Ascension Providence Hospital, Southfield and Novi

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 50223 Based on interview and record review, the facility failed to ensure nursing staff consistently implemented ordered pressure injury prevention and wound care interventions for one (P1) of ten patients reviewed for pressure injury prevention and treatment, resulting in deterioration of P1’s coccyx pressure injury requiring surgical debridement and treatment for infection. Findings include: See tag A-0395”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50223 Based on interview and record review, the facility failed to ensure nursing staff consistently implemented ordered pressure injury prevention and wound care interventions for one (P1) of ten patients reviewed for pressure injury prevention and treatment resulting in deterioration of P1’s coccyx pressure injury requiring surgical debridement and treatment for infection. Findings include: Review of the clinical record revealed P1 was a 60-year-old male admitted on 02/09/2026 after presenting to the emergency department via emergency medical services with altered mental status. P1’s medical history included diabetes mellitus with neuropathy, congestive heart failure, chronic obstructive pulmonary disease (COPD), rheumatoid arthritis, chronic pain syndrome, and impaired mobility requiring the use of a wheelchair and/or walker at baseline. Due to acute hypoxic hypercapnic respiratory failure, P1 required intubation and mechanical ventilation and was admitted to the Intensive Care Unit (ICU). Review of the nursing admission assessment dated 02/10/2026 at 0100 documented a Stage II pressure injury to the coccyx, present on admission, with a foam dressing intact. The admission Braden Risk Assessment score was 11, identifying P1 as being at high risk for pressure injury progression. Review of the electronic medical record revealed the facility initiated the Pressure Injury Prevention Protocol on 02/10/2026 at 0244. Ordered prevention interventions included repositioning every two hours, pressure reduction surfaces, specialty bed/mattress, positioning off bony prominences, heel offloading, peri-care after episodes of incontinence, removal of briefs, and maintaining dry, wrinkle-free linens. A Wound/Ostomy Nurse note dated 02/15/2026 documented the coccyx wound had evolved into a deep tissue injury measuring approximately 2.5 centimeters by 3 centimeters with minimal depth. The wound bed was described as mostly dark red dermal tissue with purple discoloration along the wound margins and a small amount of drainage. The Wound/Ostomy Nurse recommended the following interventions: Cleanse the wound with wound cleanser, apply Triad cream twice daily and as needed after episodes of incontinence, offload the heels using heel lift boots, reposition every two hours using a turning wedge, optimize nutritional status, utilize a soft chair cushion, continue use of the Centrella specialty bed, notify the attending physician if the coccyx wound deteriorated or failed to improve. Review of the nursing flowsheets revealed inconsistent documentation of implementation of ordered pressure injury prevention interventions. Review of the repositioning documentation identified prolonged periods without documented repositioning. Examples included: 02/21/2026 - P1 was documented as repositioned to the right side at 1800, supine at 2100, with no additional repositioning documented until 02/22/2026 at 0800, when the patient was documented as supine. 02/22/2026 - P1 was documented as repositioned to the right side at 1100 and to the left side at 2300. No additional repositioning was documented until 02/23/2026 at 0700. 02/24/2026 - P1 was documented as supine at 0600, “1 assist” at 1000, and supine again at 2000, with no additional repositioning documented during the intervening hours. Review of the nursing flowsheets also revealed multiple entries documenting the patient had “repositioned self” on 02/13/2026, 02/16/2026, 02/17/2026, and 02/18/2026. These entries were inconsistent with other nursing documentation describing P1 as bedfast with generalized weakness, edema, stiffness, and impaired mobility requiring assistance. Review of the medication administration record revealed ordered wound care treatments were not consistently implemented. Wound care ordered Triad cream twice daily and as needed on 02/15/2026. Review of the medication administration record revealed the ordered treatment was documented as not administered on the following occasions: 02/15/2026 at 1814 - Not available. 02/15/2026 at 2200 - Not given; documented, “Per pharmacist there is none stocked in the hospital.” 02/16/2026 at 1000 - Not given; schedule conflict. 02/16/2026 at 2200 - Not given; medication unavailable. 02/17/2026 at 2247 - Not given; medication unavailable. 02/18/2026 at 1000 - Not given; schedule conflict. 02/19/2026 at 1000 - Not given; medication unavailable. 03/02/2026 at 2200 - Not given. Review of nursing wound assessments revealed inconsistent documentation of the coccyx wound during hospitalization. Nursing documentation dated 02/13/2026 and 02/14/2026 described the wound as unstageable and present on admission. Documentation dated 02/17/2026, 02/21/2026, and 02/22/2026 identified the wound as Stage II. On 02/26/2026 at 1343, nursing documented the coccyx wound was unstageable, malodorous, with a black-purple wound base, demonstrating significant deterioration from previous assessments. On 03/01/2026 at 1321, a nursing note revealed, “Pt coccyx wound significantly worse from previous charting and very foul smelling. Dr. notified. A wound care consult was placed again and Dr. stated he would consult general surgery for possible debridement.” On 03/01/2026, the Wound/Ostomy Nurse documented the sacrococcyx wound had deteriorated to an unstageable pressure injury, likely Stage IV, measuring approximately 8 centimeters by 7 centimeters by 1.5 centimeters. The wound bed was described as 100 percent black/brown tissue with dark red drainage, malodor, and