Hawarden Regional Healthcare

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 53650 Based on medical record review, policy review, and staff interviews, the CAH ’ s administrative staff failed to implement a written patient care policy to direct the care for patients who require frequent repositioning and pressure offloading for the maintenance and prevention of pressure wounds. Furthermore, the CAH ’ s administrative staff failed to implement a policy to aid staff in identifying which patients require frequent offloading and identifying what frequency a patient requires offloading, for 1 out of 5 patients reviewed Patient #4 (P4). Failure to have policies to address this area of care places all patients at risk of not being frequently repositioned by nursing staff to offload pressure, placing them at risk of developing new or worsening pressure-related injuries and experiencing other serious adverse health outcomes. Furthermore, this lack of a patient care policy may have led to Patient #4 (P4) not being repositioned every 2 hours as expected by P4 ’ s practitioners, which may have contributed to P4 ’ s sacral pressure ulcer worsening, and may have contributed to P4 ’ s death caused by an infected sacral pressure ulcer. Findings include: 1. Review of the 03/2026 policy “Wound Care: Offloading” revealed in part: a. “Purpose: Wounds that have a component of pressure frequently require offloading in order to heal properly and timely.” b. “If some sort of offloading is indicated a conversation will be initiated and may include the patient, the family of the patient, the provider involved ... to properly educate and seek good offloading.” c. “The actions taken to offload will be documented in the EHR [electronic health record]” 2. Review of the 10/2025 policy “Hourly Rounding” revealed in part: a. “Purpose: To provide guidelines for addressing inpatient care needs to ... decrease skin breakdown ...” b. “Patient care needs are expected to be addressed during hourly rounds or upon request of the patient.” c. “The elements addressed in hourly rounding include: Positioning of patient- turning ...” 3. Review of Patient #4 ’ s medical record from 4/10/26 through 4/15/26 revealed the following: a. On 4/10/26 at 5:30 PM, P4 presented to this CAH ’ s Emergency Department (ED) by ambulance for complaints of chronic wound pain and not feeling well. b. On 4/10/26 at 9:51 PM, Staff C (ARNP) documented that P4 arrived via emergency medical services (EMS) with multiple Stage IV necrotic pressure ulcers, severe pain, and disorientation to place and person. Staff C further documented that a positive urine culture performed in the ED indicated probable urosepsis, which required an inpatient admission for intravenous (IV) antibiotics, clinical monitoring, and aggressive wound care. c. On 4/10/26 at 8:45 PM, Staff C (ARNP) admitted P4 to the CAH with principal diagnosis of Urosepsis, and secondary diagnosis of a Stage IV Pressure Ulcer. d. On 4/10/26 at 10:30 PM, Staff F (RN) documented that P4 had a large sacral pressure wound on P4 ’ s coccyx and a Braden Scale score of 13 (The Braden Scale is a system used to predict a patient’s risk of developing pressure injuries. A score of 13 indicates a moderate risk.) e. On 4/10/26, nursing staff did not document any repositioning for P4 for offloading of P4 ’ s chronic sacral pressure ulcer. f. On 4/11/2026 at 1:32 PM, Staff B (Physical Therapist) completed an initial evaluation of P4 ’ s chronic pressure wounds. Staff B documented that P4 had an unstageable, necrotic sacral pressure ulcer measuring 9.5 x 11.7 x 0.5 centimeters with black and brown eschar, surrounding erythema, and a foul odor. Staff B further documented that P4 experienced severe pain during repositioning. Staff B documented that P4 would require repositioning to occur every two hours in order to promote wound healing. g. On 4/11/26, nursing staff missed three required turns for P4, with the largest gap between turns at 5 hours, between 3:00 PM and 8:00 PM. h. On 4/12/26 at 9:50 PM, Staff F (RN) documented that staff had repositioned P4 every two hours and completed scheduled wound care treatments during their shift. i. On 4/12/26, nursing staff missed seven required turns for P4, which resulted in a 14-hour gap without any recorded repositioning between 10:00 PM on 4/11/26 and 12:00 PM on 4/12/26. j. On 4/13/26 at 10:08 AM, Staff C (ARNP) documented that P4 had severe pressure ulcers suspected to be at least Stage IV, but physical therapy staff could not officially stage the injuries due to the presence of necrotic tissue. k. On 4/13/26 at 10:03 PM, Staff F (RN) documented that staff had repositioned P4 every two hours and completed scheduled wound care treatments during their shift. l. On 4/13/26, nursing staff missed three required turns for P4, which included two separate five-hour care gaps occurring from 10:00 AM to 3:00 PM, and again from 3:00 PM to 8:00 PM. m. On 4/14/26 at 4:17 PM, Staff E (Physical Therapist) documented that P4’s unstageable sacral pressure ulcer now measured 12.8 x 11.4 x 0.5 centimeters with 100 percent black and brown eschar and a large amount of drainage following a selective debridement. Staff E further documented an order for nursing staff to complete dressing changes at least once daily, or more frequently if the dressing became soiled or saturated. n. On 4/14/26, nursing staff missed four required turns for P4, which