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A. Based on document review and interview, it was determined that for 1 of 5 (Pt. #1) patient records reviewed for wound care, the Hospital failed to ensure that a registered nurse supervised and evaluated the care of each patient, by failing to ensure that wound care was performed as prescribed.

Findings include:

1. On 8/2/2021, the Hospital's policy titled "Wound Care Clinician" (revised by the Hospital 9/20) was reviewed. The policy required, "...F Responsibilities of Staff RN's [Registered Nurse] in Management of the integument [skin]...Staff nurses will manage: 1. Dressing changes based on wound clinician recommendations..."

2. On 8/2/2021, the Hospital's policy titled, "Wound Vac [vacuum assisted closure] System" (revised by the Hospital 10/16) was reviewed. The policy required, "...G. Dressing application 1. Routine dressing change frequency should be every 48-72 hours, unless otherwise indicated by MD orders."

3. On 8/2/2021, Pt. #1's clinical record was reviewed. Pt. #1 was admitted to the Hospital to 3 North (Medical/Surgical Unit) on 7/13/2020 with a diagnosis of respiratory failure. Pt. #1 was transferred to the High Acuity Unit for change of condition on 8/11/2021 and was subsequently transferred to an acute care hospital on 8/11/2020 due to worsening condition.

-The skin injury/wound assessment, dated 7/14/2020, included documentation that the following wounds were present on admission: Sacrococcygeal (unstageable - eschar); midline abdomen (dehiscence - surgical); abdomen right lower left (medical adhesive related skin injury); chest left lateral (puncture); abdomen left upper (puncture); perineum (moisture related and friction related injury); Groin left (puncture); and clavicle right (unstageable - eschar).

-The wound care treatment plan, completed by the Wound Care Clinician, dated 7/14/2020, included orders for the following wound care and dressing changes:
-sacrococcygeal and left lower abdomen (clean with wound cleanser, pat dry with gauze, apply 3M barrier spray to surrounding skin, apply polymem over area, secure with tegaderm change every other day and as needed);
-left lateral chest (clean with wound cleanser, pat dry with gauze, apply 3M barrier spray to surrounding skin, apply iodoform gauze to wound bed, cover with 4X4 meplex, change every other day and as needed.);
-left upper abdomen (clean with wound cleanser, pat dry with gauze, apply 3M barrier spray to surrounding skin, cut small piece of maxorb and apply to wound bed, apply meplex over maxorb, change every other day and as needed);
-left groin (clean with wound cleanser, pat dry with gauze, apply 3M barrier spray to surrounding skin, apply 4X4 meplex over area, change dressing every other day and as needed);
-Midline Abdomen (Wound vac to be changed three times weekly by wound service);
-Perineum (clean with gauze, pat dry with gauze, apply venelex twice a day for 10 days;
-Right clavicle (to be done by respiratory therapy, clean wound with cleanser, pat dry with gauze, apply duoderm over right clavicle change every Tuesday, Thursday, and Saturday).

-The wound care treatment plans, dated 7/20/2020, 7/23/2020, and 7/27/2020, included ongoing wound care and dressing change orders for the midline abdomen (wound vac), left lateral chest, left groin, sacrococcygeal, perineum, and right clavicle.

-The wound care treatment plan, dated 7/30/2020, included ongoing wound care and dressing change orders for the midline abdomen, left lateral chest, left groin, sacrococcygeal, perineum, and the right clavicle.

-Wound Care Clinician's care activity assessments included the following documentation:
On 7/14/2020, 7/16/2020, 7/20/2020, and 7/22/2020, Pt. #1's wound assessment, wound care and dressing to the midline abdomen with the wound vac was completed by a wound care clinician.
On 7/14/2020, Pt. #1's wound care and dressing changes to the sacrococcygeal, lower left abdomen, left lateral chest, upper left abdomen, perineum, left groin, and right clavicle, was completed by the wound care clinician.
On 7/20/2020, Pt. #1's wound care and dressing changes to the sacrococcygeal, lower left abdomen, left lateral chest, upper left abdomen, perineum, left groin, right clavicle, and the left lateral foot (newly acquired) was completed by the wound care clinician.
Other than the wound care as listed above, the clinical record lacked documentation that the bedside staff nurse or the wound care clinician completed wound assessments, wound care, or dressing changes on any other dates, as ordered.

4. On 8/2/2021 at 2:27 PM, an interview was conducted with a Wound Care Clinician (E #2). E #2 stated that the wound care clinician should assess patient wounds and perform wound care weekly, and the bedside nurse is responsible for performing dressing changes and wound care based on the wound care treatment plan orders.

B. Based on document review and interview, it was determined that for 1 of 5 (Pt. #1) patient records reviewed for wound care the Hospital failed to ensure that a Registered Nurse supervised and evaluated the care of each patient, by failing to ensure the Wound Care Clinician collaborated with the physician to ensure that a wound care order was prescribed for newly identified wounds.

