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Based on record review and interview, the hospital failed to meet the requirement for the Condition of Participation for Nursing Services as evidenced by the hospital failure to ensure the RN supervised and evaluated the care of each patient by:
1) Failing to conduct and document complete assessments of pressure sores/wounds for 2 (#2, #3) of 5 (#1, #2, #3, #4, #5) patients with pressure sores/wounds;
2) Failing to ensure an RN staged pressure sores weekly per policy for 3 (#1, 2, 3) of 3 (#1, #2, #3) patients with pressure sores;
3) Failing to notify the physician to obtain orders to treat pressure sores for 2 (#2, 3) of 3 (#1, #2, #3) patients with pressure sores; and
4) Failing to follow physician orders for pressure sore/wound treatments for 2 (#1, 5) of 5 (#1, #2, #3, #4, #5) patients with pressure sores/wounds.

(See findings tag A-0395).

Based on record review and interview, the RN who was responsible for supervision and evaluation of the nursing care for each patient failed to ensure that care was provided in accordance with accepted standards of nursing practice. This deficient practice was evidenced by the nurses failure to ensure that patients with pressure sores and/or surgical wounds received care and services to prevent the further development/deterioration of pressure sores/wounds in a total sample of 5 patients.
The nursing staff:
1) failed to conduct and document complete assessments of pressure sores/wounds for 2 (#2, #3) of 5 (#1, #2, #3, #4, #5) patients with pressure sores/wounds;
2) failed to ensure an RN staged pressure sores weekly per policy for 3 (#1, 2, 3) of 3 (#1, #2, #3) patients with pressure sores;
3) failed to notify the physician to obtain orders to treat pressure sores for 2 (#2, 3) of 3 (#1, #2, #3) patients with pressure sores; and
4) failed to follow physician orders for pressure sore/wound treatments for 2 (#1, 5) of 5 (#1, #2, #3, #4, #5)patients with pressure sores/wounds.
Findings:

Review of the hospital policy titled, Wound Risk Assessment/Prevention/Management, revealed in part that staff was to assess pressure injury condition at each dressing change and document description. Wound care to do measurements initially and then at least weekly. Further review of the policy revealed it included definitions and treatment objectives for each pressure injury stage.

Patient #1
Review of the electronic medical record, assisted by S1Quality, revealed the patient was admitted to the hospital ICU on 10/18/21 with diagnoses including, sepsis, hypertension and type 2 diabetes.

Review of the initial wound assessment dated 10/18/21 by S3Wound LPN revealed the following:
- Sacrum unstageable, measures 3.5cm x 5.5cm x 0cm, wound bed has 100% soft eschar, foul odor
- Left medial heel, diabetic foot ulcer, measures 2.5cm x 3.0 cm, 100% brown eschar
- Right posterior heel, diabetic foot ulcer, measures 3.5cm x 4.0cm, 100% brown eschar
Further review of the assessment revealed that betadine moist gauze was applied to the wounds.

Review of the wound assessment dated 10/25/21 by S3Wound LPN revealed the following:
- Sacrum unstageable, measures 4.5cm x 6.5cm x 0cm, wound bed has 60% eschar (size increased)
- Left medial heel, diabetic foot ulcer, measures 3.5cm x 2.5cm, 100% brown eschar (size increased)
- Right posterior heel, diabetic foot ulcer, measures 4.5cm x 3.5cm, 100% brown eschar (size increased)

Review of the record revealed orders were obtained to treat the patient's wounds on 10/19/21 at 9:15 a.m. (One day after identifying the wounds). Review of the physician orders for treatment revealed to cleanse the wounds with normal saline, pat dry, apply betadine moist gauze, cover with gauze and border gauze. The order revealed to change the sacrum dressing daily and the heels every three days.

Review of nurses notes revealed documentation that "wound care performed" to the sacrum on 10/20/21, 10/21/21 and 10/23/21 but there was no evidence as to what type of wound care was performed. There was no documented evidence of wound care to the sacrum on 10/19/21, 10/22/21 or 10/24/21.

On 10/25/21 at 10:30 a.m., interview with S1Quality confirmed that she was unable to locate documented evidence that the patient received wound care to the sacrum on 10/19/21, 10/22/21 and 10/24/21. She further confirmed that there was no documented evidence that the above documented dressing changes were performed per physician's order because the notes did not indicate what exact type of dressing changes were performed. S1Quality also confirmed that the wounds were not staged/assessed by an RN.

On 10/26/21 at 1:00 p.m., S3Wound LPN was asked how she differentiates between a diabetic foot ulcer and a pressure sore. S3Wound LPN stated that she was trained that if a patient has a diagnosis of diabetes, then the wounds would be called diabetic foot ulcers. When asked if she had received any training/education on wounds since hired by the hospital last month, she stated no.

Patient #2
Review of the electronic medical record, assisted by S1Quality, revealed the patient arrived to the hospital's ER on 09/13/21 and was admitted with diagnoses including sepsis-suspect secondary to bilateral pneumonia, severe dehydration and acute renal failure.

The record revealed the patient arrived to the ICU floor on 09/14/21. Review of the ICU initial RN assessment dated 09/14/21 at 1:15 p.m. revealed:
Pressure ulcer upon admission to "right buttocks, unspecified stage. Barely noticeable, skin not missing dry, OTA". No dressing present.

