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Based on clinical record review, staff interview, and during the course of a complaint investigation, the facility staff failed to ensure an effective quality program was implemented regarding performance improvement concerns surrounding facility acquired pressure ulcers, family notification, and ensuring staff followed physicians orders and the patients plan of care.

The facility staff, after becoming aware that Patient #4 had developed facility acquired pressure ulcers, did not implement a Quality Assessment and Performance Improvement plan to investigate and formulate a plan of action for prevention of this type of incident in the future and staff education/re-training.

It was determined the patient's pressure ulcers developed as a result of staff failure to turn and position properly and correctly don patient's multi-podus boots which were ordered to prevent pressure ulcer formation.

The facility staff, after the fact, did initiate a turning schedule for this patient but failed to ensure a plan was developed to prevent future occurrences. There was no evidence of staff education or re-training regarding the positioning, or placement of the ordered medical devices (boots).

The facility also did not follow their procedure for complaints and grievances when the patient's (family) made a verbal complaint regarding care to the staff, did not inform the (family/responsible party) when a debridement was necessary and did not notify (family) of the procedure until after it had been completed.

Based on clinical record review, staff interview, facility document review, and during the course of a complaint investigation, the facility staff failed to ensure the care plan and physicians orders were followed for one (1) of 4 (four) patients of the survey sample Patient #4. The facility staff failed to prevent the patient from facility acquired pressure ulcers by not following the plan of care and physicians orders for prevention. The facility staff also did not follow the physicians orders for the monitoring of the patient's elimination (bladder scan).

The facility staff were aware, when Patient #4 was admitted, that the patient had multiple co-morbidities which could lead to the development of pressure ulcers (current pressure sores, compromised nutritional status, bilateral lower extremity arteriosclerosis, heart failure, diabetes, decreased mobility, and others). The staff did not turn and reposition the patient every two hours as per order nor ensured the correct placement of the multipodus boots which led to the development of deep tissue injury to the patients feet. This subsequently required debridement of the areas causing the patient a more prolonged recovery and pain.

Based on interview and document review, the facility staff failed to ensure the grievance policy was followed for 1 (one) Patient of the survey sample, Patient #4.

Patient #4's spouse had a concern/complaint which was communicated to the facility staff. The facility staff did not follow their policy concerning complaints and grievances for the Patient/spouse.

The findings included:

In an interview with the complainant on 6/13/22 at 11:00 a.m., the complainant stated that they had spoken with the facility staff regarding their concern about the development of the pressure ulcers on (Patient #4's) feet and the debridement. The complainant stated they were not notified about the debridement and had asked how the patient had developed the ulcers. The complainant stated the facility staff had apologized, but did not follow-up with them about the issues.

In an interview with Staff Member #8 (Director of Patient Care Services on 6/15/22 at 10:11 a.m., SM #8 stated they had spoken to (complainant) "one-on one but didn't write any of it down". SM #8 stated they had "talked with staff" about the concerns but had not followed up with (complainant) other than having a conversation with them. The surveyor inquired if any of the concerns expressed by (complainant) were issues that could be resolved without further investigation or education of staff. SM #8 stated, "We did look into the concerns, and talked with staff, but none of it was written down."

Email communication was provided to the surveyor by the facility staff regarding discussions with (family). These documents evidenced the following: An email from SM #15 (Charge Nurse) documented, in part: Date May 4, 2022 - "...I had a long talk with (Patient #4- Room 13- spouse) as well as (SM #13 Wound Nurse) regarding the wounds on (patient) feet and (patient's) care...(spouse) is very unhappy that (patient) developed these wounds while here and it was because of not proper turning or care provided..."

The facility Policy and Procedure for "Complaints and Grievances" was reviewed and evidenced, in part: "...A complaint is an expression of dissatisfaction by a hospital patient, family member, guardian, surrogate decision maker, significant other, or authorized representative with the care and/or services provided...Complaints are resolved at the point of service by the staff present...A formal grievance is a written or verbal complaint that is made to the hospital...regarding the patient's care, or when it is not resolved at the time the complaint is made to staff present..."Procedure:...B. Filing, Acknowledging and Investigation of a Grievance a. All grievances are to be submitted verbally or in writing to the Patient Care Experience Department, wither by the patient, the patient's representative, or a staff member to whom the grievance was reported. b. Upon being notified of a patient grievance, the Patient Experience Department will document information sufficient to identify the individual registering the concern...name pf the patient and relationship...date of receipt and nature of the concern...d...will be acknowledged in writing or by phone and documented in the system...within 7 days of receipt...e. Patient Experience Department will coordinate an investigation of the grievance...f. All grievances will be investigated with effort to achieve resolution within 30 days of receipt of the grievance...C. Documentation a. Centra Health Patient Experience department will ensure that each patient grievance is appropriately documented in the complaint management database..."

