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Based on interview and record review, it was determined the facility did not adequately supervise and evaluate the nursing care for 14 of 14 sampled patients. Specifically, for 12 of 14 patients, there was not documented evidence of oversight of nursing aides by a nurse. (Patient identifiers: 1, 2, 4, 5, 6, 7, 8, 9, 10, 12, 13, and 14). Additionally, performance of wound care tasks, peri-care and/or repositioning of patients was not documented for 7 of 14 patients (Patient identifiers: 2, 3, 6, 7, 11, 13 and 14).

Findings include:

1) Patient charts were reviewed from 03/04/2021 through 03/10/2021. For 12 of 14 sampled patients (patient identifiers: 1, 2, 4, 5, 6, 7, 8, 9, 10, 12, 13, and 14), on one or more days, the signature was missing on the 24 hour flowsheet for the nurse to sign stating a review of the nursing aides' cares and documentation had been completed.

2) In an interview with the hospital's Chief Clinical Officer (CCO) at approximately 1:30 PM on 03/09/2021, the CCO stated each day the nurses should be signing the 24 hour flowsheets on the page designated to show oversight of nursing aides.

3) Patient 2's chart was reviewed on 03/08/2021.

Patient 2 was admitted to the hospital on 01/28/2021, with diagnoses of paraplegia and morbid obesity.

Review of patient 2's medical record revealed that on 01/29/2021, an order for wound care for a wound on the left lower leg was placed: cleanse with Chlorhexidine Gluconate BID (twice per day).

The wound care order, medication administration record (MAR), and 24 hour flow sheets were reviewed. There was no documented evidence of wound care on 02/07/2021.

4) Patient 3's chart was reviewed on 03/08/2021.

Patient 3 was admitted to the hospital on 02/10/2021, with a diagnosis of T11 paraplegia.

Review of patient 3's medical record revealed that on 02/11/2021, an order for wound care for a right hip flap was placed: cleanse with Chlorhexidine Gluconate once daily.

The wound care order, MAR, and 24 hour flow sheets were reviewed. There was no documented evidence of wound care on 02/25/2021 or 02/27/2021.

5) Patient 11's medical record was reviewed on 03/09/2021.

Patient 11 was admitted to the hospital on 02/17/2021, with diagnoses of acute hypoxic respiratory failure and post COVID-19 pneumonia. Review of patient 11's medical record revealed patient 11 was bedbound and on a ventilator.

On 02/18/2021, an order was placed for wound care for wounds on the right buttock and groin: cleanse with Phytoplex No Rinse Soap BID (twice per day).

The wound care order, MAR, and 24 hour flow sheets were reviewed. There was no documented evidence of wound care on 03/04/2021. Additionally, documentation showed wound care only once per day on 02/20/2021, 02/23/2021, 02/27/2021, 03/05/2021, and 03/06/2021.

6) Patient 13's medical record was reviewed on 03/09/2021.

Patient 13 was admitted to the hospital on 01/22/2021, with diagnoses of post COVID-19 pneumonia and tracheostomy, and acute respiratory failure. Review of patient 13's medical record revealed patient 13 was bedbound and on a ventilator.

On 01/26/2021, an order was placed for wound care for wounds on the buttocks and sacrum: cleanse with Cholorhexidine Gluconate BID.

The wound care order, MAR, and 24 hour flow sheets were reviewed. There was no documented evidence of wound care on 01/31/2021 and 03/03/2021.


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7) Patient 6's medical record was reviewed on 03/08/2021.

Patient 6 was admitted to the hospital on 02/19/2021, with diagnosis of acute respiratory failure. Review of patient 6's medical record revealed patient 6 was bedbound and on a ventilator.

It was documented on a wound care note dated 02/22/2021, that patient 6 had a stage 3 sacrum/coccyx wound upon admit. Patient 6 did not have wound care orders until 02/22/2021 (3 days after admit). There was no documented evidence if wound care had been initiated and implemented prior to 02/22/2021.

According to aide protocol perineal care (cleaning the private areas of a patient; this area is prone to infection, it must be cleaned at least daily, and more if the patient is incontinent) was to be performed at least once per 12 hour shift. The Daily Flow Sheets from 02/19/2021 through 03/02/2021 were reviewed. There was no documented evidence of perineal care on 02/24/2021 and 02/26/2021 PM shifts, and the 03/01/2021 and 03/02/2021 AM shifts; there was no documented evidence of a bed bath or shower documented in its place, during the dates listed.

