HospitalInspections.org

Based on interview and record review, it was determined that the hospital failed to ensure that nursing services were furnished in a way that adequately met the needs of the patients.

Findings include:

1. The hospital failed to ensure all licensed nurses who provided services in the hospital adhered to the policies and procedures of the hospital . (Refer to tag A-398)

Based on observation, interview, and record review it was determined the hospital did not ensure all licensed nurses who provided services in the hospital adhered to the policies and procedures of the hospital for 5 of 6 sample patients with wounds. Specifically, wounds were not assessed appropriately, wound care was being provided without physician orders, and there was not a defined wound care policy. Additionally, nursing staff did not provide care according to the standard of practice they were trained on, and there was no defined policy for monitoring patients after blood transfusions. (Patient Identifiers: 1, 2, 4, 5, and 6.)

Findings include:

1. Patient 5 was hospitalized three times: from 8/28/2020 through 9/1/2020, from 9/10/2020 through 9/12/2020, and lastly from 9/12/2020 through 9/18/2020.

A review of patient 5's medical records was completed on 9/30/2020.

Patient 5's medical history included kidney transplant, chronic kidney disease, and insulin-dependent diabetes mellitus.

a. During patient 5's first admission on 8/28/2020, she was hospitalized with diagnoses including acute on chronic kidney failure, diarrhea, shingles, and edema.

i. Upon admission on 8/28/2020, a skin assessment was completed by a registered nurse (RN). The RN documented that patient 5 had a pressure ulcer to her right buttock, a bandage on her left third toe, and a skin tear to her right elbow.

The skin assessment indicated the pressure ulcer to patient 5's right buttock had no drainage, odor, or dressing in place. It was also documented that the pressure ulcer and skin surrounding the wound was red. No measurements or any other information regarding the pressure ulcer aside from the following note, "Initiate Pressure Ulcer Assessment," was recorded. Note: No pressure ulcer assessments could be found in patient 5's medical record.

The assessment documentation indicated the wound on the top of the third toe was "Not seen" due to "Bandage on toe." However, the nurse also documented that the wound and skin surrounding the third toe was pink, there was no odor, drainage, or dressing applied. The nurse did not document measurements for the wound to the third toe.

The documentation regarding the skin tear to the right elbow revealed the wound and surrounding skin was bruised. The nurse documented the skin tear had no odor, drainage, or dressing applied. The nurse did not document measurements for the skin tear.

ii. Nursing staff documented additional skin assessments for patient 5 on 8/29/2020 at 8:29 AM, 8/29/2020 at 6:36 PM, 8/30/2020 at 7:35 AM, 8/30/2020 at 11:06 PM, 8/31/2020 at 8:00 AM, 8/31/2020 at 11:21 PM, and 9/1/2020 at 7:00 AM. The documentation for each skin assessment was word for word identical to the 8/28/2020 skin assessment.

iii. Nursing notes in patient 5's medical record revealed the following information:

On 8/28/2020 at 7:50 PM, an RN documented, "...Pt (patient) does have many wounds, see wound assessment for details ..."

On 8/28/2020 at 6:30 PM, an RN documented, "...Wounds noted on pt. see wound assessment for details..."

On 8/30/2020 at 7:35 AM, an RN documented, "...Patient has multiple sores on body r/t (related to) shingles..."

On 8/30/2020 at 5:34 PM, an RN documented, "...pt does have the shigles (sic) rash over her chest and back noted. It was also passed along that she has an open wound on her butt ..."

On 8/31/2020 at 5:37 AM, an RN documented, "...Shingles blister like wound to right side under arm toward back and on chest remain tender..."

iv. There was no documented evidence of wound measurements, wound care orders, or evidence that patient 5's wounds had been cleaned or dressed during this admission.

v. On 9/24/2020, at 1:52 PM, an interview was conducted with the director of clinical informatics (DCI). The DCI confirmed no pressure ulcer assessments were documented in patient 5's medical record, and there should have been.

On 9/24/2020 at 1:58 PM, an interview was conducted with the director of case management and patient safety (DCPS). The DCPS stated the bandage on patient 5's toe should have been removed at "some point" during her hospitalization to assess the wound.

