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Based on record review and interviews the facility failed to ensure staff are adhering to policies and procedures when caring for patients with wounds for 2 (P[patient]5 and P8) of 10 (P1-P10) patients reviewed. This deficient practice could lead to new wounds, worsening of existing wounds and serious infections to the wounds.

The findings are:

A. Record review of the facility's Policy titled "Skin Care Protocol" dated 01/2022, stated "Procedure: 2- Each patient is assessed on the Braden (score to determine risk for skin injury) for Scale provided on the nursing assessment and daily flow sheet; 5 - Bathe daily with mild soap, and dry thoroughly."

B. Record review of the facility's policy titled "Pressure Injury (skin injury from pressure) Prevention" dated 05/2024, stated "Procedure: 2. A general skin assessment will be performed by the RN [Registered Nurse] or LPN/LVN [Licensed Practical Nurse / Licensed Vocational Nurse] on every shift."

C. Record review of the facility's policy titled "Turn Teams and Hourly Purposeful Rounding" dated 04/2022" stated, "Procedure: Hourly Purposeful Rounding is a systematic bedside rounding process that incorporates specific actions, done at specific intervals."

D. Record review of the facility's policy titled "Nursing Documentation Guidelines" Dated 04/2024, stated, "Policy: Proper documentation, which is thorough, accurate and meets standards reflect the quality of care you provide and is evidence that you acted as required by licensure or as ordered by the physician .... And remember: If it's not documented, it's not done. [bolded in policy] Procedure: 5 - The nursing flow sheet shall be to document assessment, treatments, procedures every shift. .... address interventions and outcomes are documented on flow sheet narrative note page 14 (paper chart). Forms must be completely filled out with no blank areas. If it's not applicable to the patient then write that. Forms that utilize "check boxes" should be completed with the initials of caregiver rather than check mark, unless otherwise indicated. Document do's: .... Document date and time of each call to physician and result of call ..."

E. Record review of the facility's policy titled "Plan of Care" dated 01/2021, stated "Policy: A . Assessment: 1. After a thorough nursing assessment is done, care plans are initiated by an RN will identify the main problems or potential problem areas..." The patient care plan will be personalized to meet individual patient care needs." "Care plans are to be updated and revised as goals are met and/or resolved."

F. Record review of P5's medical records titled. "Daily Nursing Assessment" from 11/19/2023 to 12/29/2023 did not contain a Braden score on the "Daily Nursing Assessments throughout P5 stay at facility. The record did not contain a full skin assessment. There were missing locations of wounds and description of the skin and wounds. On 12/21/2024, on the night shift purposeful rounding was not completed, and on 12/20/2024 and 12/21/2024 under Purposeful Rounding there was no rounding completed at 0200 (2:00 am) or 0400 (4:00 am). Intake and Outputs were not completed, all wounds were not documented with missing wounds to knees and left ear wounds.

G. On 12/20/2024 at 7:00 am there was no assessment of oxygen administration, on 12/18/2024 oxygen liters per minute is not completed.

H. Record review of P5's medical record there was no care plan located.

I. Record review of P5's medical record titled "Daily Nurses Assessment" there was no wound assessment from nurses providing wound care from 11/19/2023 - 12/29/2023.

P8
J. Record review of P8's medical record "Initial Nursing Assessment" dated 5/1/2024, on page 11 in the nurses note it stated" p/u @ L (pressure ulcer at left) forearm with wound, @ coccyx area (at coccyx area) [sic]" Form titled " IPOC (Interdisciplinary Plan of Care) /Team Conference Weekly Update: dated 5/14/2024, there was no mention of wounds on this form, form named 'LTAC (Long-Term Acute Care) nursing Plan of Care" P8's care plan dated 05/01/2024 with updates weekly on 05/03/2024, 05/13/2024 and 05/27/2024 on page 8, the care plan did not mention wounds or potential for impaired skin integrity at admission or through his stay at facility.

K. During interview with S(Staff)1, CNO (Chief Nursing Officer) on 5/29/2024 at 1:35 pm, S1 confirmed that Braden scores are completed daily and documented in the "Woundrounds" in the computer, and this is where you find them. When asked if it is documented in the Nurses assessment, S1 stated, "no just in the computer". S1 confirmed that wounds P8 was admitted with were not care planned and that baths had not been completed throughout the patients stay. S1 stated "if not documented it wasn't done."