8) Patient 7 was admitted to the hospital on 02/17/2021, with diagnoses of intracranial hemorrhage. Review of patient 7's medical record revealed patient 7 was bedbound and on a ventilator.

a. According to protocol, bed baths or showers were to be completed every other day or more often if needed. Bed baths were documented for patient 7 on 02/18/2021, 02/20/2021, 02/21/2021, and 02/22/2021. 02/23/2021, 02/25/2021, 02/27/2021, 03/02/2021. There was a bed bath missed on 03/01/2021 with no documentation as to why.

An interview was conducted with the CCO on 03/08/2021 at 5:07 PM regarding missing documentation. She stated that the bed bath on 03/01/2021 was not completed due to Mr. Webb being hypotensive and for fear of dropping his blood pressure even more. Bed baths were to be resumed when blood pressures were stabilized; however, this was not documented in the medical record. She stated the expectation was staff would have documented why the bath was not completed.

b. It was documented on an admission wound care note dated 02/18/2021, that patient 7 had incontinence-associated dermatitis (skin damage associated with exposure to urine or stool) to the buttocks, and it was blanchable. On 02/18/2021, it was ordered for powder then barrier cream to the affected area twice per day, and as needed. On the following dates there was no documented evidence the wound care was completed as ordered: on 02/18/2021, 02/20/2021, 02/25/2021, 02/27/2021, 02/28/2021, and 03/01/2021, it was documented one time. On 02/19/2021, it was documented zero times.

According to aide protocol perineal care was to be performed at least once per shift. The Daily Flow Sheets from 02/17/2021 through 03/03/2021 were reviewed. There was no documented evidence of perineal care on 02/19/2021, 02/20/2021, 02/23/2021, and 02/28/2021 PM shifts, and 03/01/2021 AM shift. On the 02/28/2021 AM shift there was no perineal care documented but Foley catheter care was documented 2 times; however, according to documentation patient 7 did not have a Foley catheter at the time. There was no documented evidence of a bed bath or shower documented in its place, during any of the aforementioned dates.

According to protocol and wound care orders, patient 7 was to be turned/repositioned every 2 hours. The Daily Flow Sheets from 02/17/2021 through 03/03/2021 were reviewed. There was no documented evidence of turning/repositioning on 02/18/2021 from 7:00 AM until 8:00 PM, and on 02/19/2021, 02/20/2021, 02/23/2021, 02/26/2021 PM shifts; and 02/23/2021 AM shift.

On 02/26/2021, on the nurses AM and PM shift assessment notes it was documented "sacral wound", there was no other information documented about the wound. On 03/02/2021, the wound care nurse documented: increased partial thickness skin loss with darker discoloration along the gluteal cleft/coccyx, patient was started on vasopressors which could contribute to blood perfusion issues, ordered quartet mattress to help reverse, with new wound care orders for wound care to affected area. Patient was discharged the next day.

An interview was conducted with the wound care nurse (WCN) on 03/09/2021 at 11:11 AM regarding patient 7. The WCN stated that her initial assessment of patient 7 was of normal IAD below sacrum and was blanching. She stated if a patient does not have wounds that need to be measured then she would see them every other week unless the nurse reports issues sooner. On the morning of 03/02/2021, she was planning on seeing patient 7, the nurse had also come to her that morning stating that patient's 7 sacral area became purple and non-blanching during that night after he was started on the vasopressors. The WCN stated upon assessment she noted skin fluffing and the skin was starting to breakdown on the bottom half of the wound, and the right sacral area was starting to turn purple. She immediately changed the protocol and ordered a different air mattress. The WCN stated that patient 7 was having a lot of cardiac instability which contributed to the worsening of his wound. I discussed with her the lack of documentation noted for pericare, barrier cream application as ordered, and turning and repositioning. The WCN responded that in her honest opinion documentation was an issue, and she did not believe the staff would not turn or care for the patients for entire 12 hour shifts at a time. She continued, stating skin was their thing; it was a big deal, they were sent patients with extensive complex wounds to heal them, "we do not cause them," and if a patient went long periods of time without being cared for in that capacity, and with the extent of his cardiac issues, his wound would have been far worse.

There was not enough evidence to determine if cares were not performed or were performed and not documented. Or if the worsening wound in the sacral region was due to a lack of care or from his cardiac instability and vasopressors, or a combination of both.

9) Patient 8 was admitted to the hospital on 01/19/2021, with diagnoses of bilateral lower extremity venous stasis ulcer with necrotizing cellulitis.

