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Based on interview and record review, the facility failed to assess, perform, and document wound care according to facility policy for 1 (#P-2) of 1 patients reviewed for pressure injuries resulting in the potential for providers being unaware of potential changes in the patient's condition and the potential for poor patient outcomes. Findings include:

Review of the medical record for P-2 on 8/14/2023 at 1357 revealed he was an 86-year-old male who came to the emergency department on 4/11/2023 (ED) from a sub-acute rehab (SAR) for blood in the urine. An indwelling urinary catheter was present. A sacral wound was noted to be present that was "warm to touch." The admitting H&P (history and physical) revealed there were multiple sacral decubitus ulcers. The initial nursing assessment dated 4/12/2023 at 0437 noted the patient had a Braden score (scale used to assess the risk of pressure ulcers) of 14 (moderate risk). The skin assessment revealed the following: 1. Localized abnormal wound/fragile skin - buttocks mid-line pressure injury over bony prominences, unstageable. 2. Penile mid-line - pressure injury from medical device deep tissue. 3. Right and left heel. No description provided.

On 8/14/2023 at 1610, Nurse Manager Staff E, who was assisting with the electronic medical record review, was queried as to the measurement of the wounds on admission and/or pictures of the wounds. Staff E stated wound measurements were not present and the facility did not take pictures for wound care. One nursing note was discovered dated 4/14/2023 at 1700 stating, "Sacral wound at coccyx 2.5 in (inch) x 2.5 in in white eschar covered. Sm (small) amount bloody drainage." Outside of this note and a provider consult note dated 4/12/2023 there were no measurements present. While some of the later assessments indicated the wounds were "improving"; no documentation was present to quantify how the nurse came to that conclusion. On 8/14/2023 at 1408, Nurse Manger Staff E stated during interview that nurses were expected to do a complete head to toe assessment every shift and to document anything outside of normal. She agreed the nurses should be measuring the wounds.

The medical record revealed a surgical consult was obtained on 4/12/2023 for assessment of the sacral decubitus ulcer. In the "physical exam" portion of the consult, NP (Nurse Practitioner) Staff Q documented a sacral wound Stage III that was "3.4 cm (centimeters) in diameter. Some muscle with fibrinous white material. No purulence or eschar. Right heel thickening and pressure injury." Surgical intervention was not required. Review of orders revealed an order from NP Staff Q dated 4/12/2023 at 1052 for Santyl with Opti-foam overtop daily to the buttock area. No orders were found for the penile, right heel, and left heel wounds.

During interview on 8/15/2023 at 1049, NP Staff Q stated on reading her note that the ulcer "should have been a Stage IV" because of the involvement of the muscle. When queried as to why the heel injury was not staged, she stated it was not part of the consult. Staff Q explained that injuries from the knees up were generally treated by the surgical team while injuries from the knees down were addressed by podiatry. She further stated the consult would be "signed off" by the team unless surgical intervention was required. If nursing staff noted a change, they would have to re-consult the surgical team.

Physician progress notes dated 4/12/2023 at 1700 state, "Per RN (registered nurse) and wound care, patient's sacral ulcer appears to be infected ... Patient also has R (right) heel ulcer on exam, podiatry has been consulted. Wound care on board ..." Under the section marked "Plan", a consult to wound care was present. The physician progress note dated 4/13/2023 states, "Pt (patient) was seen by both surgery and podiatry for his ulcers with no surgical intervention planned." On 4/14/2023 the plan from the physician progress note stated, "Wound care following ... Recommend wound to stay dry. Wound nurse to monitor and apply Betadine as needed..." Urology progress note dated 4/16/2023 stated, "Nursing will apply Triad paste to penis for now (sic) Consult wound care RN for ulceration at penile meatus ..."

Further review of P-2's medical record revealed no wound care assessments or progress notes made by the wound care nurse.

On 8/14/2023 at 1155, review of the complaints and grievances revealed an entry dated 5/30/2023 alleging P-2's bedsore had expanded from his back onto his buttocks. The facility conducted an investigation of this allegation beginning 6/1/2023 and noted difficulty in finding documentation from the wound care nurse and requested her input. The wound care nurse indicated on 7/6/2023 she had been on bereavement leave when the consult was placed for wound care. She stated "surgery was managing wound. Nurses were managing patients (sic) wound according to the surgical surgery teams (sic) orders and recommendations."

