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Based on observation, interview, record review and policy review the hospital failed to have an effective skin injury prevention and wound treatment program, for one current patient (#31), and two discharged patients (#15 and #26), of five patients with wounds reviewed and to ensure vital sign (VS, measurements of the body's most basic functions) monitoring was completed per hospital policy for one patient (#3) of three patients who received a blood transfusion (to administer blood into a vein). These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation: Nursing Services.

Please refer to A-395 and A-0410.


50151

Based on observation, interview, record review and policy review, the hospital failed to have an effective skin injury prevention and wound treatment program, for one current patient (#31), and two discharged patients (#15 and #26), of five 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.

Findings included:

Review of the hospital's policy titled, "Skin Care- Skin Assessment for Adult," dated 04/19/22, showed the following:
- Upon admission, two Registered Nurses (RNs) perform a skin and skin risk assessment.
- Skin integrity is assessed using the Braden Assessment (an assessment tool for predicting the risk of bed sores or pressure ulcers), on admission and then each shift thereafter.
- Areas to assess for skin integrity include over bony prominences (a part of the body where a bone is close to the skin's surface), on heels and lower extremities, the buttocks, skin folds, and under equipment, removeable devices and dressings. Identified areas of risk are to be documented in the medical record.
- Nursing interventions are initiated based upon the patient scoring a one or two in any category of the Braden Assessment. There was no direction as to which interventions were initiated when patients score a one or two in any category of the Braden Assessment.

Review of the hospital's policy titled, "Wound Care Team Consultation Guidelines," dated 12/07/20, showed nursing was to consult the Wound Care Team for confirmed pressure injuries (intact skin with an area of redness that does not go away when pressure is applied) over a bony prominence or under a medical device.

Review of Patient #15's medical record showed the following:
- She was a 62-year-old female, admitted on 01/16/25, for difficulty breathing and COVID-19 (highly contagious, and sometimes fatal, virus). The patient had a past medical history of cerebral palsy (CP, caused by abnormal brain development before birth, is a group of disorders that affect a person's ability to move and maintain balance and posture), contractures (condition of shortening and hardening of the muscles or other tissues, often leading to deformity and rigidity of joints) in all four extremities and was wheelchair bound.
- Upon admission, nursing documented a Braden Assessment which indicated she was at risk for developing pressure ulcers. There were no wounds documented.
- Nursing interventions for pressure injury (injury to the skin and/or underlying tissue, usually over a bony area) prevention included, every two hour turns and reducing linen layers.
- Due to bed availability, she remained in the Emergency Department (ED) for almost two days.
- On 01/18/25, she arrived on the inpatient unit. Nursing documentation showed during a skin assessment Patient #15 had a new pressure injury to the left heel. A pressure prevention dressing and pressure off-loading boot were applied to the left foot. Nursing consulted the wound care team at that time.

Review of the hospital's document titled, "Incident Report: 250194249," dated 01/20/25, showed the following:
- On 01/19/25, nursing staff identified a new pressure injury to Patient #15's left heel. Upon discovery, a Wound Care Team consult was placed.
- The Wound Care Team RN assessment indicated there was a pressure prevention dressing to the left heel and a pressure off-loading boot in place.
- The new pressure injury was discussed at the hospital's No-Harm meeting on 02/11/25.
- The No-Harm meeting identified factors which contributed to Patient #15's wound development. Factors included a failure to place a pressure prevention dressing or pressure off-loading boot upon admission, failure to utilize pillows or wedges to float the heels off the bed, a lack of every two hour turns and the patient remaining in the ED for two days.

