Saint Joseph’s Hospital of Atlanta, Inc.

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 46188 Based on a review of medical records, policies and procedures, and staff interviews, it was determined that the facility failed to ensure that nursing staff implemented and documented wound care assessments, wound care treatment, dressing changes, and failed to ensure that nursing staff documented accurate daily meal percentage intake for when one patient (P) (P1) of three (P1, P2, P3) patients reviewed. This failure has the potential to result in delayed treatment, delayed wound healing and deterioration of pressure injuries (PI). Findings Included: 1. Review of P1’s medical record revealed that on 04/18/2026 at 7:07 PM, an admission biophysical assessment was completed by a Registered Nurse (RN). The integumentary (skin) assessment was not completed. Review of P1’s medical record revealed that on 04/19/2026 at 06:13 AM, an RN noted that P1 had red abrasion spots above the sacrum (area along the lower back at the base of the spine), non-blanchable (a red/purple bruised area of skin that does not turn white or fade when you press it indicating that blood has leaked from the blood vessel into surrounding tissues) dark red spot on the left heel, and a left knee cut. A review Review of a “Wound, Ostomy, & Continence Nurse Consult”, dated 04/28/2026 at 08:37 AM by RN BB revealed an initial evaluation of P1’s wounds. RN BB noted the following: A review of a “Wound, Ostomy, & Continence Nurse Consult”, dated 04/28/2026 at 08:37 AM by RN BB revealed an initial evaluation of P1’s wounds. RN BB noted the following: A PI of the right thigh, categorized as a deep tissue PI, with wound care orders to provide dressing changes and treatment every 24 hours starting on 04/29/2026. Continued review revealed that P1 had a deep tissue pressure injury (DPTI) (a localized area of damaged soft tissue before the skin breaks) of the left heel, coccyx, and left buttocks. Review of P1’s medical record failed to reveal wound care treatment and dressing changes for the right thigh per orders on 04/30/2026, 05/01/2026, 05/02/2026. 05/03/2026, 05/04/2026, and 05/05/2026. 2. Review of P1’s medical record revealed that on 04/18/2026 at 23:12, P1 had a regular diet ordered by a physician. Review of P1’s medical record failed to reveal documentation of meal intake for 04/20/2026, 04/24/2026, 04/25/2026, 04/26/2026, and 05/01/2026. Review of P1’s medical record revealed that on 05/10/2026 at 19:34 was ordered to have nothing by mouth (NPO) due to possible aspiration. Review of the facility’s policy titled, “Delivery of Patient Care via the Nursing Process,”, effective date 02/20/2026, revealed that the purpose of the policy was to provide a patient-centered framework nurses use to develop an individualized patient plan of care. Review of the facility’s policy titled, “Delivery of Patient Care via the Nursing Process”, effective date 02/20/2026, revealed that the purpose of the policy was to provide a patient-centered framework nurses use to develop an individualized patient plan of care. Continued review revealed, Implementation of Care, the nurse assigned to the patient is responsible and accountable for implementing provider and nursing orders. Review of the facility’s policy titled, “Assessment and Reassessment of Patients,”, effective date 05/27/2026, revealed that the purpose of the policy was to identify initial assessment and reassessment components of the patient’s condition by assigned discipline. Continued review revealed, Procedure, General Information: 5. Reassessment of the patient’s condition should be performed periodically at appropriate intervals. Review of the facility’s policy titled, “Documentation System,”, effective date 07/20/2020, revealed that the purpose of the policy was to detail the nursing process documentation system. Continued review revealed, Documentation Responsibilities, One, Assessment and Intervention: a. Documentation of changes in a patient’s condition, the interventions implemented, the patient’s subsequent response, and pertinent physician/staff notifications should be made at the time they occur or within an appropriate time frame of the occurrence. Continued review revealed, Implementation of Care, the nurse assigned to the patient is responsible and accountable for implementing provider and nursing orders. A telephone interview was conducted on 07/08/2026 at 09:26 AM with RN AA. RN AA said that he does not recall P1. RN AA said that when a patient is admitted to the unit, a full head-to-toe skin assessment should be completed. RN AA said that all wounds should be documented and that they may initiate a nurse-driven protocol to provide simple wound treatment until a member from the wound, ostomy, and continence (WOC) team assesses the patient. RN AA said that staff are to follow the orders of the WOC team members and document all dressing changes and treatment as appropriate. RN AA said that clinical staff are responsible for assisting patients with meals and should document the amount that the patient consumes for each meal. An interview was conducted on 07/08/2026 at 9:40 AM with Registered Nurse (RN) RN BB. RN BB is a wound, ostomy, and continence (WOC) RN who provided care for P1. RN BB said that she does not recall P1. RN BB will input wound care orders and update the primary RN for P1 to ensure they understand the plan of care (POC). RN BB said that the frequency of dressing changes depends on the amount of drainage and severity of the wound. RN BB said that sometimes patients are not medically stable for assessments and so WOC RNs are unable to turn them to assess wounds on their backs. RN BB said that she would leave a note in the patient’s chart on why an assessment or follow-up was not completed. RN BB said that poor nutrition and immobility can affect and delay wound healing. An interview was conducted on 07/08/2026 at 9:56 AM with RN CC. RN CC is a wound, ostomy, and continence (WOC) RN at the facility and provided care for P1 but does not recall P1. RN CC said that she inputs in WOC orders that are appropriate using the facility’s WOC policies and procedures. RN CC said that the frequency of dressing changes depends on the type of wound and the amount of exudate. RN CC said that nutrition and hydration are very important for wound care healing and progression.