an infection and see what kind of medication will work best to treat the infection) was obtained and showed MRSA.
- On 02/15/23, he was transferred to SSM Hospital DePaul for further evaluation. He was intubated and sedated at the time of transfer. His discharge orders included barrier cream to the sacral area twice a day and as needed. He was on a specialty mattress, and staff were to reposition him frequently to take pressure off of his buttocks.

Review of Patient #4's medical record dated 02/15/23 to 04/01/23 showed the following:
- He was a 63-year-old male with a history of hypertension (high blood pressure), who was transferred from Hospital B to SSM DePaul for evaluation on his infective endocarditis and was admitted to the ICU.
- On 02/15/23, the Patient's admission history and physical showed a traumatic wound on the posterior buttocks. No wound description or measurements were documented.
- On 02/18/23, the patient's history and physical show a pressure injury to the sacral (buttocks) area. A length of 8 cm was documented, but no width, depth or wound description.
- On 02/22/23, at 2:49 PM, Staff XX, Registered Nurse (RN), Wound Nurse, documented the patient had dark discoloration to the buttocks consistent with a possible deep tissue injury (intact or non-intact skin that has red, maroon or purple discoloration that does not go away if pressures is applied) and a significant linear fissure (a small tear in the thin, moist tissue that lines the buttocks) to the sacral area consistent with moisture related skin damage. She recommended frequent repositioning for pressure relief.
- On 02/25/23 at 6:00 PM, the patient's sacral wound measured 15 cm in length, 15 cm in width, and 0.5 cm in depth, and was considered unstageable (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough [yellow, tan, gray, green, or brown] and/or eschar [tan, brown, or black] in the wound bed).
- On 03/01/23, at 11:25 AM, Staff XX, RN, Wound Nurse, documented the patient's sacral pressure injury (injury to the skin and underlying tissues caused by prolonged pressure; also known as bedsores or pressure sores) had opened with slough (layer of dead tissue separated from surrounding living tissue, as in a wound, sore, or inflammation) and tunneling to the wound base. General surgery was consulted for sacral wound debridement (the removal of damaged tissue or foreign objects from a wound).
- On 03/03/23, at 3:47 PM, the patient went to the OR for debridement for the sacral pressure injury. The wound measured 13 cm in length, 7 cm in width, and 3 cm in depth, and was considered a stage 3 pressure injury (a deep opening in the skin that varies in depth based on location, fatty tissue may be visible, but no bone or muscle are exposed). He also received a diverting colostomy placed (due to the sacral wound injury).
- On 03/09/23 at 3:18 PM, the patient's sacral pressure injury measured 10 cm in length, 12 cm in width, and 4 cm in depth. No staging of the wound was documented.
- On 03/13/23 at 4:01 AM, documentation showed the sacral pressure injury measured 11.5 cm in length and 14 cm in width. There was no depth or wound description documented.
- On 03/16/23, the patient underwent the second sacral wound debridement. Physician documentation showed the wound measured 12 cm in length, 13 cm in width, 3 cm in depth and was a stage 4 pressure injury (injury to the skin that extends to the bone and muscle). After the surgical debridement, the sacral pressure injury measured 11 cm in length, 12 cm in width and 6 cm in depth.
- On 03/20/23 at 9:30 AM, the sacral pressure injury measured 9 cm in length, 11 cm in width and 4 cm in depth, no staging of the wound was documented.
- On 03/23/23 at 10:34 AM, the dressing was changed to the sacral wound but no measurements were documented. A surgical note indicated that the sacral pressure injury was a stage 4 pressure injury.
- On 03/28/23, the patient had a third debridement of the sacral pressure injury. No measurements or staging of the wound was documented.
- On 03/31/23 at 1:03 PM, the dressing was changed to the sacral pressure injury, but no measurements or staging of the wound was documented.
- On 04/01/23 at 8:50 PM, the patient passed away.

During an interview on 06/07/23 at 1:08 PM, Staff F, RN, ICU Unit Manager, stated Patient #4 was in ICU for an extended period of time. When he was admitted to the ICU he had a small wound on his sacral area that continued to get bigger. The family talked with her about the patient's sacral wound. The physician discussed with the family why the wound got worse and the family was satisfied with the explanation. The patient had three surgeries on his sacral area, and was in multi-organ failure. The physician explained the patient's condition with the family and they chose to put the patient on comfort measures. She expected the patients to be turned every two hours, unless otherwise ordered by the physician. She expected head to toe assessments to be completed every shift.