On 9/24/2020 at 2:16 PM and 2:34 PM, interviews were conducted with the DCI. The DCI stated any sores related to patient 5's shingles should have been documented on the nursing skin assessments and were not. The DCI confirmed there was no documented evidence of wound measurements, wound care orders, or wound treatment provided in patient 5's medical record for this admission.

b. During patient 5's second admission on 9/10/2020, she was hospitalized with a diagnosis of dehydration with hyperkalemia.

i. Upon admission on 9/10/2020, a skin assessment was completed by an RN. The RN documented that patient 5 had three skin tears to the back of her right arm, diabetic ulcers to the left third toe, a diabetic ulcer to the right second toe, a pressure ulcer to her middle buttock, three large skin tears to the upper right area of her back, and blisters to her left ankle.

The skin assessment indicated the skin tears to patient 5's right arm had no drainage or odor and had a dry and intact dressing. The nurse documented no other information regarding the skin tears to the right arm.

The documentation on the assessment revealed the diabetic ulcers and skin surrounding the left third toe were red, with no drainage or odor. The nurse also documented that the ulcers were covered with a dressing that was dry and intact. The nurse noted no measurements of the diabetic ulcers to the left third toe.

The skin assessment indicted the diabetic ulcer and skin surrounding patient 5's right second toe were red. The nurse also documented that the ulcer to the right second toe had no odor, drainage, or dressing. The nurse did not document measurements for the diabetic ulcer to patient 5's right second toe.

The skin assessment indicated the pressure ulcer to patient 5's middle buttock was 0.0 centimeters deep (width and length was not recorded), red with darkly pigmented skin around the wound, had "None; Bloody" drainage with no odor, and no dressing was applied. The following note, "Initiate Pressure Ulcer Assessment" was also documented.

The assessment further indicated the three large skin tears and skin surrounding patient 5's back were bruised. The nurse also documented that the wounds had bloody drainage with no odor, and a dry and intact dressing was in place. No measurements of the "Three large skin tears and bruising" was documented.

Lastly, the nurse documented that the outer left ankle was red with red blisters, which had no drainage, odor, or dressings. No measurements of the blisters to the left ankle were documented.

ii. The nursing staff documented a skin assessment on 9/11/2020 at 9:00 PM. All documentation was identical to the initial skin assessment dated 9/10/2020, aside from the addition of, "2 small open wounds," to patient 5's right buttock. The nursing staff documented the wounds were red, with darkly pigmented skin around the wound. The nurse documented that the wounds had no drainage or odor and that the nurse "applied acyrllic (sic) drsg (dressing)," which was dry and intact.

The skin assessment dated 9/12/2020 at 8:28 AM was identical to the 9/11/2020 skin assessment documented at 9:00 PM.

iii. A pressure ulcer assessment form completed by nursing staff dated 9/12/2020 at 8:37 AM indicated this was a "Follow Up Evaluation." The nurse noted that one site was being "scored," and the site was closed, with no exudate. The nurse documented the location of the pressure ulcer was patient 5's "Coccyx." The nurse documented the pressure ulcer was a stage I pressure ulcer, pink in color, and the tissue within the pressure ulcer was "Closed-Resurfaced." The nurse documented that the wound condition was "Erythematous (skin redness)" with no drainage or odor. The nurse documented patient 5 had no pain at the site. There were no other pressure ulcer assessment forms for this stay in patient 5's medical record.

iv. Nursing notes and a physical therapy note in patient 5's medical record revealed the following information:

On 9/11/2020 at 12:40 AM, an RN documented, "...She has multiple skin issues that I documented in the assessment. She has 3 large skin tears on her back that were bleeding and had soiled her bed pad. I cleaned these areas and placed tegaderm dressings. She has 3 skin tears that have dressings on them on her right arm. Bruising on chest, left arm. Her right arm has been causing her some pain. Her legs are both swollen and red with some blistering with small amount of fluid weeping. Has what she called diabetic ulcers to top of her toes on both feet. Both of her heels are a little red and soft. Has large redness to buttocks with closed wound that appears to be healing. She stated that it was a large pressure ulcer that has gotten better..."

On 9/11/2020 at 6:13 AM, an RN documented, "...She has multiple skin tears over her entire body but mainly to her right side..."

On 9/11/2020 at 8:00 AM, a PT documented, "...Pt has several open skin tears in R (right) mid back and R UE (upper extremity). All are dressed by nursing."

On 9/11/2020 at 8:26 AM, an RN documented, "...She has several skin tears all over hers (sic) right arm and across her back that are all dressed."

