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Based on interview and record review, the hospital failed to follow the procedures of the hospital when there was no documentation indicating wound treatment was implemented as ordered for two of three patients (Patients 3 and 8).

These failures had the potential for patients' needs not being met and worsening health conditions.

Findings:

1. A review of Patient 3's History and Physical indicated Patient 3 was admitted to the hospital on 1/09/25, and the chief complaint was intracranial hemorrhage (a type of stroke that causes bleeding within the skull).

A review of Patient 3's Wound Care Note, dated 1/20/25, indicated that Patient 3 had two wounds: wound #1, located on the right nostril, had scattered dry scabs with blanchable redness. The treatment plan for this wound were to cleanse with normal saline, pat dry, apply Aquaphor, and leave open to air, to be done daily. Wound #2, located on the left medial upper leg, was a deroofed blister. The treatment plan for this wound were to clean with normal saline, pat dry, apply TheraHoney, and cover with a foam dressing, to be done every other day and as needed for soiling.

A review of Patient 3's Wound Care Notes, dated 1/24/25, indicated that the patient had a pressure injury wound: wound #3, located on the right upper inner nare, was a deep tissue pressure injury. The treatment plan for this wound were to cleanse with normal saline, pat dry, apply a thin layer of Triad cream, to be done daily, and leave open to air.

A review of Patient 3's nursing documentation revealed no record indicating that Aquaphor was applied to wound #1 on 1/22/25 and 1/23/25, that TheraHoney and foam dressing were applied to wound #2 on 1/24/25 and 1/26/25, and that Triad cream was applied to wound #3 on 1/25, 1/26, and 1/27/25.

During a concurrent interview and record review with the wound care nurse (WCN) on 3/19/2025 at 10:00 a.m., the WCN stated that the wound care nurse assessed the patient's wounds and recommended the treatment plan. The bedside nurse should be responsible for changing the dressings daily or as ordered. The WCN confirmed that there was no documentation indicating Aquaphor was applied to wound #1 on 1/22/25 and 1/23/25, no documentation showing TheraHoney and foam dressing were applied to wound #2 on 1/24 and 1/26/25, and no documentation indicating Triad cream was applied to wound #3 on 1/25, 1/26, and 1/27/25.

2. A review of Patient 8's History and Physical indicated Patient 8 was admitted to the hospital on 1/24/25, and the chief complaint was acute respiratory failure.

A review of Patient 8's Wound Care Note, dated 1/28/25, indicated that Patient 8 had two pressure injury wounds: wound #1, located on the midback over the spine, was an unstageable pressure injury, and wound #2, located from the coccyx to the bilateral buttocks, was a deep tissue pressure injury. The treatment plan for both wounds included cleaning with normal saline, patting them dry, applying triad, and covering them with a foam dressing daily.

A review of Patient 8's nursing documentation revealed no record indicating that Triad and foam dressing were applied to wound #1 and wound #2 on 2/1, 2/2 and 2/6/25.

During a concurrent interview and record review with the WCN on 3/21/2025 at 10:27 a.m., the WCN reviewed Patient 8's nursing documentation and confirmed that there was no documentation indicating that Triad and foam dressing were applied to wound #1 and wound #2 on 2/1, 2/2 and 2/6/25.

A review of the hospital's policy, Wound Assessment and Management: Vascular, Surgical, and Pressure, effective dated 12/20/2023, indicated, "Wounds will be assessed with every dressing change ... Every dressing change will include the following assessment: Location, Wound Bed Description... All wound dressings must be dated, timed, and include the initials of the person who changed the dressing."