Highpoint Hospice

“Based on review of the Journal of Wound Ostomy and Continence Nursing’s “Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System”, review of the National Institutes of Health “Patient Safety and Quality: An Evidence-Based Handbook for Nurses”, policy review, medical record review, observation and interview, the facility failed to accurately and appropriately assess pressure ulcers for 2 of 6 (Patient #1 and Patient #5) sampled patients with pressure ulcers. 1. Review of the Journal of Wound Ostomy and Continence Nursing’s “Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System” dated November/December 2016, revealed, “...A pressure injury is localized damage to the skin and underlying soft tissue...The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear...Stage 1 Pressure Injury...Intact skin with a localized area of nonblanchable erythema [skin discoloration that stays red or bruised when pressed and released]...Stage 2 Pressure Injury...Partial-thickness loss of skin with exposed dermis...wound bed is viable [capable of living and growing], pink or red, moist...Adipose (fat) is not visible and deeper tissue is not visible. Granulation tissue [new, vascular connective tissue that forms at the base of a wound during the healing process], slough [layer or mass of dead non-viable tissue that separates from healthy surrounding tissue and is typically soft, moist, stringy and yellowish, tan or grayish in color] and eschar [thick, dry and leathery layer of dead, necrotic tissue that forms over a severe wound ulcer], are not present...Stage 3 Pressure Injury...Full-thickness skin loss, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges), is often present. Slough and/or eschar may be visible...Stage 4 Pressure Injury...Full-thickness skin and tissue loss with exposed or directly palpable fascia [fibrous connective tissue], muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining [when tissue destruction extends beneath the intact skin at the wound margins], and/or tunneling [when tissue destruction extends beneath the surface of the skin, creating narrow passageways or tracts into surrounding tissue] often occur...Unstageable Full-Thickness Pressure Injury...Full-thickness skin and tissue loss in which the extent of tissue damage with the ulcer cannot be confirmed because it is obscured by slough or eschar...” 2. Review of the National Institutes of Health “Patient Safety and Quality: An Evidence-Based Handbook for Nurses” dated April 2008, revealed, “...The nurse should assess and stage the pressure ulcer at each dressing change...its [pressure ulcer] location, size (length, width, and depth), and color of the wound; amount and type of exudate [a fluid rich in protein, cells, and cellular debris that escapes from blood vessels and deposits in nearby tissues]...odor; nature and frequency of pain if present...color and type of tissue/character of the wound bed, including evidence of healing...or necrosis [unnatural death of living tissue in the body]...and description of wound edges and surrounding tissue...should be assessed and documented...” 3. Review of the facility policy titled, “WOUND ASSESSMENT DOCUMENTATION AND PHOTOGRAPHY,” dated 3/1/2021, revealed, “… all wounds will be assessed with appropriate documentation within the medical records…Document the following in the medical records…Treatment and condition of the wound each visit…Appearance of the wound bed (black, yellow or red)…Wound measurements (weekly) including the length, depth, and width of the wound in centimeters…Staged the wound weekly…” 4. Record review for Patient #5 revealed a Start of Care (SOC) of 6/28/2026 with diagnoses of Moderate Protein-Calorie Malnutrition, Hypertension, Hear Failure, Peripheral Vascular Disease, and Chronic Ulcer Right Foot with Necrosis. Review