On 9/11/2020 at 9:00 PM, an RN documented, "...Skin with multiple open areas noted et (sic) drsg in place..."

On 9/12/2020 at 5:00 AM, an RN documented, "...Drsg applied to buttock on right side. No drainage noted to open wound no s/s (signs and symptoms) infection noted..."

On 9/12/2020 at 8:40 AM, an RN documented, "...Pt. has multiple skin tears and sore over body..."

v. Patient 5's care plan dated 9/11/2020 listed the following objective, "(Name of patient 5) will show signs of wound healing," with interventions to include, "Change dressing as ordered." A second objective listed on patient 5's care plan was that she would show signs of ulcer healing and that a referral would be made to consult with the wound care nurse. Note: There was no documented evidence of wound care orders or referral to the wound care nurse in patient 5's medical record.

vi. The documentation in patient 5's medical record indicated patient 5 had the wounds to her back cleaned and dressed once, and the wound to her buttocks dressed but not cleaned once during this admission. No documented evidence could be found that the other four wounds had been cleaned or re-dressed during this admission. There was also no documented evidence of complete wound measurements.

vii. On 9/24/2020, at approximately 3:10 PM, an interview was conducted with the DCI. The DCI confirmed there were no physician orders for wound care treatment in patient 5's medical record.


c. During patient 5's admission on 9/12/2020, she was re-hospitalized with a diagnosis of gastrointestinal bleed.

i. Upon admission on 9/12/2020 at 10:04 PM, a skin assessment was completed by an RN. The RN documented that patient 5 had a skin tear to her lower right arm, a diabetic ulcer to the top of her right second toe, a diabetic ulcer to the top of her third left toe, three large skin tears to the upper right area of her back, a pressure ulcer to her coccyx, and a skin tear to the back of her lower right arm.

The skin assessment indicated the skin tear and the skin surrounding patient 5's lower right arm was bruised. The nurse also documented that the skin tear had no drainage, no odor, and was covered with a dry and intact dressing. The nurse did not document measurements of the skin tear.

The skin assessment indicted the diabetic ulcer and skin surrounding patient 5's right second toe was red. The nurse documented that the ulcer to the right second toe had no odor, drainage, or dressing. No measurements were documented for the diabetic ulcer to patient 5's right second toe.

The documentation on the assessment revealed the diabetic ulcer and skin surrounding the left third toe was red, with no drainage or odor. It was also documented that the ulcer was not covered with a dressing. No measurements were documented for the diabetic ulcer to the left third toe.

The assessment further indicated the three "large" skin tears and surrounding skin on patient 5's back were bruised. It was also documented that the wounds had bloody drainage with no odor, and a dry and intact dressing was in place. No measurements of the "Three large skin tears and bruising" was documented.

The skin assessment indicated the pressure ulcer to patient 5's coccyx was red with darkly pigmented skin around the wound, had no drainage or odor, and a dry and intact dressing was in place. The following note, "Initiate Pressure Ulcer Assessment" was also documented.

Lastly, the nurse documented that the skin tear and surrounding skin to patient 5's right arm was bruised, had no drainage or odor, and had a dry and intact dressing. No measurements of the skin were documented.

ii. Nursing staff documented additional skin assessments for patient 5 on 9/13/2020 at 7:10 AM, 9/13/2020 at 6:58 PM, 9/14/2020 at 9:37 AM, 9/14/2020 at 6:30 PM, 9/15/2020 at 8:00 AM, 9/15/2020 at 8:19 PM, 9/16/2020 at 7:30 AM, 9/16/2020 at 11:30 PM, 9/17/2020 at 8:30 AM, 9/17/2020 at 10:25 PM, and 9/18/2020 at 7:20 AM. The documentation on each assessment regarding patient 5's skin tear to her lower right arm, diabetic ulcer to the top of her right second toe, diabetic ulcer to the top of her third left toe, three large skin tears to the upper right area of her back, pressure ulcer to her coccyx, and skin tear to the back of her lower right arm were word for word identical to the initial skin assessment dated 9/12/2020 at 10:04 PM.

iii. A pressure ulcer assessment form completed by nursing staff dated 9/14/2020 at 7:30 AM indicated this was an "Initial Evaluation." A nutritional assessment was documented, and it was noted that five sites were being "scored," and the sites had no exudate. No further information regarding the five sites was documented.

