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Based on a review of one of one (Patient's #1) electronic medical record, the electronic medical record contained no written consultative evaluation from the wound care physician as ordered by the hospitalist on 10/08/2017 at 0324.

Findings included:

A review of Patient #1's closed electronic medical record revealed that Patient #1 was admitted to the hospital on 09/19/2017 and discharged on 02/21/2018 due to ongoing medical complications from a suicidal attempt by self-strangulation with anoxic brain injury.

Review of Nursing Note, entered on 10/18/2017 at 03:29 and performed at 10/08/2017 at 03:24 revealed that "0230 discovered trach area with open area with black sutures at edges measured 6.0 cm by 3.0 cm with 0.3 cm depth, wound with yellow drainage present. Pictures taken. Dr. Huddlelston (hospitalist) notified and examined patient ordered wound care MD consult and pulmonary MD consult. Wound cleansed with normal saline and H20 and reapplied drain sponge to trach area."

Review of the electronic medical record failed to reveal documentation of a written consultative evaluation by a wound care physician.

Interview on 10/04/2018 with facility staff revealed the wound care physician would often document separately form the electronic medical record.

The above was confirmed during an exit interview with the facility Physician Advisor and Chief Quality Officer on the afternoon of 10/04/2018.