Virtua Willingboro Hospital

“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: 50602 Based on staff interviews, review of two of 12 medical records (Patient (P)1 and P12), and a review of facility policy, it was determined that the facility failed to ensure that nursing staff implement facility policies and procedures that address: 1) completion of wound assessments; 2) repositioning patients every two hours; and 3) placing referrals for wound ostomy care nurse consults. Findings Include: Facility policy titled, “Skin and Wound Care: At Risk for or Impaired Skin Integrity- Assessment, Pressure Injury [areas of skin and tissue damage caused by prolonged pressure] Staging, Prevention & Treatment Recommendations,” effective on 04/24/24, stated “...Nursing Assessment: 1. Initial assessment of a patient with impaired skin integrity should include identification of impaired skin integrity, assessment of risk for developing impaired skin integrity, prior history of pressure injury...3. A skin assessment should be completed by the nurse per the nursing flowsheet in the electronic medical record-upon admission/transfer to each unit then every shift...Nursing Interventions: ...2. Institute appropriate interventions according to Braden Scale Assessment [assessment tool that evaluates a patient’s risk of developing pressure ulcers.], assessed risk factors, and the assessed needs of the patient ...4. Consult the Wound Care Nurse for multiple stage 2 or greater pressure injuries, all hospital acquired pressure injuries regardless of staging, and/or as an educational resource for wound healing-Licensed practitioner or Nurse in collaboration with the multidisciplinary team if appropriate can initiate referral/consult ...Nursing Documentation: 1. Document preventative measures taken and any changes made to the interdisciplinary plan of care based on the ongoing assessments of the patient’s needs and risk factors. 2. Document wound assessment upon admission or initial wound presentation then daily and/or with each treatment in the electronic medical record. Documentation should include location, type, stage if pressure injury, size (LxWxD in centimeters including tunneling and undermining-see frequency below, wound bed appearance, periwound condition, drainage (amount, color, odor, consistency), sign or symptom of infection, ...Attachment A: Braden Scale [tool used to assess a patient’s risk of developing pressure injuries] Pressure Injury Risk Assessment...The Mobility Ability to change and control body position...2. Very Limited Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. ...Attachment B: Recommendations for Interventions to Prevent Pressure Injuries Based on Risk Factors...Risk Level...Moderate Risk: Braden Score 13-14. High Risk: Braden Score 10-12, Very High Risk: Braden Score 9 or Below... Attachment C: Skin Bundle Checklist Recommendations (unless contraindicated) ...Braden less than or equal to 18 or based on additional risk factors activate/update care plan ...Document Q [every] 2 hr repositioning or per individualized patient turn schedule; Document elevate heels each shift ...Offload/reposition Q 2 hr or per individualized patient turn schedule (wedge, pillows, Leaf, HOB [head of bed] less than or equal to 30 degrees) ...Offload frequently if OOB [out of bed] chair recommend hourly...” 1. On 02/11/26 at 10:38 AM, on E2, a medical surgical unit, Staff (S) 19 explained their process to prevent skin breakdown. S19 stated it begins with a skin assessment upon admission with another RN, so two pairs of eyes are verifying the patient’s skin status. At 10:56 AM, S10 stated that on Wednesdays, all RNs [Registered Nurses] reassess and remeasure all wounds. During a review of P12’s medical record, in the presence of S1, it was identified that P12 was admitted to the facility on 01/01/26. The medical record lacked completion of an initial skin assessment, in accordance with facility policy. P12 had a Braden Score between 11 and 14 documented throughout his/her admission. The “Integumentary” [skin] section on the assessment flowsheets, dated 01/02/26 at 3:18 PM and 01/03/26 at 2:17 PM stated, “...Within Defined Limits [WDL] ...” and on 01/04/26 at 11:11 AM was also documented “ ...Within Defined Limits ...” On 01/04/26 at 11:16 PM it stated, “Exceptions to WDL ...Silicone Foam Prevention Dressing Location- sacrum ...Skin Color-Red ...” The same Integumentary assessment was documented on 01/05/26 at 1:05 PM and 01/06/26 at 11:16 AM. P12’s flowsheet, dated 01/06/26, stated, “ ...Pressure Injury ...Buttocks Left ...Date First Assessed: 01/06/26 ...Time First Assessed: 2000 [08:00 PM] ...Pressure Injury 01/06/26 Sacrum ...Date First Assessed: 01/06/26 ...Time First Assessed: 2000 ...” The same assessment was documented on 01/07/26 at 12:07 AM, the date P12 was discharged. These assessments lacked staging, appearance, and the size of the pressure injury, in accordance with facility policy. These findings were confirmed by S1 during medical record review. 