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Based on record review, interview and policy review, the facility failed to measure and document wounds in the medical record. This affected two (Patients #1 and #9) of ten medical records reviewed for wound care documentation. The faciliy's census was 376.

Findings include:

1. Patient #1 was admitted to the facility on 12/18/23 and discharged on 01/13/24. On admission, 12/18/23, Patient #1 had a stage I pressure ulcer to right ischium. There was no wound description or initial or weekly measurements of the pressure ulcer to the right ischium. A photograph and corresponding documentation dated 01/08/24 at 10:05 AM documented the ulcer to the right ischium was still a stage I.

During an interview on 09/05/24 at 1:23 PM, Staff C confirmed the wound was not measured.

2. Patient #9 was admitted to the facility on 08/30/24 and discharged on 09/06/24. Patient #9 was first assessed as having a pressure ulcer to the perineum on 09/03/24 at 9:40 AM. The medical record contained documentation stating the pressure ulcer was present prior to admission. The medical record did not contain wound descriptions or measurements on admission.

During an interview on 09/09/24 at 8:16 AM, Staff A confirmed the wound had no description or measurements on admission.

The facility's policy titled "Care of the Adult and Pediatric Patient with Skin Breakdown Care and Pressure Injury Prevention Protocol", dated 12/16/20, stated the registered nurse (RN) is responsible for the assessment, plan, and evaluation of the pressure injury prevention plan. The RN may delegate select interventions for pressure injury prevention to unlicensed personnel. Document in within 24 hours of admission or transfer, two RNs will assess and sign off on the skin assessment in the electronic medical record. Pressure injuries are described, staged, and measured on admission or when discovered.. All pressure injuries are described and documented with each dressing change (not to exceed once daily). Pressure injuries are measured weekly.

Based on record review, interview and policy review, the facility failed to administer pain medication in the dose ordered by the physician. This affected one (Patient #9) of ten medical records reviewed for pain medication administration. The faciliy's census was 376.

Findings include:

Patient #9 was ordered to receive Oxycodone IR (immediate release) 5-10 milligrams (mg) every three hours as needed on 09/02/24 at 3:47 PM. The order stated to administer 5 mg for moderate pain, rated a 4-6 on a one to ten pain scale, and 10 mg for severe pain, greater than or equal to a seven on the pain scale.

On 09/02/24 at 10:22 PM, Patient #9 received Oxycodone 10 mg for a pain level of five. At 6:43 PM, Patient received Oxycodone 10 mg for a pain level of six. The patient was supposed to receive only 5 mg per the physician order.

During an interview on 09/09/24 at 8:03 AM, Staff A confirmed Patient #9 was not given the correct dose of pain medication.

Review of the policy titled "Pain Management of the Adult Patient Protocol", dated 04/14/22, upon receiving an order for medication administration where the ordered dose and/or frequency is expressed as a range (e.g., Morphine 2 mg to 4 mg every 4 to 6 hours as needed), the order will be interpreted according to the following guidelines: The patient's clinical condition will be assessed in regard to medication needs prior to administration of the first dose and all subsequent doses; medication administration will typically be initiated with the least amount or smallest measured dose of medication ordered, dependent upon the patient's clinical condition. If the patient's clinical condition necessitates, the administration can be initiated at the highest dose.