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Based on record review and interview, the facility's registered nurse failed to supervise and evaluate the nursing care in accordance with the patient's needs, facility's policy and procedures; and the physician's order for 1 of 1 patient (Patient #1) reviewed with complaint allegations in the area of nursing services.

Specifically, Patient #1's Post Anesthesia Care Unit (PACU) record dated 10/30/23 from 12:18 PM to 8:45 PM (over 8 hours) did not include nursing documentation or monitoring for fluid output once the wound vac was placed and did not include assessment documentation of the wound site dressing after the initial post-operative assessment in order to ensure Patient #1 was free from surgical complications.

Findings included:

Review of Complaint Intake Information for TX00478758 dated 11/6/23 for Patient #1, revealed the following allegations:

On 10/30/23 Patient #1 had a wound debridement on the left lower buttock. While in the recovery room, a wound vac was placed over the wound. Patient #1 had concern while in the Post Anesthesia Care Unit (PACU) due to the wound vac started to continuously beep. The nurse on duty was aware and stated it was not a concern. Patient #1 was then moved to an inpatient hospital room. The nurse on that unit said something was not right with the wound vac and she removed it; finding that Patient #1 was "bleeding profusely."

Patient #1 was then taken back into surgery and a blood transfusion was performed. Patient #1 was not provided with any explanation as to the reason for the bleeding or wound vac issues.

Review of facility Policies and Procedures revealed the following:

1.) Intake and Output Guidelines Policy #: PC-3040, last reviewed/revised 09/23, in part;
It is the policy to accurately measure the total amount of fluids taken in and eliminated by all routes to determine fluid balance status and needs -as ordered by a physician.
PROCEDURE
INDICATIONS MAY INCLUDE:
o Physician orders "Intake and Output"
o The nurse caring for a patient on I&O is responsible to ensure that accurate intake and
output records are maintained.
o The patient's intake and output, by all routes, is accurately recorded on the patient's chart.
ASSESSMENT:
o Physician's order
o Total output to include urine from bedpan, bedside commode, Foley catheter, emesis,
blood loss, drainage from gastric decompression, wound drainage, paracentesis,
thoracentesis or other procedure, i.e., Jackson Pratt
DOCUMENTATION:
o Total and record I&O each shift on graphic sheet and Cerner as appropriate.

2.) Postoperative Documentation Policy #: SUR-1113, last reviewed/revised 09/23, in part;
o The postoperative nurse should provide quality nursing documentation that helps to ensure
continuity of care, provides legal evidence of the processes of care delivered and supports
evaluation of patient care.
PROCEDURE:
The postoperative nurse documents intake and output.
o The postoperative nurse documents the plan of care, treatments, interventions, patient
response and discharge planning including outcomes.

3.) Assessment Of Surgical Patients Policy #: SUR-1026, last reviewed/revised 09/23, in part;
- The patient's physiological response and tolerance to the procedure are continually
reassessed throughout the operative experience by all members of the surgical team,
including the Circulating RN and the anesthesia provider. Modifications and changes in the
plan of care are based on reassessment data.
- The patient's postoperative status is reassessed upon admission, throughout the patient's
stay and upon discharge from the Post Anesthesia Care Unit (PACU). This information is
documented on the PACU Record and communicated to the Nursing Services staff, who
will continue the care of the patient. The data is available on the patient's medical record to
provide collaborative interdisciplinary care for the patient's optimal and expedient recovery.

Review of Patient #1's PACU Post-Operative Report dated 10/30/23 from 12:18 to 20:45 documented the following:
A.) Initial Post-Operative Assessment completed by Registered Nurse (RN) #2 at 12:18 checked the box indicating [surgical] dressing was "clean/dry/intact" with type: foam to left buttock. Wound Vac Continuous at 125 mmHg [millimeter of mercury]. Further review of the Post-Operative Report's Nurse's notes and additional notes revealed no further documentation regarding the surgical dressing.


B.) In the area of Intake on the Post-Operative Report documented, "No IVF [Intravenous Fluids] in PACU." The Output area of the Post-Operative Report was documented F/C [Foley Catheter] for Type and Amount of Output as; 1600 and 500 for the amounts, with no times.

The nurse's notes on the post operative report indicated the following at 12:38: Patient received from phase I, wound vac in place to left buttocks at 125 mmHg on continuous.

Further review of the Post-Operative Report revealed there was not any documentation of the wound vac drainage fluids (output); to include if any fluids were captured from the wound vac into a reservoir/cannister.

Review of Patient #1's Intake and Output (I&O) orders from Physician #1 dated 10/30/23 at 16:32 indicated "routine" I&O orders.

Review of Patient #1's History and Physical dated 10/30/23 at 19:19 documented Patient #1 as a 50-year-old male with stage IV decubitus ulcer at the left gluteus. Patient admitted and underwent a left ischial decubitus debridement including bone with a wound VAC placement in preparation for definitive surgical intervention in 48-72 hours.

Interview on 12/5/23 at 4:50 PM with Registered Nurse (RN) #1 who treated Patient #1 once transferred from PACU to the floor stated after she received Patient #1 from PACU, the CNA reported to her that Patient #1 wanted to talk to her because the wound vac kept beeping. RN#1 said she removed the blankets back from Patient #1 and saw bleeding from the wound vac bandage area. RN #1 said she cleaned up Patient #1 to make sure it was not old blood and then 30-45 minutes later, it continued to bleed out around the bandage, so she notified the Doctor reporting that it was, "bleeding like a faucet." RN #1 said she had already changed out the gauze and it continued to soak up with blood. RN#1 told the Doctor that he needed to come and assess Patient #1 because there was "too much blood" and she was holding the gauze in the wound with her finger to keep the patient from bleeding out and his blood pressure dropping. RN #1 said the wound vac was "not working" for whatever reason that was; but thought it may be due to the foam placement.

Interview on 12/5/23 at 5:13 PM with the Wound Care RN stated that output fluids from a wound vac should be documented in the patients record. The Wound Care RN stated the wound vac machine will alarm if there is a leak, or some type of malfunction. An alarm can occur if there is a kink in the hose, or the canister needs to be changed from the output, or there could be an issue with placement. The Wound Care RN stated there should be documentation in the patients record in the area of Wound Vac; however confirmed Patient #1 did not have any nursing documentation in the record related to the fluid output of the wound vac.

Interview on 12/5/23 at 6:00 PM with the PACU LVN #1 stated that he cared for Patient #1 in phase 2 of the PACU while Patient #1 was waiting for a bed to transfer to the floor. LVN #1 said if the wound vac is alarming/beeping then it could be due to a "leaky seal". LVN #1 stated when a wound vac alarms, that he verifies the seal and then verifies that there is drainage into the canister. LVN #1 stated he does not document in patient's records the output of fluids that are captured from the wound vac; post-surgical. LVN #1 said that when he transfers a patient from PACU to the floor, he reports to the floor nurse if it's the "first canister or not too much drainage." LVN #1 confirmed there was not any documentation in Patient #1's record regarding an output amount of fluids from the wound vac. LVN #1 also confirmed that he had not completed any documentation of the visualization of the wound dressing site to include if it was intact, bleeding, etc.