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Based on medical record review, staff interview, and policy review, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient (A395).

Based on medical record review, staff interview, and policy review, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for six of six medical records reviewed for patients with wounds (Patient #1, #5, #7, #8, #9, #10 ). The total sample was ten records. The facility active census was 143.

Findings include:

Review of the policy titled, Wound Care Including Dressings, Negative Pressure Wound Therapy, Removal of Drains, Packing, and Pressure Injury Care Including Prevention, effective date 10/26/21, revealed the purpose is to to delineate the responsibilities of nursing personnel associated with assessing and documenting wound care. The policy includes guidelines for assessing and documenting patient risk factors for pressure injury development, assessing and documenting actual skin breakdown related to pressure, implementing a plan for care for patients at risk for impaired skin integrity, utilizing therapeutic modalities appropriately and documenting the use of therapeutic modalities and/or responses to interventions. Per policy all wounds should be measured and documented on admission and weekly thereafter, or with any significant change noted.

Wound measurements are as follows: Use a measuring device to determine the size (length (L) x width (W) x depth (D)) of a wound in centimeters (cm). Assess skin at least daily and notify the physician of any new or decline in skin integrity or wounds, obtain specific wound care orders if standing wound care orders are not appropriate, nurse or physician will consult wound care team for stage two or greater pressure injury or concerns about prevention and treatment.

1). Review of the medical record for Patient #1 revealed on 12/28/22 at 5:51 PM the patient presented to the emergency department with a chief complaint of swelling to the right side of the jaw/neck. The patient was noted to have advanced dementia with poor oral intake over a week with difficulty swallowing and multiple choking/aspiration episodes. The patient was diagnosed with a submandibular abscess with surgical intervention required. The emergency department noted a pressure injury to the left hip with the stage unknown.

On 12/29/22 at 1:05 PM the operative report noted an active pressure injury to the left hip.

Review of the Registered Dietitian documentation dated 01/03/23 at 11:47 AM revealed a stage 2 pressure injury (shallow with a reddish base. Adipose (fat) and deeper tissues are not visible, granulation tissue, slough and eschar are not present. Intact or partially ruptured blisters that are a result of pressure can also be considered stage 2 pressure ulcers) with a Braden score of ten indicating a high risk for skin breakdown.

Review of the nursing admission assessment dated 12/29/22 at 8:05 AM revealed no evidence of wound measurements and/or characteristics of a wound as per policy. Per the record the wound care nurse did not see the patient until 01/13/23 at 10:45 AM at which time the patient was observed to have an unstageable pressure injury to the sacrum with no measurements and/or characteristics of the wound documented and none thereafter. The wound care nurse did not see the patient again until prior to discharge on 01/17/23 at 12:08 PM.

These findings were confirmed in an interview with Staff F on 02/28/23 at 2:00 PM.

2). Review of the medical record for Patient #5 revealed the patient presented to the emergency department on 12/02/22 at 4:06 PM due to an altered mental status. The patient was diagnosed with a urinary tract infection and severe sepsis and was admitted to the facility on 12/02/22 at 9:23 PM. The emergency department physician noted the patient had become less mobile and appeared to have multiple pressure injury wounds. A wound referral/consult was completed for the left heel wound and sacral decubitus ulcer.

The wound care nurse saw the patient on 12/03/22 at 10:30 AM and noted wounds to the right hip, lateral right ankle, left heel, coccyx, left hip, and a uretal stent with suture non intact. The medical record lacked evidence of wound measurements to the multiple identified areas on the nursing admission assessment dated 12/02/22 at 9:05 PM and/or by the wound care nurse on 12/03/22 as per policy. The patient was not seen again by the wound care team and was discharged on 12/08/22.

This finding was confirmed in an interview with Staff F on 03/01/23 at 10:13 AM.

