Henry Ford Allegiance Health

“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: 36887 Based on interview and record review, the facility failed to ensure nursing personnel followed facility policy regarding pressure injury prevention for 1 (P-1) of 2 patients reviewed for a pressure injury resulting in the development of pressure injury. Findings include: Review of the medical record for P-1 revealed she was an 82-year-old female admitted to the facility from 4/29/2026-5/13/2026 with acute hypoxic respiratory failure, heart failure, asthma/COPD exacerbation, severe pulmonary hypertension and severe protein calorie malnutrition. Review of the initial nursing assessment on 4/29/2026 at 2330 revealed an initial Braden score (tool used to determine risk of pressure injury based on a score between 1-4 of certain areas of patient assessment including sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Scoring of 15-16 is mild risk, 12-14 is moderate risk, and less than 11 is severe risk) of 13. The skin was described as “fragile”, with redness and blanching but did not describe whether that was over a certain area or over the whole body. The coccyx area was noted to have scarring present. Skin protection was placed including limited use of adhesives, incontinence pads, a sacral silicone foam dressing, skin-to-device padding, and transparent dressings were present to the IV (intravenous) site so redness could be easily visualized. An external female catheter was also in place to assist with moisture issues as P-1 was incontinent of urine. The initial assessment did not document any open wounds. Throughout P-1’s hospitalization, the Braden scores remained in the “moderate risk” range. Review of provider orders revealed one on 5/3/2026 for turning every 2 hours based on the mobility sub-score. If the sub-score for mobility was 2 or less, the order was to turn every 2 hours. If the sub-score was 3, the turning was to be encouraged and or assisted. Clinical Nurse Specialist Staff V explained on 5/28/2026 at 1225 the positioning/re-positioning of patients was based on their Braden score according to the facility policy. P-1’s sub-score for mobility was 2 (very limited-makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently) each day of admission to the facility (exception of 5/5/2026 where the scoring was not documented). Further review of the nursing flow sheet revealed pillows were used for positioning and interventions were in place for pressure reduction and skin protection. P-1 was also encouraged to frequently shift her weight; however, with a Braden sub-score for mobility of 2 consistently throughout her hospitalization, P-1 was unable to effectively comply. Documentation was not consistent in the record and indicated P-1 was not repositioned every 2 hours as follows: Date Time 5/3/2026 1203 Order given 1217-1632 No documentation 1632-2007 No documentation 2007-2349 No documentation 5/4/2026 2349 (5/3)-0312 No documentation 1000-1500 Seated - no position change 1500-2000 Supine, head elevated - no position change 2000-0000 Right side lying - no position change 5/5/2026 0528-1200 No documentation 1400-1600 Supine, head elevated - no position change 1600-2000 No documentation 5/6/2026 2200 (5/5)-0600 Neutral head, neutral body - no position change 0600-1300 No documentation 1300-2000 No documentation 5/7/2026 2200 (5/6)-0556 Neutral head, neutral body - no position change 0800-1200 Seated - no position change 1200-1935 No documentation 2009-0000 No documentation 5/8/2026 0600-0945 No documentation 0945-2000 No documentation 2000-2300 Left side lying - no position change 5/9/2026 2300 (5/8)-0200 Right side lying - no position change 0400-0836 Left side lying - no position change 0836-1400 Supine, head elevated - no position change 1436-1922 No documentation 5/10/2026 1600-2014 No documentation 5/11/2026 1200-1600 Left side lying - no position change 1600-2000 No documentation 2000-0000 No documentation 5/12/2026 0400-0824 No documentation 0824-1200 No documentation 1600-2000 No documentation 5/13/2026 0800-1200 Supine, head elevated - no position change 1200-1855 No documentation 1855 Discharged Review of the complaint and grievance log on 5/28/2026 at 1315 revealed an entry for P-1 regarding care/treatment. Review of the complaint dated 5/8/2026 revealed P-1 had complained of pain and it was discovered she had developed “a sore” on her buttocks. Further review of the medical record revealed a wound consult dated 5/9/2026 at 1036 noted a “Coccyx: stage 2 pressure injury present, partial thickness open ulcer noted, which bleeds easily... Right buttock: stage 2 pressure injury present. Partial thickness red open blister noted... Right upper medial buttock: stage 2 PI (pressure injury) present. Site is red and dry...” On 5/29/2026 at 0946, Wound Care Nurse Staff N stated a Stage 2 pressure injury was when the top layer of skin was open or there was an intact blister over a bony prominence. She stated when she turned P-1 to do her assessment, she noted the presence of moisture. She cleaned the wounds listed above and applied a barrier cream to them. When asked when she reassessed P-1, Staff N stated she signed off of P-1’s care the same day of the consult because there was no clear outline of when to reassess this type of injury. Facility policy #19077216 titled “Pressure Injury Prevention” effective 10/22/2025 states, “Upon admission (within eight hours of admission) all in-patient adult patients with the exception of maternal-child and non-geriatric adult psychiatric patients, will have pressure injury risk assessment consisting of: A comprehensive skin assessment... A Braden Risk Assessment (see Attachment 2): to identify individual risk for developing pressure injuries as soon as possible (within 24 hours of admission)... Any patient with the following is considered to be at risk for pressure injury development 1. Braden score of 18 or less... 2. Bedfast and/or chairfast individuals 3. Alterations to intact skin on pressure points... 