The concerns were discussed with SM #7, 8, 9, 16 (Education Coordinator) and #17 (Executive Assistant) on 6/15/22 at approximately 12:30 p.m.

Based on clinical record review, staff interview and document review, the facility staff failed to ensure the family/spouse/responsible party for Patient #4 was notified of a procedure (debridement of pressure ulcers of the feet) prior to the procedure being done and obtained consent.

The findings included:

Patient #4 was admitted to the facility on 4/6/22 with diagnoses that included, but were not limited to: Cardiac arrest, anoxic encephalopathy, acute respiratory failure, bilateral lower extremity arteriosclerosis, diabetes, and pressure ulcers (stage 2 of the sacrum and stage 2 of the neck).

Further review of the clinical record revealed on 4/18/22 documentation of the following: "Ankle- right outer, pressure injury, suspected DTI (deep tissue injury). Left heel - pressure injury, unstageable suspected DTI. Left foot outer- purple, Left inner foot, purple." There was documentation of foam dressing applied to the areas for protection.

On 4/27/22 a "Wound Consult" was obtained. The consult documented, in part: "...being evaluated today by the wound care team in consultation for multiple wounds including deep tissue injuries to the bilateral feet and ankles...treatment thus far has included dry dressings and offloading with frequent turning, an alternating air mattress, and bunny boots in bed...overall examination of the patient's skin reveals...scattered areas of deep tissue injury are noted to the bilateral ankles and at the bilateral heels and the lateral and medial aspects of the feet...Assessment/Plan...15. Pressure induced deep tissue damage of the right heel. 16. Pressure induced deep tissue damage of the left heel. 17. Pressure induced deep tissue damage of left ankle. 18. Pressure induced deep tissue damage of right ankle... Debridement performed today..."

There was no documentation in the clinical record the patient was informed of the procedure. There was no documentation of the Responsible Party/spouse being notified of the debridement prior to the procedure being performed.

In an interview with the (family/spouse) of Patient #4 on 6/13/22 at 11:00 a.m., they stated, "I was not told they were going to be cutting on (Patient #4's) feet. I had no idea those places were so bad as to need to be cut on. I was not told until after it was done. I had told them that I wanted to be kept up to date on anything that went on...they did not tell me until after they had already done it..."

On 6/13/22 at 2:00 p.m., the surveyor interviewed Staff Member #13 (Wound Care Nurse) regarding Patient #2's wounds and treatment. SM #13 stated, "I do wound rounds on Mondays, Wednesdays and Fridays. When I discovered the areas on the feet I noticed the bottoms of the heels were boggy (soft) and we placed protective dressings and got the patient some "moon boots" (Prevalon boots). The patient had the hard boots (multi-podus). Two weeks into the patients hospitalization it was discovered the hard boots had not been placed properly and the patient had developed DTI (deep tissue injury) on both the right and left feet...I got the wound care provider to see the patient and we started weekly rounds on (Patient #4) and there was debridement done...I spoke with (spouse) about the wounds..." The surveyor inquired as to whether the conversation took place before or after the debridement procedure. SM #13 stated, "After..."

Staff Member (SM) # 12 (Wound Care Provider) was interviewed on 6/15/22 at 10:15 a.m. and stated, "I was contacted about (Patient #4) on April 27th, that was my first contact. (Patient #4) had unstageable wounds and DTI (deep tissue injury) on both heels...I did an I&D (incision and drainage)...there was also some debridement done...we do not obtain a consent for this, because it is based on need...the (spouse/family) was never here when I saw the patient, so I had no contact with (them)..." SM #13 (Wound Care Nurse) stated, "I contacted (spouse) after the debridement on the phone..."


