SSM Health St Mary’s Hospital - Madison

“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: 29972 Based on record review and interviews, facility staff failed to perform nursing assessments, interventions, and evaluate patient care needs to prevent skin breakdown in 3 of 10 medical record reviews (Patient (Pt) #1, #2, #3); and failed to ensure that patient care plans are kept current and revised and/or updated in response to changes in the patient assessment and failed to ensure nursing interventions are implemented based on ongoing assessments of patient care needs in 2 of 10 medical records reviewed (Pt #1 and #3), in a total of 10 medical records reviewed. Findings Include: The facility staff failed to perform nursing assessments, interventions, and evaluate patient care needs to prevent skin breakdown. See Tag A-0395. The facility staff failed to ensure that patient care plans are kept current and revised and/or updated in response to changes in the patient assessment and to ensure nursing interventions are implemented based on ongoing assessments of patient care needs. See Tag A-0396.”

“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: 29972 Based on record review and interviews, facility staff failed to perform nursing assessments, interventions, and evaluate patient care needs to prevent skin breakdown in 3 of 10 medical record reviews (Patient (Pt) #1, #2, #3), in a total sample of 10 medical records reviewed. Findings Include: Review of policy and procedure titled, “Documentation Standards Guideline” last revised 12/02/2024 revealed: - “Assessments and ordered interventions are documented upon their completion by the clinician performing the assessment/intervention.” Review of policy and procedure titled, “Skin Care for Adults” last revised 02/06/2025 revealed: - “As part of the physical assessment, a head to toe skin assessment will be conducted upon admission and at least every shift if the patient is at risk for skin breakdown or has any alteration in skin integrity. 1. A pressure risk assessment will be completed upon admission and at least daily...3. Risk factors to assess include: a. Sensory perception...b. Moisture including diaphoresis (sweating) and incontinence...c. Activity level including decreased and restricted...d. Mobility...e. Nutritional status...f. Friction and shear.” - “Assessment and documentation of all wounds will be completed every shift, and with every dressing change...observation for changes in drainage, foul order, and tissue necrosis...” - “1. Document dressing changes...1. Observe and document changes in skin surrounding wound/dressing for inflammation, edema (swelling), tenderness, maceration (softening and breakdown of skin due to prolonged moisture exposure), and/or erythema (redness)...” - “A. For patients with Braden (pressure risk assessment) score of 18 or less, without altered skin integrity, consider initiating preventative measures, such as specialty surface/mattress and the Pressure Injury Prevention Standing Order. B. For patient with altered skin integrity. 1. Upon detection of skin alteration/wound:...b. Consider utilizing the Wound and Altered Skin Integrity Standing Order Set to initiate treatment based on skin assessment...d. Conduct wound photography and measurements if indicated...e. Re-evaluate effectiveness of treatment regimen with each dressing change. If wound deteriorates, notify provider. f. Discuss with provider the need for a wound care consult for complex wound patients or deterioration of skin integrity.” Review of policy and procedure titled, “Wound Photography, Measurement and Documentation” last revised 06/12/2024 revealed: - “The following types of wounds shall be photographed: A. Pressure injuries...B. Any other wound/skin condition deemed appropriate by the nurse, wound care specialist or provider.” - “Pressure injury and wound photographs will be taken at the following times in the patient setting: A. Admission/date of initial physical examination/assessment. B. Upon detection. C. Weekly...” - “Pressure injuries need to be measured when photos are taken. Measurements should be expressed in centimeters...Include in the photo: A. Measuring guide...” Review of Pt #1’s medical record revealed Pt #1 was admitted to the inpatient unit on 12/08/2024 at 9:18 PM and discharged on 01/23/2025 at 11:25 AM to home Hospice care. Review of Pt #1’s History and Physical dated 12/08/2024 at 10:01 PM revealed, “61 year old...with complex recent history presented to outside hospital with loss of motor function and sensation of bilateral lower extremities, inability to void (urinate) or defecate (bowel movement), and umbilical hernia leaking stool...over the past few weeks he has been having increasing back pain, he then fell in the bathroom at the chiropractor’s office last week and since then has had progressive numbness and inability to move his extremities.” Review of Pt #1’s “Wound and Altered Skin Integrity Standing Orders” dated 12/09/2024 at 8:57 AM revealed, “Wound or dressing assessment and documentation will be completed every shift and with dressing changes...Observe and document changes in skin surrounding wound/dressing...Reevaluate effectiveness of treatment regimen with each dressing change. If wound deteriorates, notify provider. Discuss with provider the need for a wound care consult for complex wound patients or deterioration of skin integrity. Wound photo per policy.” Review of Pt #1’s “Wound Pressure Injury Prevention Standing Orders--Patients with Braden Score of 18 or less” dated 12/09/2024 at 8:57 AM revealed the following; - “Apply cream/lotions/ointments to dry skin...” - “Keep head of bed below 30 degrees...” - “Consider implementing protective dressing.” - “Educate patient to turn and/or reposition frequently with goal of at least every 2 hours and at least every 1 hour for sitting...Initiate individual turn schedule on patients unable to turn themselves.” - “Use pillows or positioning wedge/devices...” - “Keep pressure off heels-use