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Based on policy review, medical record review, and interview the hospital's nursing services failed to provide oversight and supervision to ensure care was provided to meet the patient's needs by providing accurate assessment of the skin, providing accurate wound assessment and documentation for 4 or 5 (Patient #1, #2, #4 and #5) sampled patients.

The finding include:

1. Medical record review of Patient #1 revealed the patient was admitted and in less that 24 hours she was transferred to [Named Hospital] #2 Emergency Room and was admitted. Patient #2 was readmitted to the facility on 12/13/2022 from [Named Hospital #2] where the patient developed a Stage II to the coccyx and a Stage 1 to the right buttock.

[Named Hospital] #2 had the pressure injuries documented on discharge.

Review of the Initial Treatment Plan for Patient #1 revealed no treatment plan with interventions for the Stage II and Stage I pressure injuries.

After readmission there was not an initial skin assessment completed, no continuous documentation of repositioning or offloading, no wound care assessment, treatment orders, the Braden Scale showed the patient was at moderate risk with a Stage II to the coccyx and a Stage I to the right buttock.

On 12/22/2022 Patient #1 was transferred back to [Named Hospital] #2 Emergency Room where she was admitted. The Wound Care Documents on 12/22/2022 revealed that Patient #1 had an Unstageable to the sacrum measuring Length 8.0 cm [centimeter], Width 9.0 cm [centimeter], Depth 0.1 cm centimeter, black/purple color was noted with small serosanguineous drainage and skin peeling.

Review of the hospital's medical records revealed no initial skin assessment, no initial wound assessment, no weekly wound documentation, no wound care consults, no dietary assessments, no doctors order for treatment, no plan of care with interventions, no continuous monitoring, and no documentation of continuous turning or offloading every 2 hours or as needed.

2. Medical record review of Patient #2 revealed the patient was admitted with a surgical would to the left elbow, and a gluteal cleft tear.

There was no initial plan of care for the elbow and the gluteal cleft tear. The skin assessments were inaccurately documented with stating skin was within normal limits..

3. Medical record review of Patient #4 revealed the patient was admitted with a Right infected great toe, and abrasions to bilateral forearms, shin.

Review of the Initial Treatment Plan for Patient #1 revealed no treatment plan with interventions for the left elbow and gluteal cleft tear.

The skin assessments were inaccurately documented stating skin was within normal limits.

4. Medical record review of Patient #5 revealed the patient was admitted with an unstageable left heel pressure injury with measurement of Length 5 cm [centimeter], Width 5 cm [centimeter] and no measurement for the depth.

The Braden scale with a total score of 17 was an indication that Patient #5 was at a mild risk for a pressure injury. Patient #5 has an unstageable wound.

There was an referral e-mailed to a registered dietician on 4/13/2023 with no response. This surveyor received this information on 4/17/2023.

The skin assessment were inaccurately documented stating skin was within normal limits.

Refer to A395

Medical record review for Patient #1 revealed no initial plan of care with documented interventions for wound assessment and care.

Medical record review of Patient #2 revealed no initial plan of car with documented interventions for wound assessment and care.

Refer to A396

Based on medical record review, policy review, and interview the facility failed to ensure nursing services provided adequate oversight and supervision to ensure patient's needs were met when skin assessments to prevent the development of pressure injuries were not performed for 4 of 5 (Patient #1, #2, #4 and #5) sampled patients. The facility's nursing services failed to accurately and completely document wounds and wound assessments on 1 of 5 (Patient #1) sampled patients and nursing services failed to document pressure relief and offloading for 4 of 5 (Patient #1, #2, #4 and #5) sampled patients with skin problem and pressure injuries.

The findings include:

1. Review of the facility's "Patient Rights and Responsibilities" policy with an effective date of "6/2022" revealed, "...To ensure all facility staff and contract staff shall observe these patient's rights to respect and foster the patient's dignity, autonomy, positive self-regard, civil rights and involvement in his/her care...Considerate, dignified, and respectful care, provided in a safe environment, free from all forms of abuse, neglect...Appropriate assessment and management of pain..."

