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Based on record review and interview the facility failed to ensure that nursing adequately evaluated the nursing care for patient #2 to ensure preventative measures were put in place to prevent skin breakdown and frequently assess the wound to evaluate the nursing care for the patient.

Findings include:

Record review of facility policy "Pressure-Injury Prevention and Management Procedure dated 06/30/2016, stated on:
Page 4, 1. Identify individuals at risk for developing pressure injury and initiate early prevention interventions.
Page 11, Manage activity/mobility; turn or offload pressure every two (2) hours.

Record review of wound care notes, dated 09/21/2018 at 09:29 by wound care nurse, (ID # 69), revealed reason for consult skin and wound assessments. She documented the following:

Sacrum: stage 2 Pressure Injury; partial thickness, skin loss over bony prominence with shiny red smooth wound bed, exudate, small amount of serosanguinous exudate. Length 4.5 cm x width 5.5 cm x depth 0.1 cm.

Record review of wound care noted dated 10/1/2018 at 12:38 documented by wound care nurse (ID #82), who documented:

Sacrum: unstageable pressure injury: appearance wound bed 60% moist pink tissue, 40% moist yellow slough, Exudate: small amount of serosanguineous exudate
Measurements: length 5.0 cm x width 7.0 cm x depth 0.1 cm.
Right ischium: unstageable pressure injury: appearance, wound bed 100% loosely adhered leathery black tissue, Exudate: moderate amount of serosanguineous exudate. Measurements: length 4.0 cm x width 4.0 cm x depth 0.0 cm. Neck under trach flange- full thickness moisture and friction; approximately length 0.8 cm x width 1.0 cm x depth 0.2 cm. Wound bed moist, pale pink tissue, no undermining, no tunneling/induration edges well defined, no drainage, no orders, no signs of infection, periwound intact.

Interview and record view of nurses' notes on 07/23/2019 at 2:00 with, RN, clinical manager (ID # 69) who stated:
"We are supposed to turn patients every two hours, it appears looking at the note, the nurses did not turn ID #4 on a consistent basis".

"Wound care should be done at least every 24 hours, if ordered daily. I remember the patient and we did do dressing changing daily because it took more than one nurse to assist. The notes reveal we only have three days of dressings changes and we are not documenting it was done".