horizontally under leg or heel offloading device. Float heels.” - “Use pressure redistribution surfaces (low loss air mattress) for bedfast and chairfast patients.” Review of the “Mepilex Border Sacrum for Prevention Application Guide” (no date) revealed: - “Apply Mepilex Border Sacrum if patient meets any of the following criteria: ...Current redness in sacral/coccygeal area...Inability to reposition oneself...” - “Use tabs to gently peel back dressing and inspect skin every shift; reposition following inspection.” - “Change dressing every 3 days...” - “Document assessment of sacral area per protocol.” - “Notify (wound care) nurse for suspected pressure ulcer development.” - “May aid in the prevention of pressure ulcers by protecting the skin from moisture, friction and shear in combination with an individualized comprehensive pressure ulcer prevention protocol.” Review of Pt #1’s Braden Scale flowsheet data revealed on 12/08/2024 at 9:20 PM, Pt #1’s admission Braden Score (pressure risk assessment) was a 12. Pt #1’s Braden Score revealed that “Sensory Perception” was “very limited”, “Activity” was “Bedfast”, “Mobility” was “very limited”, “Nutrition” was “Probably Inadequate”, and “Friction and Shear” was a “Problem”. Review of Pt #1’s Mobility flowsheet data from 12/08/2024 through 12/19/2024 revealed the following documentation of repositioning: -On 12/12/2024, documentation revealed that Pt #1 was positioned in the bed on his left side from 4:15 AM until 10:00 AM (5 hours and 45 minutes). There was no documented evidence that staff repositioned Pt #1 every 2 hours while in bed as per orders. -On 12/13/2024, documentation revealed that Pt #1 was positioned in the bed on his left side from 8:25 AM until 12:19 PM (3 hours and 54 minutes). There was no documented evidence that staff repositioned Pt #1 every 2 hours while in bed as per orders. -On 12/13/2024, documentation revealed that Pt #1 was positioned in the bed in Semi-Fowlers from 12:19 PM until 12/14/2024 at 12:43 AM (12 hrs and 24 minutes). There was no documented evidence that staff repositioned Pt #1 every 2 hours while in bed as per orders. -On 12/14/2024, documentation revealed that Pt #1 was positioned in the bed in Semi-Fowlers from 7:16 AM until 12:29 PM (5 hours and 15 minutes). There was no documented evidence that staff repositioned Pt #1 every 2 hours while in bed as per orders. -On 12/14/2024, documentation revealed that Pt #1 was positioned in the bed on his left side from 12:29 PM until 4:40 PM (4 hours and 9 minutes). There was no documented evidence that staff repositioned Pt #1 every 2 hours while in bed as per orders. -On 12/14/2024, documentation revealed that Pt #1 was positioned in the bed in Semi-Fowlers from 4:40 PM until 12/15/2024 at 12:13 PM (19 hours and 33 minutes). There was no documented evidence that staff repositioned Pt #1 every 2 hours while in bed as per orders. -On 12/16/2024, documentation revealed that Pt #1 was positioned in the chair from 1:10 PM to 8:35 PM (7 hours and 25 minutes). There was no documented evidence that staff repositioned Pt #1 every hour while in the chair as per orders. -On 12/17/2024, documentation revealed that Pt #1 was positioned in the bed in Semi-Fowlers from 12:32 AM until 09:56 AM (9 hours and 24 minutes). There was no documented evidence that staff repositioned Pt #1 every 2 hours while in bed as per orders. -On 12/18/2024, documentation revealed that Pt #1 was positioned in the chair from 8:57 AM to 4:25 PM (7 hours and 28 minutes). There was no documented evidence that staff repositioned Pt #1 every hour while in the chair as per orders. Review of Pt #1’s Mobility flowsheets from 12/08/2024 through 12/26/2024 revealed documentation that the Head of Bed (HOB) elevation was at 45 degrees on the following dates: -On 12/14/2024 from 9:30 AM to 12:29 PM (2 hours and 59 minutes). -On 12/15/2024 from 8:52 AM to 2:50 PM (5 hours and 58 minutes). -On 12/21/2024 from 10:14 AM to 6:57 PM (8 hours and 43 minutes). -On 12/26/2024 from 12:54 PM to 7:18 PM (6 hours and 24 minutes). Per Pt #1’s orders the HOB should be 30 degrees or less (to help prevent pressure injuries). Review of Pt #1’s Hygiene flowsheets from 12/08/2024 through 12/19/2024 revealed that there was no documented evidence of staff ensuring that Pt #1 received and/or staff offered a bath and/or oral care on 12/12/2024, 12/13/2024, 12/15/2024, 12/16/2024, 12/17/2024, and 12/18/2024. Review of Skin Care/Prevention flowsheet data from 12/08/2024 through 12/23/2024 revealed that there was no documentation of skin care interventions in place on 12/10/2024, 12/11/2024, 12/12/2024 (PM shift), 12/13/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/20/2024, 12/21/2024, and 12/22/2024. Review of Pt #1’s Wound flowsheet data revealed a “Pressure Injury Coccyx” was “Present on Admission” and first assessed on 12/08/2024 at 9:20 PM. The “Wound Bed Assessment” revealed it was “Light purple; Deep pink; nonblanchable red” and “Open to air (no dressing).” Exudate (drainage) Description was “None” and the “Peri-wound Skin Assessment” revealed, “Intact; Dry.” Review of Pt #1’s “Pressure Injury Coccyx” wound nursing assessments from 12/08/2024 through 12/19/2024 revealed the following: -On 12/09/2024 at 8:00 AM, documentation for “Dressing/Treatment revealed, “Cleansed; Silicone dressing (Mepilex).” -On 12/10/2024 at 12:00 AM, 8:00 AM, 4:00 PM, and 11:20 PM, “Unable to assess” is documented for the Wound Bed Assessment. Per the “Mepilex Border Sacrum for Prevention Application Guide,” staff should “use tabs to gently peel back dressing and inspect skin every shift.” -On 12/11/2024 at 4:00 AM, 8:00 AM, 12:29 PM, 4:49 PM, and 8:00 PM, “Unable to assess” is documented for the Wound Bed Assessment. -On 12/12/2024, there was no documentation of nursing staff completing an assessment of Pt #1’s coccyx pressure injury on PM shift (7:00 PM to 7:00 AM). -On 12/13/2024 at 9:49 AM, “Unable to assess” was documented for the Wound Bed Assessment; there was no documentation of nursing