Review of Patient #26's medical record showed the following:
- She was a 96-year-old female, transferred to the ED on 11/12/24, for a left femur fracture (broken thigh bone) she sustained from a fall.
- Nursing documentation indicated she had a skin tear to her left elbow, her left foot was swollen and her Braden Assessment indicated she was at risk for developing pressure ulcers.
- Nursing interventions implemented included, every two hour turns, side to side turns, pressure prevention dressing to both heels, reduction of linen layers, and use of wedges or pillows for offloading.
- On 11/13/24, she went to the Operating Room (OR) for an open reduction internal fixation (ORIF, surgery to fix severely broken bones) of her leg.
- She developed several complications post-operatively which included developing blood clots in both lower extremities, severe bleeding related to the anticoagulant medication (drugs used to prevent blood clots) used to treat the blood clots, and requiring multiple blood transfusions (to administer blood into a vein).
- On 11/16/24, a skin assessment indicated that Patient #26 developed a pressure injury to her right heel. A prevention dressing had been utilized but off-loading boots were not. A Wound Care Team consult was placed and off-loading boots were applied.
- On 11/18/24, a virtual Wound Care Team visit recommended the right heel wound be cleansed daily with soap and water.
- On 11/24/24, a pressure injury to her left heel was identified and the pressure injury to the right heel, had progressed from a Stage 2 pressure injury (a shallow opening in the skin with red or pink tissue or may present as a fluid filled blister) to a deep tissue pressure injury (DTI, intact or non-intact skin that has red, maroon or purple discoloration that does not go away if pressure is applied. Skin in this area may feel soft, firm or mushy and underlying damage is usually present). No prevention dressings were in place to either heel and the off-loading boots were in the room but not on the patient. An in-person Wound Care Team consult was initiated.

Review of the hospital's document titled, "Incident Report: 240190905," dated 11/18/24, showed the following:
- Patient #26 developed a Stage 2 pressure injury to her right heel, which was not present on admission.
- On 12/02/24, unit staff who cared for Patient #26 received education in the form of flyers related to pressure injury prevention and pressure injury education was added to the unit's huddle board.
- On 12/11/24, hospital acquired pressure injuries (HAPI) were discussed at the unit's staff, and the unit's stock of preventative dressings and off-loading boots for the heels was increased. Unit leadership began focused rounds on patients identified as being at high risk for pressure injuries.

Review of the hospital's document titled, "Incident Report: 240191259," dated 11/25/24, showed the following:
- On 11/24/24, nursing identified that Patient #26 had developed a HAPI to her left heel and the Stage 2 pressure injury to her right heel, had progressed to a DTI.
- No prevention dressings or pressure off-loading boots had been applied to either heel. There was one off-loading boot in the room, sitting on a shelf at the bedside.
- Action items which included, education for staff who cared for Patient #26, posting pressure injury prevention flyers, adding pressure injury prevention information to the unit's huddle board and plans to discuss Patient #26's injuries at the unit's next staff meeting.

Review of Patient #31's medical record showed the following:
- She was a 66-year-old female, transferred from an acute care hospital on 02/12/25, for respiratory failure (respiratory failure (condition in which not enough oxygen passes from the lungs into the blood).
- Upon her admission she was placed in the intensive care unit (ICU, a unit where critically ill patients are cared for) and had 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) on her left heel.
- Recommendations for wound care included two hour turns, reduction of linen layers, wedges or pillows for offloading, side to side turns, a pressure prevention dressing and off-loading waffle boots to prevent pressure to the right heel, a nutrition consult and dressing changes to the left heel on Monday and Thursdays.
- On 02/20/25, nursing documentation, during a wound re-check, indicated Patient #31 had a new pressure wound on her right heel. A prevention dressing was in-use on the right heel but her off-loading boots were at the bedside and not on her.

Observation on 02/26/25 at 10:40 AM, in the ICU, showed Patient # 31 had a wound to the outside part of the right heel. The wound was a small, elongated area with redness that did not go away when pressure was applied.

During an interview on 02/24/25 at 2:30 PM, Staff N, Nurse Manager, stated that all patients had a skin assessment performed by two RNs upon admission to the hospital or unit. Patients with a Braden Score of less than 18, were considered as being at high risk for developing pressure injuries. Those patients would have pressure preventative interventions placed which included, every two hour turns, off-loading boots for the heels, and preventative dressings over bony prominences (a part of the body where a bone is close to the skin's surface).

During an interview on 02/24/25 at 3:10 PM, Staff P, Nurse Manager, stated that every ICU patient was turned or offered to turn, every two hours. To prevent pressure injuries to the heels, pressure off-loading boots were used. The patient's heels would also be elevated using pillows or wedges.