of the Hospice Recertification and Plan of Care (POC) dated 6/28/2026 to 9/25/2026, revealed “… SN [Skilled Nurse] effective 6/28/2026…3WK1 [3 week 1], 2WK2, 3WK1, 1WK1, 2WK8, 5PRN [5 as needed]…CLEASE WOUND TO RIGHT 5TH TOE WITH WOUND CLEANSER, APPLY BETADINE SOAKED GAUZE…CLEANSE WOUND TO RIGHT HEEL, CLEANSE WITH WOUND CLEANSER USING CLEAN TECHNIQUE APPLY BETADINE…” Review of the “Wound Record Report,” dated 6/28/2026, revealed “…5TH TOE, RT [right], PU [pressure ulcer] STAGE 1 [one]…DIST [distal] PLANTAR, RT, UNSTAGE [unstageable] PU SLOUGH/ESCHAR…5 toe, RT PU STAGE I…Onset Date 6/28/2026…Wound Detail…6/28/2026…MEASUREMENTS TAKEN…NO…TOTAL NECROTIC TISSUE AMOUNT…51 – 75 % [percent]… 7/6/2026… MEASUREMENTS TAKEN…NO…TOTAL NECROTIC TISSUE AMOUNT…76 – 100 %...DIST PLANTAR, RT, UNSTAGE PU SLOUGH/ESCHAR…Wound Detail…6/28/2026…LENGTHX [BY]WIIDTHXDEPTH(CM) [centimeters]…1 X 1 X 0…DEPTH DESCRIPTION…NECROTIC…TOTAL NECROTIC TISSUE AMOUNT…76 – 100 %...7/6/2026… MEASUREMENTS TAKEN…NO…DEPTH DESCRIPTION…NECROTIC…TOTAL NECROTIC TISSUE AMOUNT…76 – 100 %...” Review of the “HOSPICE PHYSICIAN ORDER,” dated 7/2/2026, revealed “…CLEANSE RIGHT HEEL . APPLY BETADINE, ALLOW TO DRY. LEAVE OPEN TO AIR…CEANSE RIGHT 5TH TOE. APPLY BETADINE. ALLOW TO DRY. LEAVE OPEN TO AIR…” Observation at Patient #1’s home during a home visit on 7/6/2026 at 1:00 PM, revealed a wound on the lateral side of the right 5th toe was covered in eschar and a wound on the lateral side of the heel was approximately a dime size eschar. The facility failed to provide measurements of the wound weekly according to the facilities policy. The facility failed to stage the wound to the 5th toe that was covered in eschar. During an interview on 7/8/2026 at 2:07 PM, the Executive Director stated the nursing staff members should measure and staged the pressure ulcers weekly and if a pressure ulcer is covered in eschar it’s unstageable. The Executive Director stated the pressure ulcers were not measured weekly and on admission showed eschar on the 5th toe and the heel…” 5. Record review for Patient #5 revealed a Start of Care (SOC) of 1/13/2026 with diagnoses of Cerebral Infarction, Heart Disease, and Atrial Fibrillation. Review of the Hospice Recertification and Plan of Care dated 4/13/2026 to 7/11/2026 revealed, “...SN [Skilled Nurse] effective 4/13/2026 2WK[Week]13 [2 times a week for 13 weeks]...” Review of the “HOSPICE PHYSICIAN ORDER,” dated 6/30/2026 at 12:12 PM, revealed “…WOUND CARE FOR RIGHT ANKLE…CLEANSE WOUND WITH CLEANSER UNSING CLEAN TECHNIQUE. APPLY SANTYL TO SLOUGH. COVER WITH FOAM DRESSING. CHANGE TWICE WEEKLY…” Review of the “Client Coordination Note Report” dated 6/30/2026, revealed, “…NP [Nurse Practitioner]…PRESENT FOR VISIT…WOUND ON RIGHT ANKLE, HAS PURLENT DRAINAGE WITH AN ODOR. SANTYL ORDERED FOR WOUND CARE…” Review of the “Client Coordination Note Report” dated 6/30/2026, revealed Patient #5 had a wound identified to the right ankle, the facility failed to document the wound measurement, treatment and condition of the wound, appearance of the wound bed, depth and location, surrounding tissue, amount of drainage, and stage of wound. Review of the “Client Coordination Note Report” dated 7/2/2026, revealed there was no documentation of the treatment and condition Patient #5’s wound. Review of the “Client Coordination Note Report” dated 7/7/2026, revealed there was no documentation of the treatment and condition Patient #5’s wound. Review of “Wound Assessment Tool Report,” revealed no documentation of the wound was entered. During an interview on 7/9/2026 at 3:00 PM, the Executive Director (ED) stated our policy is wounds are measured weekly, and treatment and condition are to be done each visit. The ED stated there was no documentation of the wound measurement, complete wound assessment, or treatment of Patient #5’s wound.”