Review of the facility's "Wound Care" policy with an reviewed/revised date of "2/26/2021" revealed, "...To identify "at risk" patients and implement preventative care to reduce the risk of pressure injury development...To maintain skin integrity and promote wound healing using a systematic approach and monitoring process...To Provide a consistent process for accurate and complete documentation of wound assessments and treatments...A thorough inspection of the patient's skin must be accomplished within the first 24 hours of admission/readmission to the facility...Documentation of findings on the admission should include any alterations in skin integrity, such as: reddened areas, scratches, skin tears, etc...Notification to the physician and the family or responsible party must be completed timely...Obtain orders and implement treatments for wound care as appropriate...Braden Scale...This assessment should be completed on admission/re-admission, weekly for the first month...These recommended guidelines are for identifying those patients at risk for compromised skin and for implementing preventative measures and treatment protocols. The LPN [Licensed Practical Nurse] or RN [Registered Nurse] will notify the physician for specific wound treatment upon admission or on day of wound development...Preventative measures and interventions must be implemented as soon as the patient is identified as high risk. All efforts should be made to make interventions patient specific... Clinicians are responsible for monitoring skin problems and interventions weekly. Clinicians must review not only the wound condition but should also assess the patient's nutrition and hydration status. Management of the patient's diet to ensure adequate nutrients are provided to support healing as necessary. Notify dietician as needed. Identification and management of illnesses that might impede healing such as peripheral vascular disease, diabetes mellitus...is also important...Clinicians should monitor lab values as indicated and as ordered by the Physician (i.e. [that is] BUN [Blood Urea Nitrogen], HBG [Hemoglobin], Prealbumin or Albumin and Creatinine...Once a pressure ulcer is identified, an assessment must be documented. This must reflect that Physician and family were notified and what treatments/interventions were initiated...The Weekly Wound Progress Note must be initiated by the nurse. The Date of Onset and the location must be documented. This will be completed weekly and PRN [as needed]. Pressure injuries must be assessed and measured weekly...If the healing status is poor or no progress is noted, the facility should consult with the physician to seek alternative treatment and/or interventions...Weekly document is to be recorded on a Weekly Wound Progress Note. A separate form must be completed for each wound. This is a permanent part of the patient' medical record..."

2. Medical record review revealed Patient #1 was admitted on 12/5/2022 with diagnosis of Brief Psychotic Disorder.

Review of the presenting symptoms for [Named Hospital] #1 on 12/5/2022 at 7:54 AM revealed, "...Mobility: Weakness...Activity: Chair...Arthritis: Osteo-arthritis...DM [Diabetes Mellitus] Type II...morbid obesity...Ambulatory needs: Wheelchair...Impaired Skin Integrity Treatment Plan/Wound Care protocol indicated: No..."

Review of the admission Braden Scale (used for predicting pressure injuries) on 12/06/2022 at 3:25 AM revealed a total Score of 14 [Moderate Risk 13-14].

Review of the initial skin assessment on 12/6/2022 at 3:55 AM revealed, "...Skin temperature warm...usual weight 269...Impaired Skin Integrity Treatment Plan/Wound Care protocol indicated: No..."

Medical record review revealed that Patient #1 was transferred to [Named Hospital] #2 Emergency Room 24 hours after being admitted to [Named Hospital] #1 on 12/6/2022 with the chief complaint of being unresponsive and Tachycardic.

Review of [Named Hospital] #2 Incision/Wound documentation on 12/12/2022 at 8:00 AM revealed, "...Pressure ulcer...Bony prominence...Pressure Ulcer Stage II

Medical record review revealed that Patient #1 was readmitted to [Named Hospital] #1 on 12/13/2022 with an admitting diagnosis of Vascular Dementia, Severe, with other Behavioral Disturbance.

Review of the initial assessment on 12/13/2022 at 4:30 PM readmission revealed, "...Nutritional: Not Applicable...Impaired Skin Integrity Treatment Plan/Wound Care protocol indicated: Yes..."

