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Based on interview and record review, the facility failed to ensure a registered nurse 1) supervised and evaluated nursing care, 2) failed to implement their policy and procedure for wound care management and 3) failed to follow physician orders for 1:1 feeding assistance for 1 (#2) of 5 patient's reviewed for nursing services and within acceptable standard of practice resulting in the potential for unrecognized, unmet patient needs and the potential for harm for patient # 2. Findings include:

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A-0395 Based on interview and record review the facilty failed to ensure that a Registered Nurse followed physician orders for 1:1 feeding assistance and failed to ensure nursing staff followed their policy and procedure for wound care management for 1 (#2) of 5 patients reviewed for nursing services.

Based on record review and interview, the facility failed to ensure nursing staff implemented their policy and procedure for wound care management for 1 (#2) of 2 patients reviewed for impaired skin integrity and failed to ensure 1 (#2) of 3 patients reviewed for 1:1 feeding assistance was supervised by the registered nurse resulting in unmet care needs.
Findings include:

Medical record review on 11/1/2021 at 1000 was conducted with the Director of Clinical Informatics Staff (F) and revealed the following:
Patient (#2) was a 32-year-old female who was admitted to the facility on 9/9/2021. She was discharged home on 9/17/2021.

Review of the admission nursing assessment dated 9/9/2021 at 0400 revealed the patient (#2) had the following alterations in skin integrity that included:
1. An anterior right palm wound that measured 14 centimeters (cm) in length (l) and 6 cm in width (w).
2. A right posterior thigh stage 2 pressure ulcer that measured 3 cm (l) 3 cm in (w).
3. A right buttock stage 4 pressure ulcer that measured 14 cm in (l) 14 cm in (w) and 4 cm in depth (d).
4. A middle left buttock stage 3 pressure ulcer that measured 6 cm (l) 3 cm (w) 1 cm (d).
5. An open wound to the 2nd left finger with a necrotic wound bed. There were no measurements documented.
The patient's Braden Score was listed at "13", (range of less than 18 equaled at risk for forming pressure sores).

Review of the Wound Care Specialist (WOC) Consultation dated 9/9/2021 at 1544 documented the following:
Patient (#2) assessed per consult...Patient stated she has a wound care nurse that comes to her home and uses Medihoney twice per day because her dressings are typically too saturated with daily dressings changes. Two pressure injuries noted.
Wound assessment as follows:
1. Stage 4 pressure injury right trochanter 4 cm (l) 4 cm (w) 0.5 cm (d).
2. Stage 4 pressure injury left ishium 9 cm (l) 15 cm (w) 3 cm (d).
Review/Management: "Irrigated both wounds with normal saline and pat dry. Applied Hydrofera Blue Ready Transfer to wound bed and lightly packed with roll gauze then covered with Allevyn."
Impression and Plan Education and Follow-up:
Follow up Plan: WOC RN to follow.
Dressing change orders placed to be completed by bedside nurses. Will continue to follow loosely while in hospital. However, there was no further evidence in the medical record that documented the patient (#2) was assessed or evaluated by the WOCN for her anterior palm wound nor her left 2 index finger wound. There was no evidence in the medical record that documented the patient's dressing were changed after 9/9/2021. There was no evidence that patient's wounds were measured after her admission on 9/9/2021. There were no evidence in the medical record that nursing staff obtained treatment orders for the patient's right anterior palm wound or her left 2 index finger wound.

Review of Speech Pathology and Language (SPL) consultation dated 9/9/2021 at 0905 documented the following:
"...Recommended diet Regular with thin liquids. Feed only when alert, Up at 90 degrees for feeding. Swallow Supervision Recommended: One on one."
A review of physician orders for patient #2 dated 9/10/2021 at 1342 documented the following: 1:1 regular diet.

Further review of the medical record revealed the patient (#2's) regular diet intake was only recorded on 9/15/2021. Staff documented the patient had consumed 50 percent of her meal.

Review of a hand x-ray for patient #2 dated 9/14/2021 at 0949 revealed the following:
Clinical History: 32- year- old female with pain. EMR reports trauma history.
Technique: Lateral view of the left hand
Findings:
There is a non-displaced fracture at the second distal phalanx with overlying soft tissue defect at the dorsal aspect of the finger.
Impression:
1. Non-displaced fracture of the second distal phalanx with overlying soft tissue defect.

Review of Orthopedic Surgery Consultation dated 9/14/2021 at 1553 revealed the following:
History of Present Illness:
32-year- old female with Previous Medical History of quadriplegia...Ortho/Hand consulted secondary to patient biting the tip of her 2nd finger off secondary to Acute Mental Status. Patient states it occurred on 9/9/2021.
Impression/Plan
1. Left open distal phalanx fracture of pointer finger from human bite. Intravenous Antibiotics. Pain control. Wet to dry dressings changes. No weight bearing.
However, there was no evidence that wet to dry dressing changes were performed.

On 11/2/2021 at 1130 an interview and review of patient #2 medical record was conducted with Registered Nurse Administrative Director Staff (D). She was asked to explain and provide evidence that documented nursing staff performed wound care dressing changes for the patient's pressure injuries after 9/9/2021. Staff D was asked to explain and provide evidence that documented nursing staff obtained orders for wound care for the patient's right anterior palm wound and the patient's left 2 finger wound. Staff F was asked to explain and provide evidence that documented nursing staff consistently followed the physician's orders for 1:1 feeding assistance for patient #2.
On 11/2/2021 at 1150 Staff F said there was none.

Review of the facility's "Skin and Wound Care" Policy 2 PC 5200, with an effective date of April 10 2018 documented the following:
III. The RN is responsible for the assessment, planning, evaluation and documentation of skin and wound care. Wounds are assessed with each dressing changed and characteristics documented in the medical record. However, that was not done.

Review of the facility's "Pressure Injuries: Prevention and Care" Policy 2 PC 5202, with an effective date of August 31, 2017 documented the following:
III. Policy
A. An RN using the Braden Scale assesses each patient admitted to (name of facility) inpatient unit for risk for pressure ulcer development.
1. Braden Scale score of 18 or less or low subscale scores indicates that the patient is at risk for developing a pressure ulcer. Interventions targeting risk areas are implemented to prevent and manage pressure ulcers.
2. Patients with actual or healing pressure ulcers are considered at a high level of risk...
C. RN responsibilities:
1. Assessment, planning, documentation and evaluation of skin and hospital and community acquired pressure ulcer/ wound care with shift assessment. Pressure ulcers are measured on admission, every Monday, upon development, or deterioration...4. Initiate EMR orders for pressure ulcer prevention and management based on patient risk assessment and/or presence of pressure ulcer(s). Interventions are directed toward specific subscale risk factors....8. Consult dietitian for Braden Scale Score less 18 or Braden subscale nutrition score of less or pressure of pressure ulcer. However, that was not done.

Review of the facility's "Patient Assessment and Documentation", Policy 2 PC 201 Effective date 11/15/2019 documented:
Documentation Scope of Practice:
Acute Care Hygiene, Nutritional Intake. Frequency: Every Shift by RN, Student Nurse , Patient Care Associate, or Student Nurse Associate.
However, that was not done.