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Based on facility policy review, record review, and interview, the facility failed to ensure care was provided in accordance with the needs of the patient for 1 (Patient #1) of 3 patients when staff failed to properly assess the patient for their risk of developing pressure ulcers and failed to properly prevent and treat pressure ulcers.

Findings included:

Review of a facility policy titled "Patient Assessment and Reassessment," effective 03/27/2012, revealed, "The assessment of the care or treatment required to meet the needs of the patient will be ongoing throughout the patient's hospital stay, with the assessment process individualized to meet the needs of the patient population." The policy noted, "Documentation must be timely, accurate and complete and provide a "picture of the patient."

Review of a facility policy titled "Management of Pressure Ulcers," revised on 10/03/2012, revealed, "Any pressure ulcer present at the time of admission will be identified. Any pressure ulcer developed after admission will be identified. Factors that lead to the development of a pressure ulcer, the potential for development of additional ulcers or for the deterioration of the pressure ulcers will be identified, assessed and addressed." The policy noted, "Nursing staff will take initial pictures and, as needed, identify, date and month for medical treatment of the patient. Call physician to report condition of pressure ulcer and for treatment orders. The physician will differentiate the type of ulcer" and "The physician will determine the stage of the ulcer." The policy further revealed that nursing staff were to "Follow physician's orders for treatment of the pressure ulcer, including cleansing and dressing."

Review of a facility policy titled "Skin Care for Patients who are High Risk for Skin Breakdown," revised on 01/18/2015, revealed "Patients who are at high risk or [sic] skin breakdown usually fall into one or more of the following categories: Age 65 years or older. Paraplegic. History of prior decubitus. Presence of altered skin integrity. Thin or emaciated patient. History of poor nutrition. Tube feeders. Immobile or bed confined patient." The policy indicated, "When preparing the room for a newly admitted patient who is at high risk for skin breakdown, an air mattress will be placed on the bed." The policy indicated "Heel and/or elbow protectors will be utilized as needed" and "Patients at high risk for skin breakdown will be turned to a new position as needed, at least every two hours and more frequently as required."

Review of a facility policy titled "Dietary Consults," reviewed in May 2010, revealed "To ensure that all patients admitted to the Swing Bed unit will have a nutritional assessment on all patients." A procedure section revealed in part, "1. Patients admitted will have an order at the time of admission for a dietary consult" and "3. The dietician will be responsible for doing a nutritional assessment within 48 hours if [sic] admission to ensure that the patient is receiving any and all appropriate dietary counseling."

Review of Patient #1's medical record indicated the facility admitted the patient on 11/10/2021 to the geriatric psychiatric unit and then admitted the patient to a swing bed (a bed used to provide skilled nursing services) within the facility on 12/02/2021.

A review of a hospital record titled "Emergency Room Outpatient Record" revealed the facility admitted Patient #1 on 11/10/2021 with a chief complaint of psychosis.

A review of a hospital record titled "Change of Service Note-Geri psych to swing bed" revealed the facility admitted the patient to a swing bed for treatment for weakness and gait instability on 12/02/2021.

Review of a record titled "BH: Admission & Initial Assessment (C/H)", dated 11/10/2021, revealed it did not indicate Patient #1 had any pressure ulcers.

Review of Patient #1's medical record revealed it lacked evidence of an assessment for the patient's risk of developing pressure ulcers after admitting to the swing bed. The records also did not indicate a dietary consultation had been completed after admitting to the swing bed.

Review of Patient #1's "Patient Progress Notes" from 12/02/2021 to 12/17/2021 indicated staff did not start documenting the patient's meal intake in the progress notes until 12/10/2021. The Patient Progress notes did not show any intake amount eaten by the patient on 12/10/2021 for dinner, 12/11/2021 for dinner, 12/12/2021 for dinner, 12/13/2021 for lunch or dinner, 12/14/2021 for breakfast, lunch, or dinner, 12/15/2021 for dinner, or 12/16/2021 for lunch or dinner, and no meal intake was documented for 12/17/2021.