staff completing an assessment of Pt #1’s coccyx pressure injury on PM shift. -On 12/14/2024 at 9:59 AM, “Unable to assess” was documented for the Wound Bed Assessment; there was no documentation of nursing staff completing an assessment of Pt #1’s coccyx pressure injury on PM shift. -On 12/15/2024 at 8:52 AM, there was no documentation of an assessment of the Wound Bed; there was no documentation of nursing staff completing an assessment of Pt #1’s coccyx pressure injury on PM shift. -On 12/16/2024 at 9:09 AM, “Unable to assess” was documented for the Wound Bed Assessment. -On 12/17/2024 at 3:59 AM and 5:03 PM, “Unable to assess” was documented for the Wound Bed Assessment; there was no documentation of nursing staff completing an assessment of Pt #1’s coccyx pressure injury on PM shift. -On 12/18/2024 at 9:21 AM, “Unable to assess” was documented for the Wound Bed Assessment; there was no documentation of nursing staff completing an assessment of Pt #1’s coccyx pressure injury on PM shift. Per review of the Wound flowsheet data for Pt #1’s “Pressure Injury Coccyx,” there was no documented evidence of a Wound Bed assessment from 12/09/2024 at 12:00 PM until 12/19/2024 at 10:17 AM (10 days), at which time on 12/19/2024, the Wound Bed Assessment revealed, “Deep purple,” the Exudate was “Moderate; Odorous,” and the “Peri-wound Skin Assessment” was documented as “Red” (worsening from previous assessment). Pt #1 was admitted on 12/08/2024 with a coccyx wound that was red and the skin was intact (Stage 1). Review of Wound Care Registered Nurse (RN) progress notes dated 12/23/2024 at 5:02 PM, revealed the “Pressure Injury Coccyx,” was a “Large full thickness unstageable pressure injury...” Per review of Wound Care RN progress notes dated 12/27/2024 at 3:14 PM, the “Pressure Injury Coccyx” deteriorated to a “Full thickness stage 3...” Review of Pt #1’s Wound flowsheet data, revealed a second “Pressure Injury Buttock left” that developed during the hospital stay and was first assessed on 12/19/2024 at 9:45 AM. Review of the Wound flowsheet documentation from 12/08/2024 to 12/23/2024 for both pressure injuries, revealed there was no documentation of wound measurements as per policy. Review of Pt #1’s Wound Care orders revealed a Wound Care consult was not ordered until 12/23/2024 at 5:03 PM; 4 days after the initial assessment of the Buttock pressure injury and 4 days after the Coccyx pressure injury assessment showed deterioration of the wound. Review of Pt #1’s Discharge Summary dated 01/23/2025 at 10:07 AM revealed that Pt #1 required surgical debridement (removal of dead tissue) of the coccyx and buttocks wounds on 12/25/2025, 12/30/2025, and 01/07/2025. Pt #2: Review of Pt #2’s History and Physical (H&P) dated 12/05/2024 at 3:53 AM revealed, “...a 37 year old...admitted after presenting to the emergency department with subacute confusion, nausea and emesis (vomiting), diarrhea, abdominal pain. Review of Pt #2’s medical record revealed that Pt #2 was admitted on 12/04/2024 at 9:51 PM and transferred to the Intensive Care Unit (ICU) on 01/07/2025 at 12:23 PM. Pt #2 was a current patient at the time of the medical record review on 03/26/2025 at 10:00 AM. Review of Pt #2’s “Wound Pressure Injury Prevention Standing Orders--Patients with Braden Score of 18 or less” dated 12/06/2024 at 4:19 PM revealed the following; - “Apply cream/lotions/ointments to dry skin...” - “Keep head of bed below 30 degrees...” - “Consider implementing protective dressing.” - “Educate patient to turn and/or reposition frequently with goal of at least every 2 hours and at least every 1 hour for sitting...Initiate individual turn schedule on patients unable to turn themselves.” - “Use pillows or positioning wedge/devices...” - “Keep pressure off heels-use horizontally under leg or heel offloading device. Float heels.” - “Use pressure redistribution surfaces (low loss air mattress) for bedfast and chairfast patients.” Review of Pt #2’s Braden Scale flowsheet data revealed on 12/06/2024 at 7:00 AM, Pt #2’s Braden Score was a 14. Pt #2’s Braden Score revealed that “Sensory Perception” was “Slightly Limited”, “Activity” was “Chairfast”, “Mobility” was “Silently Limited”, “Nutrition” was “Very Poor”, and “Friction and Shear” was a “Potential Problem.” Review of Pt #2’s Neurological nursing assessment on 12/06/2024 at 7:00 AM revealed that Pt #1 was disoriented to person, place, situation, and time. Review of Pt #2’s Physical Therapy Evaluation on 12/10/2024 at 1:45 PM revealed Pt #2’s Bed Mobility was “Maximum Assistance (2 assist)” for “Supine (flat on back) to Sit”; “Total Assistance (2 assist)” for “Sit to Supine”; and “Maximal Assistance to left” for “Rolling.” Review of Pt #2’s Mobility flowsheet data from 12/05/2024 through 12/18/2024 revealed the following documentation of repositioning: -On 12/07/2024, documentation revealed that Pt #2 was positioned in the bed in Semi Fowler’s (on back) from 12:00 AM until 5:30 AM (5 hours and 30 minutes). There was no documented evidence that staff repositioned Pt #2 every 2 hours while in bed as per standing orders. -On 12/07/2024, documentation revealed that Pt #2 was positioned in the bed in Semi Fowler’s from 10:00 AM until 7:59 PM (8 hours and 59 minutes). There was no documented evidence that staff repositioned Pt #2 every 2 hours while in bed as per standing orders. -On 12/08/2024, documentation revealed that Pt #2 was positioned in the bed in Semi Fowler’s from 4:34 AM until 8:00 PM (15 hours and 26 minutes). There was no documented evidence that staff repositioned Pt #2 every 2 hours while in bed as per standing orders. -On 12/10/2024, documentation revealed that Pt #2 was positioned in the bed in Semi Fowler’s from 6:00 AM until 10:00 PM (16 hours). There was no documented evidence that staff repositioned Pt #2 every 2 hours while in bed as per standing orders. -On 12/12/2024, documentation revealed that Pt #2 was positioned in the bed lying on his left side from 12:01 PM until 8:00 PM (7 hours and 59 minutes). There was