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Based on the review of medical records, policies and procedures, and staff interviews, it was determined that the facility failed to provide adequate wound care, or implement measures to prevent the development of pressure ulcers for two patients (P) (P#1 and P#2) of four patients (P#1, P#2, P#3, and P#4) reviewed.


Findings included:


Medical record review revealed that P#1 was admitted to the facility on 7/19/25 at 1:43 p.m.


A review of a nursing admission health history on 7/19/25 at 3:57 p.m. revealed that P#1's skin was warm and dry and with no documented pressure injuries.


A review of a history and physical on 7/19/25 at 1:55 p.m. failed to reveal documentation of pressure injuries. Further review of a 'Pressure Injury Risk Score' revealed that P#1 was not at risk for a pressure injury.


Documentation under the nursing assessment by Wound Care Nurse (WCN) GG on 7/21/25 at 2:59 p.m. revealed that P#1 had no skin issues/alterations. Recommendations were to turn and reposition every two hours and off load both heels and arms.


On 7/22/25 at 2:06 p.m. a review of 'Wound Care Notes' revealed that P#1 had no skin issues.
A wound care note on 7/24/25 at 3:05 p.m. failed to reveal skin issues. Documentation by WCN GG on 7/28/25 at 2:56 p.m. revealed that P#1's sacral area was intact with light red/purplish skin discoloration.. Wound was covered with a barrier paste. No other skin issues were noted. Both heels were offloaded and wedge placed under the right side. Right arm elevated due to weeping. A review of a shift assessment on 7/31/25 at 8:00 a.m. revealed that a pressure injury to the buttock was assessed and staged as a deep tissue injury (DTI). DTI was not present on admission. A review of WCN GG ' s progress notes on 7/31/25 at 1:49 p.m. revealed that P#1 had developed a deep tissue injury (DTI) on the sacrum with a plan to cover with Mepilex (a foam absorbent dressing for treating chronic or acute wounds) and to offload both heels.

A continued review of WCN GG ' s progress notes on 8/5/25 revealed that P#1 had a large blister on the posterior thigh with a skin breakdown on the left heel in addition to the deep tissue injury on the sacrum. The plan was to cleanse with saline and cover with Mepilex.

Further review of WCN GG's progress notes on 8/7/25 at 4:06 p.m. revealed documentation that the blister on the left thigh had burst, and the plan was to continue cover with Mepilex, while the deep tissue injury on the left heel remained stable.


Documentation failed to reveal that P#1 was turned every two hours as per protocol, and failed to reveal the frequency of the dressing changes.


A review of MD KK ' s documentation under the discharge summary on 8/13/25 at 9:22 a.m. failed to reveal documentation of a pressure injury. P#1 was discharged to a lower level of care in stable condition.


A review of P#1 ' s medical record from Facility (F) #2, a Long-Term Acute Care Hospital revealed that P#1 arrived to F#2 on 8/13/25 at 2:38 p.m. with the diagnosis of Acute Respiratory Failure with Hypoxia (a sudden condition where the lungs cannot get enough oxygen into the blood to meet the body ' s needs).


