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Based on document review and interview, facility staff failed to notify a patients family member or POA (Power of Attorney) of a new pressure injury and evolving of an existing pressure injury for 1 of 10 medical records reviewed. (P1)

Findings include:

1. Facility policy titled, "Patient/Parent Rights and Responsibilities, Complaints and Grievances", no policy number, publication date 06/22/2023, indicated under Your rights as a patient: As a patient of this facility, you have the right: To participate in decisions about care, treatment and services, which may include family and loved ones, as permitted by the patient or decision maker; this includes the development and Implementation of an Inpatient treatment or care plan, outpatient treatment or care plan, pain management plan and discharge plan. To be informed of outcomes of care, treatment and services, including unexpected outcomes.

2. Review of P1's MR (Medical Record) indicated the following: Nursing documentation dated 9/15/2024 at 8:00 pm indicated P1's skin was intact with no skin symptoms. On 9/16/2024 P1's skin was assessed at midnight, 4:00 am, and 8:00 am as intact with no skin symptoms. On 9/17/2024 a stage 2 pressure injury, full thickness, red, blisters noted above the pressure ulcer, with erythema was documented as present upon admission at 12:00 pm. Physical Therapy note documentation dated 9/17/2024 at 1:31 pm indicated P1's skin integrity annotation as Per nursing skin auditor N9 (Registered Nurse), patient has a stage 2 pressure injury on sacrum. Physician note documentation dated 9/18/2024 indicated P1's child who is also the patient's POA had a discussion with the medical provider about the patient's disposition and plan of care. P1's skin was documented as warm. This note lacked documentation about a sacral pressure injury. Wound consult note documentation dated 9/18/2024 indicated two wounds were present near the sacrococcygeal area. One more distally which was staged at two and the proximal was staged as a 3. The measurement for this wound was 4.5 x 3.5 cm (centimeters) (Proximal Wound). The distal wound was cleansed, and the zinc barrier cream was applied and left open to air. Wound progress note documentation dated 10/10/2024 indicated P1 developed a deep tissue injury to the left medial great toe over a bunion. This wound measured 2 cm by 2 cm, purple in color, and was intact. P1's sacral stage 3 evolving deep tissue injury present on admission measured 2.5 cm by 3.3 cm, was yellow and red in color, and had evidence of re-epithelialization.
P1's MR lacked nursing reporting skin issues to provider and provider notification to the patients child of ongoing and new pressure injuries.


3. In an interview on 12/4/24 at approximately 2:46 pm am with A2 (Clinical Nurse Specialist) confirmed P1's medical record did not, but should have contained physician notification of advancing staging of P1's stage 2 sacral wound to a stage 3 sacral wound, nor was a provider notified of the new pressure injury to the left medial great toe and should have been.

4. In a telephone interview on 12/4/24 at approximately 2:29 pm with MD1 (Medical Doctor) confirmed he/she wasn't notified by nursing that P1 had a sacral wound nor that P1 developed a new pressure injury on his/her toe. MD1 also confirmed he/she did not recall having a conversation with P1's child regarding these wounds.

Based on document review and interview, facility nursing staff failed to notify a provider of a new and/or ongoing pressure injuries, failed to document every 2-hour turning and/or repositioning of a patient, and failed to document every 4-hour head-to-toe skin assessments for 1 of 10 medical records reviewed. (P1) See tag A0395.


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, facility nursing staff failed to notify a provider of a new and/or ongoing pressure injuries, failed to document every 2-hour turning and/or repositioning of a patient, and failed to document every 4-hour head-to-toe skin assessments for 1 of 10 medical records reviewed. (P1)

Findings include:

1. Facility policy titled, "Escalation of Patient Safety Concerns", no policy number, publication date 03/05/2022, indicated under VI. PROCEDURES: A. The registered nurse (RN) recognizes a change in the patient's condition requiring provider intervention. B. The RN is responsible for communicating changes in the patient's condition that may require specific treatment to the provider and following the attached escalation guides as warranted. (Appendix A)

2. Facility policy titled, "Documentation Standards", no policy number, publication date 08/05/2024, indicated under V. POLICY STATEMENTS: A. GENERAL DOCUMENTATION STANDARDS. 1 Registered Nurses are accountable for the patient assessment and documentation process. 2. Document assessment parameters pertinent to the patient;s specific condition when the patient's physical assessment/reassessment fall outside of the defined normal limits.

3. Facility standards of care titled, "AAHC Standards of Care for RNs - PCU", no policy number, updated 2024, indicated under Frequency/Task and Minimum Documentation: Q (every) 2 hrs. Vital Signs, Neurological checks, if ordered, Turn, reposition (HOB 30 degrees or greater as applicable, document which side patient is turned, IV access site assessment, Restraints safety checks, Patient safety checks, Toileting, ROM, food/fluid, Pain score if on continuous pain infusion(e.g., Epidural, Ketamine, end-of-life medications), Flap checks, if ordered. Q 4 hrs., Head-to-toe assessment (skin, wounds, drains/tubes, incisions, Document FIO2/delivery source/device, Pain assessment/sedation/POSS, Patient-controlled Epidural anesthesia (PCEA), vital signs Q 4 hrs, HR, RR, SpO2, Signs iAware: review and sign, Intake and output assessment (drains, tubes, feeds, PO), Vital signs, Empty drains and document.