Email communication was provided to the surveyor by the facility staff regarding discussions with (family). These documents evidenced the following: An email from SM #15 (Charge Nurse) documented, in part: Date May 4, 2022 - "...I had a long talk with (Patient #4- Room 13- spouse) as well as (SM #13 Wound Nurse) regarding the wounds on (patient) feet and (patient's) care...(spouse) is very unhappy that (patient) developed these wounds while here and it was because of not proper turning or care provided..."

The facility policy and procedure "Patient Care Plan" evidenced, in part: ..."XII. Organizational Ethics and Patient Rights...1. Informed Consent: The physician is responsible for informing the patient about procedures to be performed. This included an explanation of risks, benefits, alternatives, and consequences of treatment or non-treatment. Consent for the procedure is given by the patient. A patient or their legal representative has the right to refuse treatment..."

The concerns were discussed with SM #7, 8, 9, 16 (Education Coordinator) and #17 (Executive Assistant) on 6/15/22 at approximately 12:30 p.m.

Based on clinical record review, staff interview, facility document review and during the course of a complaint investigation, the facility staff failed to ensure the Quality Program identified, investigated and implemented preventative actions and education to prevent adverse patient events and injuries.

The facility staff, after becoming aware that a patient (Patient #4) had developed facility acquired pressure ulcers, did not implement a Quality Assessment and Performance Improvement plan to investigate, formulate a plan of action for prevention, and ensure staff education/re-training. The facility also did not follow their policy and procedure for complaints and grievances after facility staff received a complaint from the family of Patient #4 and did not notify the (family) until after a debridement procedure was performed.

The findings included:

Patient #4 was admitted to the facility on 4/6/22 with diagnoses that included, but were not limited to: Cardiac arrest, anoxic encephalopathy, acute respiratory failure, bilateral lower extremity arteriosclerosis, diabetes, and pressure ulcers (stage 2 of the sacrum and stage 2 of the neck). The physicians orders for skin care and preventive measures included; float heels, Prevalon boots, multipodus boots, pillows, heelz-up, and turn every two hours. Patient #4 was not able to wear a LEAF positioning monitor due to the patient having a pacemaker.

("Leaf Monitoring Protocol : Criteria for placement of LEAF sensor (Must meet 2 or more of these requirements): 1. Moderate (13-14), high (10-12) or severe (< or equal to 9) risk on the Braden scale. 2. Patient's stay is greater than 2 weeks. 3. Patient is immobilized and cannot help you turn. 4. Admitted with a current pressure injury (not caused by a medical device). 5. Patient develops a pressure injury during their stay...6. Patients requiring mechanical ventilation..." An Addendum document was also presented, which evidenced: "If your patient has a pacemaker or AICD (Automated Internal Cardiac Defibrillator) please do not place a leaf sensor on them... (LEAF sensor : A lightweight sensor that attaches to the patient's chest, monitoring whether they are sitting, standing or lying down - on their left side, right side, back or prone.)"

Further review of the clinical record revealed on 4/18/22 (12 days after admission) documentation of the following: "Ankle- right outer, pressure injury, suspected DTI (deep tissue injury). Left heel - pressure injury, unstageable suspected DTI. Left foot outer- purple, Left inner foot, purple." There was documentation of foam dressing applied to the areas for protection.

After discovery of the patient's acquired pressure ulcers, the facility did implement a turning program for the patient based on the turning schedule for a patient in another room. There was no documentation of any formal education or retraining for staff regarding the turning schedule or for other patients who might not meet the criteria for the LEAF monitor. There was no documented education regarding the training/re-training of staff regarding correct placement of the multi-podus boots.

On 6/14/22 at 12:50 p.m., Staff Member #8 (Director of Patient Care Services) stated, "We looked through the charting and talked to staff..." SM #9 (Quality) stated, "There was some email communications (SM #8) has about discussions with staff...the patient was put on the same turning schedule as the patient in the room next door..."

On 6/15/22 at 12:20 p.m. SM#8 stated, "We have been doing some chart audits and we have a spreadsheet for checking things off..." The surveyor inquired as to whether there had been a plan of correction or investigation for the concerns, however, the facility staff did not provide any evidence of any investigation or plan for prevention of re-occurrence of the concerns at the time of exit.

