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Based on observation, interview and record review the facility failed to provide organized nursing services that follow the nursing process of identifying and responding to patient needs through assessment, care planning and documentation two (#1 and #3) of 6 patients reviewed for wounds out of a total sample of 10, resulting in increased risk of unmet care needs for all 297 patients. Findings include:

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A-0395 Failure to perform consistent wound care and dressing changes; create and update Nursing Care Plans and Interventions, Consistently measure and assess wounds, and perform wound care in a sanitary manner.

Based on document review, observation, and interview the facility failed to ensure that A Nursing Care Plan for Impaired Skin Integrity was developed for one (#1) of 6 patients reviewed for wounds, out of a total sample of 10, failed to ensure that Nursing Care Plans were updated with wound treatment interventions and wound descriptions for two (#1 and #3) of 6 patients reviewed for wounds out of a total sample of 10, and failed to ensure that the Nursing Care Plan goal of promoting skin integrity was implemented by ensuring regular, sanitary and as ordered wound treatments/dressing changes were done for two (#1 and #3) patients reviewed for wounds out of a total sample of 10, resulting in the potential for impaired wound healing for two of 10 reviewed out of a total of 297 patients in the facility. Findings include:

On 2/18/18 at approximately 1300 Patient #1's clinical record and all additional paper documentation was reviewed with Staff J , and on 2/18/18 at approximately 1400, Patient #3's clinical record and all additional paper documentation was reviewed with Staff J and the following discrepancies with wound treatment orders, consistent performance of wound treatments, and Nursing Care Plan updates and Interventions were revealed, which had a potential adverse effect on the Goals of the Nursing Care Plan for Skin Integrity:

Patient #1 was a 77 year old female who resided in a nursing home (SNF) and had three admissions to the facility in 2017. Admission diagnoses included Acute Shortness of Breath, Exacerbation of Chronic Obstructive Pulmonary Disease (COPD), and Urinary Tract Infection (UTI).

For the Patient #1's first admission in 2017, a Nursing Admission Assessment dated 3/31/17 at 2200 documented that the patient was admitted with a Stage III sacral Pressure Injury. There were no initial measurements of the wound and no weekly wound measurements and assessment of wound progress, noted on the Nursing Care Plan, or elsewhere in the clinical record, as required per facility policy for this admission, . There were no orders for dressing changes or wound care for Patient #1 for this admission, and no documentation of the type or frequency of dressings needed, the number, stage, location, size or wound progress noted on the Nursing Care Plans. The first wound care note for Patient #1 was on 4/8/17 (nine days after admission), and did not contain measurements to enter on the Nursing Care Plan, as required per policy, Review of the EMR and all additional medical record information (provided per request) with Staff J revealed there was no documentation of Pressure Injury dressing changes before 4/6/17 at 1600 (seven days after admission), potentially effecting the Goals on the Nursing Care Plan for Skin Integrity , initiated on 3/31/17. There was no documentation to indicate whether the wound had gotten worse or better during admission.

Patient #1 was readmitted (admission #2) on 7/31/17 through 8/28/17 for a diagnosis of Peg Tube dislodgment. A Nursing Admission Assessment dated 7/31/17 documented that the patient had an unstageable wound on the coccyx on admission. The Nursing Care Plan for impaired Skin Integrity, initiated on 7/31/17, documented that Patient #1 had "a big Pressure sore", but contained no measurements or treatment interventions (orders). There were no descriptions of wound progression or weekly measurements noted on the Nursing Care plans. A bone scan done on 8/4/17 at 1422 documented the patient had osteomyelitis and septic arthritis at the site. The nursing care plan was not updated to reflect this. Dressing changes and daily wound assessments were documented on the nursing flow sheets, but contained no measurements or assessment of healing or worsening. The only Wound Care Note with measurements for this four week admission was dated 8/7/17, and documented that the wound was a Stage IV (full thickness, exposing bone or tendon), measuring 7 cm long x 6 cm wide x 4 cm deep. This finding was not entered on the Nursing Care plan. There was no documentation to indicate whether the wound had gotten worse or better during admission.