On 8/15/2023 at 1150, requests were made for the dates the wound care nurse was unavailable and for an interview with the wound care nurse. At that time, Chief Nursing Officer (CNO) Staff C stated the wound care nurse had resigned 8/4/2023 and she had not yet been replaced.

On 8/15/2023 at 1330, review of the dates for leave by the wound care nurse were reviewed and showed the wound care nurse was available for the entire 4/11-2/5/2023 admission of P-2.

Review of the medical record revealed the facility failed to document detailed nursing wound assessments once per shift according to policy for the following shifts:

4/12/2023 at 0228 - right and left heel wounds no documentation
4/12/2023 at 0437 - right and left heel wounds no documentation
4/12/2023 at 0800 - penile and left heel wounds no documentation
4/14/2023 at 0300 - states "assessed" for buttock, penile, and right heel, but no documentation of assessment details; left heel no documentation
4/16/2023 at 2000 - penile, right heel and left heel had no documentation of assessment details
4/17/2023 at 2244 - no documentation for any of the wound assessments
4/21/2023 at 1424 - states "assessed" for buttock and penile wounds, but no documentation details of the assessment; right and left heel wounds no documentation
4/22/2023 at 0800 - left heel wound no documentation details of assessment

Further review of the medical record revealed the facility failed to perform dressing changes according to physician orders on the following dates:

4/13/2023 - No dressing changes
4/14/2023 - Only one dressing change
4/17/2023 - No dressing changes

On 8/15/2023 at 1116, RN Staff N stated the beside nurse should be measuring wounds. "That was done by the wound care nurse previously, but we should be doing that now."

Review of the policy for wound care revealed the policy number was blank. The policy titled "Skin Care, Wound Prevention, and Treatment Guidelines" effective 6/13/2023 states, "Skin assessment is done on every patient by the RN upon admission, transfer to new unit, in response to change in a condition, and for every shift, and includes assessment for actual or potential risk of skin breakdown, pressure, and wound injury ... Attention is given to pressure points, e.g., occiput, ear, elbow, iliac crest, sacrum/coccyx, ischial tuberosity, trochanter, knee, malleolus, heel and toe ... Attention is given to skin surrounding and/or in contact with medical device(s) e.g., skin under cervical collar, skin around tracheostomy tube ... Attention is given to the following: persistent erythema, non-blanching erythema, blisters, discoloration, unusual tissue consistency such as firm or boggy, change in sensation such as pain or itching ... "Braden Score" is determined with each assessment (minimally every shift ...) ... A patient with a Braden score less than or equal to 16 is referred to the Wound Care Service (skin and wound registered nurse, WCC [Wound care certification]) for consultation ... Assessment and Braden score must be documented in the EMR [electronic medical record]. If the patient refuses assessment, their refusal must be documented in the EMR ... Documentation of preventative measures and effectiveness, treatment progress of injury and wound, education, and patient and family response occur in the EMR ... When skin breakdown, injury and/or wound is discovered either on admission or during the hospital stay, the clinical nurse will implement the following interventions ... Inform the medical staff immediately giving the type of injury/wound, location, size, appearance of surrounding tissue an injury/wound bed, color, drainage, odor, presence or absence of pain, presence or absence of pulse ... Document in the EMR the following: Type of breakdown, injury or wound; Location Size in centimeters (length x width x depth using cephalocaudal orientation); Appearance of wound bed; Presence/absence of tunneling or undermining using clock face orientation; Stage or category as appropriate; Color, presence/character of slough and/or eschar; Presence/character of exudate; Odor; Condition of surrounding skin; Presence/absence of pain; Presence/decrease/absence of pulse ... A Wound Care Service consultation is completed by the wound care nurse Monday through Friday ... If no treatment orders are received within 24 hours of placing the wound care consult, contact the primary physician for treatment orders ... All pressure and wound injuries are measured at the time of admission and every Sunday as well as the day of discharge. Measurements are documented in the EMR ... All pressure and wound injuries are assessed for appearance, estimated depth, color, odor, description of surrounding tissue and be, and exudate with every dressing change and on the day of discharge. Dressing application or change is done per protocol, wound consult or physician order. All dressings are marked with date, time and caregiver's initials. Dressing application and change is documented in the EMR along with assessed information."