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Based on interviews and document reviews, the facility was not able to demonstrate adherence to nationally recognized infection prevention and control guidelines for the development and transmission of facility acquired infections. On 07/01/22 at 01:45 PM, SA notified the Chief Nursing Officer (CNO) of an Immediate Jeopardy (IJ) at C-1225, Leadership Responsibilities for failure to implement strategies in their COVID-19 Action Plan to mitigate the transmission of infectious disease when the facility had an outbreak of eight patients and eight staff on one unit that tested positive for COVID-19. In addition, the facility was cited standard level deficiencies at C-1200 Infection Prevention and Control Program, C-1204 Infection Prevention and Control Organization and Policies, C-1231 and 1240 Leadership Responsibilities. The cumulative effect of these deficiencies warranted a Condition level citation at CFS 485.640 C1200 Infection Prevention and Control Program.

Findings include:

1) Cross reference C-1204 Infection Prevention and Control
The facility did not have a qualified individual, through education, training, experience or certification in infection prevention and control appointed responsible for the infection prevention and control program. The Chief Nursing Officer was assigned responsibility, but did not have the training or qualifications.

2) Cross reference C-1225
The facility failed to demonstrate they had an operational system in place to investigate and implement interventions to mitigate and control an outbreak (occurrence of more cases than expected in a given area or among a specific group of people over a particular period of time) of COVID-19. On survey entrance 06/30/2022, it was reported that the facility had eight COVID-19 positive patients and eight Covid-19 positive staff on one unit identified during the time period of 06/24/2022 to 06/27/2022.

3) Cross reference C-1231
The facility infection prevention and control policies were not current and based on current nationally recognized guidelines.

4)Cross reference C-1240 Leadership Responsibilities
The facility did not routinely monitor and document staff adherence to proper Personal Protective Equipment (PPE) selection and use, including donning and doffing.

Based on interviews and document review, the facility did not have an individual qualified through education, training, experience or certification in infection prevention (IP) and control (IC), appointed responsibility for the IP/IC program. The Chief Nursing Officer (CNO), who does not have any IP/IC training has been designated as the responsible individual for the program. In addition, there was no documentation the CNO was appointed by the Governing Board or responsible individual based on the recommendations of medical staff leadership and nursing leadership.

Findings include:

1) Reviewed the "Director of Infection Prevention and Quality Job Description/Performance Appraisal" document last revised date 09/18/2018. The job description listed the following qualifications for the position: "2. B.S. Degree in Nursing Microbiology, Public Health Medical Technology, or related field required. Related license or certification. 3. CIC (certification of infection control) certification from the Board of Infection Control and Epidemiologist preferred. Ability to take certification examination in 3 years or less years of employment required."

2) Review of the CNO's resume revealed she did not complete a Certification Board for Infection Control & Epidemiology (CIC) and had not participated in any infection control courses organized by recognized professional societies (e.g., Association for Professionals in Infection Control and Epidemiology (APIC), Society for Healthcare Epidemiology of American.) In addition, the CNO did not have any in infection control or prevention experience.

3) The facility completed a tool ("Infection Prevention and Control Assessment Tool for Acute Care Hospitals"/ICAR) from Department of Health & Human Services Centers for Disease Control and Prevention to assess the facility IC program and practices.

Review of the assessment dated 02/25/2022 revealed the facility did not have a trained individual allocated hours for responsibility of the IP program. The facility plan was "... for the ACNO (Assistant Chief Nursing Officer) to learn the IP role and performing the IP duties."

In the ICAR section for the IC Program Infrastructure, the question: "The person(s) charged with the directing the infection prevention and control program at the hospital is/are qualified and trained in infection control," the facility marked "No." The IC Consultant documented "Not IP Certified, recommend joining APIC at National and Local level ..."

4) On 06/30/2022 at approximately 10:00 AM, during an interview with the CNO, she said when she was hired at the facility there was an individual trained in IC responsible for the IC/IP program. She went on to say the IP Director resigned shortly after she (CNO) was hired and since that time she has been assigned responsibility for IP. The CNO confirmed she had no experience in IP/IC and had not taken any courses or seminars. She said she does as much reading to learn as possible. The CNO said the facility has been recruiting for the IP/Quality position, but have not been successful filling it. She said the facility had considered utilizing a consultant, but deemed it cost prohibitive.