Review of nurses notes from 09/15/21 - 9/20/21 revealed documentation of a pressure ulcer to the patient's coccyx.
Review of the nurses notes dated 09/16/21 revealed an abscess to the left thumb was identifed.
Review of the nurses notes dated 09/18/21 revealed pressure sores to the ears and heel were identified.
Review of the nurses notes dated 09/19/21 revealed a blister to the right arm was identifed.
Further review of the nurses notes dated 09/20/21 revealed the patient had wounds to the sacrum, left thumb, bilateral feet, right arm and bilateral ears.

Further review of the record revealed the patient was discharged on 09/20/21 at 4:49 p.m. back to her prior living arrangements at the nursing home.

During the electronic record review with S1Quality on 10/25/21 at 1:00 p.m., she confirmed that she was unable to find documented evidence of assessments/measurements/staging of any of the patient's wounds and no evidence of physician notification or orders to treat the wounds.

On 10/25/21 at 1:50 p.m., interview with S1Quality and S2CNO confirmed that there was no documented evidence to determine if the patient's wounds improved or deteriorated. They further stated that the hospital was without a treatment nurse during this time and the nurses on the floor were supposed to be doing the wound care services. When asked if there was any monitoring during that time to ensure the nurses were performing adequate wound care services, they stated no.

Patient #3
Review of the electronic medical record, assisted by S1Quality, revealed the patient was admitted to the hospital on 10/09/21 with diagnoses of severe sepsis and intra-abdominal abscess. The record revealed that the patient had emergency surgery on the night of 10/09/21 for resection of the colon and a deep incision and debridement of the abdominal wall abscess.

Review of nurses notes dated 10/11/21 revealed the only wounds that the patient had was a surgical incision wound to the abdomen.
Review of nurses notes dated 10/13/21 revealed a Stage 2 to the coccyx and a Stage 2 to the left gluteal cleft was identifed. There were no measurements or description of the pressure sores.
Review of nurses notes dated 10/14/21 revealed a wound to the right stump was identifed. There was no documented assessment of the wound.

Further review of the nurses notes revealed that from 10/16/21 - 10/20/21, the nurses documented wounds to the abdomen, sacrum, left gluteal cleft and right stump, but no assessments/staging of the wounds were documented.

Review of physician orders revealed:
10/11/21 - change abdominal dressing every Sunday
10/13/21 - order changed to pack abdominal wound with saline moist roll gauze and cover with ABD pad daily

Review of S3Wound LPN's nurses notes dated 10/12/21 - 10/20/21 revealed documentation that wound care was "performed" to the abdominal wound, but did not indicate what specific type of treatment was provided.

Review of S3Wound LPN's nurses notes dated 10/17/21 revealed that the foam dressing to the right AKA stump was changed. Review of the record revealed no evidence of a physician treatment order for the right stump.

Review of S3Wound LPN's nurses notes dated 10/20/21 revealed a Stage 2 pressure sore to the mid-back was identifed. There was no assessment of this wound.

Further review of the nurses notes revealed that on 10/20/21 at 9:15 p.m., the patient was transferred to a long term acute hospital.

On 10/25/21 at 3:30 p.m., interview with S1Quality confirmed that there were no assessments/mearsurements/staging by the RN to the patient's sacrum, left gluteal cleft, right stump or mid-back pressure sores. S1Quality further confirmed that there were no documented evidence that the physician was notified of these areas or that orders were obtained to treat. S1Quality stated that nurses should not just document wound care was "performed", but should document the exact treatment that was provided.

On 10/26/21 at 2:00 p.m., interview with S3Wound LPN revealed that she obtained orders to treat the patient's sacrum wound, but must have forgotten to put them in the computer. When asked if she documented the treatment to the sacrum, she stated "I should have." When asked how she becomes aware of newly identified wounds on patients, she stated that the nurses are supposed to let me know. S3Wound LPN stated she has only been in this position for less than a month and is still learning.

Patient #5
Review of the electronic medical record, assisted by S1Quality, revealed that the patient was admitted to the hospital from the ER on 10/11/21 with diagnoses including respiratory failure and COPD.

Review of the initial ICU RN assessment dated 10/12/21 at 12:45 a.m. revealed no skin issues. Further review of the record revealed on 10/13/21, the patient had a total abdominal colectomy with ileostomy surgery.

Review of physician orders dated 10/15/21 revealed treatment orders to cleanse abdominal wound with normal saline and pack gently with saline moist roll gauze, cover with ABD pad daily.

Review of nurses notes revealed the abdominal incision dressing was "changed" but did not indicate the exact treatment performed. There was no documented evidence that the abdominal incision dressing was changed on 10/19/21 and 10/23/21.

Review of S3Wound LPN's nurses notes dated 10/22/21 revealed that a Silver Alginate dressing was placed to the abdominal wound bed. Record review revealed no physican order for this treatment.

On 10/26/21 at 11:15 a.m., interview with S1Quality confirmed that there was no physician order in the electronic medical record for Silver Alginate. S1Quality further confirmed that there was no documented evidence that the patient received daily dressing changes as ordered by the physician.

On 10/26/21 at 2:00 p.m., interview with S2CNO revealed that she was unaware of the above patient issues involving wounds. S2CNO stated that she was aware that RNs were supposed to stage/assess pressure sores weekly, but nothing has been put into place yet. S2CNO stated that S3Wound LPN has only been employed for a month. When asked if S3Wound LPN had been provided any training/education since hired to oversee wound care for the hospital, she stated no.