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Based on record review and interview the facility failed to ensure that wounds were reported to the provider and failed to ensure wound care was being done on 1 (P [patient] 11) of 10 (P11-P20) patients reviewed for wound assessment and care. This deficient could lead to worsening of wounds, infection and decline in patient's health.

The findings are:

A. Record review of facility's policy titled, "Evaluation" dated 07/2012 under "Procedures" it stated, "Evaluation is the formal process in which wound characteristics, underlying conditions and contributory medical history are identified/quantified. Evaluation should result in treatment approaches including elimination or compensation for causative factors and a prognosis for healing. . . 3. Evaluation results are communicated to the members of the care team through documentation, case conference, and care planning. 4. Treatments should also be re-evaluated every 2 - 3 weeks. If no wound progression noted treatment change should be considered. If no change in treatment done documentation should occur as to why current treatment maintained."

B. Record review of facility's policy titled, "Wound Documentation" dated 07/2012 under "Procedures" it stated, "1. Documentation about the wound provides valuable information about wound progress or lack of progress. 2. On admission and/or discovery, the clinician initiates the wound document process. . ."

C. Record review of a nursing admission note for P11 on 10/03/2024 at 4:23 PM stated, "Skin assessment performed. Pt [patient] has skin tears on L [left] elbow, R [right] wrist and hand and R forearm and wrist. Abrasion [scrape] in middle of back, running next to spine. Pressure ulcer [localized damage to skin related to pressure] on coccyx [base of spinal column, also known as the tailbone] that appears red and sloughing skin [skin that is coming off]."

D. Record review of provider admission note for P11 on admission date 10/03/2024 does not reveal evidence that provider noted the wounds or was made aware of P11's wounds.

E. Record review of orders for P11 did not reveal any wound care orders for patient's wounds.

F. Record review of the discharge skin assessment for discharge date 11/10/2024 revealed a diagram that noted the abrasion in the middle of the patient's back and pressure ulcer on the patient's coccyx.

G. During an interview with Staff (S)6, Registered Nurse on 03/14/2024 at 2:07 PM it was asked what the wound care process was for the facility, S6 stated they notify the provider to assess it and put orders in. S6 stated they chart wound care in shift notes.

H. During an interview with S1, Chief Nursing Officer on 03/14/2024 at 3:15 PM it was confirmed that there was no wound care orders or wound care done for P11. S1 confirmed that the provider should have been notified and that would be evident in the documentation and orders.