included a seven-hour gap in repositioning from 3:00 AM to 10:00 AM. o. On 4/15/26 at 5:59 AM, Staff G (Social Worker) documented that P4’s family chose for P4 to return to the long-term care facility under a skilled care level for continued wound treatments and assistance with activities of daily living. p. On 4/15/26 at 09:01 AM, Staff I (ARNP) completed a discharge summary for P4 and documented that P4 would discharge back to the long-term care facility with orders to resume previous wound care treatments and to take oral Bactrim twice daily for five days to complete the antibiotic regimen for an Escherichia coli (E. coli) urinary tract infection. q. On 4/15/26 at 9:57 AM, Staff K (Physical Therapist) documented that P4’s necrotic, unstageable sacral pressure ulcer remained at an increased size of 12.8 x 11.4 x 0.5 centimeters at the time of discharge, and that P4 remained entirely dependent on staff for full body repositioning and transfers. r. On 4/15/26, nursing staff did not document any turns for P4 prior to P4 ’ s discharge at 9:01 AM, which created an 11-hour gap in care following the last recorded entry at 10:00 PM on 4/14/26. 4. A review of Patient #4 ’ s (P4) medical record from 4/21/26 through 4/23/26 revealed the following: a. On 4/21/26 at 2:57 PM, P4 presented to this CAH ’ s ED by ambulance with complaints of severe sacral pain and hypotension. b. On 4/21/26 at 3:00 PM, Staff J (ARNP) documented that P4 presented with a blood pressure of 99/41, severe sacral pain rated 8/10, and a severely compromised sacral pressure wound displaying extensive eschar and erythema extending into the thoracic area. Staff J further documented that lab results revealed an elevated lactic acid of 2.8 and significant anemia with a hemoglobin of 8.1, which required treatment with intravenous (IV) morphine, IV fluids, and an inpatient admission for IV antibiotics and advanced wound care. c. On 4/21/26 at 4:57 PM, Staff J (ARNP) admitted P4 to this CAH for treatment of a sacral decubitus ulcer (pressure ulcer). d. On 4/21/26 at 5:38 PM, Staff J (ARNP) placed an order for P4 to be repositioned every 2 hours for offloading of P4 ’ s pressure wounds. e. On 4/21/26, nursing staff did not document any turns for P4 until 10:00 PM, which created an initial four-hour gap in care and left P4 without any further recorded turns for the remainder of the calendar day. f. On 4/22/26 at 10:53 AM, Staff M (Physical Therapist) documented P4 ’ s initial wound care evaluation, which had been performed on 4/21/26. Staff M documented that the necrotic, unstageable sacral pressure ulcer measured 12 x 13 x 1.0 centimeters with 2 centimeters of undermining, 90 percent brown/black eschar, surrounding erythema, a strong odor, and large serosanguinous drainage. Staff M recommended two-hour position changes, maintaining the head of the bed below 30 degrees, and twice-daily absorbent dressing changes. g. On 4/22/26 at 1:08 PM, Staff K (Physical Therapist) documented P4 ’ s 2nd wound care session performed on 4/22/26. Staff K documented that the unstageable sacral pressure wound retained a strong odor, purulent drainage, and erythema. Staff K further documented a selective debridement of a moderate amount of necrotic tissue from the wound. h. On 4/22/26 at 3:45 PM, Staff J (ARNP) documented that after a discussion regarding the overall prognosis, P4 and the power of attorney elected to transition to comfort care measures the following day. i. On 4/22/26, nursing staff missed six required turns for P4, which included a seven-hour gap in repositioning between 2:00 PM and 9:00 PM. j. On 4/23/26 at 10:20 PM, Staff E (Physical Therapist) documented that P4’s care plan shifted to comfort care measures. Staff E documented that the sacral wound maintained significant erythema, a mild odor, and large purulent, serosanguinous drainage. k. On 4/23/26 at 10:06 AM, Staff J (ARNP) placed orders to transition P4 ’ s care to hospice care, and placed a Do Not Resuscitate order. l. On 4/23/26, nursing staff missed five required turns for P4, which resulted in a 10-hour gap without any recorded repositioning between 9:00 PM on 4/22/26 and 7:00 AM on 4/23/26. m. On 4/24/26, nursing staff missed five required turns for P4, which included a six-hour gap in care between 3:00 PM and 9:00 PM. n. On 4/25/26, nursing staff missed six required turns for P4, with the largest repositioning gaps consistently spanning four hours. o. On 4/26/26, nursing staff missed six required turns for P4, with the largest repositioning gaps routinely spanning four hours throughout the day. p. On 4/27/26 at 9:25 PM, Staff C (ARNP) documented that P4 died on 4/27/26 at 8:49 PM, due to primary bacteremia and an infected sacral pressure ulcer. q. On 4/27/26, nursing staff failed to provide any documentation of turns for P4 prior to P4 passing away at 8:49 PM on this date, which left P4 without any recorded repositioning for the entire day. 5. During an interview on 6/3/26 at 10:15 am, Staff C (ARNP) confirmed having admitted P4 to this CAH on 4/10/26. Staff C acknowledged not placing an order for P4 to be repositioned every 2 hours at any point during P4 ’ s hospitalization. Staff C reported that providers do not routinely input explicit orders for a two-hour repositioning frequency, stating that turning schedules are treated as an unwritten, implied standard of care. Staff C reported that P4 would have required repositioning every two hours during hospitalization but could not recall why they failed to place a specific medical order for this intervention. 