mild erythema of the periwound skin. A General Surgery consultation was requested. A General Surgery consultation dated 03/01/2026 documented a Stage IV sacral pressure ulcer measuring approximately 8 centimeters by 7 centimeters with undermining extending approximately 6 centimeters to bone. Significant eschar covered the majority of the wound circumference. The surgeon determined surgical debridement was indicated. Review of the clinical record revealed P1 underwent bedside surgical debridement on 03/02/2026. A Pulmonology progress note dated 03/04/2026 at 1241 documented P1 had an infected Stage IV sacral decubitus ulcer status post surgical debridement. The note documented intravenous Rocephin was increased to 2 grams every 24 hours, intravenous Flagyl was initiated, and local wound care was continued. During interview on 06/26/2026 at 1257, Wound/Ostomy Nurse staff T, stated the Wound/Ostomy Team evaluates all hospital-acquired pressure injuries and patients with Stage III, Stage IV, unstageable, and deep tissue injuries. Staff T stated nursing staff are responsible for implementing pressure injury prevention interventions for patients with Stage II or lower pressure injuries or patients at risk for pressure injury development. Staff T stated if a pressure injury deteriorates, nursing staff should notify the physician immediately, consult the Wound/Ostomy Nurse, and implement the recommended treatment plan. Staff T further stated deteriorating pressure injuries and hospital-acquired pressure injuries are entered into the facility’s RL reporting system “because it’s something that happened that really shouldn’t have, so we can talk about areas of improvement,” and to notify leadership so a process improvement review can be completed. During interview on 06/26/2026 at approximately 1300, Risk Manager, Staff N stated hospital-acquired pressure injuries are entered into the facility’s incident reporting system; however, pressure injuries documented as present on admission are not entered unless there is a concern regarding the care provided. When asked how the facility determines whether there was a problem with the care provided if an event is not investigated, Staff N stated, “I would have to look into it.” Review of the facility’s incident report log did not identify an RL event or investigation related to the documented deterioration of P1’s coccyx pressure injury during hospitalization. During interview on 06/26/2026 at 0936, Chief Nursing Officer Staff B stated the facility’s pressure injury prevention process includes implementation of the pressure injury prevention bundle, turning teams, two-person skin assessments, wound care consultation, and investigation of hospital-acquired pressure injurie. Staff B stated if a pressure injury develops during hospitalization, leadership reviews the event to determine opportunities for improvement. After review of the survey findings, Staff B stated, “What you found was unacceptable and the documentation was very poor.” Review of the facility’s “Pressure Injury Prevention” policy revealed the policy applies to “all nursing staff caring for inpatients.” The policy states: ...”For Braden score of 18 or less, implement the Henry Ford Health PIP Protocol with interventions aimed at modifying each risk area.” ...”Implement wound care as appropriate for wound type, stage and characteristics.” ...”If a pressure injury or any other alterations to intact skin are present, clearly describe and document the alterations including: Appearance of the wound bed, drainage, surrounding skin, and odor... Measurements... STAGE of pressure injury... Indicate if Present On Admission (POA)... Notify the provider of findings.” ...”Initiate a Wound/Ostomy Nurse Consult for: Stage III, IV, unstageable pressure, deep tissue injury... Non-healing pressure injuries... Deterioration of pressure injury... [and] Any question regarding the pressure injury treatment plan.” ...”Document interventions and outcomes in the EHR.””

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 47415 Based on record review and interview, the facility failed to ensure the medical record for 1 (P-1) of 4 psychiatric patients reviewed for clinical certification for mental health care, contained documentation of the examination conducted by the signer of the clinical certification, resulting in an incomplete medication record. Findings include: A clinical certification form was filled out and signed by Staff GG on 9/23/25 at 1919. No corresponding documentation was found in the record regarding the details of Staff GG’s examination of P-1. On 10/21/25, at 1430 a phone interview with Staff GG revealed that he completed the certification on 9/23/25, and that he was not the initial provider to see P-1. Staff GG stated he received a handoff from the prior shift and worked the next day. Staff GG stated the typical process in the ED for a psychiatric evaluation includes medical clearance first, followed by a social work evaluation and petition, if criteria met, the physician certification is done. He did not remember if he made a medical record entry for P-1 regarding his psychiatric exam and completing the certification. On 10/22/25 at 1117, an interview with Staff X revealed that it was his expectation that a medical record note be entered after a clinical certification is completed. On 10/22/25, review of the policy titled, “Treatment and Services, Formal Voluntary and Involuntary Admission Process” dated 8/18/25 revealed, “Clinical Certificate ...the written conclusion of a physician ...that an individual is a person requiring treatment, together with the information and opinions, in reasonable detail, that underlie the conclusion ...A petition must be completed by a person who has personally observed and/or seen evidence of behaviors or action(s) documenting the patients need for further psychiatric evaluation and treatment ...Any individual 18 years of age or over may file a petition ...Two clinical certificates are required. They must be completed by a ...physician ...”.”