It was documented on the admission wound care note dated 01/21/2021, that patient 8 had very complex lower leg venous ulcers with exposed muscle and tendon and areas of necrotic tissue upon admission.

Patient 8's updated wound care orders dated 01/27/2021 were for dressing changes 2 times per week to the left thigh and right leg. There was no documented evidence wound care was performed on 01/29/2021 and 02/05/2021 for both wound sites.

It was also documented on 02/09/2021 and 02/11/2021 that wounds continued to improve and had decreased in sized, were epithelized, and had good granulation with no signs or symptoms of infection. Patient 8 was discharged to home health on 02/11/2021.

10) Patient 14 was admitted to the hospital on 02/08/2021, with diagnosis of acute respiratory failure secondary to COVID-19. Review of patient 14's medical record revealed patient 14 was bedbound and on a ventilator.

It was documented on a wound care note dated 02/10/2021, that patient 14 had an 8x8x0.3 centimeter sacral wound on admit with areas of necrosis, non-blanching, deep tissue injury.

According to aide protocol perineal care was to be performed at least once per shift. The Daily Flow Sheets from 02/08/2021 through 03/06/2021 were reviewed. There was no documented evidence of perineal care on 02/17/2021 both AM and PM shifts, and the PM shifts for 02/20/2021, 02/23/2021, 02/24/2021, 02/25/2021, 02/26/2021, 03/01/2021, 03/04/2021 and 03/05/2021. There was no documented evidence of a bed bath or shower documented in its place, during the dates listed.

According to protocol and wound care orders, patient 14 was to be turned/repositioned every 2 hours. The Daily Flow Sheets from 02/08/2021 through 03/06/2021 were reviewed. There was no documented evidence of turning/repositioning on 02/10/2021 AM shift, 02/17/2021 AM/PM shifts, 02/20/2021 AM/PM shifts, 02/23/2021 PM shifts, 02/24/2021 PM shift, 03/04/2021 after 11:00 AM with none documented on the PM shift either, 03/06/2021 AM last documented at 10:00 AM then not again until 6:00 PM.

There was no evidence of a new or worsening wound that correlated with the lack of documentation. On 03/03/2021, the wound care nurse documented the following: wound measured 6.6x7x0.1 cm 80% epithelized and now stage 3. Wound showed significant improvement.

It appears cares may have been performed but not documented, for patient 14.

11) In an interview with the CCO at 1:38 PM on 03/09/2021, the CCO stated if the MAR did not show wound care documentation, then it may also be documented in the nurse's narrative of the 24 hour flow sheets. She stated that if wound care was not documented there either, then there was not another place that it would be documented in the medical record.

12) No care issues were identified during observations and interviews with patients and staff. However, on 03/09/2021, due to documentation issues noted in patient 7's medical record the sample was expanded to review the medical records for all active bedbound patients; there were 4 (patients 11 through 14). Review of the first 10 and the additional 4 medical records revealed similar documentation concerns. However, there was not enough evidence to correlate the lack of documentation to negative outcomes to the patients. Patient 7 was the only patient that showed a worsening wound, but again there was not enough evidence to determine if cares were not performed or were performed and not documented. Or if the worsening wound in the sacral region was due to a lack of care or from his cardiac instability and vasopressors, or a combination of both.

Based on interview and record review, it was determined the facility did not ensure nursing staff developed and kept current nursing care plans for 14 of 14 sampled patients. (Patient identifiers: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14)

Findings include:

On 03/04/2021, surveyors requested 10 medical records (5 current inpatients and 5 discharged patients) for sample patient medical record review. The sample was expanded and 4 more records (all active bedbound inpatients) were requested on 03/09/2021. For 14 of 14 (9 active patients and 5 discharge patients) medical records reviewed, nursing care plans, which were the nursing portion of the Interdisciplinary Disciplinary Team (IDT), were not initiated as soon as possible after admission, they were not consistent with the medical care plan and nursing assessments, goals and interventions were not described for all problems listed, and/or the care plans were not revised/updated when changes in the patients' condition occurred.


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The following were examples of issues found with the care plans:

1. Patient 6's medical record was reviewed on 03/08/2021.

Patient 6 was admitted to the hospital on 02/19/2021, with diagnosis of acute respiratory failure. Review of patient 6's medical record revealed patient 6 was bedbound and on a ventilator.