In an interview with the complainant on 6/13/22 at 11:00 a.m., the complainant stated that they had spoken with the facility staff regarding their concern about the development of the pressure ulcers on (Patient #4's) feet and the debridement. The complainant stated they were not notified about the debridement and had asked how the patient had developed the ulcers. The complainant stated the facility staff had apologized, but did not follow-up with them about the issues.


In an interview with Staff Member #8 (Director of Patient Care Services on 6/15/22 at 10:11 a.m., SM #8 stated they had spoken to (complainant) "one-on one but didn't write any of it down". SM #8 stated they had "talked with staff" about the concerns but had not followed up with (complainant) other than having a conversation with them. The surveyor inquired if any of the concerns expressed by (complainant) were issues that could be resolved without further investigation or education of staff. SM #8 stated, "We did look into the concerns, and talked with staff, but none of it was written down."

Email communication was provided to the surveyor by the facility staff regarding discussions with (family). These documents evidenced the following: An email from SM #15 (Charge Nurse) documented, in part: Date May 4, 2022 - "...I had a long talk with (Patient #4- Room 13- spouse) as well as (SM #13 Wound Nurse) regarding the wounds on (patient) feet and (patient's) care...(spouse) is very unhappy that (patient) developed these wounds while here and it was because of not proper turning or care provided..."


The facility Policy and Procedure for "Complaints and Grievances" was reviewed and evidenced, in part: "...A complaint is an expression of dissatisfaction by a hospital patient, family member, guardian, surrogate decision maker, significant other, or authorized representative with the care and/or services provided...Complaints are resolved at the point of service by the staff present...A formal grievance is a written or verbal complaint that is made to the hospital...regarding the patient's care, or when it is not resolved at the time the complaint is made to staff present..."Procedure:...B. Filing, Acknowledging and Investigation of a Grievance a. All grievances are to be submitted verbally or in writing to the Patient Care Experience Department, wither by the patient, the patient's representative, or a staff member to whom the grievance was reported. b. Upon being notified of a patient grievance, the Patient Experience Department will document information sufficient to identify the individual registering the concern...name pf the patient and relationship...date of receipt and nature of the concern...d...will be acknowledged in writing or by phone and documented in the system...within 7 days of receipt...e. Patient Experience Department will coordinate an investigation of the grievance...f. All grievances will be investigated with effort to achieve resolution within 30 days of receipt of the grievance...C. Documentation a. Centra Health Patient Experience department will ensure that each patient grievance is appropriately documented in the complaint management database..."

On 4/27/22 a "Wound Consult" was obtained. The consult documented, in part: "...being evaluated today by the wound care team in consultation for multiple wounds including deep tissue injuries to the bilateral feet and ankles...treatment thus far has included dry dressings and offloading with frequent turning, an alternating air mattress, and bunny boots in bed...overall examination of the patient's skin reveals...scattered areas of deep tissue injury are noted to the bilateral ankles and at the bilateral heels and the lateral and medial aspects of the feet...Assessment/Plan...15. Pressure induced deep tissue damage of the right heel. 16. Pressure induced deep tissue damage of the left heel. 17. Pressure induced deep tissue damage of left ankle. 18. Pressure induced deep tissue damage of right ankle... Debridement performed today..."

There was no documentation in the clinical record the patient was informed of the procedure. There was no documentation of the Responsible Party/spouse being notified of the debridement prior to the procedure being performed.

In an interview with the (family/spouse) of Patient #4 on 6/13/22 at 11:00 a.m., they stated, "I was not told they were going to be cutting on (Patient #4's) feet. I had no idea those places were so bad as to need to be cut on. I was not told until after it was done. I had told them that I wanted to be kept up to date on anything that went on...they did not tell me until after they had already done it..."

During the survey from 6/13 through 6/15/22, the surveyor discussed the concerns regarding Patient #4's facility acquired pressure ulcers and the lack of evidence regarding turning and repositioning per orders. The surveyor also discussed the interview statements regarding the concerns that the patient's boots, designed to prevent pressure ulcers, were not placed properly contributing to the development of pressure ulcers. Also, the surveyor discussed the concerns that the staff were not following orders for the bladder scans every 8 (eight) hours. This was discussed with Staff Member #8 (Director of Patient Care Services), SM #9 (Quality) and SM #7 (Chief Executive Officer).

