Prisma Health Hillcrest Hospital

“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: 28883 Based on record reviews, interviews, and review of hospital policy, the hospital failed to ensure nursing staff provided appropriate wound care services for Patients (Pt)1, 5, and 7, 3 of 7 patients reviewed with wounds. The findings included: Cross refer to A-398; 482.23(b)(6) Supervision of Contract Staff related to the hospital’s failure to provide adequate supervision of nursing personnel related to the adherence of policy and procedure for wound care.”

“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: 28883 Based on medical record review, staff interviews, and review of hospital policy, nursing staff failed to ensure comprehensive wound assessment, timely initiation of treatment, physician notification, and ongoing documentation of wound care for 3 of 7 patients reviewed with identified pressure injuries or wounds Patients (Pt)1, 5, and 7. This failure placed patients at risk for worsening skin breakdown, infection, and delayed wound healing. The findings included: Patient #1 Record review on 7/22/25 at 10:30 AM revealed the hospital admitted Pt 1 on 4/18/25 at 5:56 PM with a change in mental status. Review of the admission nursing assessment dated 4/18/25 at 9:51 PM revealed 2 nurses assessed the skin and noted redness and a tear to the sacrum. The patient’s Braden score was 14, indicating a high risk for pressure ulcers. A silicone foam border dressing was placed on the sacrum at the time. Review of physician’s orders revealed no order had been placed for the treatment of the tear to the sacrum noted on the admission assessment. In the skin assessment flowsheet, nursing staff documented redness to the sacrum on 4/19/25 at 9:45 AM and again at 10:15 PM, with a Braden score of 14. On 4/20/25 nursing documented a silicone foam dressing on the sacrum, and on 4/20/25 at 9:15 AM, that the patient had blanchable redness. On 4/21/25 at 9:00 AM, 4/21/25 at 7:53 PM, and 4/22/25 at 9:00 AM, the skin was noted as within defined limits (which indicated there were no abnormalities noted). On 4/23/25 at 9:30 AM and again at 3:42 PM, nursing documented redness to the sacrum; and at 7:04 PM, that the silicone foam border dressing was in place. A wound consult order had been placed by a floor nurse on 4/23/25 at 7:06 PM for assistance with validation of pressure injury staging. There were no orders for treatment of this pressure injury or description of the pressure injury/wound detailed in the nursing documentation. On 4/24/25 at 8:45 AM, nursing documented redness, and at 9:03 PM- redness to the sacrum. There had been nothing documented by nursing on the flowsheets or nursing notes related to the presence of a tear or wound since the admission nursing assessment. On 4/25/25 at 7:55 AM, a nurse documented s/he had been informed in report that the patient had a pressure injury to the sacrum, stage 2. The nurse noted that there was no documentation in the chart about the wound. S/he had not been able to assess the patient yet but noted the wound care nurse had been made aware of the wound. A nursing entry dated 4/25/25 at 11:20 AM revealed Pt 1 had a sacral pressure injury that had been treated by the Wound Care Nurse with medihoney and bordered foam. Documentation by the Wound Care Nurse dated 4/25/25 at 11:20 AM revealed Pt 1 had a stage 3 pressure ulcer on the medial sacrum, described as having a wound bed that was moist, with tenderness and slough. Review of the Wound Care Nursing Note dated 4/25/25 at 11:20 AM revealed a dressing had not been present over the wound on assessment. The wound measured 1.5 centimeters (cm) x 1 cm x 0.3 cm. The periwound was described with maceration, softening of tissue by soaking in fluids, with blanchable redness. Periwound color was white, pink, with minimal slough. The wound was cleansed with normal saline gauze, with skin prep barrier applied, and leptospermum honey gel to the wound bed, and barrier film foam with border. A physician’s order was placed 4/25/25 at 12:24 PM for wound care to the medial sacrum, to cleanse with normal saline and gauze, apply skin barrier to the periwound, apply medihoney, and cover the primary dressing with border foam. This treatment had been ordered daily and as needed. Review of nursing documentation on the flowsheet revealed there was no documentation that the ordered treatment had been provided to the medial sacrum on 4/28/25. Review of nursing documentation revealed there had been no nursing assessment of the wound for the evening shift on 4/30/25 and 5/1/25. During an interview on 7/22/25 at 11:43 AM, Registered Nurse (RN) #1 reviewed the record for Pt 1 and verified the findings. When asked about what interventions had been done when the skin tear