4. Fragile skin 5. Existing pressure injury of any stage, including those pressure injuries that have healed. 6. Impairments in blood flow to the extremities from vascular disease or diabetes 7. Pain in areas of the body exposed to pressure. E. Consider the impact of other factors on increasing the risk for pressure ulcer development... Elderly patients (80 years or greater)... For patients identified to be at risk for pressure injury, initiate the [hospital system name] Pressure Injury Prevention Protocol (PIPP) (Attachment 4)... For patients who have any Braden or Braden Q individual subscale score of 3 or less, implement interventions aimed at modifying each risk area.” Policy attachments included the following: Attachment 1: Braden Pressure Injury Risk Assessment Scale Attachment 2: Braden Q Pediatric Pressure Injury Risk Assessment Scale Attachment 3: Braden Assessment: Pressure Injury Prevention Protocol - “Braden/PIP Intervention orders... Nursing Interventions Turn and reposition Q 2 hours using a repositioning device (Braden mobility subscore 2 or less)...” Attachment 4: National Pressure Injury Advisory Panel (NPIAP) Pressure Injury Prevention Points Attachment 5: National Pressure Injury Advisory Panel (NPIAP) Pressure Injury Stages Attachment 6: Wound Assessment and Documentation Terminology”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to inform 2 (P-1, P-3) of 3 patients or patient representatives/durable power of attorney (DPOA) of 1) findings on a computerized tomography scan (CT scan) and 2) an incident resulting in denial of the patient/patient representative’s right to be informed of changes and make decisions in the patient’s plan of care. Findings include: 1) On 4/23/2024 at 1241, review of the medical record for P-1 revealed she was a 72-year-old female who presented to the Emergency Department (ED) on 8/5/2023 at 0735 after being hit in the head by the trunk of her car the day before. She denied loss of consciousness and denied being on blood thinners. A CT of the head without contrast was obtained. Radiologist Staff P read the scan as being negative. The negative findings were communicated to the patient by the ED physician and she was discharged home. Further review of the medical record revealed P-1 returned to the ED on 10/26/2023 at 1304 with a chief complaint of left forehead numbness, headache, and left eye tingling for the past 3 days. The patient stated she had increased stress at work that ended with termination the day before. A CT of the head and neck with contrast was ordered. Results indicated there was an “extra-axial lesion overlying the right frontal convexities measuring up to 1.2 cm (centimeters) most likely a meningioma (a usually non-cancerous tumor that arises from the membranes surrounding the brain and spinal cord) not significantly changed from 8/5/2023.” ED physician notes dated 10/26/2023 stated, “I discussed her imaging with her particularly emphasized the meningioma. Patient states that she was not made aware that she had a meningioma on imaging back in August.” On 4/24/2024 at 0923, Radiologist Staff P, who read the CT on 8/5/2023, stated during interview he had the opportunity to look at the CT imaging from both 8/5/2023 and 10/26/2023 and stated he agreed with both reports. Staff P explained that a CT of the head without contrast was the most common CT that was done, and its purpose was a “stat study.” Approximately 1000 images were obtained during the scan. The purpose was to look for major concerns such a bleeding, fractures, or trauma - anything that would require immediate surgical intervention. The images were read and reported quickly, in this case, within 10 minutes of the scan being done. Staff P further explained that the study on 10/26/2023 was a different study with a completely different reason. He stated there were approximately 5000 images obtained with this study and the contrast helped to clarify the images causing the sensitivity to be higher for picking up lesions that may be present. In this case, there was a “very tiny” 1.2 cm lesion along the skull. Staff P stated it was normally very difficult to identify abnormalities close to the skull; however, once identified, he went back and looked at the 8/5/2023 CT images without contrast and was able to see that it was present. 