A pressure ulcer assessment form completed by nursing staff dated 9/15/2020 at 7:25 AM, indicated this was a, "Follow Up Evaluation." It was noted that one site was being "scored," and the site had a light amount of exudate and epithelial tissue was the type of tissue present. The nurse documented the location of the pressure ulcer was patient 5's "Sacrum." The nurse documented the pressure ulcer was a stage II pressure ulcer that was red in appearance with a scant amount of non-odorous bloody drainage. No measurements were documented in the assessment form.

Pressure ulcer assessments completed by nursing staff on 9/15/2020 at 8:19 PM, 9/16/2020 at 5:00 PM, 9/16/2020 at 11:30 PM, 9/17/2020 at 10:04 PM, and 9/18/2020 at 7:00 AM, had identical documentation to the pressure ulcer assessment form completed on 9/15/2020 at 7:25 AM. No measurements were documented in the assessment form.

iv. Nursing notes in patient 5's medical record revealed the following information:

On 9/12/2020 at 10:04 PM, a licensed practical nurse (LPN) documented, "...She has skin tears on her right arm that are dressed with bandaids, skin tears on her back that have tegaderm in place, pressure ulcer on coccyx with a tegaderm..."

On 9/13/2020 at 9:13 AM, an RN documented, "...She does have multiple skin tears to BUE (bilateral upper extremities) and bruising noted. Skin tears are covered..."

On 9/13/2020 at 7:00 PM, an RN documented, "...a sore to coccyx with tegaderm absorbent in place. All intact and non draining. She has redness to her left 3rd toe...and right arm with weeping edema and third spacing..."

On 9/14/2020 at 8:00 AM, an RN documented, "...pt has sores which are on the anatomical man (skin assessment) and covered with bandages ..."

On 9/14/2020 at 6:00 PM, an RN documented, " ...She has a HX (history) of diabetes and has several skin issues. She has a red right arm with 3 skin tears, a skin tear that occurred to her left arm when removing some tape this shift, redness and pitting edema to BLE, skin weeping of both arms, a sore on the coccyx, and sore on her right back. All sores and skin tears have dressings applied, dry and intact..." Note: There was no documented evidence that the new skin tear documented in the nursing note above was added to any of patient 5's skin assessments during this admission.

On 9/14/2020 at 6:30 PM, an RN documented, "...She is on bedrest and turn q2 (every two hours) with a pressure ulcer to coccyx. Dressing CDI (clean dry and intact). Also has tegaderm absorbent dressings all along back and right ribs. She also has 3 skin tears to her right arm that are dressed with a foam dressing. IV (intravenous) to right upper arm, and skin tear to Left arm that is dressed with gauze and tegaderm..."

On 9/15/2020 at 8:50 AM, an RN documented, "...Pt. has multiple bruises and sores all over body. 3 skin tears noted to the right arm, 1 skin tear to the left arm. Pt. has a pressure sore on her buttocks...Linens changed and patient's dressing to her back changed and new dressing placed..."

On 9/16/2020 at 7:30 AM, an RN documented "...She has several skin issues including a pressure sore to the coccyx, 3 skin tears to her right arm, a skin tear to the left arm, some old shingles/bruising on the back and chest..."

On 9/16/2020 at 11:30 PM, an RN documented, "...Drsg to buttock clean dry et (sic) intact...Drsg to back in place but has come off on bottom of wound. Applied a foam drsg for reinforcement. Right arm is wrapped from wrist to arm pit et (sic) is clean dry et (sic) intact. Drsg in place to left FA (forearm) near elbow with shadow drainage noted. Wound noted to her toed digit 2 with non draining scabbed area to left foot et (sic) digit 2 right foot discolored..."

On 9/17/2020 at 7:00 PM, an RN documented, "...Patient has dressing on her back from shingles..."

On 9/18/2020 at 4:57 AM, a licensed practical nurse (LPN) documented, "...Patient has multi (multiple) sores with dressings on both arms and back and buttocks..."

v. Patient 5's care plan dated 9/12/2020 listed the following objective, "(Name of patient 5) will show signs of wound healing," with interventions to include, "Change dressing as ordered." A second objective listed on patient 5's care plan was that she would show signs of ulcer healing and that a referral would be made to consult with the wound care nurse. Note: There was no documented evidence of specific wound care orders or referral to the wound care nurse in patient 5's medical record.

vi. On 9/15/2020 at 8:47 AM, a physician order revealed physical therapy was needed for, "wound care. Ulcer to coccyx." Note: There was no documented evidence that physical therapy completed any wound care for patient 5.