Review of Patient #1's "Patient Progress Notes" showed a note dated 12/02/2021 at 7:25 AM that showed a Braden Scale (an assessment tool to determine if a patient was at risk of developing pressure ulcers) score of 19, indicating the patient was not at risk of pressure ulcers. Patient Progress Notes dated 12/02/2021 indicated the patient was discharged to swing bed services on 12/02/2021. Patient Progress Notes dated 12/07/2021 showed the first notes indicated the patient was being repositioned. Patient Progress Notes dated 12/10/2021 indicated the patient had a Stage 2 pressure ulcer (partial thickness loss of skin that looked like a shallow, open ulcer with a red/pink wound bed) on the patient's "buttocks" for which a dressing was applied. Patient Progress Notes dated 12/10/2021, amended on 12/11/2021, indicated the patient had a blister to their "big toe" and a Stage 1 pressure ulcer (non-blanchable redness of intact skin) was noted on the patient's right heel. The note indicated heel protectors were applied on 12/11/2021.

Review of Patient #1's "Patient Progress Notes" showed a hydrocolloid dressing was placed on the patient's sacral wound on 12/10/2021, 12/12/2021, and 12/16/2021. The Patient Progress Note on 12/16/2021 indicated there was not a dressing on the patient before one was placed that day.

Review of a document titled "Pain Location", dated 12/09/2021, indicated the patient had a Stage 2 pressure ulcer on their sacrum (bone at the base of the spine). The document indicated the patient was turned every two hours while in bed and a cushion in the patient's wheelchair.

Review of a document titled "Pain Location," dated 12/12/2021, revealed pain was indicated on the patient's sacrum and right heel.

Review of a document titled "Pain Location," dated 12/15/2021, indicated locations of the patient's pain included the patient's sacrum, a blister on the patient's left big toe, and a bruised labia. The document also indicated the patient's right heel was "blackened."

Review of Patient #1's medical records revealed no evidence of wound treatment orders. The record also did not indicate any physician notes regarding the patient's sacral wound.

Review of Patient #1's medical record indicated the patient discharged from the facility on 12/17/2021.

On 10/11/2023 at 1:10 PM, Registered Nurse (RN) #1 confirmed via email that there was no specific Braden Scale policy but the policy titled "Skin Care for Patients who are High Risk for Skin Breakdown" had some of the same categories.

During an interview on 10/11/2023 at 1:10 PM, Licensed Practical Nurse (LPN) #3 said that common items used in the prevention of wounds were wedges, pillows, foam dressings, baby powder, and an egg crate mattress topper. She confirmed that there were no air mattresses at the facility. She said patients did not like the egg crate mattress toppers, and they were not commonly used. She also reported that repositioning was key to help with skin breakdown as well. She said preventive measures were typically documented under nursing notes or "devices used," but that there was not a specific place for staff to document it. She said the nurses' notes were where any documentation regarding wound dressings would be as well.

During an interview on 10/11/2023 at 1:30 PM, the Registered Dietician (RD) said she went into the facility to see patients in person once a month but otherwise worked remotely to review patient records and advise the facility on dietary matters. She said that typically dietary consultation orders were used but she tried to look at all the swing bed patients. She said examples of documentation she would look at in a patient's chart included laboratory results and documentation of meal intake. The RD said meal intake was usually documented under nursing notes, but noted that such documentation did not always occur. She said it was mostly breakfast and lunch that got documented. She said if a patient was at risk of skin breakdown and was not eating or did not have much of an appetite, she would advise a nutritional supplement, depending on what was available. She said if the patient was eating, she would advise extra protein portions or the addition of milk with each meal. She said all advisement by the RD was under the dietician notes in the record and was also communicated to the kitchen and nurses via phone call.

During an interview on 10/11/2023 at 4:25 PM, LPN #3 said that nurses informed the physician regarding a wound, who then evaluated the wound when they saw the patient. LPN #3 said staff also kept the physician informed regarding the progress of the wound and attempted to be with the physician when they saw the patient, when possible. She said the facility had wound treatment items such as wound dressing, wound cleanser, and barrier cream. LPN #3 said they used barrier cream even if an area was reddened on a patient. LPN #3 said it was the physician's discretion regarding what was used to treat a wound otherwise.