Review of the medical record review on 12/13/2022 did not reveal an initial admission skin assessment.

Review of the Braden Scale (used for predicting pressure injuries) on readmission on 12/13/2022 revealed a Total Score of 14 [Moderate Risk 13-14]. Patient #1 has a Stage II pressure injury to the coccyx and a Stage 1 to the right buttock.

Review of the Nursing Flowsheet on 12/13/2022 at 10:40 PM revealed, "...Movement and ambulation Gerichair...Gait/Movement Unobserved...Skin Temperature WNL [within normal limits] Color WNL Condition WNL Turgor WNL..." Patient #1 mobility is in a Gerichair and her movement had been unobserved and her skin assessment is in within normal limits and she has a Stage II to the coccyx and a Stage 1 to the right buttocks.

Review of the Client Doctors orders from 12/13/2022 through 12/22/2022 did not revealed any orders for treatment of the pressure injuries.

Review of the nursing progress note on 12/14/2022 at 5:00 AM revealed, "...8:00 PM received resting in bed awake and alert..."

Review of the History and Physical on 12/14/2022 at 8:00 AM revealed, "...2nd [Named Hospital] #1 admit - [Named Hospital] #1 for this 70 yo [year old] w [white] female...She had been sent here last week w [with] episodes of psychosis, including hyperreligious delusions...hallucinations and refusal of care. On eval [evaluation] here she was found to be unresponsive w [with] a heart rate of 210, w [with] regular sVT [Superventricular Tachycardic - a irregularly fast heartbeat] see on EKG [records the electrical signal from the heart to check for different heart conditions]. She was tx [transferred] to [Named Hospital] #2 where she received...countershock w [with] reobtaining nsr [normal sinus rhythm]. She was also found to have uti [Urinary Tract Infection] and was tx [treated] w [with] iv [intravenous] abx [antibiotic]. While at hospital she continued to refuse meds, hallucinate, and threaten to kill staff. She was sent back to [Named Hospital] #1 for further eval [evaluation] and tx [treatment]...Skin: stage 2 decub [decubitus] presacral...Plan: tx [treatment] plan for decub [decubitus]..."

Review of the Nursing Progress Notes on 12/14/2022 at 9:00 AM, "...Patient is up in Gerichair..."

Review of the Nursing Progress Notes on 12/15/2022 at 9:45 AM "...Patient is in Gerichair...8:15 PM...Sitting in geri chair in dinning area..."

Review of the Nursing Flowsheet on 12/15/2022 at 8:15 PM revealed, "...Movement and Ambulation: Gerichair...Gait/Movement Non-Ambulatory...Skin: Temperature WNL, Color WNL Dryness..."

Review of Client Doctors Orders on 12/16/2022 at 2:47 PM revealed an order for a treatment at bedtime. Apply Xeroform to open areas on sacrum, apply foam dressing and offload.

Review of the Medication Administration Record on 12/16/2022 at 2:47 PM revealed no successful administration events on file through a D/C [discontinue] Effective date of 12/22/2022 at 5:45 AM.

Review of the Nursing Flowsheet on 12/16/2022 at 8:00 PM revealed, "...Movement and Ambulation: Gerichair...Gait/Movement Non-Ambulatory... Skin:Temperature WNL, Pale,Turgor WNL ...Skin comments: stage II to coccyx/right buttock..."

Review of the Nursing Flowsheet on 12/17/2022 at 8:00 AM revealed, "...Movement and Ambulation: Gerichair...Skin...Temperature WNL, Color WNL... Skin Comments: Stage II to sacrum..."

Review of Nursing Progress Notes on 12/17/2022 at 8:00 AM, "...Patient resting in geri chair in the dining room...1:10 PM revealed, "...Patient in geri chair in dining room...2:00 PM...Patient is dining room in geri chair..."