no documented evidence that staff repositioned Pt #2 every 2 hours while in bed as per standing orders. -On 12/13/2024, documentation revealed that Pt #2 was positioned in the bed in Semi Fowlers from 4:00 AM until 10:00 AM (6 hours). There was no documented evidence that staff repositioned Pt #2 every 2 hours while in bed as per standing orders. -On 12/14/2024, documentation revealed that Pt #2 was positioned in the bed in Semi Fowlers from 8:59 PM until 12/15/2024 at 9:55 PM (12 hours and 56 minutes). There was no documented evidence that staff repositioned Pt #2 every 2 hours while in bed as per standing orders. Review of Pt #2’s Mobility flowsheets from 12/05/2024 through 12/18/2024 revealed documentation that the Head of Bed (HOB) elevation was at 45 degrees on the following dates: -On 12/07/2024 from 7:59 PM to 12/8/2024 at 10:00 PM (14 hours and 1 minute). -On 12/10/2024 from 10:00 PM to 12/11/2024 at 11:30 AM (13 hours and 30 minutes). -On 12/14/2024 from 8:59 PM to 12/17/2024 at 6:49 PM (more than 3 days). Per Pt #2’s orders the HOB should be 30 degrees or less (to help prevent pressure injuries). Review of Pt #2’s Hygiene flowsheets from 12/05/2024 through 12/18/2024 revealed that there was no documented evidence of staff ensuring that Pt #2 received and/or staff offered a bath and/or oral care on 12/09/2024, 12/10/2024, 12/11/2024, 12/12/2024, 12/13/2024, 12/14/2024, and 12/15/2024; there was no documentation of Pt #2 receiving a bath until 12/17/2024 at 5:22 PM (8 days). Review of Pt #2’s Wound flowsheet data revealed that an “Other Wound Sacral/Coccyx” was first assessed on 12/11/2024 at 4:01 PM (7 days after admission), per documentation the wound was not present on admission. Pt #2’s wound assessment documentation revealed, “Deep purple...Defined edges...Tenderness...Scant (drainage)...Cleansed; Foam dressing.” Review of Pt #2’s Wound Care Nursing orders dated 12/13/2024 at 5:32 PM revealed to cleanse the bilateral buttocks daily and as needed with soap and water or theraworks wipes; remove old barrier cream and apply a thin film of barrier cream with zinc. Per wound care orders, “Reposition every 2 hours.” Review of Pt #2’s Wound flowsheet nursing assessments from 12/11/2024 to 12/18/2024 for “Other Wound Sacral/Coccyx” revealed: -On 12/12/2024 at 8:00 AM to 12/15/2024 at 9:00 AM (3 days); the “Dressing Status” was documented as “Open to Air” or “Not Applicable.” There was no documented evidence of staff applying a protective dressing as per policy. Review of Pt #2’s Wound flowsheet nursing assessments from 12/11/2024 to 12/18/2024 for “Other Wound Sacral/Coccyx” revealed that there was no documented evidence of nursing staff completing a wound assessment every shift (as per policy) on the following shifts: -12/12/2024--PM shift -12/13/2024--Day shift -12/14/2024--Day shift and PM shift -12/15/2024--PM shift -12/16/2024--Day shift and PM shift -12/17/2024--PM shift -12/18/2024--Day shift Review of Pt #2’s Wound flowsheet nursing interventions from 12/11/2024 to 12/18/2024 for “Other Wound Sacral/Coccyx” revealed that there was no documentation of nursing interventions addressing Pt #2’s Wound Care orders on the following shifts: -12/12/2024--Day shift and PM shift -12/13/2024--Day shift -12/14/2024--Day shift -12/15/2024--Day shift and PM shift -12/16/2024--Day shift and PM shift -12/17/2024--Day shift Review of Pt #2’s Wound flowsheets from 12/11/2024 to 12/18/2024 and Wound Care RN progress notes on 12/19/2024, 12/31/2024, and 01/22/2024 revealed no documented evidence of staff measuring Pt #2’s wound as per policy. Review of Pt #2’s operative report dated 01/04/2025 at 10:30 AM revealed, “(Pt #2) is a 37 year old...who has been admitted to the hospital for close to a month...since that time, he has developed a sacral decubitus ulcer that now warrants debridement (removing dead/damaged tissue)...A 10 blade was used to sharply excise the area of necrotic (dead tissue) blackened eschar over the patient’s sacrum (lower end of spine)...A pocket of purulence (pus) was found on the patient’s left side...This is a stage 4 wound...” Pt #2 did not have the sacral/coccyx wound on admission (12/04/2024) and the wound was not identified until 12/11/2024, the wound deteriorated and progressed to a Stage 4 on 01/04/2025. Pt #3: Review of Pt #3’s History and Physical (H&P) dated 12/23/2024 at 6:56 PM revealed, “...a 38 year old...who presented to the ED (Emergency Department)...after a MVC (Motor Vehicle Crash)...Pt was a restrained passenger of a rollover vehicle that was traveling 55 mph (miles per hour)...He was found to have fractures of C (cervical) 5/6 (vertebrae)...He is able to move his upper extremities, but unable to move his lower extremities...” Review of Pt #3’s medical record revealed that Pt #3 was admitted to the ICU on 12/23/2024 at 11:04 PM. Pt #3 was a current patient at the time of the medical record review on 03/26/2025 at 1:00 PM. Review of Pt #3’s Braden Scale flowsheet data revealed on 12/24/2024 at 1:19 AM, Pt #3’s Braden Score was a 12. Pt #3’s Braden Score revealed that “Sensory Perception” was “Very Limited”, “Activity” was “Bedfast”, “Mobility” was “Very Limited”, “Nutrition” was “Probably Inadequate”, and “Friction and Shear” was a “Potential Problem.” Review of Pt #3’s Wound flowsheet data revealed a “Pressure Injury Buttock Left (wound #1)” and a “Pressure Injury Buttock Right (wound #2)” that developed during the hospital stay and was first assessed on 01/07/2025 at 5:18 PM (15 days after admission). Pt #3’s wound assessments documented at 7:20 AM revealed, “Shallow open ulcer...pink base...foam dressing...” Review of Pt #3’s “Pressure Injury Buttock Left” and a “Pressure Injury Buttock Right,” wound nursing assessments from 1/06/2024 to 01/18/2024 for revealed that there was no documented evidence of nursing staff completing a wound assessment every shift (as per policy) on the following shifts: -01/07/2025--PM shift -01/08/2025--PM shift -01/10/2025--Day shift and PM shift -01/11/2025--PM shift -01/12/2025--Day shift -01/13/2025--PM shift -01/14/2025--Day shift -01/15/2025--Day shift and PM shift -01/16/2025--Day shift and PM shift -01/17/2025--Day shift -01/18/2025--Day shift and PM shift Review of Pt #3’s Wound Care orders on 01/08/2025 at 11:31 AM, revealed to cleanse the bilateral buttocks with Theraworks (wipes) on Tuesday, Thursday, and Saturday and as needed if soiled; cover the wounds with sacral mepilex. Review of Pt #3’s “Pressure Injury Buttock Left” and a “Pressure Injury Buttock Right,” nursing assessments from 01/06/2025 to 01/22/2025, revealed there was no documentation of nursing interventions addressing Pt #3’s Wound Care orders on the following days: -Saturday 01/11/2025, Tuesday 01/14/2025, Thursday 01/16/2025, Saturday 01/18/2025, and Tuesday 01/21/2025. Review of Pt #3’s Wound flowsheet data revealed a “Pressure Injury Coccyx (wound #3)” developed during the hospital stay and was first assessed on 01/14/2025 at 10:43 PM (22 days after admission). Pt #3’s wound assessments documented at 7:20 AM revealed, “Deep purple;White...Small (drainage)...Defined edges...Subcutaneous tissue visible...Red (peri-wound)...Silicone dressing...” RN Wound Care consult for Pt #3’s hospital acquired Coccyx pressure injury was not ordered until 01/20/2025 at 3:14 PM; 6 days after the initial assessment. Review of Pt #3’s Wound Care orders dated 01/20/2025 at 3:14 PM, revealed to cleanse the Coccyx wound daily and as needed with normal saline, apply nickel thick layer of Santyl to coccyx wound bed, and cover with sacral mepilex. Review of Pt #3’s “Pressure Injury Coccyx” wound nursing interventions from 1/20/2024 to 01/27/2024, revealed there was no documentation of nursing interventions addressing Pt #3’s Wound Care orders on the following days: -01/20/2025, 1/23/2025, 01/25/2025, and 01/26/2025. Review of Pt #3’s “Pressure Injury Coccyx” wound nursing assessments from 01/14/2024 to 01/27/2024, revealed that there was no documented evidence of nursing staff completing a wound assessment every shift (as per policy) on the following shifts: -01/15/2025--Day shift -01/16/2025--Day shift -01/17/2025--Day shift -01/18/2025--Day shift and PM shift -01/19/2025--Day shift and PM shift -01/20/2025--PM shift -01/21/2025--PM shift -01/22/2025--Day shift and PM shift -01/23/2025--PM shift -01/24/2025--PM shift -01/26/2025--Day shift and PM shift Review of Pt #3’s Wound Care RN progress note dated 01/20/2025 at 2:53 PM, revealed Pt #1’s Coccyx wound measured 3 x 2 x 0 cm (centimeters). Review of Pt #3’s Physician “Brief Op (operative) Note” dated 01/27/2025 at 9:38 AM, revealed Pt #3 had a procedure “Incision and Debridement of Decubitus Ulcer (pressure injury) and wound vac placement.” Per Operative note, the “findings” revealed a sacral wound measurement of 14 x 8 x 4 cm (increased in size from 7 days ago). Review of physician assistant progress note dated 01/26/2025 at 10:53 AM revealed, “Per beside RN, Dr...expressed significant amount of bloody purulent drainage from sacral pressure ulcer this AM. Continued hypotension since then. Concern for sepsis with likely source sacral wound. Per interview with Wound Care Registered Nurse (RN) E on 03/26/2024 beginning at 10:34 AM, RN E stated that a wound care consult should be ordered if a patient comes in with a stage 1 pressure injury that does not respond to treatment and a wound care consult should be ordered anytime a patient develops a pressure injury in the hospital. RN E stated the Wound Care RN needs to get involved if the wound is getting worse and the interventions are not effective. RN E stated that that the wound care evaluation should be done no more than 72 hours after the consult is ordered. RN E stated that there is not a policy that guides the RN Wound Care practice including time frames for evaluations and how often assessments are conducted. RN E stated that the staff RN completes the interventions recommended by the Wound Care RN. Per interview with RN Manager G on 03/25/2025 at 11:51 AM, RN G stated that staff should document turning patient every 2 hours in the nursing flow sheets in “real time.” RN G stated that if a patient develops a wound in the hospital nursing staff should update the care plan and put interventions in place, document the wound assessment every shift, take a picture of the wound upon discovery, and consult the Wound Care RN. RN G stated that bed baths should be offered daily and refusals should be documented.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 29972 Based on record review and interview the facility staff failed to ensure that patient care plans are kept current and revised and/or updated in response to changes in the patient assessment and to ensure nursing interventions are implemented based on ongoing assessments of patient care needs in 2 of 10 medical records reviewed (Patient (Pt) #1 and #3), in a total of 10 medical records reviewed. Findings Include: Review of policy and procedure titled, “Care Planning” last revised 12/02/2024 revealed; - “The care plan will include individualized and measurable goals with interventions identified to help the patient reach the established goals/outcomes.” - “The initial care plan is based on assessment, treatment and services that are appropriate to the patient’s specific assessed needs. The nursing care plan is kept current by ongoing assessments of the patient’s needs and of the patient’s response to interventions, assessment of patient treatment goals, and updating or revising the patient’s nursing care plan in response to assessments.” - “Documentation Process: A. Utilize the electronic health record for development of the individualized care plan. B. Select the appropriate template or problem based on patient assessment/reassessment. C. Select the appropriate goals for the patient based on assessment/reassessment...D. The plan of care is based on the patient’s goals, time frames, settings, and services to meet the goals. Enter the expected goal end date to indicate when you would expect