29955 2) On 4/23/2024 at 1500 an interview was conducted with staff V, resident of internal medicine. Staff V was queried if he had been the staff member to inform the family of the incident of the fall. Staff V stated, “I’m not sure if I was the first person to let them know... they (family) acted as though they were already told ...I ’ m not sure.” On 4/23/2024 at 1545 an interview was conducted with staff W, attending of internal medicine. Staff W was queried if she had been the staff member to inform the family of the incident of the fall. Staff W responded, “No... I think they already were aware of the fall. We receive report in the morning from the night shift physician ’ s. I am not sure if they called the family or not.” On 4/24/2024 at 1340 an interview was conducted with staff KK, Internal Medicine resident who was working the night of P-3 fall. Staff KK was queried if she was the physician who was stated to be responsible for calling the family of P-3 to inform the family of P-3 fall. Staff KK stated that it was the attending who was supposed to call the family. Staff LL, attending physician on the night of 12/19/2023 was unable to be reached for interview prior to the end of survey on 4/24/2024. Staff Y, the house supervisor on the night of 12/19/2023 was unable to be reached for interview prior to the end of survey on 4/24/2024. Record review occurred on 4/23/2024 of the policy titled, “Disclosure of Unanticipated Events,” dated 9/28/2021, policy number 9930892. The policy states, “When a serious unanticipated outcome occurs, including one that may be caused by system(s) failures(s), the patient and, as appropriate, the family will receive timely, transparent, and clear communication concerning what is known about the event... Any care provider in any setting, including but not limited to staff physicians, house officers, and nurses, will disclose any unanticipated event when an explanation of any change in treatment is indicated.” Record review of P-3 medical record failed to show contact with P-3 guardian. Documentation on 12/20/2023 at 0605 stated the following under the title of “Assessment and Plan” subtitle “Traumatic fall”, “She experienced a traumatic fall while being transported from the stretcher to the MRI machine. This occurred on 12/19 ...patient not complaining of any pain beside her baseline body aches ...had with family and notified them of this unfortunate event.[SIC]” Review of documentation on 12/19/2023 failed to have any documentation of the event or notification to the family at the time of the occurrence.”

“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: 29955 Based on interview and record review the facility failed to ensure nursing documented daily dietary intake in one of three (P-3) patients reviewed for dietary intake, resulting in the potential for poor patient outcomes. Findings include: On 4/24/2024 at 1130 an interview was conducted with staff E, the Chief Nursing Officer of the facility. Staff E was queried who is responsible for the recording of meal consumption for a patient. Staff E responded, “It is ultimately the responsibility of the nurse although nursing assistants will sometimes record meals as well.” Staff E was then asked if a meal was not consumed would documentation be left blank. Staff E stated, “No... a percentage is to be recorded not left blank.” Record review occurred of the policy titled, “Tier 1: IPD Nursing Document: Nursing Process,” policy number 9533165, dated 2/18/2022. According to the policy it states, “The Registered Nurse (RN) will document all phases of the nursing process in the Electronic Record. Care of the patient is the priority of the healthcare team, and the nursing care will be rendered prior to the documentation in the EHR (Electronic Health Record).” Record review of P-3’s orders revealed “I/O,” (Intake and Output) entered on 12/12/2023. Record review of the Record review of P-3 medical record from 12/13/2024 to time of discharge on 12/29/2024 at 1655, for dietary consumption of meals. P-3 was deemed as a total feed related to her vision impairment. The following was revealed: 12/29: 100% breakfast, No lunch documentation 12/28: 50% breakfast, 50% lunch, 50% dinner 12/27: 100% breakfast, No lunch or dinner documentation 12/26: No documentation for breakfast, lunch, or dinner 12/25: 75% breakfast, 75% dinner, No lunch documentation 12/24: 25% breakfast, 75% dinner, No lunch documentation 12/23: No documentation for breakfast, lunch, or dinner 12/22: No documentation for breakfast, lunch, or dinner 12/21: 100% breakfast, No lunch documentation, No dinner documentation 12/20: 25% breakfast, 25% lunch, No dinner documentation 12/19: breakfast 100%, lunch 100%, No dinner documentation 12/18: dinner 25%, No breakfast documentation, No lunch documentation 12/17: breakfast 75%, lunch 50%, No dinner documentation 12/16: breakfast 50%, lunch 75%, No dinner documentation 12/15: lunch 100%, dinner 100%, No lunch documentation 12/14: breakfast 50%, dinner 25%, No lunch documentation 12/13: dinner 25%, No breakfast documentation, No lunch documentation (date of admission to inpatient and arrived on the inpatient unit after breakfast and lunch meals) Record review of a dietary consult on 12/21/2023 stated, “Follow-Up High Risk Monitoring and Evaluation: Goal is >75% meals eaten through follow up, Goal is 1 supplement(s) accepted daily through f/u (follow-up). Diagnosis: Increased protein needs (moderate) related to increased demand as evidenced by wounds, chronic hypoalbunimia [SIC] (hypoalbuminemia - when the body fails to produce enough albumin protein, or when the body loses too much albumin urine or stool). Diet/Oral Nutrition Supplements/Nutrition Support: Diet Regular; Thin Liquids; Regular texture, Diet/Feeding Assistance: total feed, Average: 61.5% average for 13 meals documented in the past 8 days. (12/13/2023 - 12/20/2023)””