Christus Spohn Hospital Corpus Christi

“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: 33326 Based on observation, medical record reviews, policy reviews, and staff interviews, the facility failed to ensure a Registered Nurse supervised and evaluated nursing care in accordance with accepted standards of nursing practice and facility policies for 3 of 10 patients (Patients #1, #6, and #10) reviewed. Specifically, nursing staff failed to consistently assess, monitor, document, communicate, and implement interventions for identified skin alterations and wounds, including failure to document wound measurements, failure to document wound characteristics and progression, failure to ensure physician notification and treatment orders, and failure to reassess wounds in accordance with facility policy. These failures had the potential to delay recognition of wound deterioration, infection, and appropriate treatment. Cross refer to A0395”

“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: 33326 Based on observation, medical record reviews, policy reviews, and staff interviews, the facility failed to ensure a Registered Nurse supervised and evaluated nursing care in accordance with accepted standards of nursing practice and facility policies for 3 of 10 patients (Patients #1, #6, and #10) reviewed. Specifically, nursing staff failed to consistently assess, monitor, document, communicate, and implement interventions for identified skin alterations and wounds, including failure to document wound measurements, failure to document wound characteristics and progression, failure to ensure physician notification and treatment orders, and failure to reassess wounds in accordance with facility policy. These failures had the potential to delay recognition of wound deterioration, infection, and appropriate treatment. Findings include: Review of the facility provided policy “Basic Wound Care-Procedure” (last revised 4/2024) reflected, “1. Wound care treatment will be initiated only after receipt of written orders/referral from a physician. 2. Wound will be evaluated by a Registered Nurse and the Wound Care Physician prior to initiation of treatment. Evaluation will include patient history, wound etiology, wound status, pre-wound characteristics, patient comorbidities, current medications, full systems review and assessment, psychosocial status and needs, spiritual needs, and functional status ...3. Taking photos of wounds ...Wound photos will be taken on admission, weekly with patient reassessment and as needed when there is a significant change in the wound status/appearance ...” Review of the facility provided policy “Pressure Injury Prevention and Management” (reviewed 7/2021) reflected, “4. When a pressure injury is initially identified, the nurse should, notify the patient’s physician and document the findings in the medical record. The patient’s physician, or qualified designee, should evaluate the patient, stage the pressure injury using the NPUAP’s system, and document in the patient’s medical record. The pressure injury stage will guide the selection of therapeutic interventions ... 5. Each pressure injury that develops should be documented in the patient’s medical record. 6. Patients admitted with an existing pressure injury are considered to be at high risk and the care plan should reflect impaired skin integrity. In some circumstances depending on the acuity of the patient, review of skin breakdown may be secondary to other emergent measures. 7. All patients admitted with, or developing, a pressure injury should have the wound measured using photography and a recognized available measurement system. Measurements should be completed and documented on admission, weekly, and on discharge. 8. The patient’s physician, or qualified designee, shall be responsible for writing orders for any medications, treatments, or pressure reducing equipment to be administered or used. Treatment plans will be individualized based on assessment and reassessment. It is recommended that a multi-disciplinary team be involved in the pressure injury management. Additionally, the physician, or designee, may initiate a Wound Care Consult as indicated or if the wound(s) shows no signs of improvement with the current pressure injury interventions. 9. The pressure injury, any dressings, and the patient’s response to treatment interventions will be reassessed each shift by a RN or LVN. Documentation will be recorded in the patient’s medical record.” 