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Based on observation, interview, and record review, the hospital failed to ensure that nursing services were furnished or supervised by a registered nurse and consistent with nationally accepted standards of practice as evidenced by:

1. The hospital nursing policy did not give clear guidance for nursing staff on the expectations for assessing pressure ulcers (skin breakdown over bony prominences caused by prolonged pressure and/or friction). Refer to A 392, finding 1.

2. The unit nurses and Wound and Ostomy Certified Nurses did not assess three of six wound patients as outlined in the hospital policies (Patients 1, 4, and 7). Refer to A 392, finding 2a-c.

3. Wound care orders for three of six wound patients (Patients 1, 4, and 7) were not followed. Refer to A 392, finding 3 a-c.

4. The documentation of patient repositioning was not accurate to ensure that two of six wound patients (Patients 1 and 7) were repositioned routinely. Refer to A 392, finding 4a-b.

5. Wound care documentation was not detailed enough to determine what care was provided for three of six wound patients (Patients 1, 4, and 7). Refer to A 392, finding 5.

6. Wounds were not photographed every seven days as outlined in the hospital policy for two of six wound patients (Patients 1 and 4). Refer to A 392, finding 6.

7. Nursing staff failed to to ensure evaluation of nursing care when medical nutrition supplements, dietary intake and/or weight discrepancies were not documented six of 10 patients at nutritional risk (Patients 1, 4, 7, 8, 9, and 10). Refer to A 392, finding 7a-f.

8. Failure of nursing personnel to follow isolation precaution procedures for one of ten sampled ptients (Patient 5). Refer to A 749, finding 1.

9. Failure of nursing personnel to store breast milk according to nationally accepted standards. Refer to A 749, findings 2 and 3.


The cumulative effect of these systemic problems had the potential to compromise the health of patients, cause injury or harm to patients due to inaccurate patient assessments, cross contamination, infection, and improper wound care; and resulted in the inability of the hospital to comply with the statutorily-mandated Condition of Participation for Nursing Services.

Based on observation, interview, and record review, the hospital failed to ensure that nursing services were furnished or supervised by a registered nurse and consistent with nationally accepted standards of practice as evidenced by:

1. The hospital nursing policy did not give clear guidance for nursing staff on the expectations for assessing pressure ulcers (skin breakdown over bony prominences caused by prolonged pressure and/or friction).

2. The unit Registered Nurses (RN) and Wound and Ostomy Certified Nurses (WOCN) did not assess three of six patients with wounds as outlined in the hospital policies (Patients 1, 4, and 7).

3. Wound care treatment orders for three of six patients with wounds were not followed (Patients 1, 4, and 7).

4. The documentation of patient repositioning was not accurate to ensure that two of six patients with wounds were repositioned routinely (Patients 1 and 7).

5. Wound care documentation was not detailed enough to determine what care was provided for three of six patients with wounds (Patient 1, 4 and 7).

6. Wounds were not photographed every seven days as outlined in the hospital policy for two of six patients with wounds (Patients 1 and 4).

7. Nursing staff failed to to ensure evaluation of nursing care when medical nutrition supplements, dietary intake and/or weight discrepancies were not documented for six of 10 patients at nutritional risk (Patients 1, 4, 7, 8, 9, and 10).

These failures had the potential for patients to experience skin breakdown and worsening of wounds that could jeopardize their overall health status.

Findings:

1. On 9/21/16, the hospital policy, titled, "Skin Integrity, Prevention, and Treatment of Impaired Skin Integrity," dated 9/9/16, read, "ASSESSMENT: Nurses are responsible for identifying patients with potential alterations and those with actual alterations in skin integrity. Nurses are responsible for identifying and implementing interventions to prevent tissue injury and promote healing.....Any impairment of skin integrity on admission is documented to include location, size (length, width, depth in cm (centimeters), drainage, dressing, wound type, i.e. skin tear, venous (in veins) ulcer, rash, etc., ... Documentation includes completion of Photographic Wound record form with a picture attached and initiation of the dynamic (changing) wound group... Pressure ulcers are assessed using a disposable cm ruler or transparent single use measurement guide. Document length, width, in cm... Pressure ulcers are measured and documented weekly. Documentation will include location, size, stage, tracking (skin overhanging a dead space), undermining (skin overhanging a wound edge), drainage, odor, infection and presence of necrotic tissue. The RN will NOT stage any wound that may be related to pressure. The RN will order a wound care consult and the Wound Care Nurse will assess and stage if appropriate."