the goal to be met. E. Select appropriate interventions to assist the patient with reaching the individualized goals...” Pt #1: Review of Pt #1’s Wound flowsheet data revealed a “Pressure Injury Coccyx” was “Present on Admission” and first assessed on 12/08/2024 at 9:20 PM. The Wound Bed Assessment revealed it was “Light purple; Deep pink; nonblanchable red” and “Open to air (no dressing).” Exudate (drainage) Description was “None” and the “Peri-wound Skin Assessment” revealed, “Intact; Dry.” Review of Pt #1’s Wound flowsheet data revealed a second “Pressure Injury Buttock left” that developed during the hospital stay and was first assessed on 12/19/2024 at 9:45 AM. Review of Pt #1’s care plans revealed, “Altered Skin Integrity” care plan started on 12/09/2024, with a goal of “Skin integrity is maintained or improved.” Review of Pt #1’s care plan revealed there was no documented evidence of nursing staff updating and/or revising the care plan to address Pt #1’s “Pressure Injury Coccyx” wound worsening and developing a second wound injury (Pressure Injury Buttock left) while in the hospital. Per review of the Wound flowsheet data for Pt #1’s “Pressure Injury Coccyx,” there was no documented evidence of a “Wound Bed” assessment from 12/09/2024 at 12:00 PM until 12/19/2024 at 10:17 AM (10 days). Pt #1’s Altered Skin Integrity care plan was not kept current due to a lack of ongoing assessments of Pt #1’s “Pressure Injury Coccyx” wound, to ensure Pt #1’s skin needs are met as per policy. Pt #3: Review of Pt #3’s History and Physical (H&P) dated 12/23/2024 at 6:56 PM revealed, “...a 38 year old...who presented to the ED (Emergency Department)...after a MVC (Motor Vehicle Crash)...Pt was a restrained passenger of a rollover vehicle that was traveling 55 mph (miles per hour)...He was found to have fractures of C (cervical) 5/6 (vertebrae)...He is able to move his upper extremities, but unable to move his lower extremities...” Review of Pt #3’s Braden Scale flowsheet data revealed on 12/24/2024 at 1:19 AM, Pt #3’s Braden Score was a 12. Pt #3’s Braden Score revealed that “Sensory Perception” was “Very Limited”, “Activity” was “Bedfast”, “Mobility” was “Very Limited”, “Nutrition” was “Probably Inadequate”, and “Friction and Shear” was a “Potential Problem.” Review of Pt #3’s “Skin/Tissue Integrity” care plan started on 12/24/2024 revealed there was no documentation in the care plan of interventions implemented to address Pt #3’s skin care needs. Review of Pt #3’s Wound flowsheet data revealed a “Pressure Injury Coccyx (wound #3)” developed during the hospital stay and was first assessed on 01/14/2025 at 10:43 PM (22 days after admission). Review of Pt #3’s “Altered Skin Integrity” care plan started on 01/09/2024, with a goal of “Skin integrity is maintained or improved, revealed there was no documented evidence of nursing staff updating and/or revising the care plan to address Pt #3 developing a hospital acquired “Pressure Injury Coccyx” wound despite the skin interventions in place. Review of Pt #3’s “Pressure Injury Coccyx” wound nursing assessments from 01/14/2024 to 01/27/2024, revealed that there was no documented evidence of nursing staff completing a wound assessment every shift (as per policy) on the following shifts: -01/15/2025--Day shift -01/16/2025--Day shift -01/17/2025--Day shift -01/18/2025--Day shift and PM shift -01/19/2025--Day shift and PM shift -01/20/2025--PM shift -01/21/2025--PM shift -01/22/2025--Day shift and PM shift -01/23/2025--PM shift -01/24/2025--PM shift -01/26/2025--Day shift and PM shift Pt #3’s Altered Skin Integrity care plan was not kept current due to a lack of ongoing assessments of Pt #3’s “Pressure Injury Coccyx” wound, to ensure Pt #3’s skin needs are met as per policy. Per interview with Registered Nurse (RN) Director D while reviewing medical records on 03/25/2025 beginning at 2:10 PM, RN D stated that nursing staff should follow the care plan policy.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 44431 Based on record review and interview the facility failed to include the patient and caregiver/support person in the discharge planning process for 1 Patient (Pt.) #1 out of 12 patient records reviewed and failed to re-evaluate patient (Pt. #1) condition prior to discharge for 1 out of 12 patient records reviewed. Findings Include: The facility failed to re-evaluate the patient (Pt. #1) condition prior to discharge see Tag: A-0802 The facility failed to include the patient (Pt. #1) and caregiver/support person in the discharge planning process see Tag: A-808”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 44431 Based on Record review and interview the facility failed to re-evaluate the condition of 1 of 12 (Patient #1) patients reviewed prior to discharge. Findings: Patient #1 was hospitalized as a result of trauma from a severe fall on 10/21/2024 and required physical therapy, occupational therapy and speech therapy. Pt. #1 was diagnosed with a traumatic brain injury due to a skull fracture and subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) and subdural hemorrhage (bleeding on the outside of the brain). Pt. #1 was discharged home with home health services on 10/28/2024. Review of Facility Policy last reviewed 10/28/2024, titled, “Discharge Planning,” revealed, “Discharge planning will begin upon admission with an assessment of each patient’s potential continuing care needs. Discharged patients will receive verbal and written instructions regarding their continuing care needs including arrangements for placement and other services...The hospital must discharge the patient, and also transfer or refer the patient....with all the necessary medical information pertaining to the patient’s current course of illness and treatment....The discharge planning process and the discharge plan shall...ensure an effective transition of the patient from hospital to post-discharge care....