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Based on medical record review, policy review, and staff interview, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient (A395).

Based on medical record review, policy review, and staff interview, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for one of 10 medical records reviewed (Patient #1). The census was 328.

Findings include :

Review on 12/27/21 of the policy titled, Wound Care Including Dressings, Negative Pressure Wound Therapy (NPWT), Removal of Drains, Packing, and Pressure Injury Care Including
Prevention, issued 12/01/16, reviewed 10/10/18, effective 10/26/21, revealed wounds are assessed and measured at admission, then assessed daily, and measured weekly thereafter. All wounds should be measured and documented on with any significant change. Skin is to be assessed daily and the physician should be notified of any new or declining wounds. For pressure, staff should utilize pressure redistribution surfaces, reposition at least every 2 hours, keep the head of the bed no greater than 30 degrees and apply protective cream and/or skin prep to heels and other bony prominences several times a day.

Review of Patient #1's medical record revealed an admission date of 10/18/21 with COVID-19 as a diagnosis. Staff I completed the skin assessment on 10/18/21 at 8:00 PM. The assessment showed the patient had a coccyx wound that had no drainage or odor. The wound bed was pink and pale, and a barrier cream was applied. There was no wound nurse consult and/or physician notification or measurements noted. Further review of the patient's record revealed staff applied the barrier cream as needed, cleaning the wound at least once a day and placed the patient on a pressure reduction mattress with constant repositioning. Staff would apply an absorbent dressing as protection to the area at times. At times staff would leave the wound open to air.

On 11/01/21 Staff J put in a wound care consult. On 11/01/21 the wound care nurse, Staff K assessed the patient and found two Stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister), one on the patient's coccyx and one on the left ischium. The left ischium was identified as a deep tissue injury opening to a Stage 2 pressure injury measuring 5 centimeters (cm) x 4 cm x 0.1 cm. The coccyx Stage 2 pressure ulcer was identified as "present on admission." No measurements were noted for this wound.

Review of the wound care orders dated 11/01/21 revealed nursing was to clean the wound and apply Triad paste (paste used for light-to-moderate levels of wound exudates. Helps maintain an optimal wound healing environment to facilitate natural autolytic debridement) twice a day. Review of nursing wound care flow sheets revealed on 11/05/21 no treatment was provided to the wound as ordered. On 11/07/21, 11/08/21 and 11/11/21 there was only one treatment documented as completed. On 11/08/21 the wound care nurse, Staff L, assessed Patient #1's wounds. The left ischium was now staged as a Stage 3 pressure injury ((Full thickness skin loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining/tunneling) measuring 6 cm x 4.5 cm x 0.2 cm with deep red non-granular tissue and peeling peri-wound tissue. The coccyx wound was now assessed to be a Stage 3 pressure injury measuring 12 cm x 7 cm x 0.2 cm.

The patient's coccyx wound that was present on admission on 10/18/21 was not measured on admission, nor was it measured weekly per policy. There was no evidence the physician was notified of the patient's coccyx wound when it was identified on admission. There were no measurements of the coccyx wound when the wound consult was made on 11/01/21 even though the wound was identified as a Stage 2 at that time. A second wound on the patient's left ischium, that was not present on admission, was identified as a Stage 2 at that time. It measured 5 cm x 4 cm x 0.1 cm. The Triad paste was not applied as ordered between 11/01/21 and 11/08/21. On 11/08/21, one week later, both wounds had progressed to Stage 3.

These findings were verified with Staff C on 12/28/21 at 2:00 PM.

This deficiency substantiates Substantial Allegation OH00127860.