The policy continues with "Staging: (By WOCN or Wound Care Specialist only) and Treatment of Pressure Ulcers. Each wound care stage (rating of wound by depth as 1 to 4 with 1 being intact skin with non-blanchable (does not go away when touched) redness, usually over bony prominences and 4 being full thickness wound exposing bone, tendon, or muscle. Each stage described a different treatment the nurse may start and all stages indicated a WOCN consult should be obtained.

On 9/22/16 at 8:45 am, Administrative Nurse (ARN) A reviewed the above policy. ARN A acknowledged that the policy indicated wounds should be staged with assessment and that treatment was to be initiated prior to a WOCN consult and this also would require the RN to stage a wound to ensure the correct treatment was initiated for a pressure ulcer. ARN A stated RNs did not always stage wounds correctly and that WOCNs were more reliable in this task. ARN A demonstrated that a WOCN could verify the accuracy of the RN assessment of wound stage on the Photographic Wound Documentation form. ARN A further acknowledged that the policy was not clear for what was expected of the unit RNs.

2a. On 9/21 and 9/22/16, Patient 1's record was reviewed. Patient 1 was admitted to the hospital on 9/9/16 with a primary diagnoses of non-healing wounds with possible osteomyelitis (infection of the bone), and had a severe leg weakness with marked loss of sensation in lower extremities. The history and physical indicated Patient 1 was able to walk one to two steps in assisting with transfers from the wheelchair. The photographic wound documentation, dated 9/9/16, contained four wound assessments as follows:

- Right buttocks, preliminary stage by the unit RN listed as stage 3, no final stage by WOCN on 9/12/16, no size, or depth.

- Left buttocks, preliminary stage by the unit RN listed as stage 4, no final stage by WOCN on 9/12/16, no size, or depth, odor, wound bed, surrounding skin color, or wound edge assessment.

- Right hip, preliminary stage by the unit RN listed as stage 4, no final stage by WOCN on 9/12/16, no size, or depth, odor, surrounding skin color, or wound edge assessment.

- Left hip, preliminary stage by the unit RN listed as stage 3, no final stage by WOCN on 9/12/16, no size, or depth, odor, surrounding skin color, or wound edge assessment. This form contained a reference to see note.

Patient 1's record contained a General Wound Note, dated 9/12/16, that clarified wound edges, wound bed, for each of the wounds and the surrounding skin for the right buttocks. The note did not contain assessments of size or odor of the four wounds and did not contain the surrounding skin assessment for all wounds except the right buttocks wound.

On 9/21/16 at 4 pm, ARN A acknowledged the above findings were not consistent with the hospital's policy on skin integrity.

2b. Patient 1's record indicated that the WOCN reassessed Patient 1 again on 9/15/16. Patient 1's record did not contain any other records by a WOCN after 9/15/16.

ON 9/22/16, the Inpatient Assessment and Reassessment policy, dated 8/14/16, indicated that WOCN assessment was to be done within two days of referral and reassessment was to be done every three days and with significant change in the wound.

On 9/22/16 at 9 am, ARN A acknowledged that the hospital policy for time frames for assessment and reassessment were not followed.

On 9/22/16 at 11:20 am, WOCN A stated that reassessment were done at the professional discretion of the WOCN. WOCN A further stated that the WOCN does not document or communicate with the unit RNs regarding their anticipated reassessment. WOCN A was not aware of the hospital Assessment and Reassessment policy time frames. WOCN A could not account for why Patient 1 had not been reassessed by a WOCN since 9/15/16, seven days prior.