The facility failed to demonstrate they had an operational system in place to investigate and implement interventions to prevention and control an outbreak (the occurrence of more cases than expected in a given area or among a specific group of people over a particular period of time) of COVID-19. The facility had an outbreak of eight COVID-19 patients and eight COVID-19 positive staff on one unit during the time period of 06/24/2022 to 06/27/2022. The facility was unable to provide documentation the positive cases were investigated to identify if the infection was Healthcare Facility Acquired Infection (HAI) or community acquired.

On 07/01/22 at 01:45 PM, SA notified the Chief Nursing Officer (CNO) of an Immediate Jeopardy (IJ) at C-1225, Leadership Responsibilities for failure to implement strategies in their COVID-19 Action Plan to mitigate the transmission of infectious disease when the facility had the COVID-19 outbreak. In addition, the facility did not follow national standards and either conduct contact tracing for staff exposure, or test staff As a result of this deficiency there was increased potential for transmission healthcare acquired infection of COVID-19 with the potential for serious adverse outcomes.

Findings include:

1) On survey entry 06/28/2022 at approximately 08:30 AM, the Chief Nursing Officer (CNO) said the facility currently had eight COVID-19 positive patients and eight COVID-19 positive staff on one unit. On 06/30/2022 requested all documentation related to the outbreak (i.e. line listing, contact tracing, investigation, analysis, monitoring, interventions)

2) On 06/29/2022 reviewed the Infection Control Plan last reviewed 03/24/2022. The plans included the following: "The overarching goal for the Kahuku Medial Center's (KMC) infection prevention and control program is to reduce the risk of acquisition of healthcare-associated infections (HAI) in patients and occupationally acquired infections in healthcare workers."

The IC Plan included the following:
"The IC committee shall be responsible for: ...iii. Review of surveillance data, ...looking particularly for unusual epidemics, clusters of infections... The committee initiates or approves actions to prevent or control infection."
The Infection Preventionist (IP) responsibilities included "viii. Identifies and evaluates clusters of infections and potential outbreaks. ...xv. Investigates exposures to communicable disease and initiates appropriate measures to prevent the transmission of disease."
"8 a.) ...Employee Health (EH) to develop protocols for prevention of occupationally acquired infections including screening and vaccination, management of exposures, and furlough of infectious employees."

3) Reviewed the facility policy titled "Outbreak Investigation of Infectious Disease" last review date of 02/22/2022. The purpose of the policy was; "To provide guidance for Infection Prevention in the event of a potential/actual outbreak of an infectious disease." The policy statement was; "It is the policy of Kahuku Medical Center to have consistent and standardized methods for management of infectious disease outbreaks."

The procedure directed staff to implement the following "In the event of an infectious disease outbreak in Kahuku Medical Center:"
"1. Assemble a multidisciplinary team to investigate the outbreak."
"2.b. Determine if further investigation is warranted."
"3. Manage Outbreak, ...b. Implement and measure compliance with basic infection control procedures.... d. Notify those responsible for infection and including ...staff members directly involved in the care of the patients, ..."
"4. Data collection that organizes the information and ensures the same information is obtained for each case. ...c. Risk factors (procedures performed, devise used, caregiver information)."
"5.a. Characterize the cases by person, place, and time. a. Line listing will assist in evaluating case information in order to examine what factors are common to cases."
"6. Report finding to organizational leadership and regulatory authorities as appropriate: a. Circumstances leading to the outbreak. b. Summary of the outbreak investigation. c. Case definition and data analysis. d. Outline of Control measures. e. Plan for continued surveillance and ongoing infection prevention and control measures."

4) Employee Health provided a one page document that was used for contact tracing. The document included the following: "1. Staff that worked with a positive patient in the last 24 hours, 2. Exposure (significant or not), 3. Date of positive test. 4. Source Control (if personal protective equipment was worn, length of exposure, and 5. If the employee was up to date (included one booster) with COVID vaccine."Review of the document revealed the following:

The document listed two of the eight patients with COVID-19 and the following details: "Room 208" tested positive on 06/24/2022. Nine staff that worked on the unit 24 hours prior to when Room 208 tested positive, were contacted to determine if exposure was significant or not. One staff (S)1 was listed to be positive on 06/23/2022, and S2 was identified to have a significant exposure. There was no information documented for source control on S2 and no documentation if S2 was tested or quarantined.
"Room 218 " was listed with no details of when tested positive, and there was only one staff listed to determine exposure.
The patients did not have any other identifier other than Room number.