A review of the nursing flowsheets on 8/13/25 at 5:30 p.m. revealed under the integumentary section that P#1 had exceptions to WDL (within defined limits). Documentation under the nursing flowsheets revealed that P#1 had the following wounds present on admission (at the LTC):
- Wound Pressure Injury Neck (Trach Site) Midline/Middle/Center, Anterior, DTPI (deep tissue pressure injury - a serious type of pressure injury that damages the soft tissue beneath the skin). First assessed 8/13/25 at 3:02 p.m. with a wound length of 1.5 cm, width of 1.5 cm, and depth of 0 cm.
- Wound Pressure Injury Sacrum, Unstageable, necrotic tissue. First assessed 8/13/25 at 2:55 p.m. with a wound length of 7 cm, width of 6 cm, and Depth of 0 cm.
- Wound Pressure Injury Ischial Tuberosity/Ischium Right, DTPI. First assessed 8/13/25 at 2:56 p.m. with a wound length of 5 cm, width of 6 cm, and depth of 0 cm.
- Wound Pressure Injury Back Right, Lateral, DTPI. First assessed 8/13/25 at 2:59 p.m. with a wound length of 0.5 cm, width of 0.6 cm, and depth of 0 cm.
- Wound Pressure Injury Trochanter Right, Stage 1. First assessed 8/13/25 at 3:00 p.m. with a wound length of 7 cm, width of 5 cm, and depth of 0 cm.
- Wound Pressure Injury, Elbow Right, DTPI. First assessed 8/13/25 at 3:01 p.m. with a wound length of 5 cm, width of 7 cm, and depth of 0 cm.
- Wound Pressure Injury Trochanter Left, Posterior, Stage 1. First assessed 8/13/25 at 3:05 p.m. with a wound length of 7 cm, width of 7.2 cm, and depth of 0 cm.
- Wound Pressure Injury Heel/Calcaneus Left, DTPI. First assessed 8/13/25 at 3:05 p.m. with a wound length of 4 cm, width of 2.2 cm, depth of 0 cm.
- Wound Pressure Injury Heel/Calcaneus Right, Stage 1. First assessed 8/13/25 at 3:06 p.m. with a wound length of 1.5 cm, width of 1 cm, and depth of 0 cm.
- Wound Pressure Injury Knee Left, Lateral, Stage 1. First assessed 8/13/25 at 3:06 p.m. with a wound length of 2.5 cm, width of 3.7 cm, and depth of 0 cm.
- Wound Pressure Injury Knee Left, Lateral. First assessed 8/13/25 at 3:06 p.m.


A review of the physician discharge summary on 8/16/25 at 3:20 a.m. revealed that P#1 developed bradycardia (low heart rate) and hypotension (low blood pressure). Documentation revealed that resuscitative efforts was attempted for 40 minutes with no return of circulation and P#1 was pronounced deceased at 1:09 a.m.


P#2 was admitted to the facility on 7/17/25 at 6:23 p.m. via the emergency department with the diagnosis of generalized weakness.


A review of the integumentary (skin) assessment on 7/17/25 at 5:34 p.m. under the Emergency Record, revealed that P#2 ' s skin was warm, dry, and intact with no complaints of lesions, rash, wounds, bruises, petechiae, or abrasions.


A review of the history and physical (H&P) on 7/17/25 at 6:24 p.m. revealed that P#2 ' s skin was dry and intact.


Documentation under the clinical documentation record on 7/21/25 at 8:00 p.m. revealed that P#2 had a blister on the distal left thigh. The plan was to cleanse with normal saline and apply non-adhering silicone foam. The image submitted by RN PP on 7/21/25 at 7:51 p.m. revealed a wound on the upper left lateral leg.


Documentation failed to reveal that P#2 was turned every two hours as per the facility ' s policy/protocol.


P#2 was discharged to the facility ' s hospice care unit on 7/22/25 at 4:44 p.m. with the discharge diagnosis of Altered Mental Status/Metabolic Encephalopathy (related conditions where the brain ' s function is impaired due to metabolic or chemical imbalances in the body).


Review of the facility ' s policy titled " Assessment and Reassessment of the Patient, " #18592279, last revised 9/25, revealed that patients would be assessed at admission and continuing throughout discharge. Healthcare professionals from varying disciplines functioned collaboratively to plan patient care based on analysis of findings from the assessment process. Patients were reassessed at appropriate intervals throughout the care process, including during and after invasive procedures and following a change of condition. It was important to include family in the assessment process.
The pharmacist would assess the patient concerning drug therapy while entering orders on the patient ' s profile before dispensing medications. Inappropriate therapy should have been reviewed, and the physician consulted if necessary.
The policy further stated that on the Medical/Surgical Unit, the RN would begin an initial assessment of the patient ' s needs on admission to the unit. The assessment would be completed within 12 hours. Information would be collected on an ongoing basis to reflect the patient ' s status and care needs. Each patient would be assessed at a minimum of every shift by an RN or LPN, and with any changes in the patient ' s condition. Documentation of all reassessments would be found in the patient ' s medical record.
The policy further revealed that the RN would begin an initial assessment of patient needs on admission to the Critical Care Unit. The assessment would be completed within four hours. Information would be collected on an ongoing basis to reflect the patient's status and care needs. Each patient would be reassessed every shift and with any change of condition. Focused reassessments would occur at least every four hours. An RN would reassess the patient at least every 12 hours. Documentation of all assessments would be in the patient ' s medical record.
Review of the facility ' s policy " Plan for the Provision of Patient Care, " #10086628, last revised 1/25, revealed that the Chief Nursing Officer had the responsibility and accountability for overall nursing care. Each patient care area had an assigned Director of Nursing. The Director of Nursing had 24-hour accountability for the management of nursing care and practice. The Registered Nurse accepted responsibility, accountability, and authority for the assessment, identification of patient care needs, planning of care, implementation of care, and evaluation of care.