2. On 02/11/26 at 1:05 PM, review of two of 12 medical records (P1 and P12), in the presence of S1, revealed the following: In P1’s medical record the following was documented: On the flowsheets, the following wounds were documented upon admission on 12/29/25 at 1:00 AM: “Wound ...Sacrum ...Wound ... Back Lateral; Left; Lower ...Wound ...Heel Left; Right ...” A wound consult note with a Date of Service 12/29/25 at 11:05 AM, stated “ ...Wound/Ostomy Assessment: ...1. Location: sacrum/coccyx[tailbone]/cleft[dimple]/buttocks POA [present on admission] Etiology: suspected deep tissue pressure injury [DPTI-] evolving and evidence healing stage 2 and moisture/friction/incontinence. Wound bed: skin tone variations-darker tones and hypopigmentation, suspected discomfort to touch ...2. Location: Heels POA Etiology: suspected pressure injury evolving DPTI/friction ...3. Location: L iliac crest area POA Etiology: suspected pressure injury evolving DPTI/friction ...RECOMMENDED NURSING MEASURES & SUMMARY ...Recent Braden per EMR: 12 ...Offload/Reposition in bed Q 2 hours, Offload Q hour if OOB in chair & if patient able shift own weight Q15 mins ...” On P1’s flowsheets, the Braden Scale score documented throughout P1’s admission, ranged between 9 at the lowest to 14 at the highest, indicating that P1 was at moderate to high risk of developing pressure injuries, with mobility documented as “Very limited”. P1’s flowsheets, under the “Activity and Safety” section lacked documentation of P1 being repositioned every two hours on the following dates: On 12/31/25 at 12:25 AM, 2:18 AM, and 6:16 AM, it stated, “Lying left side; Pillow support”. Between 12:25 AM and 6:16 AM, it was documented that P1 was laying on his/her left side. Upon interview at 1:56 PM, S1 confirmed that the position documented should have been different than “left side” to indicate that the patient was turned. The next documented repositioning was at 8:13 PM. Between 12:25 AM and 6:16 AM, and between 6:16 AM and 8:13 PM, the medical record lacked documentation that P1 was repositioned every two hours. On 01/01/25, between 7:01 AM and 3:44 PM, the medical record lacked documentation that P1 was repositioned every two hours. On 01/02/25 at 6:06 AM, it stated, “Lying right side; Pillow support,” and at 12:04 PM, it stated, “Lying left side; Pillow support; Wedges”. Between 6:06 AM and 12:04 PM, there was no documentation that P1 was repositioned every two hours. At 12:37 PM, it stated “Lying right side; Pillow support,” and at 10:15 PM, it stated, “Lying left side; Semi Fowler’s[lying on back with head of the bed elevated at between 30 and 45 degrees]; Pillow support”. Between 12:37 PM and 10:15 PM, there was no documentation that P1 was repositioned every two hours. On 01/04/26 at 12:15 AM, 2:26 AM, 4:03 AM, and 6:21 AM, it stated, “Supine [lying on back],” followed by documentation at 8:15 AM, that stated, “Semi Fowler’s”. Between 12:15 AM and 8:15 AM, there was no documentation that P1 was repositioned every two hours. P12’s medical record review revealed the following: P12 was admitted to the facility on 01/01/26. The medical record lacked documention of an initial skin assessment. P12 had a Braden Score between 11 and 14 documented throughout his/her admission indicating that P12 had a moderate to high risk of developing pressure injuries, with mobility documented as “Very limited”. On P12’s flowsheets, under “Activity and Safety,” the medical record lacked documentation of being repositioned every two hours on the following dates: On both 01/02/26 at 12:50 AM and 01/03/26 at 12:58 AM, it stated, “Semi Fowler’s; Pillow support.” Between 01/02/26 at 12:50 AM and 01/03/26 at 12:58 AM, there was no documentation that P12 was repositioned every two hours. On 01/03/26 at 2:13 PM, it stated “Lying left side; Wedges”. On 01/03/26, between 12:58 AM and 2:13 PM, there was no documentation that P12 was repositioned every two hours. On 01/04/26 at 3:04 PM, it stated, “Lying right side.” At 11:07 PM, it stated “Lying left side; Wedges; Pillow support.” Between 3:04 PM and 11:07 PM, there was no documentation that P12 was repositioned every two hours. On 01/05/26 at 7:04 PM, it stated, “Pillow support; Wedges”. At 11:59 PM, it stated, “Lying right side; Wedges”. Between 7:04 PM and 11:59 PM, there was documentation that P12 was repositioned every two hours. P12’s flowsheet dated 01/06/26 stated, “ ...Pressure Injury ...Buttocks Left ...Date First Assessed: 01/06/26 ...Time First Assessed: 2000[08:00 PM] ...Pressure Injury 01/06/26 Sacrum ...Date First Assessed: 01/06/26 ...Time First Assessed: 2000 ...” During medical record review, it could not be determined if P1 and P12 were repositioned every two hours. S1 confirmed these findings during review of the medical records. 3. On 02/11/26 at 10:56 AM, S10 stated that on Wednesdays, RNs reassess and remeasure all wounds. If the nurses identify new skin breakdown after admission, the changes should be documented in EPIC [electronic medical record], pictures should be taken, an order for a wound care nurse consult should be placed, and an incident report documented. During review of P12’s medical record with S1, the assessment flowsheets dated for P12’s admission on 01/01/26, lacked documentation of a skin assessment or the presence of wounds. P12 had a Braden Score between 11 and 14 documented throughout his/her admission, indicating that P12 had a moderate to high risk of developing a pressure injury, with mobility documented as “Very limited,” indicating P12 would need assistance with repositioning him/herself. Braden Policy? Under “Integumentary” on the assessment flowsheets dated for 01/02/26 at 3:18 PM and 01/03/26 at 2:17 PM, it stated, “ ...Within Defined Limits ...” and on 01/04/26 at 11:11 AM was also documented “ ...Within Defined Limits ...” On 01/04/26 at 11:16 PM it stated, “Exceptions to WDL ...Silicone Foam Prevention Dressing Location- sacrum ...Skin Color-Red ...” The same Integumentary assessment was documented on 01/05/26 at 1:05 PM and 01/06/26 at 11:16 AM. P12’s flowsheet dated 01/06/26, stated, “ ...Pressure Injury ...Buttocks Left ...Date First Assessed: 01/06/26 ...Time First Assessed: 2000 [08:00 PM] ...Pressure Injury 01/06/26 Sacrum ...Date First Assessed: 01/06/26 ...Time First Assessed: 2000 ...” At 2:48 PM, S1 confirmed that a wound care consult was not placed for P12, and that since the wounds were not identified upon admission, therefore indicating they were acquired while in the hospital, that a wound care nurse consult should have been placed.”