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Based on interview and record review the hospital failed to ensure there was an ongoing evaluation for the treatment of 1 of 1 (Patient #1) patient's wound. The patient was admitted to the hospital with a right hip wound that was almost healed. The wound deteriorated during the patient's admission to the hospital.

Findings included:

Patient #1 was a 21-year-old male who was admitted to the hospital on 05/09/2023. He had a medical history of sleep apnea, lung disease, scoliosis, on BiPAP at night, congenital Cytomegalovirus infection, cerebral palsy, spastic quadriplegia, developmental delay, epilepsy, feeding tube dependence, blind, nonverbal at baseline who presented to the Emergency Department with shortness of breath.

Patient #1 was admitted with a right hip wound. Nursing notes dated 05/10/23 indicated the wound was extra small (less than 4 sq cm). It was approximately the size of a quarter. The wound depth was partial thickness. It was less or equal to 0.3 cm. It was a shallow wound.

An order for a Wound Care Consult was requested by the provider on 05/10/2023.

The wound care nurse did not assess Patient #1 until 7 days later on 05/17/2023. There was no documented measurements of the right hip wound. The patient was seen by the wound care nurse on 05/25/2023. There was no documentation of measurements of the right hip wound. The patient was seen one last time by the wound care nurse on 05/26/2023. The wound measured 4 cm X W 4 cm X 00.2 cm.

Nursing Notes dated 05/30/23 indicated the right hip wound had a brown/black and pink eschar necrosis. The wound size was approximately the size of a 2 x 2 gauze.

Patient #1 was discharged on 06/02/23. There were no wound care notes on 05/31/23-06/02/23.

During an interview on 08/23/23 at 1:45 PM with Personnel #5, Director of Wound Care she confirmed Patient #1's right hip wound had deteriorated during his hospital admission. She also confirmed the wound consult referral was made on 05/10/23 but the patient wasn't seen by a wound care nurse until 5/17/23. She said a wound care nurse usually assessed a patient within 24-48 hours after a referral to the wound care department was made.

During an interview on 08/23/23 at 1:50 PM with Personnel #4, Wound Care Nurse she confirmed that measurements were not documented for Patient #1's right hip wound on 5/17/23 and 5/25/23. She stated that there should have been measurements documented.