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 45841 Based on record reviews, policies and procedures and, staff interviews, it was determined that the facility failed to ensure that one patient (P) (P#1) of three patients reviewed was appropriately transported when it was determined that P#1 was transported without oxygen which led to decreased oxygen saturations and the need for increased oxygen. Findings included: Review of the “Hematology & Oncology Telemedicine Progress Note,” dated 12/15/2025 at 1:30 PM, for P#1 revealed the patient’s pulse oxygen saturation (amount of oxygen circulating in your blood-normal 95% to 100%) was 75-85% on room air. The progress note revealed the patient did not have labored breathing and was speaking in full and complete sentences. The progress note revealed the patient was transported to the emergency department in a wheelchair with a nurse and the patient’s family member. Review of the “History and Physical Exam,” dated 12/15/2025, revealed P#1 had been sent from an outpatient office to the emergency department that day for further evaluation of hypoxia (low levels of oxygen in the body’s tissues). The exam notes revealed that diagnostic imaging indicated the patient had extensive masses in their neck and chest, and there were concerns for vascular compression and pulmonary embolism. The exam notes revealed pleural effusions (fluid buildup around the lungs) were also found. Review of the “Clinical Notes,” dated 12/17/2025 at 5:00 PM, revealed P#1 came back from the radiation department, and there was no supplemental oxygen connected to the patient’s nasal cannula (NC); the patient’s oxygen saturation level was 82% on room air. The notes revealed that the patient had received 4 liters (L) of oxygen via NC. The notes revealed the patient’s oxygen saturation level went up to 95%, and the supplemental oxygen was turned down to 3L with the patient’s oxygen saturation level at 93-94%. The notes revealed that the physician was notified. Review of an undated facility document titled “Patient Rights & Responsibilities,” indicated patients had the right to, “Expect your care to be given in an environment free from neglect, exploitation, and verbal, mental, physical, and sexual abuse.” Review of facility policy titled “Non-Critical Patient Transport,” dated 02/24/2025, indicated, “During transport, the transporter is responsible for ensuring safe patient movement. The transporter is responsible for monitoring the patient’s condition, assessing medical and transportation equipment if within scope of work, maintaining isolation precautions, and supporting the patient throughout the transport.” The policy indicated, “Upon arrival in the receiving department, the transporter should consult with the receiving personnel predetermined by the receiving department.” The policy indicated that the sending department was to “Set the oxygen flow,” and the receiving department was to “Place patient on necessary medical equipment required for department.” During an interview on 01/16/2026 at 11:24 a.m., Registered Nurse (RN) #4 stated that the usual process when transport staff brought a patient back to their floor was to let the nursing staff know, and if the patient was on supplemental oxygen, the transporter would ask the nurse to connect the patient’s supplemental oxygen to the wall. She stated she recalled the situation with P#1 and being transported back from the radiation department. She stated that the patient was brought back to their room, and she heard the family screaming. She stated that she went into the room, and the patient’s supplemental oxygen was not connected. She stated that she called the radiation department and spoke with the nurse, who stated they had connected the patient’s oxygen tubbing to the supplemental oxygen tank. RN #4 stated she was not the patient’s primary nurse, but she was the charge nurse that day, so when she heard the family screaming, she responded. She stated that she filed a safety report. She stated she did not see the transporter during that time. RN #4 stated that the patient was not disoriented and did not have any issues with their voice. She stated the patient was not showing signs of distress or shortness of breath; the only issue assessed with the patient was a low pulse oxygen level. During an interview on 01/16/2026 at 1:28 p.m., the Support Services Manager (SSM) stated that they only had the non-critical transport policy, and other education and procedures were verbally communicated. The SSM stated the transporters were not to touch medical devices to connect or disconnect them. During an interview on 01/16/2026 at 2:17 p.m., Patient Transport Lead (PTL) #9 stated that the process for transporting a patient with supplemental oxygen included getting a portable oxygen tank and having the nurse hook up the patient to the portable oxygen tank from the wall. PTL #9 stated that when he arrived with a patient, he would notify the clinical staff member, and they would switch the patient’s supplemental oxygen from the portable tank to the wall if they were on supplemental oxygen. PTL #9 stated that when Transporter #8 transported Patient P#1 alone, he had been restocking portable oxygen tanks on the unit. PTL #9 stated Transporter #8 called him because the family was “going off” and arguing. He stated that his understanding was that Transporter #8 had connected the supplemental oxygen but had not turned it on. He stated that Transporter #8 “got spooked” by the family arguing and left the room. Attempts were made to contact Transporter #8 on 01/16/2026, at 1:26 PM, 2:03 PM, and 2:40 PM and were unsuccessful.”