Review of the Nursing Progress Notes on 12/18/2022 at 8:00 AM, "...Patient resting in dining room in geri chair...12:00 PM...Patient resting in dining room...1:50 PM...Patient sitting in geri chair. Reclined geri chair to elevate legs..."

Review of the Nursing Flowsheet on 12/18/2022 at 8:00 PM revealed, "...Movement and Ambulation: Gerichair...Gait/Movement: Unobserved...Skin...Temperature WNL, Color WNL...Condition WNL, Turgor WNL..."

Review of the PT [Physical Therapy] Screen on 12/19/2022 revealed, "...Wounds: Present... Wound Comments: pressure area sacral area...Additional Comments...stage 2 decubitus sacral area...Pt. [patient] using w/c [wheelchair] and pt. [patient] reports not amb [ambulatory]..."

Review of the Nursing Progress Note on 12/19/2022 at 4:10 AM revealed, "... 8:00 PM...resting in geri chair in dayroom..."

Review of the Nursing Flowsheet on 12/19/2022 at 9:20 AM revealed, "...Movement and Ambulation: Gerichair...Skin...Condition WNL [within normal limits]..."

Review of the Nursing Flowsheet on 12/19/2022 at 9:20 AM revealed, "...Movement and Ambulation: Gerichair...Skin...Condition WNL [within normal limits]..."

Review of the Nursing Flowsheet on 12/19/2022 at 8:10 PM revealed, "...Movement and Ambulation:Gerichair...Gait/Movement: Non-Ambulatory...Skin...Color WNL [within normal limits], Bruising..."

Review of the initial treatment plan revealed a created date of 12/20/2022 at 11:36 AM. Patient #1 was readmitted to the hospital on 12/13/2022. There was no documentation an individualized treatment plan was developed or implemented for Patient #1 skin or wound care on readmission to [Named Hospital] #1.

Review of the [Named Hospital] #1 transfer list on 12/22/2023 revealed a transfer to [Named Hospital] #2 Emergency Room with a chief complaint of Lethargy, Decreased Urinary Output and Hypotension.

Review of [Named Hospital] #2 Wound Care Documents on 12/22/2022 revealed, "...Pt [patient]...lying in bed, morbidly obese. Sacrum with unstageable pressure ulcer measuring 8.0 cm x 9.0 cm x 0.1 cm, black/purple, small serosanguineous drainage, skin peeling..."

Review of all nursing assessments from admission on 12/5/2023, readmission on 12/13/2022 and discharge 12/22/2022 there was no documentation of continuous turning or offloading in the nursing progress notes for pressure relief at least every 2 hours and as needed.

Review of medical records from 12/5/2022 through 12/22/2022 revealed no documentation of a thorough inspection of Patient #1's skin within the first 24 hours of admission/readmission to the facility. On the readmission on 12/13/2022 revealed a treatment that was ordered by the physician for wound care but there were no documentation of this treatment other than a dressing had been changed occasionally in the Nursing Progress Notes. There was no documentation that Patient #1's family had been notified and was not documented in a care plan meeting. There was a Braden Score was 14 (Moderate Risk 13-14) on the 12/5/2023 admission. On the 12/13/2022 readmission Patient's #1 Braden Score was 14 (Moderate Risk 13-14) the Patient #1 was identified to have a Stage II coccyx and Stage I to right buttock. The Braden Score of 14 (Moderate Risk 13-14) did not identify Patient #1 as high risk; which also put Patient #1 in risk for further compromised skin breakdown. There was no documentation of a care plan for immediate interventions to implement preventative measures and treatment protocols. There was no continuous monitoring for skin assessments documented. There was no documentation of a wound care consult. There was no documentation of a nutritional assessment to assess the patient's diet or ensure the hydration status. Patient #1 had the following diagnoses that would contribute to the healing process: Hypertension heart disease with heart failure, Congestive Heart Failure, Diabetes Mellitus with Diabetic Neuropathy and Morbid (severe) Obesity. Once Patient #1 was identified to have a pressure ulcer, there was no documentation of an assessment, treatments and/or interventions implemented. There was no Week Wound Progress Note initiated by the nurse with the date of onset, location, measurements, healing status, progress or a consult with the physician to seek alternative treatment or interventions. There should have been two separate forms because there were two wounds (Stage II coccyx and Stage I to right buttock).