Findings include:

1. On 8/2/2021, the Hospital's policy titled, "Wound Treatments" (revised by the Hospital 7/20) was reviewed. The policy required "Protocol - All patient wounds will be treated consistent with facility-approved guidelines and physician orders. The wound clinician (WOCN, WCC, CWS, or those staff actively pursing those certifications) will evaluate all patients with wounds and pressure ulcers and will write specific wound care orders for the patient in collaboration with the physician..."

2. On 8/2/2021, Pt. #1's clinical record was reviewed. Pt. #1 was admitted to the Hospital to 3 North (Medical/Surgical Unit) on 7/13/2020 with a diagnosis of respiratory failure. Pt. #1 was transferred to the High Acuity Unit for change of condition on 8/11/2021 and was subsequently transferred to an acute care hospital on 8/11/2020 due to worsening condition.

-The skin injury/wound assessment dated 7/14/2020, included documentation that the following wounds were present on admission: Sacrococcygeal (unstageable - eschar); midline abdomen (dehiscence - surgical); abdomen right lower left (medical adhesive related skin injury); chest left lateral (puncture); abdomen left upper (puncture); perineum (moisture related and friction related injury); Groin left (puncture); and clavicle right (unstageable - eschar).

-The skin/injury wound assessment dated 7/20/2020, included documentation of newly Facility acquired wound to the foot (left lateral). The documentation included, " ...type of wound - undetermined, pressure injury present upon admission - no ...possible new wound ...soft adhered, black eschar ..." The clinical record lacked documentation of wound care orders for the left lateral foot wound.

3. On 8/3/2021 at 9:34 AM, an interview was conducted with the Chief Nursing Officer (E #7). E #7 stated that the wound care clinician is responsible for the more complexed wound care. E #7 stated that the staff bedside nurses perform wound care as indicated on the wound care orders. E #7 stated that wound care should be documented, but if care is not documented it does not mean that the care was not provided. E #7 stated that if a new wound is identified, wound care orders should be written and carried out as prescribed.

C. Based on document review and interview, it was determined that for 1 of 5 (Pt. #1) patient records reviewed for wound care, the Hospital failed to ensure that a Registered Nurse supervised and evaluated the care of each patient, by failing to ensure the Wound Care Clinician performed weekly wound care and assessments.

Findings include:

1. On 8/2/2021, the Hospital's policy titled, "Wound care Nurse Clinician" (revised by the Hospital 9/20) was reviewed. The policy required, "...Process A...Based on the wound assessment and level of skin integrity alterations, patients are either followed by a wound clinician or a staff nurse. Patients with multiple complex skin integrity issues are assessed and managed by a wound clinician weekly and as needed...."

2. On 8/2/2021, Pt. #1's clinical record was reviewed. Pt. #1 was admitted to the Hospital to 3 North (Medical/Surgical Unit) on 7/13/2020 with a diagnosis of respiratory failure. Pt. #1 was transferred to the High Acuity Unit for change of condition on 8/11/2021 and was subsequently transferred to an acute care hospital on 8/11/2020 due to worsening condition.

-The skin injury/wound assessment dated 7/14/2020, included documentation that the following wounds were present on admission: Sacrococcygeal (unstageable - eschar); midline abdomen (dehiscence - surgical); abdomen right lower left (medical adhesive related skin injury); chest left lateral (puncture); abdomen left upper (puncture); perineum (moisture related and friction related injury); Groin left (puncture); and clavicle right (unstageable - eschar).

-Wound Care Clinician's care activity assessments included the following documentation:
On 7/14/2020, 7/16/2020, 7/20/2020, and 7/22/2020, Pt. #1's wound assessment, wound care and dressing to the midline abdomen with the wound vac was completed by a wound care clinician.
On 7/14/2020, Pt. #1's wound care and dressing changes to the sacrococcygeal, lower left abdomen, left lateral chest, upper left abdomen, perineum, left groin, and right clavicle, was completed by the wound care clinician.
On 7/20/2020, Pt. #1's wound care and dressing changes to the sacrococcygeal, lower left abdomen, left lateral chest, upper left abdomen, perineum, left groin, right clavicle, and the left lateral foot (newly acquired) was completed by the wound care clinician.

-The clinical record lacked documentation that the bedside staff nurse or the wound care clinician completed wound assessments, wound care, or dressing changes on the days other than 7/14/2020, 7/20/2020, and 7/22/2020.

3. On 8/2/2021 at 2:27 PM, an interview was conducted with a Wound Care Clinician (E #2). E #2 stated that the wound care clinician should assess patient wounds and perform wound care weekly and the bedside nurse is responsible for performing dressing changes and wound care based on the wound care treatment plan orders.

4. On 8/3/2021 at 8:53 AM, an interview was conducted with the Executive of Clinical Services and Quality Manager (E #4). E #4 stated that a weekly wound assessment should be completed by the wound care clinician and documented in the clinical record when patients have complexed wounds. E #4 stated that Pt. #1 had complexed wounds.