1.) Patient #1: Review of Patient #1’s medical records reflected an admission of a 52-year-old-male admitted on 7/04/2026 for an infected fistula (intra-venous line used to provide dialysis treatments). An observation on the afternoon of 7/6/2026, at 2:00 pm of the facility’s medical surgical unit revealed Patient #1 had a gauze wrap covering his upper left forearm. The gauze wrap was not dated when it had been applied, and you could not see through the gauze. Review of Patient #1’s photographed left forearm skin picture, dated 7/4/26, revealed a large reddened/swollen area of approximately 8 cm (centimeters) X 6 cm, extending from the upper left forearm to the bend of the arm. Below the bend, there were numerous dark purple bruising in multiple locations. The fistula site, located on the upper left forearm, had a blackened spot surrounded by a white exudate as well as a small scab next to the site. Review of Patient #1’s nursing skin assessment dated 7/6/2026 at 1:30 pm reflected “Epidermis thin with loss of subcutaneous Tissue”. The assessment did not include any dimensions or further description of the impairment, and did not include a photograph. During an interview, on 7/7/2026 at 3:15 pm, Staff #10, Chief Medical officer, when asked if someone was admitted with signs of cellulitis (reddened, swollen), what should the nurses do? Staff #10, Chief Medical Officer stated, “Usually I would tell them to mark out the site (draw a ring around the reddened swollen area to determine if the swelling has gone down or increased) and because I’m putting them on antibiotics I want to see if the antibiotic works.” During an interview, on 7/6/26 at 1:00 pm, in the administrative conference room, Staff #2, Director of Nursing (DON) confirmed Patient #1’s physician’s orders did not include the treatment of the infection site and confirmed the facility did not have a policy for assessing and monitoring of cellulitis. 2.) Patient #6: During a review of patient #6’s medical records, reflected an admission on 12/5/25. Patient #6’s medical records included a picture dated 12/18/2025, taken by a nurse, revealing an open area on the buttocks with a moist white center with a redden area surrounding the wound. The size of wound was not identified in the picture. The wound appeared to be approximately 6 cm x 3 cm with full thickness of skin loss. The nurse’s note, documented reflected, “Wound 12/18/25 Skin Tear Sacrum (Active) Date First Assessed/Time First Assessed: 12/18/25 0700 Primary Wound Type: Skin Tear Location: Sacrum”. The nurse’s notes did not describe the treatment or preventions put in place to prevent further skin deterioration. During an interview on the morning of 7/7/26 at 12:15 pm, in a conference room, Staff #9, the wound care nurse stated in part; while viewing the Patient #16’s picture dated 12/18/25, the wound care nurse stated in part, that the wound care team had been treating the patient daily for heel/foot wounds. When asked if the wound on the sacrum was a skin tear, Staff #9 stated, “It looks like stage 3 (pressure injury).” Review of the provider note dated 12/30/25 reflected, “Pressure injury of coccygeal region, stage 3 Assessment: Acute Plan: Stage III pressure ulcer to coccyx is showing improvement-continue daily vashe irrigation, triad cream application, as well as offloading patient every 2 hours to prevent further skin breakdown. - Goal: wound closure. Follow up frequency: daily. Response to treatment: improvement.” During an interview on the morning of 7/7/26 at 1:00 pm, Staff #1, DON confirmed the sacral wound was not noted or documented on until 12/18/25 and it was unclear when the wound had developed and what treatments had been attempted. 3.) Patient #10: Review of Patient #10’s medical records revealed an admission on 05/01/2026. Review of Patient #10’s medical records reflected a nurse’s note on 5/15/2026, documented a sacral wound; Wound 05/15/26 Pressure Injury Blister Sacrum (Active) the note did not provide the size, depth or a description of the wound. The nurse did nto take a photograph of the skin impairment or docuement the treatments and preventative measure put in place to prevent further skin deterioration. A review of the physician’s orders for 5/15/2026-5/18/2026, did not include treatment orders for the wound. Review of Patient #10’s medical records revealed, on 05/16/26 at 5:56 am, a wound care consultation was placed by the nurse. Reason for consult? Possible pressure injury Location: SACRUM. The nurse’s notes do not reflect whether the physician was informed or had provided treatment orders. Review of the Patient #10’s nurse’s skin assessments reflected the following treatments: 5/16/26 Open to air; the skin assessment did not include measurements or a picture of the wounds. 5/17/26 Open to air; the skin assessments did not include measurements or a picture of the wounds. 