The concerns were again discussed with SM #7, 8, 9, 16 (Education Coordinator) and #17 (Executive Assistant) on 6/15/22 at approximately 12:30 p.m.

Based on clinical record review, staff interview, facility document review, and during the course of a complaint investigation, the facility staff failed to ensure the care plan and physician's orders were followed for 1 (one) of 4 (four) patients of the survey sample, Patient #4.

Patient #4 developed unstageable pressure ulcers to both feet due to, in part, the facility staff not following orders for the correct placement/use of ordered medical devices (multipodus boots) and not following the care plan and orders for turning and repositioning. The patient also had physicians orders for bladder scanning every eight hours which was not done as per order.

The findings included:

Patient #4 was admitted to the facility on 4/6/22 with diagnoses that included, but were not limited to: Cardiac arrest, anoxic encephalopathy, acute respiratory failure, bilateral lower extremity arteriosclerosis, diabetes, and pressure ulcers (stage 2 of the sacrum and stage 2 of the neck). The physicians orders for skin care and preventive measures included; float heels, Prevalon boots, multipodus boots, pillows, heelz-up, and turn every two hours.

Multipodus boots are a protective "boot" used to prevent pressure of the heels and to prevent foot drop. It aids in healing pressure ulcers and minimizes pressure while allowing for circulation to the foot/heel.
Prevalon Boots are used to help reduce the risk of bedsores by keeping the heel floated, relieving pressure. Prevalon boots have a cushioned bottom that floats the heel off the surface of the mattress, helping to reduce pressure.
Heelz-up is positioning the legs with a pillow or foam device to keep pressure off the heels enabling the heels to be "floated".

The clinical record documented upon admission, Patient #4 did not have any pressure areas to the feet. (Nursing Assessment 4/6/22)

Further review of the clinical record revealed on 4/18/22 documentation of the following: "Ankle- right outer, pressure injury, suspected DTI (deep tissue injury). Left heel - pressure injury, unstageable suspected DTI. Left foot outer- purple, Left inner foot, purple." There was documentation of foam dressing applied to the areas for protection.

On 4/27/22 a "Wound Consult" was obtained. The consult documented, in part: "...being evaluated today by the wound care team in consultation for multiple wounds including deep tissue injuries to the bilateral feet and ankles...treatment thus far has included dry dressings and offloading with frequent turning, an alternating air mattress, and bunny boots in bed...overall examination of the patient's skin reveals...scattered areas of deep tissue injury are noted to the bilateral ankles and at the bilateral heels and the lateral and medial aspects of the feet...Assessment/Plan...15. Pressure induced deep tissue damage of the right heel. 16. Pressure induced deep tissue damage of the left heel. 17. Pressure induced deep tissue damage of left ankle. 18. Pressure induced deep tissue damage of right ankle... Debridement performed today..."

DTI - (Deep Tissue Injury) is an injury to a patients underlying tissue below the skin's surface that results from prolonged pressure in an area of the body. Similar to a pressure sore, a deep tissue injury restricts blood flow in the tissue causing the tissue to die. (woundsource.com)

On 5/18/22 it was documented, "Procedure Name: Excisional debridement of necrotic subcutaneous tissue and slough of bilateral foot deep tissue injuries and left shoulder wound..."

Pressure ulcer stages: Stage I- Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
Stage II -Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
Stage III- Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Stage IV- Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
Deep Tissue Injury - Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. (National Pressure Ulcer Advisory Council - pressure ulcer stages)

On 6/13/22 at 2:00 p.m., the surveyor interviewed Staff Member #13 (Wound Care Nurse) regarding Patient #2's wounds and treatment. SM #13 stated, "I do wound rounds on Mondays, Wednesdays and Fridays. When I discovered the areas on the feet I noticed the bottoms of the heels were boggy (soft) and we placed protective dressings and got the patient some "moon boots" (Prevalon boots). The patient had the hard boots (multi-podus). Two weeks into the patients hospitalization it was discovered the hard boots had not been placed properly and the patient had developed DTI (deep tissue injury) on both the right and left feet...I got the wound care provider to see the patient and we started weekly rounds on (Patient #4) and there was debridement done...I spoke with (spouse) about the wounds...when they were turning the patient they sometimes don't turn the whole body and just turn the upper portion leaving the feet in one position which with the hard boots not placed properly caused pressure. There was also a question of the turning schedule, I believe... There was education for the staff and we went over the turning protocol and proper placement of the boots. The hard boots are usually used when the patient is up and the soft boots would be used in bed...we go over pressure ulcer prevention with staff..." When asked if there was any evidence of education or re-training for staff regarding the issue of Patient #4's positioning and use of devices (boots), SM #3 stated they had talked to the staff but there was no formal in-servicing that could be presented.