On 10/11/2023 at 4:35 PM, the DON confirmed via email that Physician #7, the admitting physician for Patient #1 and the physician that oversaw all of Patient #1's medical care, was currently out of the country on vacation and not available to discuss wound treatment.

During an interview on 10/11/2023 at 4:45 PM, Physician #6, who was a current admitting physician at the facility but who had no involvement in the care of Patient #1, said the nurses would notify the physician of changes with the patient and the first line of wound treatment and defense was repositioning. Physician #6 said if a wound started to become more severe, then management changed to treatments such as antibiotics, topical medications, and even debridement (removal of damaged tissue), if necessary. Physician #6 said if the wound was too severe, the patient may be transferred for a higher level of care, as the facility did not have a surgical or wound care team. Physician #6 said he would refer to nursing or pharmacy related to the topical medication that would be used as he worked at several hospitals, which all stocked different items.

On 10/11/2023 at 12:41 PM, the Director of Nursing (DON) confirmed via email that it appeared their swing bed charting system did not have a breakdown or calculation for the Braden Scale. She also confirmed via email that there was no dietary order consultation entered upon Patient #1's admission to the swing bed and confirmed she did not see wound care orders in the patient's record.

During an interview on 10/11/2023 at 12:55 PM, the DON said if there was not a specific swing bed policy, staff were expected to use the regular nursing policy that was used for medical/surgical patients. The DON said specialty mattresses the facility used were egg crate mattresses that could be placed on top of the existing mattresses. She reported that patients often did not like them. The DON said the facility did not have the option of using an air mattress. The DON said she did not know if the egg crate mattress could lead to an increase in skin breakdown.

During an interview on 10/11/2023 at 5:05 PM, the DON confirmed that there were no photos of the pressure ulcers in Patient #1's record, and that Physician #7's notes did not contain an assessment or mention of the Stage 2 pressure ulcer on the patient's sacrum.

Based on facility policy review, record review, and interview, the facility failed to ensure the medical record included an accurate assessment of the health status and needs of a patient by the physician for 1 (Patient #1) of 3 records reviewed. Specifically, the facility physician failed to assess the patient's sacral pressure ulcer or place wound care orders.

Findings included:

Review of a facility policy titled "Management of Pressure Ulcers," revised on 10/03/2012, revealed "Any pressure ulcer present at the time of admission will be identified. Any pressure ulcer developed after admission will be identified. Factors that lead to the development of a pressure ulcer, the potential for development of additional ulcers or for the deterioration of the pressure ulcers will be identified, assessed and addressed." The policy noted, "Nursing staff will take initial pictures and, as needed, identify, date and month for medical treatment of the patient. Call physician to report condition of pressure ulcer and for treatment orders. The physician will differentiate the type of ulcer" and "The physician will determine the stage of the ulcer." The policy further revealed that nursing staff were to "Follow physician's order for treatment of the pressure ulcer, including cleansing and dressing."

Review of Patient #1's medical record indicated the facility admitted the patient on 11/10/2021 to the geriatric psychiatric unit and then admitted the patient to a swing bed (a bed used to provide skilled nursing services) on 12/02/2021.

A review of a hospital record titled "Emergency Room Outpatient Record" revealed the facility admitted Patient #1 on 11/10/2021 with a chief complaint of psychosis.

A review of a hospital record titled "Change of Service Note-Geri psych to swing bed" revealed the facility admitted the patient to a swing bed for treatment for weakness and gait instability on 12/02/2021.

Review of a record titled "BH: Admission & Initial Assessment (C/H)," dated 11/10/2021, revealed it did not indicate Patient #1 had any pressure ulcers.

Review of Patient #1's medical record did not show an assessment for the patient's risk of developing pressure ulcers after admitting to the swing bed. The records also did not indicate a dietary consultation had been completed after admitting to the swing bed.