Interviews on 4/3/2022 beginning at 10:00 AM the Director of Nursing (DON) was asked if there was a wound care consult and a nutritional assessment done on Patient #1. The DON stated, "...No..."

3. Medical record review revealed that Patient #2 was admitted on 4/11/2023 with a diagnosis of Brief Psychotic Disorder.

Review of the Admission/weekly Wound Assessment and Summary on 4/11/2023 revealed, "...Wound #1...Location Left elbow...Wound Type: surgical...Measurements...Length 4 cm [centimeters] Width 2 cm depth UTD [unable to determine]...Wound #2...Location" gluteal cleft...type...tear...Measurements: Length 0.4 cm Width: 0.2 cm Depth 0.1 cm..."

Review of the Client Doctor Orders on 4/11/2023 revealed an Daily AM order to cleanse Eschar wound on Left elbow with wound cleanser, pat dry, apply mupirocin and foam dressing. Change daily and as needed. Monitor for signs and symptoms of infection.

Review of the Initial Treatment Plan for Patient #2 on 4/11/2023 revealed no documentation of an individualized plan that was developed or implemented for Patient #2 skin or wound care on admission.

Review of the nursing assessment on 4/11/2023 at 7:45 PM revealed, "...Skin: Temperature WNL [within normal limits], Color WNL, Dryness, Turgor WNL...Skin Comments: surgical incision area of concern to left elbow with warmth (Temperature WNL) and swelling. Patient #2 cannot have a skin assessment within normal limits when there is a surgical incision area of concern to the left elbow wound with eschar and also has a gluteal cleft tear.

Review of the Client Doctor Orders on 4/12/2023 revealed an at bedtime order to cleanse Eschar wound on Left elbow with wound cleanser, pat dry, apply mupirocin and foam dressing. Change daily and as needed. Monitor for signs and symptoms of infection.

Review of the Client Doctor Orders on 4/12/2023 revealed an order every 12 hours and as needed to apply moisture barrier to gluteal tear every shift until resolved.

Review of the nursing assessment on 4/12/2023 at 8:00 AM revealed, "...Skin: Temperature WNL, Color WNL, Turgor WNL...Skin Comments: Left elbow surgical site covered with foam dressing ( hx [history] of incision dehiscence, eschar at site, mupirocin + [plus] foam dressing ordered).

Review of the nursing assessment on 4/12/2023 at 11:18 PM revealed, "...Skin: Temperature WNL, Color WNL, Condition WNL, Turgor WNL..."

Review of the nursing assessment on 4/13/2023 at 9:19 PM revealed, "...Skin: Temperature WNL, Color WNL, Condition WNL, Turgor WNL, Bruising...Skin Comments: Drsg [dressing] to left humerus C [Clean]/D [Dry]/I [Intact]..."

Review of the Braden Scale (used for predicting pressure injuries)on 4/14/2023 revealed an total score of 12 (10-12- High Risk) which is a indication of a high risk. (Braden Scale should have been completed 24 hours after admission).

Review of the nursing assessment on 4/15/2023 at 7:45 AM revealed, "...Skin: Temperature WNL, Skin: Condition WNL..."

Review of the nursing assessment on 4/15/2023 at 8:00 PM revealed, "...Skin: Temperature WNL, barrier cream to buttocks..."

Review of the nursing assessment on 4/16/2023 at 8:20 AM revealed, "...Skin: Temperature WNL, Condition WNL..."

Review of the nursing progress notes during the patient's hospitalization did not document a continuous turning or offloading for pressure relief at least every 2 hours and as needed.

4. Medical record review revealed that Patient #4 was admitted on 4/11/2023 with a diagnosis of Brief Psychotic Disorder.