Review of the Critical Care Unit (CCU) Routine Care Guidelines, no date or policy number, revealed that an admission assessment, history, and first point of contact would be completed on every CCU patient within four hours. A complete assessment would be done every shift. A focused assessment of the systems involved would occur at least every four hours and as frequently as the patient ' s condition warranted. Vent patients would be reassessed every two hours. Immobile patients would be turned every two hours as tolerated. Turns would be documented in the electronic health record under " Routine Daily Care. " All notes would be documented in the electronic health record, including a receiving note, notes about changes in condition, patient transfer/discharge, and hand-off notes. Sepsis screenings would be assessed and documented every shift. Rounds would be conducted on patients every hour during the day and every two hours at night to address pain, position, personal needs, and potty.


An interview occurred in the facility ' s conference room on 11/11/25 at 10:40 a.m. with the Vice President, Quality (VPQ) CC, who stated that wound consultation was only done if a physician ordered it, as the wound care management was physician-driven.


An interview occurred in the facility ' s conference room on 11/11/25 at 11:00 a.m. with Registered Nurse (RN) DD, who stated that patients were turned/repositioned every two hours, but this was not documented in the EMR.


An interview occurred in the facility ' s conference room on 11/11/25 at 11:15 a.m. with Charge Nurse (CN) EE, who stated that if a patient had any skin ulcer/wound, a picture would be taken, and documentation would be done under the skin alteration section in the EMR, and a wound consultation would be requested.


An interview occurred in the facility ' s conference room on 11/11/25 at 11:30 a.m. with Registered Nurse (RN) FF, who stated that P#1 was transferred from the medical-surgical unit to the intensive care unit after he aspirated. RN FF stated that P#1 was on the ventilator, and he developed a shallow wound while on admission. RN FF stated that the staff could not turn P#1 every two hours as per protocol because of his (P#1) oxygen requirement and because he was bedbound. RN FF also stated that P#1 ' s family may have been present at some point when P#1 ' s wounds were being assessed, but he (RN FF) was not quite sure if P#1 ' s family was notified when P#1 developed the pressure ulcers.


An interview occurred in the facility ' s conference room on 11/11/25 at 12:00 p.m. with Wound Care Nurse (WCN) GG, who stated that P#1 developed a wound on the sacrum due to moisture, and the wound got worse while he (P#1) was on admission at the facility. WCN GG stated that he tried as much as possible to do a wound assessment on patients daily, depending on the caseload, but he was not able to see P#1 daily. However, there was a wound care order in place for the nurses to follow. WCN GG also stated that the nurses needed to document the two-hourly turning in the nurses' notes and were responsible for notifying the patient ' s family of any change in condition the patient may have had.


An interview took place in the facility ' s conference room on 11/12/25 at 10:10 a.m. with Education Coordinator (EC) NN, who stated that nurses should be documenting patients ' turning as education was provided through a platform called Dynamic Health and the HealthStream.


An interview took place with the Chief Nursing Officer (CNO) UU on 11/12/25 at 11:16 a.m. in the Compliance Officer ' s office. CNO UU said there was a standard Plan of Care in the electronic medical record that was produced and completed by the Registered Nurse. There was a list of issues or concerns focused on a patient ' s present diagnoses and admission. Top priorities were given an outcome measure of improvement, stability, maintenance, or occasionally decline. The outcome measures were given an expected timeframe. Interventions were based on the assessments. For instance, if a patient came with a wound, the interventions would be within the skin assessment and not specifically laid out in the Plan of Care. The electronic record had a process intervention screen that included assessments, and anything additional added by the physician. Care Plans were derived from focused priorities and not every problem. Care Plan updates were required every 24 hours based on the nursing assessments.


A telephone interview occurred on 11/13/25 at 5:15 p.m. with RN PP, who stated that all she could remember was that P#1 was constantly having bowel movements and had to be cleaned frequently. RN PP stated that she could not recall if P#1 had any wounds/ulcers. RN PP did not recall P#2.