Review of Patient #1's "Patient Progress Notes" showed a note dated 12/02/2021 at 7:25 AM that showed a Braden Scale (an assessment tool to determine if a patient was at risk of developing pressure ulcers) score of 19, indicating the patient was not at risk of developing pressure ulcers. Patient Progress Notes dated 12/02/2021 indicated the patient was discharged to swing bed services on 12/02/2021. Patient Progress Notes dated 12/07/2021 showed the first notes indicating the patient was being repositioned. Patient Progress Notes dated 12/10/2021 indicated the patient had a Stage 2 pressure ulcer (partial thickness loss of skin that looked like a shallow, open ulcer with a red/pink wound bed) on the patient's "buttocks" for which a dressing was applied. Patient Progress Notes dated 12/10/2021, amended on 12/11/2021, indicated the patient had a blister to their "big toe" and a Stage 1 pressure ulcer (non-blanchable redness of intact skin) on the right heel. The note indicated heel protectors were applied on 12/11/2021.

Review of Patient #1's "Patient Progress Notes" showed a hydrocolloid dressing was placed on the patient's sacral wound on 12/10/2021, 12/12/2021, and 12/16/2021. The Patient Progress Note on 12/16/2021 indicated there was not a dressing on the patient before one was placed that day.

Review of a document titled "Pain Location," dated 12/09/2021, indicated the patient had a Stage 2 pressure ulcer on their sacrum (bone at the base of the spine). The document indicated the patient was turned every two hours while in bed and a cushion was in the patient's wheelchair.

Review of a document titled "Pain Location," dated 12/12/2021, revealed pain was indicated at the patient's sacrum and right heel.

Review of a document titled "Pain Location," dated 12/15/2021, indicated pain locations included the patient's sacrum, a blister on the patient's left big toe, and a bruised labia. The document also indicated the patient's right heel was "blackened."

Review of Patient #1's medical records revealed no evidence of wound treatment orders. The review also revealed no evidence of physician notes regarding the patient's sacral wound.

Review of Patient #1's medical record indicated the patient discharged from the facility on 12/17/2021.

During an interview on 10/11/2023 at 4:25 PM, Licensed Practical Nurse (LPN) #3 stated nurses informed a physician regarding the presence of a wound, who then evaluated the wound when they saw the patient. LPN #3 said staff would also keep the physician informed regarding the progress of the wound and attempted to be with the physician when they saw the patient. She noted the facility had wound treatment items such as wound dressings, wound cleanser, and barrier cream. LPN #3 said they would use barrier cream even if an area was reddened on a patient. LPN #3 said it was the physician's discretion regarding what was used to treat a wound otherwise.

On 10/11/2023 at 4:35 PM, the Director of Nursing (DON) confirmed via email that Physician #7, the admitting physician for Patient #1 and the physician that oversaw all of Patient #1's medical care, was currently out of the country on vacation and not available to discuss wound treatment.

During an interview on 10/11/2023 at 4:45 PM, Physician #6, who was a current admitting physician at the facility but who had no involvement in the care of Patient #1, said the nurses would notify the physician of changes with a patient, noting the first line of wound treatment and defense was repositioning. Physician #6 said if a wound started to become more severe, then wound management evolved to wound treatments, such as antibiotics, topical medications, and debridement (removal of damaged tissue), if necessary. Physician #6 said if a wound was too severe, the patient might be transferred for a higher level of care, as the facility did not have a surgical or wound care team. Physician #6 said he would refer to nursing or pharmacy related to the topical medication that would be used as he worked at several hospitals, which all stocked different items.

During an interview on 10/11/2023 at 5:05 PM, the DON confirmed that there were no photos of the pressure ulcers in Patient #1's record, and that Physician #7's notes lacked evidence of an assessment or mention of the Stage 2 pressure ulcer on the patient's sacrum.

Based on facility policy review, record review, and interviews, the facility failed to ensure that reports of treatments, documentation of complications, or pertinent information to monitor the patient's progress were fully and accurately included in the medical record for 1 (Patient #1) of 3 records reviewed. Specifically, facility staff failed to document meal intakes, wound assessments, receive wound care orders, or transcribe wound care orders in the patient's record.

Findings included:

Review of a facility policy titled "Patient Assessment and Reassessment," effective 03/27/2012, revealed "The assessment of the care or treatment required to meet the needs of the patient will be ongoing throughout the patient's hospital stay, with the assessment process individualized to meet the needs of the patient population." The policy noted, "Documentation must be timely, accurate and complete and provide a "picture of the patient [sic]."

