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Based on record review and interview, the facility failed to ensure wound care was provided as ordered for one (1) of two (2) patients (ID # 1).

Findings include:
Record review of facility policy titled "Inpatient Wound Care Services Scope of Services, Responsibilities and New Consults (North Cypress Campus Only), dated 10/2020, showed the following information:

PROCEDURE:
1. SERVICES PROVIDED AND RESPONSIBILTY OF WOUND CARE SPECILIST
A.Evaluation and recommendation for treatment of, but not limited to:
i.Ostomy care ...
ii. Pressure injuries
iii. Venous ulcers ...
B. Assists with education for staff to perform ordered interventions

D. May perform daily or scheduled patient care interventions if warranted by complexity of wound (to be determined by wound care specialist during establishment of treatment plan).

E. Interdisciplinary communication with physician, nursing staff, social services staff, case managers, dietitians, and other therapeutic clinicians to determine the need for adjunct services or outside referrals upon discharge. This might include assistance with orders for negative pressure wound therapy, therapeutic support surfaces, specialty offloading devices, home health services, or other outpatient follow up.

7. DOCUMENTATION

a. Wound care center personnel trained in wound care will document evaluations and recommendations for treatment in the patient's electronic medical record.
i. Notes will be documented under Wound Specialists Documentation
ii. Recommendations are made in wound care specialists note
1. Primary nurse is to be notified of recommendations and is responsible to notify physician.

Review of medical record for patient (ID#1) showed the following:

Wound care consult care note: 7/21/23
RIGHT FOOT was cleaned with mile soap and water patted dry with clean gauze.
LATERLA RIGHT FOOT: measuring 11.5 cm x 12.0 cm x 0.2, red tissue, partial flap attached, peri wound is edematous, ecchymosis, erythema. Small serosanguineous drainage, edges and flap are delicate. Aquacel AG was applied and covered with ABD and secured with Kerlix and Medipore tape.
Patient tolerated well. Primary nurse aware.

Wound Care Treatment Order 7/21/23:
Primary Nurse to perform all dressing changes
***RIGHT LATERAL FOOT***MWF and PRN
Remove old dressings and discard. Cleanse gently with NS, pat dry with clean gauze. Apply Aquacel AG and cover with Kerlix and Medipore.

Wound care consult note: 7/24/23
PI 2 on coccyx
Patient was soiled with bowel movement, pericare done.
PI stage 2 gluteal cleft. Cleansed with NS, patted dry, applied zinc. No border foam due to frequent bowel incontinence.

Changed dressings to right foot. Removed old dressings and discarded, Cleansed with NS and patted dry with gauze. Applied Aquacel aG, ABD Kerlix and taped.

Wound care Treatment Order 7/24/23
Primary Nurse to perform all dressing changes
Stage 2 PI gluteal cleft-daily and prn
Remove old dressings and discard. Cleanse with NS, pat dry. Apply Zinc cream. No mepilex border due to frequent bowel incontinence.

No daily nursing documentation could be located for dressing changes to gluteal cleft.

Dressing changes to right foot were documented on 7/21/23, 7/24/23, 7/28/23, 7/29/23, 7/30/23, 7/31/23 and 8/1/23.

Interview with CMO (ID# 53) and VP of Quality (ID# 51) on 9/18/23 at 12:00 PM agreed with the above findings with CMO (ID# 53) stating that nursing staff should carry out orders for dressing changes and document appropriately.