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Based on interview and record review, the facility failed to ensure that a Registered Nurse supervised and evaluated nursing care was for 1 (#1) of 5 patients resulting in the potential for less than optimal outcomes for patient (#1).
Findings include:

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A-0395 Based on interview and record review the facility failed to ensure that a Registered Nurse supervised and monitored the nursing care for 1 (#1) of 5 patients, resulting in the delayed treatment for patient #1.

Based on interview and record review the facility failed to ensure that a Registered Nurse (RN)
1). Supervised and monitored the nursing care for 1 patient (#1) and
2). failed to ensure a RN implemented their policy and procedure for Pressure Injury Prevention and Treatment for 1 (#1) of 5 patient's reviewed for nursing care, resulting in the delayed wound care treatment for patient #1.

Findings include:

Record review on 12/6/2021 at 1300 revealed patient (#1) was a 62-year-old male who was admitted to the facility on 3/18/2021, with diagnoses that included malfunction of tracheostomy. According to the History and Physical (H&P) the patient had a previous medical history that included mitral fibrillation, history of Deep vein thrombosis and Hypertension. The patient resided in a skilled nursing facility and presented to the Emergency room after he pulled out his tracheostomy.

Review of the nursing admission assessment dated 3/18/2021 documented the patient was admitted with unstageable pressure injuries on his coccyx and buttocks.
A wound care consultation was ordered on 3/18/2021.

Review of a wound care consultation for patient #1 dated 3/22/2021 documented:
Assessment/Interventions/plan:
Patient is alert and presents with an Unstageable (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) sacral/coccyx pressure injury that measured 6.0 by (x) 4.0 x 2.3 centimeters (cm) with 100 percent (%) of the wound bed covered with yellow slough (liquefied or wet dead tissue) that was firmly adherent to the wound, surrounding skin with severe erythema and moisture damage. Moderate to large amount of purulent non-foul drainage was noted.

The patient had an Unstageable left buttock pressure injury that measured 5.0 x 5.5 x 0.0 cm with more than 50 % of the wound bed covered with yellow slough moderately adherent to the wound bed and a moderate amount of purulent non-foul drainage was noted.

Both wounds cleansed with normal saline wound gel applied to wound bed, and covered with silicone foam dressing, until Santyl (medication ointment used for removal of dead tissue) available, once available apply daily and as needed to areas with slough present, and cover with gauze, secure with medi pore tape. Also recommending Surgical Evaluation for possible Incision and Drainage (I & D).
However, those recommendations were not performed.

On 12/7/2021 at 0940 a review of the medical record for patient #1 was conducted with wound care nurse Staff H. At that time, Staff H confirmed she saw the patient and made recommendations for the use of Santyl for the treatment of the patient's unstageable pressure injuries and the recommendations for a Surgical Evaluation. Staff H was asked if there had been a shortage of Santyl and she replied there was not. Staff H was asked to explain why those aforementioned recommendations were not carried out. Staff H replied she communicated those recommendations with the assigned nurse on that date.

Staff H said it was the responsibility of the nurse to put in the order for Santyl. Staff H said it was the responsibility for the unit clerk to put in the order for the Surgical Evaluation. Staff H said it was her expectation that the nursing staff and medical doctors would review her consultation as well and carry out her recommendations.

Additionally, further review of the medical record revealed there was no evidence that documented collaboration with the physician, patient or caregiver involvement documented in the plan of care for the patient's pressure injuries.

An interview was conducted with the Chief Nursing Officer (Staff A) on 12/7/2021 at 1430. Staff A was queried regarding the lack of nursing staff follow up with the wound care recommendations per Staff H and queried regarding who was responsible for ensuring those orders were placed and performed. She replied, the wound care nurse should have put the orders in.
However, that was not done.

Review of the facility's "Pressure Injury Prevention and Treatment" policy, dated last revised on 9/14/2021 documented:
II. General Information:
...C. Patients with pressure injury will be assessed and staged per National Pressure Injury Advisory Panel (NPIAP) guidelines...
Procedure:
...H. Plan of care should be developed in collaboration with the physician, patient, caregiver, and documented in the care plan.
I. Documentation should reflect initial and on-going assessments, physician collaboration, interventions, goals, and family/caregiver involvement. This is documented in the Care Plan in the electronic record.
IV. References:
NPIAP. 2019. Prevention and Treatment of Pressure Ulcers/Injuries in Clinical Practice, The International Guidelines 2019; Guidelines.www.npiap.org
However, this was not done.

Review of NPIAP Guidelines 2019 for unstageable pressure injuries documented:
Obtain a surgical consultation for an individual with a pressure injury that:
o Has advancing cellulitis or is a suspected source of sepsis
o Has undermining, tunneling, sinus tracts and/or extensive necrotic tissue not easily removed by conservative debridement
However, this was not done.