2c. On 9/22/16, Patient 4's record was reviewed with ARN A. Patient 4 was admitted to the hospital on 9/7/16 with a primary diagnoses of bilateral thigh abscesses (collection of pus with the skin swollen and inflamed around it) and cellulitis (a bacterial skin infection) of the right lower leg. Patient 4's record indicated a WOCN assessed these wounds on 9/8, 9/12 (4 days later), and 9/16/16 (four days later). No other WOCN notes were present in Patient 4's record, five days later.

In a concurrent interview, ARN A acknowledged the time frames for WOCN reassessment were not followed.

2d. On 9/22/16, Patient 7's record was reviewed with ARN A. Patient 7 was admitted to the hospital on 8/19/16 with diagnoses that included possible sepsis (blood infection) from an infected pressure ulcer. Patient 7's record had photographic wound documentation, dated 8/19/16, and contained three wound assessments as follows:

- Right ischium (sitting bone) which had no preliminary stage assessed by the RN or a final stage assessed by the WOCN on 8/22/16, 3 days later.

- Left ischium which had no size, depth, or edges/surrounding tissue, or preliminary stage assessed by the RN or a final stage assessed by the WOCN, 8/22/16, 3 days later.

- Coccyx (tailbone) no size, or preliminary stage assessed by the RN or a final stage assessed by the WOCN, 8/22/16, 3 days later.

In a concurrent interview, ARN A acknowledged the timeframe for WOCN assessment were not followed.

3a. On 9/21/16 at 8:45 am, ARN A stated the frequency of dressing changes is governed by the hospital's "Wound Care Guidelines" which indicate that all stage 2, 3, and 4 pressure ulcers should have daily dressing changes and as necessary.

Patient 1's record was reviewed with ARN A and did not inlcude any documented dressing changes for Patient 1's four pressure ulcers on 9/13/16. (Refer to 1a for details of pressure ulcers).

On 9/22/16 at 8:45 am, ARN A acknowledged that Patient 1's pressure ulcers were not dressed daily as required by the hospital guidelines.

3b. Patient 4's record contained General Wound Notes, dated 9/8 and 9/12/16, that indicated that Patient 4 was caring for his wound himself and not following the Wound Care Guidelines or physician orders. Patient 4's record did not indicate that Patient 4's physician was notified or approved of Patient 4's self care of his wounds.

On 9/22/16 at 12 noon, ARN A reviewed Patient 4's record and acknowledged no order for self care was present, nor a report to the physician of Patient 4's self care of his wounds.

3c. Patient 7's record contained a physician's order, dated 8/22/16 at 4:55 pm, for a right breast dressing change with Xeroform (a type of dressing) every two days. Patient 7's record contained documentation that the dressing was changed on 8/23/16. Patient 7's record did not contain evidence of a dressing change on 8/25/16.

Patient 7's coccyx wound was not changed daily as indicated in the Wound Care Guidelines, with the only dressing change documented on 8/23/16.

Patient 7's right ischium wound was not changed daily on 8/22, 8/23, and 8/24/16.

On 9/22/16 at 2:40 pm, ARN A acknowledged that Patient 7's record did not contain documented wound care dressing changes as ordered.

4a. The hospital Wound Care Guidelines indicated pressure relief measures should be taken for all wounds and that patients should be turned every two hours.

Patient 1's record indicated that she turned herself but did not contain information as to which side. Patient 1's record contained only one documentation on 9/10/16 at 3:58 pm that she was positioned to the right side. (Refer to 2a for details of Patient 1's condition and wound severity).

On 9/22/16 at 8:45 am, ARN A acknowledged that repositioning was not documented every two hours for Patient 1, in a manner that ensured compliance with this nursing intervention.

4b. Patient 7's record did not contain information on which side Patient 7 was positioned as follows:
- 8/20/16 - from midnight to 6 pm on 8/21/16, 42 hours;
- 8/21/16 - from 6 pm to 10 pm, 4 hours;
- 8/22/16 - from midnight to 2 am, 2 hours; from 9 am to 2 pm, 5 hours;
- 8/23/16 - from 7 am to 5 am on 8/25/16, 46 hours;
- 8/25/16 - from 7 am to 8/26/16 at 7 pm, 36 hours.

On 9/22/16 at 2:35 pm, ARN A acknowledged that repositioning was not documented every two hours for Patient 7, in a manner that ensured compliance with this nursing intervention.