6. During an interview on 6/3/26 at 9:45 am, Staff I (ARNP) reported that providers did not routinely input specific orders for patient repositioning frequencies and instead operated under an unwritten expectation that nursing staff would independently manage turning schedules. Staff I reported being unaware that orders could even be placed on patients to dictate if the patient requires repositioning and the frequency of that repositioning. Staff I confirmed that they rounded on and discharged P4 during the initial admission but did not place a repositioning order or directly communicate turning expectations to the floor staff. Staff I acknowledged a total reliance on the assumption that turning interventions occurred automatically. 7. During an interview on 6/3/26 at 3:45 pm, Staff J (ARNP) reported that providers only placed patient repositioning orders if a specific clinical reason arose. Staff J acknowledged a reliance on ad-hoc collaborative discussions with physical therapy staff to determine if frequent repositioning is needed for a patient, and at what frequency the repositioning should be performed, rather than utilizing a standardized facility protocol. 8. During an interview on 6/2/26 at 3:00 pm, Staff A (RN) reported that the facility operates without a dedicated wound care team and does not perform surgical debridements. Staff A reported that physical therapy staff provide most of the advanced wound services. Staff A stated that staff reposition dependent patients every two hours based on an expected standard of care, regardless of whether a practitioner orders the intervention. Staff A confirmed that this expectation is just an understanding amongst staff, and is not reflected in a specific protocol or guideline. Staff A confirmed that nursing assistants utilize paper tracking sheets in patient rooms to record repositioning, while the nursing staff utilize the Electronic Medical Record (EMR). Staff A acknowledged that staff do not consistently document each repositioning intervention when the facility experiences high patient volumes. Staff A confirmed providing care to P4 during P4’s admission and recalled that P4 possessed a severe, necrotic, unstageable sacral wound that caused P4 significant pain during mobility interventions. 9. During an interview on 6/3/26 at 7:30 am, Staff F (RN) reported that practitioners inconsistently place patient repositioning orders. Staff F stated that nursing staff determined turning frequencies using personal clinical judgment rather than an established facility protocol. Staff F confirmed that the nursing staff do not document repositioning interventions within the permanent medical records and rely on nursing assistants to manage a paper rounding sheet. Staff F acknowledged that staff routinely failed to record turning interventions and instead verbally monitor compliance amongst themselves. Staff F confirmed providing night-shift care to P4 during the initial admission and reported that staff repositioned P4 based on memory rather than documented entries. 10. During an interview on 6/2/26 at 3:45 pm, Staff E (Physical Therapist) reported that the physical therapy department would rely on informal communication to recommend to nursing staff that they should reposition certain patients at least once every two hours. Staff E reported that if a practitioner does not place a specific two-hour turning order into the EMR, physical therapy staff would usually reach out to the practitioner to request them to place the order. Staff E confirmed treating P4’s sacral wound during P4’s initial admission and stated that P4 required two-hour repositioning intervals due to the presence and severity of P4 ’ s wounds. 11. During an interview on 6/3/26 at 12:00 pm, Staff B (Physical Therapist) reported an unfamiliarity with any specific facility protocol or policy governing the two-hour repositioning standard for patients with Stage IV pressure wounds. Staff B confirmed that P4 required repositioning every two hours due to a severe sacral pressure ulcer. Staff B reviewed P4 ’ s recorded turning logs and confirmed that nursing staff failed to perform the required repositioning interventions consistently. Staff B further acknowledged that the documented measurements of P4 ’ s sacral wound showed an increase in size during the hospitalization, which could indicate that the wound deteriorated. 12. During an interview on 6/3/26 at 1:25 pm, Staff H (Nurse Manager) reported that P4 ’ s documented repositioning logs failed to meet acceptable standards of care. Staff H reviewed the repositioning data and confirmed that staff failed to perform the expected repositioning interventions every two hours. 13. During an interview on 6/3/26 at 3:30 pm, Staff L (Director of Patient Care) reported that checking and repositioning dependent patients every two hours occurred as an unwritten custom rather than an established facility protocol. Staff L stated their preference is for providers to place specific orders for repositioning rather than relying on unwritten expectations. Staff L further reported that staff must document all turning interventions and confirmed that if a repositioning entry lacked documentation within the medical record, management must assume staff failed to perform the task.”