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A. Based on document review and interview, it was determined that for 2 of 4 (Pt. #7 and Pt. #8) clinical records reviewed for wound care management, at Location A, the Hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient by failing to complete the physician's order for wound care.

Findings include:

1. On 5/31/2022, the clinical record for Pt. #7 was reviewed. Pt. #7 was admitted on 5/6/2022, due to respiratory failure. Pt. #7's clinical record included a physician's order on 5/26/2022, for daily wound care to right chest with betadine paint. Pt. #7's clinical record lacked documentation that the daily wound care was completed on 5/29/2022 and 5/30/2022.

2. On 5/31/2022, the clinical record for Pt. #8 was reviewed. Pt. #8 was admitted on 5/13/2022, due to respiratory failure. Pt. #8's clinical record included a physician's order on 5/21/2022, for daily wound care to left foot with normal saline. Pt. #8's clinical record lacked documentation that the daily wound care to left foot was completed on 5/30/2022.

3. On 6/1/2022, the Hospital's job description for registered nurses (undated) was reviewed and included, "... Essential Functions... Receives physician's orders, ensures transcription is accurate and documents completion..."

4. On 5/31/2022 at approximately 11:30 AM, findings were discussed with E #15 (Nurse Educator). E #15 could not provide documentation that the physician's orders were completed.

B. Based on document review and interview, it was determined that for 2 of 4 (Pt. #7 and Pt. #8) clinical records reviewed at Location A, the Hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient by failing to complete the Braden Scale Assessment (skin assessment for risk for developing pressure ulcer).

Findings include:

1. The Hospital's policy titled, "Skin and Wound Care Program Overview" (dated 6/2020) was reviewed and included, "... This policy establishes guidelines to provide individuals with high-quality... skin and wound care... Policy... 1. Pressure Ulcer Risk Assessment a. Braden Scale completed by admitting nurse upon admission then daily..."

2. On 5/31/2022, the clinical record for Pt. #7 was reviewed. Pt. #7 was admitted on 5/6/2022, due to respiratory failure. Pt. #7's Braden Scale Assessment scores were between 10-11 (high risk to develop pressure ulcer) from 5/26/2022 through 5/28/2022. The clinical record lacked Braden Scale Assessment on 5/29/2022.

3. On 5/31/2022, the clinical record for Pt. #8 was reviewed. Pt. #8 was admitted on 5/13/2022, due to respiratory failure. Pt. #8's Braden Scale Assessment score was 11 (high risk to develop pressure ulcer) from 5/26/2022 through 5/28/2022. The clinical record lacked Braden Scale Assessment on 5/29/2022.

4. On 5/31/2022, findings were discussed with E #15 (Nurse Educator). E #15 stated that Braden Scale Assessment should be completed daily. E #15 could not provide documentation that the assessments were completed for Pt. #7 and Pt. #8.