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Based on record review and interview, the hospital registered nurse failed to supervise and evaluate the nursing care of 1 patient (Patient #1) in which the patient was not assessed and treated by the wound care team.

Findings included:

Patient #1 was admitted to the hospital on 07/26/2023 with worsening wounds to her legs. Her legs were swollen and red with clear fluid drainage present. Patient #1 had a past medical history of an implantable loop monitor, hypertension, cognitive impairment, chronic pain due to degenerative disc disease, dyslipidemia, peripheral neuropathy and lacumar infarcts. She had associated shortness of breath worse on exertion with dry cough.

Provider # 9 note dated 07/27/2023 at 8:51 AM indicated bilateral lower extremities with cellulitis on lower legs with chronic venous stasis dermatitis. Provider #13 note dated 07/27/2023 at 1:51 AM indicated bilateral extremities red with superficial open wounds.

Patient #1 was seen by Personnel #13, and orders were placed for wound care consult to evaluate and treat on 07/27/2023.

During the record review, the wound care team did not evaluate and treat Patient #1.

During an interview on 10/18/2023 at 12:00 PM, Personnel #7 confirmed she received a wound care consult on patient #1 and failed to complete the wound consult. She stated she did not notify nursing staff or the provider the wound care consult was not performed. She stated there is no facility process to ensure patients are receiving wound care.

During an interview on 10/18/2023 at 2:42 PM with Personnel #1 and #9, confirmed there is no facility process to ensure wound care consults were being completed.