[Facility] will identify at an early state of inpatient stay/admission, those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and will provide a discharge planning evaluation for those patients...A discharge planning evaluation shall include an evaluation of the patient’s likely need for appropriate post-hospital services and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services....The patient’s condition must be re-evaluated at least every seven (7) days to identify changes that require modification of the discharge plan. The discharge plan must be updated...to reflect these changes.” Ongoing review of Pt. #1’s medical record revealed OT (occupational therapy) last saw Pt. #1 on 10/25/2024, 3 days before Pt. #1’s discharge and PT (Physical Therapy) last saw Pt. #1 on 10/26/2024 2 days before Pt. #1’s discharge. Review of ST (Speech Therapy) note on 10/25/2024 at 3:03 PM revealed, “Pt. presents with cognitive deficits impacting thought organization, memory, attention and executive function skills. Pt demonstrates awareness of cognitive difficulties and was tearful at the end of session. Wife called at end of session. Discussed recommendation for ongoing ST at next level of care with Pt and wife. Both agreed with POC (plan of care). These deficits impact patient’s functional safety and independence. Patient would benefit from ongoing ST services for cognition. Consider inpatient rehab.” Review of OT note on 10/27/2024 at 8:00 AM revealed, “Attempted to see pt for schedule OT session this AM. Upon arrival to room, pt resting in bed with ice packs to forehead and reports having a bad night with headache and neck pain. Physician in room. Pt declining participation this AM requesting to rest. Pt and spouse do mention some double vision, would benefit from further assessment next session.” Review of Provider Trauma note on 10/27/2024 at 10:22 AM revealed, “Recent PTOT note suggests home PT although there was some discussion of inpatient [Facility W] rehab. Continue therapy....and placement-vs-home assessment tomorrow....Reports he is severly uncomfortable and having 10/10 pain in his neck and head. He reports no sleep due to the pain. Unable to eat due to nausea. Felt no relief with addition of Fioricet (pain medication)....Discharge Planning: Therapy Recs IPR (Inpatient Rehabilitation)...Disposition: medically stable for discharge to IPR.” Review of Provider Neurosurgery note on 10/27/2024 at 11:28 AM revealed,”We were asked to see the patient about ongoing neck pain...Discharge planning....Therapy Recs: IPR...Disposition: Medically stable for discharge to IPR.” Review of Provider Internal Medicine note on 10/27/2024 at 11:59 AM revealed, “Chief Complaint/Reason for visit: Head/Neck Trauma, awaiting placement at [Facility W].” Review of Provider Neurosurgery note on 10/28/2024 at 7:16 AM revealed, “Reports continued pain at the base of the head on the left that shoots up the back of the head and into the left eye, with blurry vision....Discharge orders in place.” Discharge order was placed by PA Z on 10/28/2024 at 11:16 AM and revealed, “Discharge Disposition Home or Self Care.” Pt. #1 was discharged on 10/28/2024 home with home health services. Review of Provider Trauma discharge summary note on 10/28/2024 completed by Physician Assistant Z and co-signed by Provider AA at 1:23 PM revealed, “Discharge Destination: Home with HH (Home Health) vs IPR.” Review of Internal Med discharge summary on 10/28/2024 at 1:33 PM revealed, “Pt. discharged before I was able to evaluate him today...Since he discharged home instead of to acute rehab, I will fax this to his primary care doctor to coordinate labs and follow up. I also called [Pt. #1] and his wife so they know to expect a call.” On 11/19/2024 at 9:30 AM in an interview with Complainant A, Complainant A stated, “It was so scary to have him at home, I could barely get him up into the house, he was crying, I was crying. I wanted to appeal but I wasn’t listened to, we were forced to go home and in the condition he was in, the discharge person and the case manager wouldn’t listen. When [Staff BB] called the next day we were able to get him into [Facility W] that day and he was there until 11/9/2024 and is home now and doing much better. We were never told we had insurance approval to go to Inpatient Rehab before discharge.” On 12/04/2024 at 8:25 AM in an interview with Therapy Director J, when asked how is it determined where a patient is discharged to, J stated, “The discharge process is collaborative, our therapy recommendation doesn’t dictate where a patient goes.” There was no documented evidence of discussions between disciplines regarding discharge planning. On 12/04/2024 at 9:10 AM in an interview with Hospitalist L when asked what is the role of the hospitalist in the discharge process, Hospitalist L stated, “We discuss every morning on rounds, I review EPIC (electronic medical record) problem list, medications, determine what orders are needed for discharge, diet, activity, follow up. As a consult I don’t always put in discharge orders.” When asked what happened with Pt. #1’s discharge and why it changed, L stated, “The recommendation was PT and OT and they were searching for IP rehab. I don’t know what happened.””