had been identified on the sacrum, RN #1 stated they put a silicone foam dressing in place, and were changing positions of the patient, with minimal layers under the patient. RN #1 verified some nurses were documenting that the skin was within defined limits (normal) when it may not have been. When asked what could have been documented to show wound care had been provided for redness to the sacrum, RN #1 stated they could have documented the use of barrier cream. RN #1 verified nurses had not been documenting assessments every shift on the skin with a description of the wound to show the progression of wounds or improvement in skin condition. RN #1 stated nurses are expected to do that. RN #1 verified there had not been wound treatment initiated for the sacral wound on 4/23/25 when the floor nurse put in the consult for assistance with pressure injury staging. RN #1 verified that treatment/continuing orders for treatment of the sacral wound had not been placed until 4/25/25. RN #1 verified there was no documentation of an assessment or treatment of the wound as ordered on the morning of 4/28/25. During an interview on 7/23/25 at 11:47 AM, RN #1 reviewed the flowsheet history for the use of barrier cream for the patient for the redness to the sacrum. Review of the flowsheets revealed the use of moisture barrier cream had been documented for only 3 instances from 4/19/25 through discharge on 5/2/25. The nursing staff had also documented the use of barrier wipes with perineal care, but the barrier wipes used did not contain a moisture barrier. Observation of the package of the barrier wipes that staff had used, provided by RN #1 revealed they were Sage Bath Hygienic full body washcloths, standard bath wipes that did not contain a moisture barrier cream. Patient #5 Record review on 7/22/25 at 1:54 PM revealed Pt 5 had been admitted to the hospital on 7/7/25 and had been emergently taken to the Operating Room for Small Bowel Pneumatosis and Perforation of the Terminal Ileum. Nursing documentation dated 7/7/25 at 10:00 PM revealed skin stripping to the buttock and redness. A pressure injury to the coccyx on the left and right had been documented on 7/12/25 at 9:40 AM by the floor nurse. An entry dated 7/12/25 at 5:00 PM indicated the wound bed was moist, pink, pale, painful, and nonblanchable. On 7/13/25 at 8:00 AM and 8:00 PM, a floor nurse documented the skin was unblanchable and a foam border dressing was in place. An order was placed on 7/14/25 at 2:20 PM for a Wound Consult to evaluate and treat the sacral wound (identified on 7/12/25 as a deep tissue injury (DTI). On 7/14/25 at 8:00 PM, a nurse documented a nonblanchable wound bed and foam border dressing applied. On 7/15/25 at 4:00 AM, the nurse noted there was scant serosanguinous drainage, with skin nonblanchable and dressing peeled back to assess and foam with border in place. On 7/15/25 at 9:40 AM, a Wound Care Nurse documented the wound bleeding, with a pink, nonblanchable, maroon color with fresh blood. The wound measured 2 cm x 1 cm x 0.1 cm. The wound nurse documented a treatment provided where the wound was cleansed with normal saline, skin prep barrier to the periwound, and leptospermum honey gel to the wound bed with the dressing changed and foam border applied. Wound treatment orders were placed on 7/15/25 at 10:46 AM for a right and left coccyx pressure injury. The unit nurses were to remove the previous dressings, cleanse the wound with normal saline and gauze, protect the periwound skin with liquid skin barrier, and apply medihoney to the open wound. Cover primary dressing with border foam. Change every other day and as needed for excessive drainage or if the dressing becomes soiled. According to the Wound Care Nurses note, the patient had a right and left coccyx Pressure ulcer Deep Tissue Injury with a shearing injury. Review of the LDA flowsheet where nurses document a description and treatment of wounds revealed they had failed to document providing the ordered wound treatment (every other day and as needed) to the right and left coccyx, DTI and shearing injury from 7/16/25 to present (7/22/25). Nurses documented they had been unable to examine the wound many times; and had peeled back the dressing to assess the wound but did not provide a description of the wound. The dressing had not been changed on 7/16/25, 7/17/25, 7/18/25, 7/19/25, 7/20/25, 7/21/25; nor had a treatment been documented by 12:30 PM on 7/22/25. Review of the record revealed the Wound Care Nurse had initially provided a treatment on 7/15/25 at 9:40 AM, and the floor nurses had not documented a treatment since then. During an interview on 7/22/25 at 3:30 PM for Pt 5, RN #1 verified that a wound had been identified on 7/12/25, orders for a wound care consult had not been placed