5. Patients 1, 4, and 7 records' all contained documentation which read "Dressing initiated" and/or "Dressing Changed per Order." The documentation did not give enough detail to know what actual dressing type /procedure was used or which physician's order was being followed.

On 9/22/16 at 3 pm, ARN A acknowledged that whether the correct, ordered dressing change was performed could not be ascertained by the documentation provided for Patients 1, 4 and 7.

6a. On 9/21/16, Patient 1's record contained wound measurements and a photographic record, dated 9/9/16. Patient 1's record did not contain any other evidence of wound measurements and photos.

On 9/21/16, the hospital policy, titled, "Skin Integrity, Prevention, and Treatment of Impaired Skin Integrity," dated 9/9/16, read, "Document the following:...f. Weekly wound measurements and photo attached to the "photographic wound record."

On 9/21/16 at 4 pm, ARN A stated the unit RNs were responsible for the weekly measurements and acknowledged this was not done for Patient 1.

6b. On 9/22/16, Patient 4's record contained wound measurements and a photographic record, dated 9/8/16. Patient 4's record did not contain any other evidence of wound measurements and photos.

On 9/22/16 at 12 pm, ARN A acknowledged wound measurements and photos were not done for Patient 4.

7a. On 9/21/16, the hospital policy, titled, "Skin Integrity, Prevention, and Treatment of Impaired Skin Integrity," dated 9/9/16, read, "Document fluid and nutritional intake."

Patient 1's record did not contain documentation of the amount meals or supplements consumed or if refused, as follows:

- 9/11/16 - lunch;
- 9/13 - lunch;
- 9/15 - lunch;
- 9/17 - lunch;
- 9/18 - lunch and supplements;
- 9/19 - breakfast, lunch, and dinner; and
- 9/20 - breakfast, lunch, and dinner.

On 9/22/16 at 9 am, ARN A acknowledged that Patient 1's documentation did not indicate an accurate record of meal and supplement consumption which was important in assessing enough protein and other nutrients for wound healing.

7b. Patient 4's record did not contain documentation of the amount meals or supplements consumed or if refused, as follows:

- 9/10/16 - dinner;
- 9/13 - snack/supplements;
- 9/14 - snack/supplements;
- 9/15 - snack/supplements;
- 9/16 - lunch and snack/supplements;
- 9/17 - lunch and dinner;
- 9/18 - breakfast and snack/supplements; and
- 9/19 - dinner and snack/supplements.

On 9/22/16 at 9 am, ARN A acknowledged that Patient 4's documentation did not indicate an accurate record of meal and supplement consumption

7c. On 9/22/16, Patient 7's record did not contain any record of diet or supplement intake.

On 9/22/15, ARN A stated Patient 7 preferred to eat organic foods brought into the hospital and the nursing staff did not have a system to account for her intake. (Refer to A 630, finding 2 for further details).


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7d. Medical record review was conducted on 9/21/16 beginning at 3 pm. Patient 8 was admitted to the hospital with diagnosis including severe dementia and failure to thrive. A history and physical dated 8/26/16 completed in the emergency room documented severe weight loss during the previous 6 months and a wound on her buttocks. Albumin (a measure of protein stores) dated 8/23, 8/25 and 8/30/16 revealed values of 2.2 milligrams/deciliter (mg/dl - a metric unit of measure), 1.8 mg/dl and 1.6 mg/dl respectively (normal values 3.5-5.0 mg/dl), indicating depleted protein stores. Admission height was documented as 5 feet 5 inches and weight was 120 pounds.

A nutrition screening assessment dated 8/26/16 completed by the Registered Nurse (RN) failed to note the weight loss. A physicians order dated 8/26/16 implemented a medical nutritional supplement 3 times per day; however there was no documentation evaluating the acceptance and/or effectiveness of the nutrition intervention. A comprehensive nutrition assessment completed by the Registered Dietitian (RD) on 8/292/16 documented inadequate oral intake, with interventions to include medical food supplements, coordination of nutrition care and monitor/evaluate food and nutrient take with a goal to consume at least 50 percent of meals and supplements.