There was no documented evidence of additional physician orders for the treatment of patient 5's wounds.

vii. A physician documented the following on 9/16/2020 at 3:18 PM, "...She (patient 5) has extensive skin breakdown especially of her upper extremities right upper extremity greatest she also has extensive shingles noted on her back...She developed extensive anasarca (generalized swelling) and wound breakdown likely secondary to extensive IV administration of fluids..."

viii. There was no documented evidence of wound measurements, specific wound care orders, or evidence that eight of the nine wounds recorded for patient 5 had been cleaned or dressed during this admission. The only wound that was documented as dressed during this admission was the skin tear to her left arm; however, there was no documented evidence that the wound was cleaned.

ix. On 9/24/2020 at approximately 3:10 PM, an interview was conducted with the DCI. The DCI confirmed there were no physician orders for wound care treatment in patient 5's medical record.

On 9/28/2020 at 10:33 AM, a telephone interview was conducted with physical therapist (PT) 1. PT 1 stated he was "surprised" there was an order for physical therapy to evaluate patient 5's wound to her coccyx. PT 1 further stated he remembered looking at patient 5's coccyx when assisting nursing staff with a brief change, and he thought patient 5 had a stage I or stage II pressure ulcer. PT 1 stated he informed the nurse at that time, "that was nothing that therapy would be responsible for; it would be nursing." PT 1 also stated he remembered patient 5 had bandages up and down her arms due to skin tears, but that PT was not involved in her wound care. PT 1 stated he would look through patient 5's medical records and get back with the surveyor.

On 9/28/2020 at 10:52 AM, a follow-up telephone interview was conducted with PT 1. PT 1 stated that for patient 5's 8/28/2020 and 9/10/2020, admit PT had not been ordered for wound care. PT 1 stated that for patient 5's 9/12/2020 admit, there was the physician order for wound care to patient 5's coccyx, but that PT was not involved in her wound care. PT 1 further stated he completed an evaluation for patient 5 on 9/14/2020 and noted patient 5 had a history of shingles and skin tears, but he was not aware of the physician order on 9/15/2020.

On 9/29/2020 at 11:01 AM, a telephone interview was conducted with the CNO, DCPS, discharge planner/case manager (DPCM) 1, and DPCM 2. The CNO confirmed that there were no documented measurements of patient 5's wounds during her 9/12/2020 admit.

On 9/29/2020 at 4:40 PM, a telephone interview was conducted with physician 2. Physician 2 stated he had cared for patient 5 as an outpatient and while she was in the hospital during her 9/10/2020 and 9/12/2020 admits. Physician 2 stated he was unaware that patient 5 had any wounds. Physician 2 stated he relied on the nurses to notify him of wounds. Physician 2 stated he would have wanted to be notified of "any skin wound." Physician 2 further stated if he had been notified, he would have ensured the wound care team was involved, orders were placed, and wounds were tracked.

d. A review of the skilled nursing facility's (SNF) medical record for patient 5 was completed on 9/30/2020.

The following nursing notes were documented in patient 5's SNF medical record:

On 9/18/2020 at 5:12 PM, a SNF LPN documented the following, "Resident received at approx. (approximately) 1530 (3:30 PM) from Castle View hospital via facility vehicle...patient has multiple skin tears and wounds with saturated bandages dated 9/12. Please see wound notes for details...Complaints of pain to chest, back, and extremities with movement."

On 9/18/2020 at 9:02 PM, the SNF director of nursing (DON) documented the following, "Wounds found on admission assessment-
#1- Skin tear Anterior right hand and wrist: 3.5 cm (centimeters) X (by) 1 cm
#2- skin tear right anterior arm just proximal from elbow area: 2 cm x 1 cm
#3- Skin tear medial right elbow joint: 1.4 cm x 1 cm
#4- Left anterior arm skin tear in a j shape: 2 cm x 1 cm
#5- Skin tear right breast medial of right nipple and underside 1 cm x 2.5
#6- skin tear right breast under and medial of nipple 0.5 cm x 1 cm
#7- skin tear with areas of ecchymosis (bruising) and necrotic tissue that are on the underside of breast that wrap to back just under right scapula: 25 cm x 4 cm (Note: This was 9.8 inches by 1.5 inches)
#8- skin tear right posterior back: 6 cm x 3.5 cm
#9- skin tear center of back near spine: 5 cm x 6 cm
All areas dressed with individual foam dressings for appropriate size. The large right breast that extend to back were covered with running foam dressings as continual dressing.