5) EH provided a log started in January 2022 with a table that included the headings: Employee name, Date of Exposure, Date of Test, and Results. The table also had columns to document if the employee was quarantined and other notes. It was noted that S2 noted above as a significant exposure was on the log as being exposed 06/23/2022, tested on 06/28/2022 and results were negative. There is no documentation if he was quarantined.

6) On 07/01/2022 at approximately 08:30 AM, during an interview with the Employee Health (EH) and the Chief Nursing Officer (CNO), reviewed the documents provided regarding the COVID-19 outbreak. EH said the employee log included staff who called in to inform her they were sick or had possible exposure, as well as staff the facility notified of potential exposure from positive patient. She (EH) said it was a way for her to document if it was determined the employee should be quarantined or not. Inquired if there was any other documentation to determine if staff had a significant exposure for the other patients, and EH said the contact tracing process was found to be very time consuming and they did not continue the process identifying who worked with the patients when the patient was found to be positive for COVID-19. It is unknown if there were staff with significant exposures.

At that time, the CNO provided an email sent to the Disease Outbreak Control Division of the State of Hawaii providing them a list of the positive patients and staff. The CNO said she had been under the impression the Department of Health would do all of the contact tracing. Discussed the option of testing all staff if resources were limited for facility contact tracing.

7) COVID-19 outbreak (06/22/2022 to 06/27/2022) timeline of positive test results established from interviews, facility documents and emails
Staff: Total of eight staff on the same unit.
06/22/2022: Two staff
06/23/2022: Three staff
06/25/2022: One staff
06/26/2022: One staff
06/27/2022: One staff
Interventions to control outbreak was a reminder to staff to keep six feet apart in all areas, including the staff eating area. There was no consideration for ongoing contact tracing to identify staff exposure, utilization of N95's for source control to reduce transmission other than when caring for a positive COVID-19 patient, or testing of all staff.

Patients: Total of eight patients on the same unit.
06/24/2022: Six patients
06/26/2022: One patient
06/27/2022: One patient
Interventions to control transmission included:
06/24/2022: Directive limiting patient visitation for two weeks (06/24/2022-07/09/2022)
06/24/2022: Testing of all patients
06/27/2022: The facility emailed the Disease Outbreak Control Division of the State of Hawaii with a list of positive staff and patients.

The facility infection prevention and control policies were not current and based on current nationally recognized guidelines.

Findings include:

1) Reviewed the facility "COVID-19 Action Plan" last updated 05/18/2022. The plan defined direct meaningful contact (significant exposure) as "If an employee has direct/meaningful contact with known COVID positive individual (Less than 6 ft for more than 15 minutes, not wearing a mask)."

The current Center for Diseases Control (CDC) guidelines updated 01/21/2022, "Interim Guidance for Managing Healthcare Personnel (HCP) with ...(COVID-19) Infection or Exposure ..."include the following recommendations: "1. Data are insufficient to precisely define the duration of time that constitutes a prolonged exposure. Until more is known about transmission risks, it is reasonable to consider an exposure of 15 minutes or more as prolonged. This could refer to a single 15 minute exposure to one infected individual or several briefer exposures to one or more infected individuals adding up to at least 15 minutes during a 24-hour period."

2) When the facility did contact tracing, Employee Health said they identified staff on the schedule for the previous 24 hours from when the patient was identified by positive test result or quarantined for symptoms. The CDC guidelines 01/21/2022, "Interim Guidance for Managing Healthcare Personnel with SARIS-CoV-2 (COVID-19) Infection or Exposure" was "a. For individuals with confirmed SARSS-CoV-2 who developed symptoms, consider the exposure window to be 2 days before symptom onset... b. For individuals with confirmed SARS-CoV-2 infection who never developed symptoms, determining infectious period can be challenging. ...i If the date of exposure cannot be determined, although the infectious period could be longer, it is reasonable to use the starting point of 2 days prior to the positive test ..."