In an interview on 9/22/16 at 11:45 am, with Dietary Management Staff (DMS) she confirmed it was the responsibility of nursing staff to document patient food/fluid intake and it would be difficult for the RD to assess the effectiveness of interventions without the information.

7e. Medical record review was conducted on 9/22/15 beginning at 11 am. Patient 9 was admitted to the hospital with diagnosis including severe diarrhea times 3 days, and gastroenteritis (inflammation of the stomach and intestines). A nutrition screening assessment dated 8/24/16, completed by the Registered Nurse (RN) documented weight loss of 2 to 13 pounds. The physician ordered a medical nutritional supplement, dated 8/31/16, three times/day.

A comprehensive nutrition assessment dated 8/26/16, completed by the Registered Dietitian (RD) noted a 10 percent weight loss during the previous 9 months with a history of Clostridium difficile (an intestinal bacteria causing diarrhea) that required previous hospitalization. The nutritional interventions were documented as medical food supplements with a plan to monitor and evaluate food and supplement intake. Albumin values (a measure of protein stores) from 8/26 to 9/6/16 revealed a range of 2.2 -2.7 milligram/deciliter (mg/dl - a metric unit of measure). Normal values were 3.5-5.0 mg/dl indicating a depletion of protein stores. Review of oral intake documents from 8/25 to 9/9/16 failed to document nutritional supplement intake.

In a concurrent interview with DMS, she confirmed it was the responsibility of nursing staff to document food/fluid intake and it would be difficult for the RD to assess the effectiveness of the interventions without complete information.

7f. Patient 10 was admitted to the hospital with diagnosis including chest pain and shortness of breath. Admission height and weight was documented on 9/1/16 at 6 am, as 106 pounds using a bed scale. A follow up weight on 9/1/16 documented at 12 pm, utilizing a bed scale, was documented as 123 pounds, a difference of 17 pounds. There was no nursing assessment of the discrepancy.

A comprehensive nutrition assessment dated 9/2/16 noted inadequate oral intake with estimated nutritional needs of 1450-1740 calories and 58-70 grams of protein, with a goal to meet at least 80 percent of nutritional needs. The goal was to monitor and evaluate intake. A follow up assessment dated 9/7/16 noted Patient 10 was not eating well, dietary intake was inadequate with a plan to monitor intake. Review of documented meal intake from 9/3 to 9/8/16 revealed inconsistent meal documentation with an average intake of 20 percent. There was no additional referral to the RD despite decreased intake for 5 days.

Treatment for pressure ulcers as recommended by The National Pressure Ulcer Advisory Panel (2015) would include adequate energy for the transport of nutrients, protein for healing damaged cells as well as nutritional supplements, to facilitate wound healing.

Based on dietetic services observations, dietary management staff interview and departmental document review the hospital failed to ensure the director of dietary services ensured that operations fully met recognized standards of practice when guidelines for raw meat storage were not consistent with food safety guidelines. This had the potential to affect all patients in a hospital census of 48.

Findings:

During initial tour of the kitchen on 9/20/16 beginning at 10:10 am, it was noted there was a document titled "Food Storage Chart" dated 9/20/16 posted on the 2-door refrigerator next to the stove. The purpose of the document was to provide guidance to dietary staff regarding the expiration and/or holding times for dry and refrigerated foods. It was noted that raw meat, based on the guidance, could be held up to four days. In a concurrent interview with Dietary Management Staff (DMS) she stated that the food chart was provided by the hospitals corporate entity and she was unsure of the standard of practice for the basis of this component of the document.

In a follow up interview on 9/20/16 at 3:30 pm, DMS provided a reference list for the holding times. It was noted that the posted food storage chart was not consistent with the standard of practice. As an example the United States Department of Agriculture recommends raw ground meats, raw sausage, fish and poultry be held for a maximum of 1 to 2 days. The hospital was unable to demonstrate that the materials received from the corporate level were reviewed for accuracy prior to implementation.

Based on review of the mass disaster preparedness plan the hospital failed to comprehensively evaluate the need for water in a disaster situation. Failure to evaluate needs based on the hospitals' demographic, location, and staffing patterns may result in compromising both patients and staff.