The clinical record was reviewed for evidence of turning and positioning every two hours per physician's order and care plan. The clinical record evidenced that from 4/8/22 through 4/18/22, when the pressure areas were discovered, the staff did not follow the every two hour turning schedule per the physician order. On 4/8/22, there was only one recorded entry found which documented at 1838 (6:38 p.m.) the patient was up in the chair. On 4/9/22, there was no documentation of any turning or repositioning. On 4/11/22 there were only 5 (five) entries for the 24 hour period. On 4/12/22 there was one documentation at 1742 (5:42 p.m.) of the patient being up in the chair. On 4/13/22 there was no documentation of turning or positioning after 1430 (2:30 p.m.) with the exception of 2232 (10:32 p.m.) when it was documented "refused". On 4/14/22 there was no documentation from 6:00 a.m. until 12:20 p.m., then no documentation after 1838 (6:38 p.m.). On 4/15/22 there was no documentation of turning/repositioning from 4:00 a.m. until 8:00 a.m. and then from 8:00 a.m. until 12:00 p.m. There was no documentation after 1400 (2:00 p.m.) that the patient was turned/repositioned. On 4/16/22 it was noted the patient was turned/repositioned only two times: 1615 (4:15 p.m.) and 18:04 (6:04 p.m.). On 4/17/22 there was only one recorded instance of turning/repositioning at 1603 (4:03 p.m.). 4/18/22- No documentation of turning/repositioning from midnight until 1229 (12:29 p.m.) and then no documentation after 1823 (6:23 p.m.).

There was only one documented refusal of the patient to be turned and repositioned during this time frame (4/8 through 4/19) which occurred on 4/13/22 at 10:32 p.m.

On 6/14/22 at 12:50 p.m., the surveyor spoke with SM #8 (Director of Patient Care Services) regarding turning/repositioning protocols and positioning devices (boots). SM #8 stated, "The multipodus boots are a hard boot and are usually used when patients are assisted to be up in the chair and they are usually four hours on, four hours off. The Prevalon boots are used in the bed and are also on that schedule. We have mobility aids that turn the patients, help them get up in the chair and walk them with therapy. They do not do hygiene. Patients have a LEAF monitor which is a sensor that reminds them when a patient needs to be turned. (Patient #4) had a pacemaker and could not have the LEAF monitor. We did place (Patient #4) on the same schedule as the patient is the adjacent room who had the monitor so they would turn both patients at the same time..."

The surveyor requested and received the "LEAF Monitoring Protocol" which evidenced, in part: "Criteria for placement of LEAF sensor (Must meet 2 or more of these requirements): 1. Moderate (13-14), high (10-12) or severe (< or equal to 9) risk on the Braden scale. 2. Patient's stay is greater than 2 weeks. 3. Patient is immobilized and cannot help you turn. 4. Admitted with a current pressure injury (not caused by a medical device). 5. Patient develops a pressure injury during their stay...6. Patients requiring mechanical ventilation..." An Addendum document was also presented, which evidenced: "If your patient has a pacemaker or AICD (Automated Internal Cardiac Defibrillator) please do not place a leaf sensor on them..." (LEAF sensor : A lightweight sensor that attaches to the patient's chest, monitoring whether they are sitting, standing or lying down - on their left side, right side, back or prone.)

Staff Member #14 (Physical Therapist Mobility Aid Supervisor) was interviewed 6/14/22 at 1:32 p.m. and stated, "I am the supervisor for the Mobility Aids. They are responsible for helping turn and position and put boots on and off to decrease pressure sores. We have the LEAF system which is a guide for them to turn and reposition...if a patient has a pacemaker or device, they cannot have the LEAF sensor...we had a meeting regarding the patient (Patient #4) and I was not aware that (pressure ulcers) were related to turning and positioning but potentially from the medical equipment....there was a board in the room that we write on that tells the staff about the turning and repositioning...it's just written on the board, I don't think there is documentation of that anywhere...the CNA (Certified Nursing Assistant) or nursing may document (turning and positioning); I was not the patient's physical therapist...I instructed them (staff) that since the patient in the adjacent room had the LEAF monitor that (Patient #4) should be put on the same schedule so that they were turned at the same time...I had no interaction with (family)..."

