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Based on document review and interview, the hospital failed to ensure nursing staff completed all information of laboratory services and care provided for 4 (four) of 11 (eleven) patients (P4, P5, P8, and P9); nursing staff failed to complete wound care orders and provide wound care in 1 (one) of 11 (eleven) patients (P1); nursing staff/unit clerk failed to print laboratory test results and include in medical record for 11 (eleven) out of 11(eleven) patient MRs reviewed.

Findings include:

1. Review of the policy titled, "Laboratory Process", last approved 08/2020, indicated the following:
Policy: To obtain laboratory results and place them on the chart for provider review in a timely manner.
Procedure: Nurse transcribes order onto patient lab sheet, which is with the patient's MAR (Medication Administration Record). Nurses/unit clerks obtain laboratory results from lab website and print results; nurses/unit clerks place printed results in the patient's medical record for the provider to review.

2. Review of the policy titled, "Skin-Pressure Ulcer Assessment and Prevention", last approved 08/2022, indicated the following:
Purpose: Patients determined to be at risk for skin breakdown shall receive the necessary care and services to prevent skin breakdown. Skin integrity shall be monitored throughout hospitalization.
Procedure: The nurse will identify all applicable nursing interventions to assist in achieving the expected outcomes and goals include but not limited to: providing wound care per provider order.

3. Review of Medical Records (MR) indicated the following:
MRs for P#4, P#5, P#8 and P# 9 lacked documentation of transcribed order, completed laboratory blood draws by nursing staff, and laboratory results

4. MRs for P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, and P#11 lacked laboratory tests results as part of the MR.

5. MR for P1 lacked documentation of daily dressing changes for wound located on right side of neck on 2/23/2023, 2/25/2023, 2/26/2023 and 2/28/2023.

6. In interview on 03/08/2023 at approximately 1415 hours with A8 (Director of Nursing), he/she confirmed that laboratory order transcription was not completed, and MR lacked documentation of completed laboratory blood draws by nursing personnel on 4 (four) out of 11 (eleven) MR reviewed.

7. In interview on 03/08/2023 at approximately 1415 hours with A8 (Director of Nursing), he/she confirmed lack of documentation present in P1 medical record of daily dressing to right neck wound.