Findings:

On 9/2/16 beginning at 3 pm, the hospital's mass disaster preparedness plan was reviewed. In a concurrent interview with Dietary Management Staff (DMS) and Administrative Staffs (AS) F and G they stated that the hospital was planning to provide water for 540 people for a period of 7 days. It was also noted that the hospital plan was limited to .5 gallon per person/day. Neither DMS or AS G were able to provide information on how the hospital determined that this amount of water would be sufficient for not only the hydration needs of patients but also for basic wound and hygiene needs. Additionally the emergency water plan was calculated on the average patient census, rather than the licensed bed count. The hospital was unable to provide a standard of practice for the determination of water needs in the event of an emergency. While there are a wide range of values that are suggested for an emergency water supply the hospital was unable to demonstrate an assessment of needs to maintain operations in a widespread disaster.

Based on observation, interview, and record review, the hospital failed to ensure that nursing services were furnished or supervised by a registered nurse and consistent with nationally accepted standards of practice as evidenced by:

1. The hospital nursing policy did not give clear guidance for nursing staff on the expectations for assessing pressure ulcers (skin breakdown over bony prominences caused by prolonged pressure and/or friction).

2. The unit Registered Nurses (RN) and Wound and Ostomy Certified Nurses (WOCN) did not assess three of six patients with wounds as outlined in the hospital policies (Patients 1, 4, and 7).

3. Wound care treatment orders for three of six patients with wounds were not followed (Patients 1, 4, and 7).

4. The documentation of patient repositioning was not accurate to ensure that two of six patients with wounds were repositioned routinely (Patients 1 and 7).

5. Wound care documentation was not detailed enough to determine what care was provided for three of six patients with wounds (Patient 1, 4 and 7).

6. Wounds were not photographed every seven days as outlined in the hospital policy for two of six patients with wounds (Patients 1 and 4).

7. Nursing staff failed to to ensure evaluation of nursing care when medical nutrition supplements, dietary intake and/or weight discrepancies were not documented for six of 10 patients at nutritional risk (Patients 1, 4, 7, 8, 9, and 10).

These failures had the potential for patients to experience skin breakdown and worsening of wounds that could jeopardize their overall health status.

Findings:

1. On 9/21/16, the hospital policy, titled, "Skin Integrity, Prevention, and Treatment of Impaired Skin Integrity," dated 9/9/16, read, "ASSESSMENT: Nurses are responsible for identifying patients with potential alterations and those with actual alterations in skin integrity. Nurses are responsible for identifying and implementing interventions to prevent tissue injury and promote healing.....Any impairment of skin integrity on admission is documented to include location, size (length, width, depth in cm (centimeters), drainage, dressing, wound type, i.e. skin tear, venous (in veins) ulcer, rash, etc., ... Documentation includes completion of Photographic Wound record form with a picture attached and initiation of the dynamic (changing) wound group... Pressure ulcers are assessed using a disposable cm ruler or transparent single use measurement guide. Document length, width, in cm... Pressure ulcers are measured and documented weekly. Documentation will include location, size, stage, tracking (skin overhanging a dead space), undermining (skin overhanging a wound edge), drainage, odor, infection and presence of necrotic tissue. The RN will NOT stage any wound that may be related to pressure. The RN will order a wound care consult and the Wound Care Nurse will assess and stage if appropriate."

The policy continues with "Staging: (By WOCN or Wound Care Specialist only) and Treatment of Pressure Ulcers. Each wound care stage (rating of wound by depth as 1 to 4 with 1 being intact skin with non-blanchable (does not go away when touched) redness, usually over bony prominences and 4 being full thickness wound exposing bone, tendon, or muscle. Each stage described a different treatment the nurse may start and all stages indicated a WOCN consult should be obtained.

On 9/22/16 at 8:45 am, Administrative Nurse (ARN) A reviewed the above policy. ARN A acknowledged that the policy indicated wounds should be staged with assessment and that treatment was to be initiated prior to a WOCN consult and this also would require the RN to stage a wound to ensure the correct treatment was initiated for a pressure ulcer. ARN A stated RNs did not always stage wounds correctly and that WOCNs were more reliable in this task. ARN A demonstrated that a WOCN could verify the accuracy of the RN assessment of wound stage on the Photographic Wound Documentation form. ARN A further acknowledged that the policy was not clear for what was expected of the unit RNs.