5/18/26 Open to air; the skin assessments did not include measurements or a picture of the wounds. Review of the wound care nurse’s notes dated 5/19/26 revealed a picture was taken of the sacrum wound. The picture revealed an approximately 10 cm (centimeter) X 10 cm circular dark purple area to the left buttocks. Within the purple area were two open wounds, the first was not measured and appeared to be approximately 3 cm x 1 cm and the second was written on a paper measuring tape recorded as “4.5 X 7 X 0.4”; measured in centimeters. During an interview on the afternoon of 7/7/26 at 1:00 pm, in the conference room, Staff #9, wound care nurse stated, “We typically follow-up on the wound consults the next day, this patient came in on a Friday evening, and she (wound care nurse) saw them on Tuesday, I don’t know why they didn’t see them on Monday.” Staff #9 further stated the wound care nurse is not available on the weekends, and the nurses are to use standing protocols for wound care. During an interview on the afternoon of 7/7/26 at 2:00 pm, Staff #1, DON confirmed the lack of a clear picture of the wound progression.” The progression will start with a (stage I) early stage bed sore where the skin remains is intact but appears discolored (red, blue, or purple) and does not turn white when pressed. Stage (II)partial-thickness skin loss with a pink or red moist wound bed, Stage (III) is when the wound penetrates through the skin’s layers, exposing the fatty subcutaneous tissue. Review of the facility provided “Wound care guidance” (undated) (used by the nursing staff as a reference for care) reflected, “Stage III: Full thickness of tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are NOT exposed. Slough may be present but DOES NOT obscure the depth of tissue loss. May include undermining and tunneling.*Apply dressing with appropriate treatment, *Consult wound care team and notify Doctor, *No diapers, *Keep wound as clean as possible, *Turn patient every 2 hrs, *Needs specialty mattress, *Consult dietary, Light/Moderate drainage: Cleanse with normal saline/vashe and apply wet to moist dressing””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 21935 Based on interviews with patient/complainant, attending emergency nurse, reviews of medical record and facility medication administration policy medication was not administered on the orders of the emergency room practitioner. Findings: a. Interview with complainant/interviewee #1 on March 26, 2025 at 1:32pm via telephone who explained she came to the emergency department on January 30, 2024 at 8:32 pm with chief complaints of chest pain and diaphoresis. The patient explained that she was assessed and received a medical screening. It was explained by the provider that the patient would receive medication to relieve pain. The patient said she waited several hours and never received this medication which would relieve her symptoms. The pain eventually subsided on its own without medications. She said she requested to leave the facility after several hours. She was advised not to leave. She was given some of the medications that she was promised earlier for treatment before she left the facility. She signed out against medical advice. b. Interview interviewee #3, Patient of concern attending emergency room nurse on March 28, 2025 at 6:16 pm who remembered the patient and admitted that she felt bad about this patient. Interviewee #3, RN said she had 4 other patients and she was trying to get to this patient room to give her the medications ordered. But everytime she tried to go to the patient of concerns room a more urgent matter would come up with one of the other 4 patient and she would have to re-direct and respond to one the other 4 patients. She said it was a very busy shift. She finally explained the matter to the charge nurse and asked charge nurse to check on the patient and administer ordered medications. c. Review of providers orders January 30, 2025 documented patient was to receive medications including Zofran injection 4mg, Morphine 4mg/ml injection, At 9:14pm on January 30, 2025 orders were added to give patient chewable aspirin 3.24mg and Nitroglycerin SL Tablet 0.4mg PO by provider Valerie Knudson,DO. Orders for Lovenox syringe 100 mg and Plavix tablet 300mg was ordered at 10:15pm. Medical record documentation shows the patient receiving Zofran injection via peripheral IV, Aspirin chewable tablet 325mg, Plavix tablet 300mg and Lovenox 100mg. Medications were administered after the patient stated that she wanted to leave the hospital and before she sign out AMA These medications were administer at 1:15am-1:16 am on January 31, 2025. d. Review of facility Medication Administration Policy Procedure H-142-p last revised in 2024. On page 1 of 4 under procedure section 4 it states “All Medications should be given via the reported route ordered by the practitioner.” The patient was ordered by practitioner at 9:14pm on January 30, 2025 to take oral medications chewable aspirin, 3. 24mg, Nitroglycerin sub-lingual tablet, Plavix tablet 300mg, Zofran injection 4mg and Lovenox syringe 100mg. -The patient was not given oral medications until after 1 am January 31, 2025 after she threatened to leave the emergency room Against medical advice (AMA).”