until 7/14/25; and treatment orders not initiated until 7/15/25 after the Wound Care Nurse assessed and treated the wound. RN #1 verified that wound care orders had not been documented as completed every other day and as needed for the right and left coccyx deep tissue/shearing injury since the Wound Care Nurse saw the patient on 7/15/25. RN #1 verified that the nurses had not been documenting a description of the wound every shift. Patient #7 Record review on 7/23/25 at 12:30 PM revealed Patient #7 had been admitted on 7/5/25 at 6:40 PM for Altered Mental Status, Acute Encephalopathy. An admission nursing assessment of the skin and reassessment on 7/6/25 at 9:09 AM revealed “redness” but did not address the sacrum. Review of the Lines, Drains, Airway (LDA) flowsheet where nursing staff document open wounds, revealed a notation that a stage 2 pressure injury to the sacrum had been identified on 7/6/25 at 12:00 Noon, with a clean dry intact wound bed with purple, red, reddened, epithelialized tissue. The wound was cleansed with normal saline and a xeroform dressing applied. There was no documentation of the sacral wound for the 7/6/25 evening shift and on 7/7/25 for the day shift. There were no physician orders placed for treatment of a sacral wound on 7/6/25. On 7/7/25 at 11:00 PM, a stage 2 pressure ulcer had been documented to the patient’s buttocks, but there was no description or measurements of the wound other than the staging. On 7/8/25 there was no documentation of a wound assessment for the day shift. On 7/8/25 at 8:03 PM, a nurse noted a stage 2 pressure injury on the sacrum. On 7/9/25 at 12:32 PM, the wound was documented as having blanchable and unblanchable redness, with the wound cleansed with normal saline, and a xeroform dressing applied. There had been no orders placed for wound treatment at this time. On 7/10/25 at 12:57 AM, a Wound Care Nurse consult had been placed to evaluate and treat the sacral wound. On 7/10/25 at 9:00 AM the nurse documented a stage 2 pressure injury to the sacrum with cream applied and covered with mepilex. On 7/10/25, at 9:00 AM, the nurse documented the dressing was intact. Pt 7 was discharged on 7/10/25. During an interview on 7/23/25 at 1:00 PM, RN #1 verified the concerns regarding missing skin assessment documentation of a description or check of the wound each shift. RN #1 verified the Wound Care Nurse had not documented an assessment of the sacral wound as the patient had been discharged on 7/10/25 prior to the Wound Nurse seeing the patient. RN #1 verified that physician orders for wound care of the sacrum had not been obtained with nursing staff documenting they had provided treatment for the sacral wound by cleaning the wound with normal saline and applying a xeroform dressing. This had been documented on 7/6/25 and 7/9/25. RN #1 was asked about what was expected when a floor nurse identifies a stage 2 pressure ulcer. According to RN #1, nursing staff are to follow the wound care orders that a physician or Wound Care Nurse puts in and assess the wound every shift. RN #1 verified there had been no communication to the physician or Wound Care Nurse requesting orders for treatment of the sacral wound. During an interview on 7/23/25, Wound Care Nurse (WCN) #1 was asked about the treatment for a stage 2 pressure ulcer. According to the nurse, it would require protection with border foam. WCN #1 stated that s/he sometimes will recommend a medihoney treatment on a stage 2 if there is a consult. If a patient developed an open wound, s/he would expect the nurses to get an order for treatment and get an order for a wound consult. Policy Review Review of the policy provided by the hospital entitled “Pressure Injury and/or Surgical Wounds: Prisma Health,” effective 4/17/24, revealed that care practices are employed to prevent skin breakdown by assessing for and identifying at risk patients. When identified, interventions to reverse tissue damage, prevent further damage and maintain an optimal wound environment for healing are utilized. The policy stated that they would implement preventive measures for all patients identified as high risk for skin breakdown that included to consult the wound ostomy nurse where available at a minimum for pressure injuries identified as stage 3, stage 4, unstageable, and or deep tissue injuries. An Authorized Practitioner (AP) order is required for wound treatment, management, and or a wound culture. Nursing staff are to perform an integumentary (skin) physical examination at a minimum of every shift and document any wounds to include the characteristic, location, and appearance including condition of surrounding skin, pressure injury staging as applicable, and measurement. Staff are to notify the AP if there is undesirable change in a wound.”