2a. On 9/21 and 9/22/16, Patient 1's record was reviewed. Patient 1 was admitted to the hospital on 9/9/16 with a primary diagnoses of non-healing wounds with possible osteomyelitis (infection of the bone), and had a severe leg weakness with marked loss of sensation in lower extremities. The history and physical indicated Patient 1 was able to walk one to two steps in assisting with transfers from the wheelchair. The photographic wound documentation, dated 9/9/16, contained four wound assessments as follows:

- Right buttocks, preliminary stage by the unit RN listed as stage 3, no final stage by WOCN on 9/12/16, no size, or depth.

- Left buttocks, preliminary stage by the unit RN listed as stage 4, no final stage by WOCN on 9/12/16, no size, or depth, odor, wound bed, surrounding skin color, or wound edge assessment.

- Right hip, preliminary stage by the unit RN listed as stage 4, no final stage by WOCN on 9/12/16, no size, or depth, odor, surrounding skin color, or wound edge assessment.

- Left hip, preliminary stage by the unit RN listed as stage 3, no final stage by WOCN on 9/12/16, no size, or depth, odor, surrounding skin color, or wound edge assessment. This form contained a reference to see note.

Patient 1's record contained a General Wound Note, dated 9/12/16, that clarified wound edges, wound bed, for each of the wounds and the surrounding skin for the right buttocks. The note did not contain assessments of size or odor of the four wounds and did not contain the surrounding skin assessment for all wounds except the right buttocks wound.

On 9/21/16 at 4 pm, ARN A acknowledged the above findings were not consistent with the hospital's policy on skin integrity.

2b. Patient 1's record indicated that the WOCN reassessed Patient 1 again on 9/15/16. Patient 1's record did not contain any other records by a WOCN after 9/15/16.

ON 9/22/16, the Inpatient Assessment and Reassessment policy, dated 8/14/16, indicated that WOCN assessment was to be done within two days of referral and reassessment was to be done every three days and with significant change in the wound.

On 9/22/16 at 9 am, ARN A acknowledged that the hospital policy for time frames for assessment and reassessment were not followed.

On 9/22/16 at 11:20 am, WOCN A stated that reassessment were done at the professional discretion of the WOCN. WOCN A further stated that the WOCN does not document or communicate with the unit RNs regarding their anticipated reassessment. WOCN A was not aware of the hospital Assessment and Reassessment policy time frames. WOCN A could not account for why Patient 1 had not been reassessed by a WOCN since 9/15/16, seven days prior.

2c. On 9/22/16, Patient 4's record was reviewed with ARN A. Patient 4 was admitted to the hospital on 9/7/16 with a primary diagnoses of bilateral thigh abscesses (collection of pus with the skin swollen and inflamed around it) and cellulitis (a bacterial skin infection) of the right lower leg. Patient 4's record indicated a WOCN assessed these wounds on 9/8, 9/12 (4 days later), and 9/16/16 (four days later). No other WOCN notes were present in Patient 4's record, five days later.

In a concurrent interview, ARN A acknowledged the time frames for WOCN reassessment were not followed.

2d. On 9/22/16, Patient 7's record was reviewed with ARN A. Patient 7 was admitted to the hospital on 8/19/16 with diagnoses that included possible sepsis (blood infection) from an infected pressure ulcer. Patient 7's record had photographic wound documentation, dated 8/19/16, and contained three wound assessments as follows:

- Right ischium (sitting bone) which had no preliminary stage assessed by the RN or a final stage assessed by the WOCN on 8/22/16, 3 days later.

- Left ischium which had no size, depth, or edges/surrounding tissue, or preliminary stage assessed by the RN or a final stage assessed by the WOCN, 8/22/16, 3 days later.

- Coccyx (tailbone) no size, or preliminary stage assessed by the RN or a final stage assessed by the WOCN, 8/22/16, 3 days later.

In a concurrent inte