DON was called to assist with assessment of 200 (patient 5) on admission. On arrival all wounds had been undressed. Resident was lying in bed calm, alert, sleepy and able to communicate. DON called (name of unknown physician) to come and assess her skin and wounds. DON then called CVH (Castleview Hospital) med surg (medical surgical unit) and the nurse reported she was unaware of status of wounds under the dressings. DON then called (name of physician 2), he reported he had not seen (name of patient 5) in CVH since 'last Saturday or Sunday'. He was unaware of the status of her skin or wounds found under right breast that wrap to right back. He stated, 'I can see her in the office next week'. While waiting for (name of unknown physician) to arrive DON did measure to document each wound site. (Name of unknown physician) did arrive at facility and entered room. He noted and assessed. Wound care orders were given. (Name of patient 5) did have c/o (complaints of) pain with touch of areas of wounds and decreased ability to raise right arm without significant pain..."

2. Patient 6 was admitted to the hospital on 8/16/2020 with diagnoses including hip fracture, cellulitis to the bilateral lower extremities, and diabetes mellitus type II.

i. Upon admission on 8/16/2020 at 11:50 PM, a skin assessment was completed by a RN. The RN documented that patient 6 reported wounds to her right and left calf and left heel. The RN noted that "UNA (sic) boot" dressings were dry and intact on both of patient 6's legs. The RN further documented, "UNA (sic) boot drsg in place applied per home health." Lastly, the RN documented that the skin around the wounds was pink, and there was no drainage or odor from the wounds. No evidence of wound confirmation or assessment to patient 6's reported wounds was documented.

ii. Nursing staff documented additional skin assessments for patient 6 on 8/17/2020 at 8:05 AM, 8/17/2020 at 7:37 PM, 8/18/2020 at 8:00 AM, 8/18/2020 at 7:58 PM, and 8/19/2020 at 8:00 AM. The documentation on each assessment regarding patient 6's wounds to her right and left calf and the left heel was word for word identical to the initial skin assessment dated 9/16/2020 at 11:50 PM.

iii. Nursing notes a PT note in patient 6's medical record revealed the following information:

On 8/17/2020 at 12:15 AM, an RN documented, "...HH (home health) is currently providing wound care to BLE using Una (sic) boot drsg. Pt states she has a wound to each calf et (sic) a wound to her left heel. Una (sic) boot dressing in place et (sic) clean dry (sic) intact et (sic) HH last changed drsg on Friday..."

On 8/18/2020 at 9:00 AM, an RN documented that patient 6 had, "...una (sic) boots on, which she has been doing at home with home health..."

On 8/18/2020 at 10:29 AM, a PT documented, "...The patient had a dressing change of the Unna boots to the BLE as well." No information regarding patient 6's skin condition under the dressings was documented.

On 8/18/2020 at 10:30 AM, an RN documented that a physical therapist was working with patient 6 and "...Changing her una (sic) boots."

iv. The following information was documented in the assessment section of patient 6's history and physical dated 8/17/2020, "...cellulitis, bilateral lower extremities. The legs were wrapped..."

On 8/18/2020, a physician documented the following, "...The lower extremities are still wrapped with Unna boots..."

v. Physician orders relating to patient 6's stated wounds could not be found in her medical record. There was also no documented evidence of an assessment of patient 6's stated wounds to her calves or left heel.

vi. On 9/29/2020 at 6:25 PM, in an email, the CNO confirmed there was no documented evidence that hospital staff assessed patient 6's calves or heel. The CNO also confirmed there were no physician orders regarding dressing changes to her lower extremities.


39836

3. Patient 1 was admitted on 9/20/20 with a diagnosis of sepsis.

A review of patient 1's medical record was completed on 9/30/2020.

Nursing assessments in patient 1's medical record revealed the following:

On 9/20/2020 at 5:11 PM, it was documented in a "Patient Assessment Report" that patient 1 had a pressure ulcer. It stated that if yes, document under pressure ulcer assessment. No pressure ulcer assessment was found for this date.

On 9/20/2020 at 5:11 PM, a skin assessment was also completed. It was documented that patient 1 had a coccyx (tailbone) wound that had blanching redness, and that the wound and skin surrounding the wound was red. There was also a spine abrasion documented, measuring 1 cm by 1 cm, the color of the wound was red and the skin surrounding the wound was pink. No dressing or wound care was documented.