Patient #1 was readmitted (admission #3) on 9/18/17. Diagnoses included Infection, and Rule Out Sepsis. A Physician's Admission History and Physical dated 9/18/17 at 1855 noted that the patient had osteomyelitis (bone and muscle infection) of a sacral decubitus (Pressure Injury). There was no Nursing Care Plan for Impaired Skin Integrity (wounds), for Osteomyelitis, or Sepsis for this admission. Nursing flowsheets noted a Stage IV sacral Pressure Injury and performance of daily dressing changes. There were no orders written for wound care/dressing changes on the clinical record, and no wound treatment/dressing change interventions noted on the Nursing Care Plan. A Bone Scan dated 9/20/17 documented the patient had osteomyelitis of the sacrum and left hip joint septic arthritis. Blood cultures were positive for Staphylococcus capitus. The Nursing care plan was not updated to reflect this. Review of nursing flow sheets revealed wet to dry dressing changes were done daily, with two days of omission, on 9/21/17 and 9/22/17. Patient #1 expired in the facility on 9/23/17.

Patient #3 was a 79 year old female who was admitted from a nursing home (SNF) to the facility on 1/25/18 with diagnoses which included Percutaneous Endoscopic Gastrostomy (PEG tube), and Infected Stage IV Pressure Injury wounds. An admission Nursing assessment dated 1/25/18 documented Patient #3 was at risk for developing pressure injuries with a Braden Scale Score of 10 (10 - 12 = high risk), and was admitted with six wounds, a right trochanter (hip) Stage IV Pressure Injury, infected Stage IV coccyx Pressure Injury, a Left buttock Pressure injury (no stage or measurements documented), a left elbow wound (no description) right leg, right heel and left heel wounds described by the podiatrist on 2/1/18 at 1440 as bilateral Stage II to III decubitus ulcers (Pressure Injuries).

Review of wound care orders from 1/25/18 through 2/18/18 for Patient #3 revealed the following order dated 2/1/18 at 1148, "twice daily (BID) santyl application with wet to dry kerlex gauze followed by ABD and paper tape" (no wound or area specified). Review of Nursing flowsheets from 2/1/18 through 2/18/18 revealed that this was done once daily instead of the two times daily that was ordered. There was no notation or updates on the Nursing Care Plan of wound treatments/dressing change interventions, wound measurements or progression.

An active (not discontinued) Wound care order for Patient #3's R leg and bilateral heel wounds, dated 1/26/18 at 1252 noted, "please flush the wounds of R lower leg and bilateral heels with Dakin solution, apply aquacel ag dressing daily." There were no further orders noted for leg and foot wounds. A Post Operative note dated 2/1/18 at 1440 documented that patient #3 had wound debridement of bilateral Stage II - III infected leg and heel ulcers. There were no updated treatment orders or Nursing Care plan updated interventions to reflect this. Review of the clinical record revealed no documentation to indicate that the heel and leg wound dressings were changed since 2/1/18.

On 2/8/18 at 1110, Staff L was observed during a dressing change on Patient #3's Stage IV (full thickness injury, exposing bone and tendon) right trochanter, sacral and left buttock Pressure Injuries (bedsores). The both of the patient's legs were wrapped with gauze and ace wrap from the toes to below the knee, and there was no date on either dressing. When queried, Staff L stated that the podiatrist had debrided the foot wounds on 1/31/17, and did not want the dressings changed. There was a meplex dressing on the patient's right elbow. Observation at this time revealed discrepancies with treatment orders, and risks for delayed wound healing related to missing treatments and cross contamination of the wounds. Patient #3's sacral and buttock wounds were covered with an undated gauze dressing that was soiled with a moderate amount of serosanguinous drainage. When queried, Staff L stated that Patient #3's wet to dry sacral and buttock dressings should be changed daily. During the wound care, Patient #3 was incontinent of stool. Staff L cleaned up the stool, removed gloves, and without sanitizing hands, applied a new pair of gloves and started to pack the sacral wound with wet gauze packing, using gloved hands to handle the gauze. When queried, Staff L stated that he was unaware that hands needed to be sanitized between glove changes.

On 2/8/18 at 1530, the Chief Nursing Officer, Staff G was interviewed and reported that per policy, wound measurements and description of wound progression should be documented within 48 hours of admission and weekly thereafter, and entered on the Nursing Care Plan. When queried, Staff G stated that missing dressing changes and failure to follow aseptic technique during wound care could have a negative impact on wound healing and skin integrity.

On 2/9/18 at 0800, review of the facility policy entitled, "Pressure Injuries, Prevention and Care", dated 8/31/17 revealed the following notations:

"RNs use the policies for basic nursing interventions and enter Electronic Medical Record (EMR) orders aimed at the prevention and management of pressure ulcers."

"Initiate and document every shift in Altered Tissue Integrity Plan of Care for patients with pressure ulcers."

"Assess patient outcomes of interventions and revise plan of care as needed."

Policies on Nursing Care Plans, following Physician's orders and wound measurement and assessment of wound progression were requested but not provided by survey exit.