During an interview on 02/26/25 at 12:40 PM, Staff FF, RN, stated that she was the charge nurse on the floor, the night Patient #15 was transferred from the ED. The patient arrived to the unit only wearing a sock and pressure to the heels was not off-loaded in anyway. When the wound on her left heel was identified, a prevention dressing and a pressure off-loading boot were applied to the left heel. She photographed the wound and placed a Wound Care Team consult. She indicated Patient #15's pressure injury was missed due to her being held in the ED for two days.

During an interview on 02/26/25 at 2:30 PM, Staff TT, Nurse Manager, stated that when skin assessments showed a patient met criteria for a Wound Care Team consult, the nurses who performed the skin assessment were responsible for placing the consult. After Patient #26 developed a pressure injury, she provided education to the unit's staff on pressure injury prevention in 12/2024. Education topics included, when to consult the Wound Care team, using pressure prevention dressings and pressure off-loading boots to the heels, every two hour turns and using pillows or wedges to off-load pressure from bony prominences. The unit also added charge nurse rounding on patients whose Braden Assessment indicated they were at risk for developing pressure injuries. During rounding, Charge nurses ensured pressure injury prevention interventions were initiated appropriately for at risk patients. For Patient #15 may have had the pressure injury when she was admitted, but it fell through the cracks since she was held in the ED for so long. Once Patient #15 arrived on the inpatient unit, nursing staff initiated all appropriate interventions based on what Patient #15's skin assessment showed.

During an interview on 02/26/25 at 3:00 PM, Staff T, RN, stated that there were orders in place for prevention of pressure wounds for Patient #31. Off-loading boots were not being placed on the patient and were found in their packaging, unopened beside her bed. The bedside nurses were responsible for performing a thorough skin assessment, photographing wounds and placing a Wound Care Team consult. When consulted, patients were triaged (process of determining the priority of a patient's treatment based on the severity of their condition) by the virtual wound care team RN. The virtual wound care team RN assessed the photos placed in the chart, made recommendations and entered orders for management. Staff T saw patients in-person, when it was determined a patient had wounds that required hands-on care. For the in-person consult, the Wound Care Team RN was only expected to provide focused assessments and management for the wounds they were consulted on. During an in-person consult a full skin assessment was performed, along with a review of the patient's medical record to ensure all the appropriate interventions were initiated. After Patient #15's pressure injury, education was provided to staff who cared for patients being held in the ED due to bed capacity. Education included skin assessments, pressure injury prevention interventions and Wound Care Team consults. Patient #31's pressure wound could have been prevented. Staff T stated, "why is this what it takes to get staff to use preventative measures."


50151

Based on interview, record review and policy review, the hospital failed to ensure vital sign (VS, measurements of the body's most basic functions) monitoring was completed per hospital policy for one discharged patient (#3) of three patients who received a blood transfusion (to administer blood into a vein) reviewed. These failures had the potential to negatively affect all patients who received blood transfusions at the hospital. .

Findings included:

Review of the hospital's policy titled, "Blood Administration (Not Including Neonates)," dated 09/21/23, showed VS were to be recorded no more than 30 minutes prior to the transfusion, within 15 to 30 minutes after the transfusion started, and within 30 minutes of the completion of the transfusion. VS to be obtained included, blood pressure (BP), heart rate (the number of times the heart beats within a certain time period), respiratory rate (RR), and temperature, for all patient populations.

Review of Patient #3's medical record showed the following:
- On 02/10/25 at 6:42 PM, nursing obtained pre-transfusion VS. VS obtained included, temperature, RR, and pulse. No BP was documented.
- At 6:44 PM, the blood transfusion was started.
- At 8:32 PM, nursing obtained post-transfusion VS. VS obtained included, BP and temperature. No pulse or RR were obtained.

During an interview on 02/27/25 at 11:00 AM, Staff C, Chief Nursing Officer (CNO), stated the nursing staff should reassess VS for blood transfusions per the "Blood Administration," policy. They were expected to obtain BP, pulse, RR and temperature during blood transfusions, at intervals defined by the policy. Transfusion reactions were identified by changes in a patient's VS when compared to their pre-transfusion VS.