HospitalInspections.org

Based on interview and record review, the facility failed to ensure that the registered nurse followed physician orders for wound care treatments and that registered nurses documented wound assessment and treatments per policy/protocol for 2 (P-1, P-8) of 5 patients reviewed for wound care resulting in the potential for unsatisfactory outcomes. Findings include:

On 5/6/25 at approximately 1430, the medical record for P-1 was reviewed with the assistance of RN Director Staff F. The record review revealed that P-1 was assessed on admission (4/16/25) with wounds on left buttock, measuring 2 centimeters (cm) x 1.5 cm, left neck measuring 1 cm x 1 cm, right lateral knee measuring 3 cm x 2 cm, and right foot, no measurements found.

An order to "irrigate wound bed with normal saline daily and as needed (PRN)" was written on 4/17/25 at 0559. No documentation that a daily wound irrigation was carried out found in the record (or refused) on any day from 4/17/25 (order date) through 4/22/25 (discharge date). Findings confirmed by Staff F during record review.

On 5/7/25 at 1115, an interview with RN Staff M in a conference room revealed she was familiar with P-1, and described his behavior as aggressive, and noted he frequently refused care. Staff M asked what is done when patients refuse care and/or medications, and she stated the refusal is documented in the record, education is given, and the provider is notified. There was no evidence this was done for P-1.


P-8 a 70-year-old man with history of chronic debility, cerebral vascular accident (CVA), Ethanol (EtOH) disorder, alcohol withdrawal seizures, and deep vein thrombosis was admitted with numerous areas of skin breakdown including unstageable wounds (documented by nursing) on left lower buttock, left foot and right heel. P-8 was an inpatient at the facility at the time of survey.

Providers note dated 5/2/25 at 1207, revealed wound care was consulted.

Wound care initiated prior to wound care consult being completed (between 5/2/25 -5/7/25) to unstageable areas by nursing, per plan of care, included: Turn every 2 hours, keep skin/dressing clean and dry.

No documentation found that protocol for unstageable pressure ulcers was implemented, including application of hydrogel impregnated gauze/thera-honey gel, or foam dressings to unstageable areas, as applicable. Pressure Ulcer (Injury) Management Order set not initiated in the record per protocol.

On 5/7/25 at 0906, a Pressure Ulcer/Wound/Ostomy Consult was documented by Staff I. Impression and plan of care for right heel, left heel, left foot, right butt, left ischium, and left hip included, topical wound care: Cleanse all wounds with normal saline with each dressing change, apply thera-honey sheet cut to fit to cover entire wound bed, cover left hip, left ischium, and right butt with foam dressing, and change dressing every 48 hours and as needed. Corresponding physician orders written on 5/7/25 at 0904.

On 5/6/25 at approximately 1330, Interview with Wound Care Nurse Staff I revealed she is helping cover the facility as the wound care position has been vacant for 3 weeks. When asked about time frames to complete a wound care consult after an order for a consult is written, Staff I stated there is no time frame defined in policy, and that she prioritizes consult orders received, based severity and patient need. Nursing staff has wound care protocols and have been trained to initiate wound care for all levels of wounds before wound care consults are done.

On 5/6/25 at 1500, an interview with CNO Staff B revealed it is her expectation that staff follow physicians orders and policies and procedures of the facility.

Review of policy titled, "Pressure Injuries: Prevention and Care" (2 PC 5202), dated 8/10/21 revealed, "RN responsibilities ...Provide assessment, planning documentation and evaluation of skin, pressure injuries, and wound care with shift assessment ...Pressure injuries are measured on admission ...DOCUMENTATION I-View ...wound location ...length, width and depth in centimeters ...dressing type and treatment ..."

Review of Nursing Wound Care Protocol revealed under the general care section:
Cleanse open ulcers/wounds with normal saline ...turn & reposition, off load pressure, Initiate Pressure Ulcer (Injury) Management Order set ... (under Unstageable Pressure Injury) Refer to pressure injury general care section ...Apply hydrogel impregnated gauze/Thera honey ...If dry black/brown necrotic tissue ...on lower extremity ...cover with foam ...kerlix wrap.