During an interview on 06/07/23 at 1:08 PM, Staff J, RN, Floor 7 North Unit Manager, stated patient #4 was on floor seven north for two weeks. The patient refused to be turned and refused dressing changes. The patient's wife stated to her that the patient had not been turned all day, so staff posted a turn schedule on the wall and initialed it every time the patient was turned. She expected the patients to be turned every two hours, unless otherwise ordered by the physician. She expected head to toe assessments to be completed every shift on every unit.

During an interview on 06/07/23 at 3:00 PM, Staff E, Director of Critical Care, stated that when Patient #4 presented to the hospital on 02/15/23, the wound on his buttocks was documented as a skin tear and was considered a traumatic wound. There were no orders or treatments addressing his buttocks wound until 02/18/23, when a pressure injury encounter was documented. She expected nursing staff to document information regarding wounds, including refusals for treatment.

During an interview on 06/07/23 at 3:00 PM, Staff E, Director of Critical Care, stated that when Patient #4 presented to the hospital on 02/15/23, the wound on his buttocks was documented as a skin tear and was considered a traumatic wound. There were no orders or treatments addressing his buttocks wound until 02/18/23, when a pressure injury encounter was documented. She expected nursing staff to document information regarding wounds, including refusals for treatment.

During interview on 06/07/23 at 3:33 PM, Staff XX, RN, Wound Nurse, stated she performed the patient's first wound consult on 02/22/23. She identified a sacral fissure and deep purple tissue that extended to both sides of the patients buttocks. She gave an order for zinc oxide for the sacral fissure, leave open to air, with frequent repositioning for the for pressure relief. Ideally she would not want the patient placed on his back unless necessary. On 03/01/23, the patient's deep purple area had opened and was tunneling. She discussed wound debridement with the family and surgeon. On 03/03/23 the patient had the wound debrided. On 03/09/23, she ordered a wound vacuum assisted closure (wound VAC, a device that decreases air pressure on a wound to help heal more quickly) and Santyl (a prescription medication that removes dead tissue from wounds) to be changed twice a week. On 03/13/23, she changed the patient's wound VAC, the wound had developed more slough and another debridement was ordered. On 03/16/23 the second debridement was completed and a wound VAC with Santyl was placed. On 03/20/23 and 03/23/23, she changed the patient's wound VAC, there were no changes identified. On 03/28/23, the patient had a third debridement and a wound VAC was placed. The sacral pressure injury was not identified until 02/18/23 and it was considered to be hospital acquired. She expected to be contacted any time a wound was identified.

During an interview on 06/07/23 at 3:50 PM, Staff BBBB, RN, stated that she was Patient #4's nurse on 02/18/23, and was the one that identified his buttocks wound as a pressure injury. She could determine from photos that the dark discoloration that had been intact on his admission was actually a deep tissue injury. There was a clear line of demarcation (the dividing line between healthy and diseased tissue) between where the wound began and the intact skin.

2. Observation on 06/06/23 at 8:50 AM, showed Staff RR, Certified Nurse Assistant, (CNA), performed catheter care on Patient #31. When Staff RR repositioned the patient, surveyors observed several dark, cracked, dry, raised areas to his buttocks, a dime sized open area to his right buttocks, and an open area to his coccyx (tailbone area).

Review of Patient #31's medical record, dated 06/06/23, from Facility C, Nursing Home, showed that Patient #31 had two open areas to his coccyx and red excoriation (referring to the skin being scraped or worn away) to his buttocks, both required wound care treatments.

Review of Patient #31's medical record, dated 06/02/23 through 06/06/23, showed that head to toe assessments were documented daily for each shift, and there was no documentation of skin breakdown to the patient's buttocks. A discharge assessment, dated 06/06/23, showed no documentation of skin breakdown.

During an interview on 06/06/23 at 9:05 AM, Staff SS, RN, stated that there was no mention of skin breakdown for Patient #31 in the report she received from nursing staff prior to beginning her shift. There was nothing in the medical record to indicate Patient #31 had skin breakdown, and he did not have any open wounds that she was aware of.

3. Review of Patient #39's medical record, dated 02/01/23 through 03/08/23, showed the following:
- He was a 90 year old male who was admitted on 02/01/23 for gangrene (localized death of tissue resulting from either obstructed blood flow or infection) of the third digit of the left foot, altered mental status, foot infection, and sepsis.
-Wound care was consulted and he was seen 02/02/23 at 10:45 am, by Staff XX, RN, for wounds on the left toes.
- Wound Care Orders were placed on 02/02/23 at 1:00 pm, which included a complete head to toe skin assessment including skin folds every shift and a skin risk score using the Braden Scale to be completed daily. Staff was to initiate an individualized turning schedule with a goal of at least every two hours and if the patient was sitting it would be one hour.
- On 03/02/23 at 12:56 pm, wound care was consulted for a new alteration to skin integrity. The wound was identified on the sacrum and showed a shallow ulceration with a pink wound base consistent to a stage 2 pressure injury (a shallow opening in the skin with red or pink tissue, or may present as a fluid filled blister.) The pressure injury was not present on admission. There were no measurements of the wound.
- Review of documentation showed that from 02/02/23-02/06/23, Patient # 39, was turned nine times. The patient should have been turned 48 times during this time period.
- There was inconsistency in the documentation of wound care and the preventative measures to prevent a hospital acquired pressure injury.