Review of the Client Doctor Orders on 4/11/2023 revealed an order Keflex (antibiotic) 500 mg [milligram] oral capsule by mouth 1 capsule every 6 hours for infection.

Review of the Admission/weekly Wound Assessment and Summary on 4/11/2023 revealed, "...Wound #1...[Right] great toe...Wound Type: Abrasion/toe nail missing...Measurements Length 2 cm...Width 1 cm ...Depth 0 cm ...Wound #2...Location Lt [Left] shin...Wound Type: Abrasion...Wound #3...Location Lt [Left Forearm]...Wound Type: Abrasion...Wound #4...Location Rt [Right] Forearm...Wound Type: Abrasion...Measurements Length: 0.5 cm Width 0.5 cm..."

Review of the nursing assessment on 4/11/2023 at 8:30 PM revealed, "...Skin: Temperature WNL, Color WNL, Condition WNL Dryness, Turgor WNL. Patient #4 cannot have skin temperature, color, condition turgor WNL when documentation revealed a wound to the right great toe with an abrasion/nail missing, an abrasion to the left shin, an abrasion to the left forearm, and abrasion to the right forearm.

Review of the nursing assessment on 4/11/2023 at 8:30 PM revealed, "...Skin: Temperature WNL, Color WNL, Condition WNL, Dryness, Turgor WNL.

Review of the Client Doctor Orders on 4/12/2023 revealed an order 500 units/1 GM [gram] topical application ointment - Cleanse R [Right] toe and apply one (1) application backtracking topically to (R) great toenail bed, cover with gauze. Change daily. Reason: Wound.

Review of the Client Doctor Orders on 4/12/2023 revealed an order to monitor abrasions to left shin, bilateral forearms and right great toe until resolved. Report sign and symptoms of infection.

Review of the nursing assessment on 4/12/2023 at 8:00 AM revealed, "...Skin: Temperature WNL, Color WNL, Condition WNL, Turgor WNL.

Review of a nursing progress note on 4/12/2023 at 10:00 AM revealed, "...Patient shows me his right great toe that is missing a toe nail; slight erythema surrounding nail bed. New toe nail partially grown in. Scant serous drainage on removed sock. Patient states he kicked something prior to admission...He has refused his antibiotic Reflex despite education..."

Review of the nursing assessment on 4/15/2023 at 10:00 PM revealed, "...Skin: Temperature WNL...Skin Comments: scratches and abrasions..."

Review of the nursing assessment on 4/16/2023 at 8:27 AM revealed, "...Skin: Temperature WNL, Condition WNL..."

Review of all nursing progress notes did not document a continuous turning or offloading for pressure relief at least every 2 hours and as needed.

5. Medical record review revealed Patient #5 was admitted on 4/12/2023 with a diagnosis of Dementia, Severe with Psychotic Disturbance.

Review of Client Doctors Order on 4/12/2023 revealed an order to apply thermoform gauze and cover with foam dressing daily to left heel and right lower leg.

Review of the nursing assessment on 4/12/2023 at 11:00 PM revealed, "...Skin: Temperature WNL, Color WNL, Condition WNL, Turgor WNL.

Review of the Admission/weekly Wound Assessment and Summary on 4/12/2023 revealed, "...Wound #1...Location Lt [Left] Heel...Wound Type:Pressure...Stage...Unstageable...Measurement Length 5 cm Width 5 cm depth ? [question]...Wound #2...Location: Rt [right] lower leg...Wound Type: Abrasion...Measurements Length 0.5 cm Width: 0.4 cm Depth 0.5 cm..."

Review of the Braden Scale (used for predicting pressure injuries) on 4/13/2023 revealed a total score of 17 (mild risk 15-18). Patient #5 has an unstageable pressure ulcer to the left heel.

Review of an appropriate Registered Dietitian Referral e-mailed on 4/13/2023 with no response as of 4/17/2023.