On 9/20/2020 at 7:10 PM, a skin assessment was completed. The same wounds were documented as the first assessment dated 9/20/2020 at 5:11 PM, with no changes noted. No dressing or wound care was documented.

On 9/21/2020 at 7:30 AM, a skin assessment was completed. The same wounds were documented as the first assessment dated 9/20/2020 at 5:11 PM, with no changes noted. No dressing or wound care was documented.

On 9/21/2020 at 8:30 AM, a pressure ulcer assessment was completed. Two spine wounds were documented. The first spine wound was red and measurements were as follows: length 0.5 cm, width 0.1 cm, and depth 0.0 cm. The type of tissue was closed-resurfaced. It was documented as a stage I pressure ulcer. The second spine wound, was red and measurements were as follows: length 0.5 cm, width 0.1 cm, depth 0.1 cm. The type of tissue was slough. It was documented as a stage II pressure ulcer. Note: This was the first documentation to indicate patient 1 had pressure ulcers.

On 9/21/2020 at 7:00 PM, a skin assessment was completed. The same wounds were documented as the first assessment dated 9/20/2020 at 5:11 PM, with no changes noted. The assessment only mentioned the spine abrasion. It did not mention the pressure ulcers on the back. No dressing or wound care was documented.

On 9/21/2020 at 11:31 PM, a pressure ulcer assessment was completed. Two wounds were documented. The pressure ulcer assessment was the same as the first on 9/21/2020 at 8:30 AM, no changes were noted.

On 9/22/2020 at 7:21 AM, a skin assessment was completed. The same wounds were documented as the first assessment dated 9/20/2020 at 5:11 PM. A skin tear to the back of the right hand was added to the skin assessment. It measured 2 cm. The color of the wound was red and the skin surrounding the wound was bruised. It was documented that the dressing was dry and intact. A pressure ulcer to the patient's right heel was added as well. The color of the wound was black, and the skin surrounding the wound was black, no measurements were recorded. No dressing changes or wound care was documented.

On 9/22/2020 at 8:00 AM, a pressure ulcer assessment was completed. The pressure ulcer assessment was the same as the first one on 9/21/2020 at 8:30 AM, no changes were noted. The pressure ulcer on the patient's heel that was documented on the last skin assessment dated 9/22/2020 at 7:21 AM was not included on the pressure ulcer assessment.

On 9/22/2020 at 7:45 PM, a skin assessment was completed. The same wounds were documented as the skin assessment dated 9/22/2020 at 7:21 AM. No changes were noted. No dressing changes or wound care was documented.

On 9/22/2020 at 7:5PM, a pressure ulcer assessment was completed. The three wounds assessed included the two ulcers to the spine and the ulcer to the heel. The assessments of the spine ulcers were the same as the first one on 9/21/2020 at 8:30 AM. The patient's heel pressure ulcer was added to the assessment. It was documented as a stage 1. The color was black, and the measurements were as follows: length 1.0 cm, width 1.0 cm, and depth 0.1 cm. The type of tissue was documented as closed-resurfaced. No dressing changes or wound care was documented.

On 9/23/2020 at 3:02 AM, a pressure ulcer assessment was completed. Only two wounds were assessed. The two pressure ulcers on the spine were assessed and the documentation of wounds did not change. The heel pressure ulcer was not assessed.

On 9/23/2020 at 8:32 AM, a skin assessment was completed. The same wounds were documented as the skin assessment dated 9/22/2020 at 7:21 AM. No changes were noted. No dressing changes or wound care was documented.

On 9/23/2020 at 7:00 PM, a pressure ulcer assessment was completed. Three wounds were assessed. The same wounds were assessed as the pressure ulcer assessment dated 9/22/2020 at 7:55 PM, with no noted changes. The heel was included on the assessment again.

On 9/23/2020 at 7:15 PM, a skin assessment was completed. The same wounds were documented as the skin assessment dated 9/22/2020 at 7:21 AM. No changes were noted. No dressing changes or wound care was documented.

On 9/24/2020 at 7:45 AM, a pressure ulcer assessment was completed. Three wounds were assessed. The same wounds were assessed as the pressure ulcer assessment dated 9/22/2020 at 7:55 PM, with no noted changes.

On 9/24/2020 at 7:45 AM, a skin as