4. Review of Patient's #74's medical record, dated 04/30/23 through 06/07/23, showed the following:
-She was a 55 year old who was admitted on 04/20/23, with the diagnosis of Methicillin-Resistant Staphylococcus aureus (MRSA, highly contagious bacteria, that causes infections in different parts of the body and is resistant to many common antibiotics), Bacterial Peritonitis (an infection of the abdominal fluid that does not come from an obvious place within the abdomen), and Chest Pain.
- On 04/30/23 at 3:25 AM, showed documentation of no wounds.
- On 05/04/23 she had T3-4 laminectomy (a type of surgery in which part of the vertebral bone is removed and ease's pressure on the spinal cord) and an evacuation of epidural abscess, (an infection inside your skull or near your spine) with post-operative orders for daily dressing changes.
- Review of documentation from 05/04/23 through 05/07/23, showed that her surgical wound was documented as clean, dry, and intact and one daily dressing change had been completed and documented.
- On 05/09/23 at 3:13 PM, a wound was identified on the coccyx that was documented as deep purple, dusky red, measurement was 0.5 cm x 1 cm x 0.0 cm. Staging was not documented.
- On 05/10/23 at 09:15 PM, wound care orders were placed that included a complete a head to toe skin assessment including skin folds every shift and a skin risk score using the Braden Scale to be completed daily. Staff were to initiate an individualized turning schedule with a goal of at least every two hours and if patient was sitting it would be one hour.
- On 05/18/23 at 1:30 PM, wound consult for negative pressure therapy for the surgical wound.
- On 05/31/23 at 9:52 AM, the wound identified on the coccyx measured 4 cm x 3 cm x 0.1 cm.
- Documentation showed that she remained in the same position on her back from 05/04/23 1:00 am until 05/05/23 when the patient was turned to the right side at 7:00 PM. On 05/06/23 documentation showed the patient as turning herself. On 05/07/23 at 7:00 pm, documentation showed the patient was on her right side and not turned until 11:00 pm. There was no documentation on 05/08/23 of the patient being turned. There was inconsistency in the documentation of wound care and periods in which Patient #74 did not get turned.

During an interview on 06/07/23 at 2:30 PM, Staff Q, Clinical Director of Progressive Care, stated that the expectation of the nursing staff was to do daily dressing changes and that it appeared as if the staff had copied and pasted the information, and the patient did not receive wound care. The wound identified on the coccyx on 05/09/23 was a hospital acquired pressure injury. There was no record of an incident report being completed, and that was required for any hospital acquired pressure injuries. She stated that the wound progressed and became larger in size and was the result of inadequate turning, inconsistent wound care, and inconsistent documentation.

During an interview on 06/07/23 at 3:30 PM, Staff XX, RN, stated that the expectation of daily dressing changes, daily wound care, and turning of patients that had a high risk for pressure injuries was the responsibility of the nurse assigned to care for the patient. The expectation was for staff nurses to do the daily assessments and ensure that the physician's orders for wound care were being followed. A hospital acquired pressure injury could be acquired as a combination from many factors like poor nutrition, but she would expect to see a new hospital acquired pressure injury or the progression of a wound injury to be primarily from the lack of turning a patient every one to two hours. Staff XX, RN, stated that all hospital acquired pressure injuries should have an incident report completed and was the responsibility of the staff nurse.

5. Review of Patient #3's medical record dated 06/03/23 through 06/05/23 showed the following:
- He was a 24 year-old-male admitted on 06/03/23 after being hit by a motor vehicle.
- He had abrasions on his face, elbow and left buttocks.
- Physicians orders dated 06/04/23 were to apply ointment to all abrasions daily.
- There was no documentation in the medical record for the abrasion on the left buttock that included a wound description, dressing change or refusal for care.

During an interview on 06/06/23 at 9:55 AM, Patient #3 stated that he did have a very sore bottom. Staff had not looked at it until he asked them to on 06/05/23.

During an interview on 06/05/23 at 3:43 PM, Staff M, RN, stated that Patient #3 refused to allow staff to assess or treat the abrasion on his buttocks. The condition of the wound was unknown because the patient refused treatment. There was no documentation in the medical record for the abrasion to Patient #3's buttocks. If the patient refused treatment, the refusal should have been documented.



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