4. Review of P1's MR indicated that Nursing documentation dated 9/15/2024 at 8:00 pm indicated P1's skin was intact with no skin symptoms. On 9/16/2024 P1's skin was assessed at midnight, 4:00 am, and 8:00 am as intact with no skin symptoms. On 9/17/2024 a stage 2 pressure injury, full thickness, red, blisters noted above the pressure ulcer, with erythema was documented as present upon admission at 12:00 pm. Wound consult note documentation dated 9/18/2024 indicated two wounds were present near the sacrococcygeal area. One more distally which was staged at two and the proximal was staged as a 3. The measurement for this wound was 4.5 x 3.5 cm (centimeters) (Proximal Wound). Wound progress noted documentation dated 10/10/2024 indicated P1 developed a deep tissue injury to the left medial great toe over a bunion. This wound measured 2 cm by 2 cm, purple in color, and was intact. P1's sacral stage 3 evolving deep tissue injury present on admission measured 2.5 cm by 3.3 cm, was yellow and red in color, and had evidence of re-epithelialization.

P1's MR lacked every 4-hour skin assessments including but not limited to 9/23/24 at 4:00 pm, 9/25/25 at Midnight, and 4:00 am, 9/27/24 at 8:00 pm, and 9/28/2024 at Midnight and 4:00 am, lacked patient turning and/or position changes every 2 hours that included but were not limited to: 9/20/2024 MR as P1's position was indicated as on his/her back, with no documentation of position change or patient refusal noted; 9/25/2024 as P1 was on his/her left side from 6:00 am -6:00 pm no documentation of position change or patient refusal noted; on 9/26/2024 P1 positioned on left side from 6:00 am - 6:00 pm, no documentation of position change or patient refusal noted; 10/13/2024 lacked turning/positioning documentation from 9:00 am to 8:00 pm. P1's MR lacked nursing reporting skin issues to provider.


5. In an interview on 12/4/24 at approximately 2:46 pm am with A2 (Clinical Nurse Specialist) confirmed P1's medical record did not, but should have contained physician notification of advancing staging of P1's stage 2 sacral wound to a stage 3 sacral wound, nor was a provider notified of the new pressure injury to the left medical great toe and should have been. Confirmed facility nursing staff should have, but did not, document required positioning/turning every 2 hours and every 4-hour skin assessments for P1.

6. In interview on 12/9/2024 at approximately 2:40 pm with N3 (Registered Nurse) confirmed nursing staff are to turn patients every two hours and assess skin every 4 hours. Documentation is to be completed by nursing for both turns and skin assessments.

Based on document review and interview, facility nursing staff failed to complete a significant event report related to pressure injuries for 1 of 10 medical records reviewed. (P1)


Findings include:

1. Facility policy titled, "Patient Incident and Significant Even Management", no policy number, publication date 09/11/2022, indicated under VI. PROCEDURES: C. Patient Disclosure of Significant Events. When a significant event results in an unanticipated patient outcome, the patient and/or the patient's family should be informed as soon as reasonably possible. The unanticipated patient outcome should be discussed with the family by the attending physician or his or her designee. Prior to discussing the unanticipated outcome with the patient and/or patient's family, the attending physician or designee may consult with Risk Management, hospital administration, or legal counsel. Refer to Patient Disclosure of Serious Clinical Adverse Events for specific information.

2. Review of P1's MR indicated that Nursing documentation dated 9/15/2024 at 8:00 pm indicated P1's skin was intact with no skin symptoms. On 9/16/2024 P1's skin was assessed at midnight, 4:00 am, and 8:00 am as intact with no skin symptoms. On 9/17/2024 a stage 2 pressure injury, full thickness, red, blisters noted above the pressure ulcer, with erythema was documented as present upon admission at 12:00 pm. Wound consult note documentation dated 9/18/2024 indicated two wounds were present near the sacrococcygeal area. One more distally which was staged at two and the proximal was staged as a 3. The measurement for this wound was 4.5 x 3.5 cm (centimeters) (Proximal Wound). Wound progress noted documentation dated 10/10/2024 indicated P1 developed a deep tissue injury to the left medial great toe over a bunion. This wound measured 2 cm by 2 cm, purple in color, and was intact. P1's sacral stage 3 evolving deep tissue injury present on admission measured 2.5 cm by 3.3 cm, was yellow and red in color, and had evidence of re-epithelialization. P1's lacked nursing reporting skin issues to provider.

3. Incident Report/Complaint/Grievance log were reviewed for the months of 6/1/24-12/1/24. P1 was listed on the incident log on 10/9/2024 in relation to developing a hospital acquired pressure injury to his/her left great toe. This incident report lacked physician notification and family notification. Review of incident reports lacked documentation of P1 sacral pressure injury and family notification of this pressure injury.

4. In an interview on 12/4/24 at approximately 2:46 pm am with A2 (Clinical Nurse Specialist) confirmed P1's medical record did not but should have contained physician notification of advancing staging of P1's stage 2 sacral wound to a stage 3 sacral wound, nor was a provider notified of the new pressure injury to the left medical great toe and should have been.