3). Review of the medical record for Patient #7 revealed the patient presented to the emergency department on 12/01/22 at 9:30 PM with a chief complaint of a sacral ulcer. The patient was paraplegic and reported having a known stage four sacral decubitus ulcer (a deep wound reaching the muscles, ligaments, or bones. They often cause extreme pain, infection, invasive surgeries, or even death) which had osteomyelitis (inflammation or swelling that occurs in the bone. It can result from an infection somewhere else in the body that has spread to the bone, or it can start in the bone often as a result of an injury) in the past. The patient reported for the past few days she noted a foul smelling odor coming from there with increased pain and was unsure if there is drainage coming from the area. The emergency department assessment noted a stage four decubitus ulcer to the left gluteus area over the ischial sacral region with images obtained. In addition, the left lower foot was warm to palpation compared to the right side with erythema (redness) to the fourth toe and bruising noted to the fourth toe and bottom of the foot. Per the physician the left foot also appeared infected with bruising noted. The patient was diagnosed with sepsis and was admitted to the facility and treatment and management of wounds.

The wound care team did see the patient on 12/02/22 with wound measurements and characteristics documented, but the nursing admission assessment dated 12/02/22 at 1:55 PM lacked evidence of wound measurements as per policy.

This finding was confirmed in an interview with Staff F on 03/01/23 at 10:43 AM.

4). Review of the medical record for Patient #8 revealed the patient presented to the emergency department on 02/15/23 at 9:07 PM with a chief complaint of chest pain. The physician documentation noted diagnoses of paraplegia with chronic stage four pressure injuries to the right and left ischium.

The wound care team saw the patient on 02/17/23 at 9:15 AM and noted the patient is not wanting to roll in bed for assessment of the sacral wound. The patient reported pain and requested the wound nurse come back after she receives pain medication. The wound nurse returned on 02/17/23 at 10:40 AM and noted sacral and right thigh wounds with images obtained.

Review of the nursing admission assessment dated 02/16/23 at 5:52 PM revealed no evidence of wound care measurements as per policy. In addition, the medical record lacked evidence of wound measurements by the wound care team.

These findings were confirmed in an interview with Staff F on 03/01/23 at 11:17 AM.

5). Review of the medical record for Patient #9 revealed the patient presented to the emergency department on 12/26/22 at 4:52 PM with a chief complaint of pruritus (itchy skin) to the bilateral lower extremities with recent treatment of sepsis related to the wounds. Per the documentation the physician noted nonpressure chronic ulcers of the lower extremities with peripheral vascular disease. The emergency department work up noted the patient to be exhibiting an acute exacerbation of heart failure requiring admission. The patient was being seen at an outpatient wound clinic with physician recommendation for amputation given the severe peripheral vascular disease and the patient declined. The patient was also noted to have a sacral decubitus ulcer with recommendation to continue wound care.

The wound care nurse saw the patient on 12/27/22 at 1:15 PM with multiple wounds noted to the the lower extremities which lacked evidence of wound characteristics and/or measurements. The medical record revealed the sacral wound was not assessed by the wound care team until 01/09/23 and again on 01/12/23 and also lacked wound measurements. In addition, the nursing admission assessment dated 12/27/22 at 1:07 AM lacked evidence of wound care measurements to the bilateral lower extremities or the sacral wound.

These findings were confirmed in an interview with Staff F on 03/01/23 at 11:52 AM.

6). Review of the medical record for Patient #10 revealed the patient presented to the emergency department on 02/03/23 at 2:05 PM with a chief complaint of a displaced gastrostomy tube. The x-ray confirmed the gastrostomy tube was not within the proximal stomach with diffuse ileus requiring intravenous antibiotics and surgical intervention. The recommendation was dressings changed twice per day to the g-tube site. The family was educated and the patient was discharged on 02/03/23.

Per the record the patient returned on 02/13/23 at 1:07 AM after an outpatient urine culture grew resistant bacterium only susceptible to vancomycin requiring hospitalization. On 02/13/23 a stage two sacral wound was identified with a consult made to the wound care team which was completed on 02/14/23 at 1:16 PM. The nursing admission assessment on 02/13/23 at 3:23 AM lacked evidence of a wound and did not include measurements and/or characteristics of the sacral wound as per policy.

This finding was confirmed in an interview with Staff F on 03/01/23 at 12:32 PM.

An interview was conducted with Staff H on 03/01/23 at 1:43 PM who reported the expectation was that the registered nurse would document measurements and characteristics of wounds as per policy with referrals completed timely.

This deficiency represents non-compliance investigated under Substantial Allegation OH00139685.