At 1:50 p.m. on 6/14/22 a Registered Nurse, SM #15 was interviewed. SM #15 stated, "I never had (Patient #4) one on one. I do know (patient) came with different boots but by then (patient) had developed the deep tissue injury. There was a wound care consult and orders to turn the patient. The patient could not use the LEAF sensor because of their pacemaker. The DTI potentially could have been from the boots and not turning to relieve the pressure...I only spoke to (family) about (family) wanting the patient transferred to (another facility) but I told (family) we are doing everything we could...we talked about things generally in staff meetings about following orders and wound care as well as turning and repositioning. SM #13 (wound care) has been sending out emails about it since (they) took over the position..."

SM #8 (Director of Patient Care) stated on 6/15/22 at 12:24 p.m. that "Turning and positioning is a standard of care that is done every two hours..."

Email communication was provided to the surveyor by the facility staff regarding discussions with (family) and the turning and positioning. These documents evidenced the following: An email from SM #15 (Charge Nurse) documented, in part: Date May 4, 2022 - "...I had a long talk with (Patient #4- Room 13- spouse) as well as (SM #13 Wound Nurse) regarding the wounds on (patient) feet and (patient's) care...(spouse) is very unhappy that (patient) developed these wounds while here and it was because of not proper turning or care provided..." Another email from SM #14 (PT- Mobility Aide Supervisor) on 5/19/22 documented, "...it does not look like the anticipated discharge for room 13 (Patient #4) is going to happen...remember to turn (patient) on room 15's turn schedule so that we can maintain consistency..." On 5/20/22 SM #14 wrote: "Can you be sure to double check room 13 (Patient #4) for positioning. (Patient) has a pacemaker so cannot be on leaf system. Unfortunately (patient) has acquired pressure injuries..."

The surveyor reviewed the clinical record further for the documentation for the bladder scans that were ordered every 8 (eight) hours. The order was placed on 5/26/22. According to documentation, the following was evidenced: On 5/27/22 a scan was documented at 0:10 (12:10 a.m.). Another scan was not documented until 5/29/22 at 3:49 (3:49 a.m.) and not again until 5/30/22 at 3:48 a.m. A scan was then documented at 2216 (10:16 p.m.) - approximately 19 hours later. Thirteen hours later, on 5/31/22 at 12:22 p.m., a bladder scan was documented. There was not another scan until 6/2/22 at 3:00 a.m. Another scan was documented at 18:03 (6:03 p.m.) but not again until 6/3/22 at 3:10 a.m. The documentation further evidenced the patient was "unable to void" on 5/27/22 from 9:00 a.m. until 5/28/22 at 22:23 (10:23 p.m.) with no documentation that any bladder scan was performed. The facility presented the surveyor with a document "Bladder Scan criteria for suspected urinary retention or removal of IUC (indwelling urinary catheter) which evidenced, in part: "...If patient has not voided 8 hours on their own or post catheter removal, perform a bladder scan and document it to check urine volume..."

On 6/14/22 at 12:50 p.m., SM #8 stated the staff should be following the orders for the bladder scan and documenting it every 8 hours.

During the survey from 6/13 through 6/15/22, the surveyor discussed the concerns regarding Patient #4's facility acquired pressure ulcers and the lack of evidence regarding turning and repositioning per orders. The surveyor also discussed the interview statements regarding the concerns that the patient's boots, designed to prevent pressure ulcers, were not placed properly contributing to the development of pressure ulcers. Also, the surveyor discussed the concerns that the staff were not following orders for the bladder scans every 8 (eight) hours. This was discussed with Staff Member #8 (Director of Patient Care Services), SM #9 (Quality) and SM #7 (Chief Executive Officer).

The concerns were again discussed with SM #7, 8, 9, 16 (Education Coordinator) and #17 (Executive Assistant) on 6/15/22 at approximately 12:30 p.m.