3) The CDC guidelines 01/21/2022 section "Recommended Work Restrictions for HCP Based on Vaccination Status and Type of Exposure" included if a HCP is up to date with vaccine doses and is determined to have had prolonged close contact with a confirmed COVID-19 individual, and the HCP is wearing a facemask, but the person with infection was not wearing a cloth or facemask, the HCP can work, but "should follow all recommendations including wearing well-fitting source control ..."
The CDC guidelines also say if an up to date vaccinated "HCP not wearing eye protection if the person with CoV-2 infection was not wearing a cloth or facemask...," the HCP can work, but should wear "well fitting source control..."

The facility COVID-19 Action Plan read "Boosted, or fully vaccinated staff ...will not need to quarantine, wear a mask for 10 days and get tested on day five. All other staff: Must quarantine for five days, get tested on day five, and must wear a mask for five days after the quarantine were. The plan does not clarify what type of "mask" this is, surgical mask or N95.
The Action Plan section "Personal Protective Equipment (PPE) Community Spread" included: During times of high community transmission of COVID-19, KMC Employees will be required to wear appropriate eye protection and mask. In high-risk areas staff will be required to wear: 1. Face shield/goggles is preferred when providing direct care/extended time with patients. 2. N95 or fitted respirator (approved through Employee Health. )" The facility plan does not follow current CDC guidelines.

4) The facility COVID-19 Action Plan and policy titled "Guidelines for Reporting Infections'" last reviewed 02/17/2022 do not include definitions of outbreak or cluster or when the facility should notify the Department of Health.

Based on interviews and document review, the facility did not routinely monitor and document staff adherence to proper Personal Protective Equipment (PPE) selection and use, including donning and doffing. The only auditing the facility routinely conducted to ensure staff compliance with Invention Prevention (IP) policies was to audit compliance with hand hygiene. As a result of this deficiency, there is the potential staff are noncompliant with policies to prevent hospital acquired infections which may potentially result in a hospital acquired infection..

Findings include:

1) Request was made for documentation of monitoring staff compliance with IP policies. Surveyor was provided with hand hygiene audits.

2) On 02/25/2022, the facility completed an "Infection Prevention and Control Assessment Tool for Acute Care Hospitals" to assess the facilities IP program and to identify areas that need to be addressed. Review of the tool revealed the facility documented they did not routinely audit (monitor and document) adherence to proper use of PPE. The consultant's (Infection Control Consultant Disease Outbreak Control Division Hawaii Department of Health) notes read "Suggest completing audits 10/month)

3) During an interview with the Chief Nursing Officer, she confirmed the facility had not initiated audits of staff adherence to PPE selection and use.

The facility's discharge evaluation failed to identify and arrange for one patients (P)3 discharge needs of a sample size of four. Specifically, the facility did not identify P3 had wound care needs at the time of discharge, and no arrangements were made for follow up care. In addition, the facility failed to document it they determined P3 had access to prescribed medications and supplies due to his limited mobility and finances. As a result of this deficiency, there was potential P3 would return for readmission to a hospital.

Findings include:

1) P3 is a 77 year old male male, who was brought to an emergency department on 12/31/2021 and admitted to the hospital after police found him unable to ambulate at a beach park. He had surgical debridement of the left lower extremity venous ulcers on 01/03/2022, and debridement and skin grafts to right shin and ankle on 01/18/2022. On 01/31/2022, he was admitted to Kahuku Medical Center (KMC) for continued Physical therapy/Occupational therapy (PT/OT), intravenous antibiotics (IV abx) and complex wound care. His past pertinent medical history included hypertension, dementia, homelessness, incontinent of urine, and he used a front wheel walker (FWW) to ambulate. P3 had antibiotics administered for 25 days. On 03/10/2022, P3 was discharged back to the community (homeless) via cab to be dropped off at the address provided by KMC which, was the Institute for Human Services (IHS) men's shelter.

2) RR of telemedicine encounter 03/09/2022 with Infectious Disease (ID) Physician (MD)1 revealed the following entries and content:
"3 shallow open wounds with serosanguineous (consisting of both blood and serous fluid discharge), no purulence (sign of infection)."
Assessment included: "1. Bilateral leg cellullitis, poorly healing wounds...2. Venous stasis ulcers, ...4. Homelessness."
Plan included: "on discharge, will give Augmentin (antibiotic) 875 mg (milligrams) po (oral) and doxycicline (antibiotic) 100 mg po bid (twice a day), take with food/water x 10 days."