Review of Client Doctors Order on 4/13/2023 revealed an order for daily afternoon (2:00 PM) - Unstageable left heel: cleanse with wound cleaner, pat dry, apply thermoform gauze, and cover with foam dressing until resolved, change daily, Offload when in bed.

Review of Client Doctors Order on 4/13/2023 revealed an order for daily afternoon (2:00 PM) - Abrasion right lower leg: cleanse with wound cleanser, pat dry, jeroboam gauze, and cover with foam dressing until resolved. Change daily.

Review of the nursing assessment on 4/13/2023 at 9:16 PM revealed, "...Skin: Temperature WNL, Color WNL, Condition WNL, Turgor WNL..."

Review of the nursing assessment on 4/14/2023 at 8:35 AM revealed, "...Skin: Temperature WNL..."

Review of the nursing assessment on 4/15/2023 at 7:42 AM revealed, "...Skin: Temperature WNL, Condition WNL..."

Review of the nursing progress notes did not document a continuous turning or offloading for pressure relief at least every 2 hours and as needed.

Based on policy review and medical record review, hospital failed to ensure the nursing staff developed and/or implemented a treatment plan which reflected individualized patient needs and the care to be provided for 2 of 5 (Patient #1 and #2) sampled patients.

The findings include:

1. Review of the facility's "Treatment Plan" policy with a revised date of "12/2021" revealed, "...The treatment plan should include...both physical and mental problems that are actively being treated...Treatment goals which are measurable...Methods and individualized approaches of treatment...who is responsible for carrying out the plans by name and disciplines interventions addressing each goal...how each goal is to be accomplished...evidence of patient and/or family involvement when appropriate...evidence of periodic review and revisions of plan...interdisciplinary participation in treatment plan...the treatment plan should be started on admission and an initial treatment plan completed within 72 hours...each staff member should review and electronically sign the plan..."

2. Medical record review revealed Patient #1 was admitted on 12/5/2022 with diagnosis of Brief Psychotic Disorder. Further review revealed Patient #1 was transferred to [Named Hospital] #2's Emergency Room on 12/6/2022 with the chief complaint of being Unresponsive and Tachycardic. Patient #1 was readmitted to [Named Hospital] #1 on 12/13/2022 with admitting diagnosis of Vascular Dementia, Severe, with other Behavioral Disturbances.

Review of the medical record review on 12/13/2022 did not reveal documentation of an initial admission skin assessment.

Review of the initial assessment on 12/13/2022 at 4:30 PM readmission revealed, "...Nutritional: Not Applicable...Impaired Skin Integrity Treatment Plan/Wound Care protocol indicated: Yes..."

Review of the nursing progress note on 12/14/2022 at 5:00 AM revealed, "...8:00 PM received resting in bed awake and alert...Stage II to coccyx and stage I to right buttock. Drsg. [dressing] applied..."

Review of the initial treatment plan revealed a creation date of 12/20/2022 at 11:36 AM. This treatment plan revealed no individualized plan that was developed or implemented for Patient #1 skin or wound care on readmission to [Named Hospital] #1.

3. Medical record review revealed that Patient #2 was admitted on 4/11/2023 with a diagnosis of Brief Psychotic Disorder.

Review of the Admission/weekly Wound Assessment and Summary on 4/11/2023 revealed, "...Wound #1...Location Left elbow...Wound Type: surgical...Measurements...Length 4 cm [centimeters] Width 2 cm [centimeters] depth UTD [undetermined]...Wound #2...Location gluteal cleft...type...tear...Measurements: Length 0.4 cm [centimeter] Width: 0.2 cm [centimeter] Depth 0.1 cm [centimeter]..."

Review of the Client Doctor Orders on 4/11/2023 revealed a Daily AM order to cleanse Eschar wound on Left elbow with wound cleanser, pat dry, apply mupirocin and foam dressing. Change daily and as needed. Monitor for signs and symptoms of infection.

Review of the Initial Treatment Plan for Patient #2 on 4/11/2023 revealed no documentation of an individualized plan developed or implemented for Patient #2 skin or wound care on admission.