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Based on a review of facility documentation, medical records (MR), and employee interviews (EMP), it was determined the facility failed to ensure nursing care policies for pressure ulcers and skin tears were followed and documented in the medical record for one of one wound care records reviewed (MR1).

Findings include:

Review on November 22, 2019, of the facility policy "Wound Care Prevention and Treatment Provision of Care" dated July 18, 2018, revealed "... Purpose: To reduce the risk of patients developing pressure ulcers through preventive measures, early recognition and treatment and to continually assess patients who are at risk for pressure ulcers due to immobility, incontinence, or disease processes. ... Protocol The following treatments will be initiated when a patient ... experiences skin breakdown or has existing breakdown. ... Stage I Intact skin with non-blanchable redness. ... ... Stage II Partial thickness loss of dermis. Open ulcer with a red/pink wound bed. May present as a shiny or dry shallow ulcer. ... Duoderm Mepilex Allevyn Skin Tears: Tear from friction or shear. ... Vaseline Gauze and kling. ..."

Review of MR1 on November 22, 2019, at 12:40 PM revealed the "Skin Monitoring Sheet" which documented the patient had bilateral breast excoriation, Stage I breakdown to the right and left ankles, and a stage II wound to buttocks/coccyx present on admission, September 24, 2019. There was no documentation the coccyx stage II breakdown had treatment from September 24, 2019, through October 10, 2019. There was no documentation the bilateral stage I breakdown on the left and right ankles had treatment from September 24, 2019, through discharge October 11, 2019.

Review of MR1 on November 22, 2019, at 12:40 PM, revealed a nursing progress note which indicated that on October 8, 2019 at 2200 there was a skin tear to the left forearm noted during care. The 3 cm x .5 cm. area was cleansed with soap and water. Band-Aids were applied. The skin was pushed together before the Band-Aids were applied to the opening. A skin note dated October 8, 2019, indicated left forearm skin tear dressing was intact. There was no documentation that a treatment was provided to the left forearm skin tear from October 1, 2019, through discharge of October 11, 2019.

Continue review of MR1 revealed no documentation the facility policy was followed for the Stage I breakdown to the right or left ankles, the coccyx Stage II breakdown, or the left forearm skin tear.

Review of MR1 on November 21, 2019, at 1:00 PM revealed a physician order for September 26 for Ace Bandage wrap to bilateral lower extremities daily and off at bedtime. There was no documentation the wraps were applied on September 26, 2019, September 27, 2019, September 29, 2019, and October 6, 2019. There was no documentation the wraps were removed at the hour of sleep on September 25, 26, 27,28, 29, 30, October 1, 2, 3, 4, 5, 6, and 9, 2019.

Interview with EMP2 on November 22, 2019, at 12:45 PM, confirmed the above findings in MR1.