3) Review of Interdisciplinary Team Meeting (IDT) notes dated 03/08/2022 revealed the following entries:
"77 yo male admitted to KMC for continued PT/OT, IV abx, and complex wound care. ..."
Nursing Notes:
"02/08 ...Continues with IV abx, wound care and therapies...."
There are no other entries addressing wound care.

Social Service (SS) Notes:
"02/09- Pt assessed and stated that he will return to his halfway home upon d/c....SS to continue to assist with pt. needs prn (as needed)."
"02/16- SS to follow up with DME (durable medical equipment) referral. Pt. plans to d/c (discharge) to IHS. SS to send referral to IHS. SS to continue to assist with pt. needs."
"02/23-Pt appealed discharge on 02/22. FWW referral still pending. ...SS also to F/U (follow up) with IHS referral that was sent for pt. dispo (disposition)."
"03/01- ...Pt. cannot go to IHS Shelter as he needs to be fully vaccinated. SS gave pt. the Boarding home List and will f/u with him regarding D/C (discharge)."
"03/09-Pt has an ID (infectious disease) appointment at 11:00 am. and could possible get extended. SS to send in supporting documents to assist with appeal."

4) The Office of Healthcare Assurance (OHCA) received a report from an external agency regarding P3's discharge. The report included the following statements:
"On the evening of 03/10/22, the AV (P3) unexpectedly showed up to the the Institute for Human Services (IHS) after hours, arriving in a cab. ..."
"On 2/16/2022, the AP (KMC) started the referral process to have AV enter IHS following his discharge. The AP indicated that AV would likely be discharged by the end of the month (2/28/22). Due to his physical limitations, IHS advised that AV would also need a bottom bunk."
"AP was informed by IHS staff of the following: Prior to AV's discharge, Kahuku Medical Center needs to contact IHS to confirm vacancy of a bottom bunk bed. AV needs to test negative for Covid-19. AV needs at least one Covid-19 vaccination for entry into IHS"
"AV requires wound care to his foot. He was discharged with limited supplies and no wound care instructions."
"AV was discharged without any medications ... Discharge summary included instructions for AV to pick up his medications from Longs Drugs, but the store location was unknown."
"AV does not have any cash on hand. AV would not have been able to purchase these medications."
"IHS paid for AV's & $18.00 co-pay for six medications."
"AV is incontinent. He arrived at IHS with only one extra incontinence brief."
"Special Considerations" included, but not limited to: alert, sometimes forgetful, appears frail, ambulates with walker, needs assistance with medication administration, wound care, and transportation.

5) A review of the facility policy titled "Discharge Planning" last review date 05/19/2022 was completed. The policy included the following statements:
"Kahuku Medical Center has an effective discharge planning process that: a. Addresses patients goals, needs and treatment preferences. ...d. Promotes effective transitions. e. Reduces factors that lead to preventable readmissions."
"A Social Work assessment to be completed within (7) business days upon patient admission by Social Worker."
"Social Worker is responsible to also provide on-going discharge planning for all SNF patients until discharge."
Discharge planning will include "involvement of the Interdisciplinary Team (IDT) in the ongoing process of developing the discharge plan, including review of the plan weekly and revision as needed...""Post-discharge plans include: a. Coordination with other providers for post-discharge care (i.e. medical appointments), scheduled by Nursing team or Ward Clerk. b. All services/resources the patient was referred to during the discharge planning process..."

6) RR of Social Service /Case management (CM) notes revealed the following entries:
02/03/2022 CM narrative note: "...Pt. stated that he does get money from SSI and used to also receive pension. ...Pt. currently stays in a halfway home which costs $250 a month, where he shares a bunk w/one other person. Pt shared he receives help from IHS for food and shelter. Pt. stated he also often has to live on the street, sleeping on park benches. Pt. explained that he is independent with all ADL's (activities of daily living), but showering uses a chair. When asked about d/c plans, pt shared he plans to return to the community, and visit back with IHS. Pt. did anticipate needing a FWW upon d/c. When asked about PT/OT/HHA (Home health Aide), pt stated he is unsure."
"Pt was A&O (alert and oriented) x3 throughout the assessment, he was cooperative however often mid conversation would change topic to speak about "Medicare parrots."
"SS to f/u with pt. in regards to DME needs, and to assist with pt. with d/c needs prn."