Review of a facility policy titled "Management of Pressure Ulcers," revised on 10/03/2012, revealed, "Any pressure ulcer present at the time of admission will be identified. Any pressure ulcer developed after admission will be identified. Factors that lead to the development of a pressure ulcer, the potential for development of additional ulcers or for the deterioration of the pressure ulcers will be identified, assessed and addressed." The policy noted, "Nursing staff will take initial pictures and, as needed, identify, date and month for medical treatment of the patient. Call physician to report condition of pressure ulcer and for treatment orders. The physician will differentiate the type of ulcer" and "The physician will determine the stage of the ulcer." The policy further revealed that nursing staff were to "Follow physician's orders for treatment of the pressure ulcer, including cleansing and dressing."

Review of a facility policy titled "Skin Care for Patients who are High Risk for Skin Breakdown," revised on 01/18/2015, revealed "Patients who are at high risk or [sic] skin breakdown usually fall into one or more of the following categories: Age 65 years or older. Paraplegic. History of prior decubitus. Presence of altered skin integrity. Thin or emaciated patient. History of poor nutrition. Tube feeders. Immobile or bed confined patient." The policy indicated, "When preparing the room for a newly admitted patient who is at high risk for skin breakdown, an air mattress will be placed on the bed." The policy indicated "Heel and/or elbow protectors will be utilized as needed" and "Patients at high risk for skin breakdown will be turned to a new position as needed, at least every two hours and more frequently as required."

Review of Patient #1's medical record indicated the facility admitted the patient on 11/10/2021 to the geriatric psychiatric unit and then admitted the patient to a swing bed (a bed used to provide skilled nursing services) on 12/02/2021.

A review of a hospital record titled "Emergency Room Outpatient Record" revealed the facility admitted Patient #1 on 11/10/2021 with a chief complaint of psychosis.

A review of a hospital record titled "Change of Service Note-Geri psych to swing bed" revealed the facility admitted the patient to a swing bed for treatment for weakness and gait instability on 12/02/2021.

Review of a record titled "BH: Admission & Initial Assessment (C/H)," dated 11/10/2021, revealed it did not indicate Patient #1 had any pressure ulcers.

Review of Patient #1's medical record revealed it lacked evidence of an assessment for the patient's risk of developing pressure ulcers after admitting to the swing bed. The records also did not indicate a dietary consultation had been completed after admitting to the swing bed.

Review of Patient #1's "Patient Progress Notes" from 12/02/2021 to 12/17/2021 indicated staff did not start documenting the patient's meal intake in the progress notes until 12/10/2021. The Patient Progress notes did not show any intake amount eaten by the patient on 12/10/2021 for dinner, 12/11/2021 for dinner, 12/12/2021 for dinner, 12/13/2021 for lunch or dinner, 12/14/2021 for breakfast, lunch, or dinner, 12/15/2021 for dinner, or 12/16/2021 for lunch or dinner, and no meal intake was documented for 12/17/2021.

Review of Patient #1's "Patient Progress Notes" showed a note dated 12/02/2021 at 7:25 AM that showed a Braden Scale (an assessment tool to determine if a patient was at risk of developing pressure ulcers) score of 19, indicating the patient was not at risk of pressure ulcers. Patient Progress Notes dated 12/02/2021 indicated the patient was discharged to swing bed services on 12/02/2021. Patient Progress Notes dated 12/07/2021 showed the first notes indicated the patient was being repositioned. Patient Progress Notes dated 12/10/2021 indicated the patient had a Stage 2 pressure ulcer (partial thickness loss of skin that looked like a shallow, open ulcer with a red/pink wound bed) on the patient's "buttocks" for which a dressing was applied. Patient Progress Notes dated 12/10/2021, amended on 12/11/2021, indicated the patient had a blister to their "big toe" and a Stage 1 pressure ulcer (non-blanchable redness of intact skin) was noted on the patient's right heel. The note indicated heel protectors were applied on 12/11/2021.

Review of Patient #1's "Patient Progress Notes" showed a hydrocolloid dressing was placed on the patient's sacral wound on 12/10/2021, 12/12/2021, and 12/16/2021. The Patient Progress Note on 12/16/2021 indicated there was not a dressing on the patient before one was placed that day.