Patient 6's care plan dated 02/22/2021 (3 days after admit) had problems listed for wound, tube feed, ventilator, mobility, and self-care. The nursing admission assessment also listed problems for incontinence, Foley catheter, and altered bladder elimination. The medical plan listed acute kidney injury, Foley, anxiety, diabetes mellitus, loosed stools with possible Clostridioides difficile (a germ that causes severe diarrhea), and history of deep vein thrombosis. None of the problems listed in the nursing assessment or medical plan were part of the IDT care plan.

2. Patient 7 was admitted to the hospital on 02/17/2021, with diagnosis of intracranial hemorrhage. Review of patient 7's medical record revealed patient 7 was bedbound and on a ventilator.

Patient 7's care plan dated 02/22/2021 (5 days after admit); this was the only IDT care plan found in the chart. The care plan lacked documentation of goals and interventions for several problem areas marked, such as incontinence, safety and/or antibiotics. Additionally, the nursing admission assessment and subsequent notes listed problems for telemetry, fever protocol (2/18/2021 and again on 02/22/2021), urinary tract infection (02/22/2021), sacral wound (02/26/2021), PICC line (02/28/2021), blood pressure with a mean arterial pressure below 65 (02/28/2021), and blood pressure protocol (03/02/2021). The medical plan listed, low blood pressure, monitor cardiac rhythm, and pulmonary embolism. None of the problems listed above in the nursing assessment or medical plan were part of the IDT care plan.

3. Patient 12's medical record was selected for review as an expanded sample on 03/09/2021.

Patient 12 was admitted to the hospital on 03/06/2021, with diagnosis of acute hypoxic respiratory failure secondary to COVID-19.

At the time of review there was no evidence of an IDT care plan in the medical record. Note: on 03/04/2021, administration was informed that we needed care plans for all sampled records. It appears there was not and IDT or nursing care plan initiated as soon as possible after admission.

4. Patient 14 was admitted to the hospital on 02/08/2021, with diagnosis of acute respiratory failure secondary to COVID-19. Review of patient 14's medical record revealed patient 14 was bedbound and on a ventilator.

Patient 14's first IDT care plan was dated 02/15/2021 and 02/16/2021 (7 and 8 days after admit). In addition to the first IDT care plan there were care plans dated 02/22/2021 and 03/01/2021. All 4 IDT care plans lacked documentation of goals and interventions for several problem areas marked, such as mental status, incontinent with Foley catheter, and/or antibiotics. Additionally, the medical plan listed diabetes mellitus insulin dependent, low blood pressure, right chest tube due to pneumothorax (removed just before first care plan formulated), extensive complex wound (was not documented on the first care plan), and thrombocytopenia; none of the aforementioned problems were part of the IDT care plans.

5. An interview was conducted with the hospital's Chief Clinical Officer (CCO) at 3:08 PM on 03/08/2021. The CCO stated the IDT meeting notes are initiated by each team member each Monday to be signed off. She stated the process starts on Monday of each week, and then the actual IDT meeting is on Wednesday each week for the finalization of the IDT planning for patients.

According to the interview and medical record review it appeared the hospital did not initiate care plans as soon as possible after admission. For example, if a patient was admitted on a Wednesday the IDT care plan would not be initiated until the following Monday. Likewise, revisions/updates to the IDT plan of care would not occur until the IDT meeting on Wednesday.

Surveyors requested policies and procedures regarding nursing care plans and interdisciplinary care planning. The hospital provided a policy titled "Interdisciplinary Treatment Planning."

Under the "Patient Care Planning" section of the "Interdisciplinary Treatment Planning" policy, surveyors found the following:

"4. Discipline specific patient planned care is documented within the appropriate therapeutic section of the medical record and provides direction to the professionals providing specific therapeutic care to the patient i.e. physical therapy documents a patient plan of therapeutic management that provides direction to the physical therapy professionals."

An interview was conducted with the hospital's CCO at 9:22 AM on 03/09/2021. The CCO stated there was not a section in the nursing section of the medical record that would provide specific nursing care interventions as the policy requires. She stated the interventions, if they were written for a patient, were only in the interdisciplinary meeting notes. The CCO stated that the boxes for nursing interventions should be checked to refer to nursing interventions for a nursing care plan. She stated there was not another section with interventions. She also stated there was not another section in the medical record where a nursing care plan could be found.

Furthermore, when reviewing the medical records, surveyors noted the interventions section on the IDT meeting notes, which had been signed off by each patient's case manager or nurse, included a section titled "Intervention" with the statement "Refer to the following discipline documentation for details" followed by boxes to check for physician, nursing, respiratory therapy, wound care, physical medicine, and nutrition. The boxes were not checked to refer to interventions from the various disciplines.