03/10/2022 at 08:14 AM; "SS informed the pt (P3) that his appeal was denied, his d/c date is 03/10, and that transportation would be ready to pick him up in the morning to take him to the IHS shelter."

7) On 06/30/2022 at 03:30 PM, during an interview with the Social Services (SS)1, she said she had worked with P3's discharge plan. At that time a review of his records was done. The SS said she was not aware P3 had any wounds, and confirmed she did not make any arrangements for wound care post discharge. SS said P3 had been given a list of boarding homes, but he did not have a phone, so they assisted him making the calls. She went on to say he did not want to spend his money on a boarding home as the cost was too much and he wanted to go to IHS, but couldn't because he was not vaccinated. SS said she was not previously aware vaccination was a requirement for IHS, and that KMC does not provide the vaccinations on site.

SS said P3 made two appeals to stay at the facility, but they had been declined and he decided to return to the street. Inquired why arrangements were made to have the taxi drop P3 off at IHS when he was not able to have a bed there. SS said his insurance pays for transportation, but they need an address of destination, so she decided to use the address of the IHS shelter. When asked if she knew if P3 was sent with any supplies or medications at the time of discharge, she said she did not know. There was no documentation of supplies or medications provided.

8) Reviewed the Wound Care Specialist (WCS) documentation on P3 on 3/7/2022 (three days before discharge) at 04:36 PM. P3 had three wounds the WCS had been monitoring and providing wound care. Summary of assessments and care on that encounter:

Right (R) Lower Extremity (LE) Lateral (outside of leg): Wound is now closed. Treatment discontinued, no dressing needed.

R LE Lower Medial (toward the midline of the body): "Wound has decreased in size. ...Recommendations: Cleanse area with NS (normal saline) and pat dry. Cover with large fabric Band-Aid. Change QD (daily) ..."

R ankle outer: "...Sharp debridement performed to remove non-viable tissue. ...Recommendations: Cleanse area with NS and pat dry. Apply Santyl (prescription required ointment for healing) to wound bed and cover with bordered foam/ Change QD...."

9) On 07/01/2022 at approximately 10:00 AM, during a phone interview with the WCS, she confirmed she had been monitoring and providing wound care to P3's three wounds since he had been admitted. The WCS confirmed the accuracy of the 03/07/2022 notes. The WCS said she was not aware P3 had been discharged and said she does not attend the IDT meetings. Inquired how wound care gets incorporated into the discharge plan, and she said nursing attends the IDT meetings, and should address wound care status and needs at each IDT meeting and incorporate into discharge plans. The WCS said it is not unusual that patients are referred to a wound care clinic for ongoing wound care and they do refer homeless patients. She went on to say the MD's usually will take her last charted recommendations for wound care for discharge or will call her if they have any questions about recommendations for discharge wound care.

10) Reviewed P3's discharge instructions dated 03/10/2022 at 10:25 AM. The instructions included, but not limited to: generic preprinted education for venous ulcer and cellulitis. The venous ulcer instructions for wound care directed P3 to "Follow instructions from your doctor about how to take care of your wound." There were no other instructions provided for the wounds. The two new antibiotics (amoxicillin and doxycycline) were listed with instructions to pick up at Longs Drug Store #9206: 1405 Ala Moana Blvd. Honolulu. and instructions to "Follow up 1 week with the ID (MD)1 physician 03/16/22."

11) P3 was instructed to see ID in the office for follow up, but the facility failed to call and make an apt prior to discharge. The facility was aware that R3 did not have a phone.
P3 used a cane and his mode of transport to obtain medications prior to admission was the city bus. At the time of discharge, he used a FWW and had limited mobility. PT had not worked with or assessed P3 ability to do stairs prior to discharge, or evaluate if it was feasible or safe for him use the city bus.
P3 was not provided any medications at discharge and it was important he continue with antibiotics. There was no documentation he had been assessed if he had access to obtain these.
P3 needed ongoing wound care at the time of discharge. There was no documentation he was able to do this by himself, and there was no referral for ongoing outpatient wound care.
P3 did not have COVID vaccinations. He was willing to take them, but there was no effort made by the facility to obtain them. He needed only a negative COVID test and one vaccination for acceptance to IHS shelter.
On 03/07/2022, the WCS recommended P3's ankle wound continue to have santyl ointment and dressing applied. MD1's telemedicine encounter 03/09/2022 did not address wound care at discharge and there was no prescription for santyl.