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 44431 Based on record review and interview the facility failed to include Patient (Pt.) #1 and their family in the discharge planning process and failed to provide discharge appeal information 4 hours prior to discharge for 1 of 12 patients reviewed (Pt. #1). Findings Include: Review of Facility policy effective date 01/04/2023, titled, “Medicare IMM (Important Message) and MOON (Medicare Outpatient Observation Notice) Corporate Policy,” revealed, “Delivery of the IM and Moon Notifications-Summary of Process:...1.[Facility] must issue the initial IM within 2 days of admission and must obtain the signature of the beneficiary or their representative. 2. [Facility] must also deliver a copy of the signed notice to each beneficiary not more than 2 days before the day of discharge....Follow up IM Notice: 1. The follow-up IM must also be provided to the patient as soon as possible prior to discharge, but no more than 2 days before....If the follow up notice is delivered on the day of discharge, the patient must be given at least 4 hours prior to discharge to consider their rights. Review of Facility Policy last reviewed 10/28/2024, titled, “Discharge Planning,” revealed, “The discharge planning process shall focus on patient goals and treatment preferences...in the discharge planning for post-discharge care. There must be documentation in the patient’s medical record of the patient’s goals and treatment preferences....and...include that the patient and their...support person was included in the development of the goals....The discharge planning process and the discharge plan shall be consistent with the patient’s goals of care and their treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care....[Facility] will identify at an early state of inpatient stay/admission, those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and will provide a discharge planning evaluation for those patients.” Review of Pt. #1’s CM (case manager) note on 10/25/2024 at 11:59 AM revealed, “Expected Discharge disposition: Inpatient Rehab Facility...CM met with pt at the bedside in conjunction with spouse...over the phone to update on dcp (discharge care plan). CM adv (advised) ...discharge... that pt (physical therapy) recommended...HH (home health) by PT if pt has no support at home and OT=IPR. (Inpatient rehab facility). PT/spouse want IPR because [spouse] works during the day and no one will be available to assist pt during that time.” Pt. #1’s medical record revealed Pt. #1 was accepted for IPR at Facility W on 10/25/2024 at 1:21 PM. Review of Nursing Progress Note on 10/26/2024 at 3:02 AM revealed nursing notified the provider Pt. #1 was having uncontrolled headache, nausea and vomiting. Review of Trauma progress note on 10/27/2024 at 10:22 AM revealed, “Wearing aspen collar for C5/6 herniated disk. Recent PTOT note suggests home PT although yesterday there was some discussion of inpatient [Name] rehab. Continue therapy, aspen collar, and placement-vs-home assessment tomorrow...Discharge Planning: Therapy Recs: IPR (Inpatient Rehab)...Disposition: medically stable for discharge to IPR.” Review of Neurosurgery progress note on 10/27/2024 at 11:28 AM revealed, “We were asked to see patient about ongoing neck pain...reports has severe pain at the base of the head on the left that shoots up the back of the head and into the left eye, with blurry vision...has intermittent numbness in the arm...reached back out to NSGY (neurosurgery) given severe pain limiting his mobility....Discharge planning:....Therapy Recs: IPR...Disposition. Medically stable for discharge to IPR.” Review of Internal Medicine Progress note completed by Hospitalist L on 10/27/2024 at 11:59 AM revealed, “Chief Complaint: Head/neck trauma, awaiting placement at [Facility W] Inpatient rehab Headache and nausea better today.” Discharge order was placed by PA Z on 10/28/2024 at 11:16 AM and revealed, “Discharge Disposition Home or Self Care.” Pt. #1 was discharged on 10/28/2024 home with home health services. Review of 10/28/2024 10:09 AM nursing note revealed, “Pt. #1 has been safe from falls this shift, up with SBA (stand by assist) and 2ww (wheeled walker)...Pertinent information: moves very slow, gets dizzy when he gets up, it does subside some but continues when he does certain moves. Plan/discharge plan: home when medically ready. D/c home today, instructions given to patient and his wife...Taken out in a w/c by staff.” Review of Pt. #1’s medical record revealed, Pt. #1’s AVS (After visit summary) was printed on 10/28/2024 at 12:42 PM. Review of CM discharge note on 10/28/2024 at 12:07 PM revealed, “Therapy Recommendation: After PT/OT evaluation they are recommending that Patient would benefit from ongoing therapy with home health...RNCM [Registered Nurse Case Manager] contacted home health liaison to request ST (Speech Therapy) be added. RNCM updated at bedside while spouse on patient’s speaker phone very upset about change in therapy recs and patient discharge disposition. IMM letter provided.” The order for Pt. #1’s discharge was placed at 11:16 AM on 10/28/2024, the IMM (this notice provides information on discharge appeal rights and per hospital policy should be given at least 4 hours prior to discharge) was documented as given in the CM note on 10/28/2024 at 12:07 PM, Pt. #1’s AVS was printed at the time of discharge at 12:42 PM. The nurses note on 10/28/2024 at 10:09 AM revealed pt. #1 was taken out by wheelchair. Pt. #1 received their IMM notice 37 minutes before getting their discharge instructions. On 11/19/2024 at 9:30 AM in an interview with Complainant A, Complainant A stated, “It was so scary to have him at home, I could barely get him up into the house, he was crying, I was crying. I wanted to appeal but I wasn’t listened to, we were forced to go home and in the condition he was in, the discharge person and the case manager wouldn’t listen. When [Staff BB] called the next day we were able to get him into [Facility W] that day and he was there until 11/9/2024 and is home now and doing much better. We were never told we had insurance approval to go to Inpatient Rehab before discharge.” Pt. #1 was discharged on 10/28/2024 home with home health services. Based on review of the patients medical record, Pt. #1’s status changed daily. The facility was initially recommending discharge to an inpatient rehab facility and then the recommendation changed on the date of discharge to home with home health services. There is no documentation as to when or why the discharge recommendation changed. There is no documented evidence that Pt.#1 or their spouse were informed the discharge plan was changing from IPR to home with home health until the day of discharge. There was no documented evidence that Pt. #1 or their spouse had been updated on the status of the referral to [Facility W] for IPR placement.”