Review of a document titled "Pain Location", dated 12/09/2021, indicated the patient had a Stage 2 pressure ulcer on their sacrum (bone at the base of the spine). The document indicated the patient was turned every two hours while in bed and a cushion in the patient's wheelchair.

Review of a document titled "Pain Location", dated 12/12/2021, revealed pain was indicated on the patient's sacrum and right heel.

Review of a document titled "Pain Location," dated 12/15/2021, indicated pain locations included the patient's sacrum, a blister on the patient's left big toe, and a bruised labia. The document also indicated the patient's right heel was "blackened."

Review of Patient #1's medical records revealed no evidence of wound treatment orders. The record also did not indicate any physician notes regarding the patient's sacral wound.

Review of Patient #1's medical record indicated the patient discharged from the facility on 12/17/2021.

During an interview on 10/11/2023 at 1:10 PM, Licensed Practical Nurse (LPN) #3 said that common items used in the prevention of wounds were wedges, pillows, foam dressings, baby powder, and an egg crate mattress topper. She confirmed that there were no air mattresses at the facility. She said patients did not like the egg crate mattress toppers, and they were not commonly used. She also reported that repositioning was key to help with skin breakdown as well. She said preventive measures were typically documented under nursing notes or "devices used," but that there was not a specific place for staff to document it. She said the nurses' notes were where any documentation regarding wound dressings would be as well.

During an interview on 10/11/2023 at 4:25 PM, LPN #3 said that nurses informed the physician regarding a wound, who then evaluated the wound when they saw the patient. LPN #3 said staff also kept the physician informed regarding the progress of the wound and attempted to be with the physician when they saw the patient, when possible. She said the facility had wound treatment items such as wound dressing, wound cleanser, and barrier cream. LPN #3 said they used barrier cream even if an area was reddened on a patient. LPN #3 said it was the physician's discretion regarding what was used to treat a wound otherwise.

During an interview on 10/10/2023 at 9:35 AM, Registered Nurse (RN) #1, Infection Control Nurse, said that staff had the same charting requirements during the COVID-19 epidemic (during the timeframe the patient was in the facility). She said the facility did not put out any advisement that staff were permitted to leave out areas of charting. She said the only thing that changed related to documentation was charting isolation requirements and precautions; however, that was a section already built into the charting system, and it would be documented according to the patient as applicable. She said there was no policy or rules and regulations regarding a timeline for when medical providers were to see patients after they admitted to a swing bed, but providers saw the patients within 24 hours of admission to a swing bed. She said for Patient #1, the physician was familiar with the patient due to their stay in the geriatric psychiatric unit.

On 10/11/2023 at 12:41 PM, the Director of Nursing (DON) confirmed via email that it appeared their swing bed charting system did not have a breakdown and calculation for the Braden Scale. She also confirmed via email that there was no dietary order consultation entered upon Patient #1's admission to the swing bed and confirmed she did not see wound care orders in the patient's record.

On 10/11/2023 at 1:10 PM, RN #1 confirmed via email that there was no policy regarding what staff should be documenting in a patient's chart but indicated the facility's policy "Patient Assessment and Reassessment" outlined when assessments should be completed for admissions. She also confirmed at that time the facility did not have a specific Braden Scale policy but indicated the facility policy "Skin Care for Patients who are High Risk for Skin Breakdown" had some of the same categories.

During an interview on 10/11/2023 at 1:30 PM, the Registered Dietician (RD) said she went into the facility to see patients in person once a month but otherwise worked remotely to review patient records and advise the facility on dietary matters. She said that typically dietary consultation orders were used but she tried to look at all the swing bed patients. She said examples of documentation she would look at in a patient's chart included laboratory results and documentation of meal intake. The RD said meal intake was usually documented under nursing notes, but noted that such documentation did not always occur. She said it was mostly breakfast and lunch that got documented. She said if a patient was at risk of skin breakdown and was not eating or did not have much of an appetite, she would advise a nutritional supplement, depending on what was available. She said if the patient was eating, she would advise extra protein portions or the addition of milk with each meal. She said all advisement by the RD was under the dietician notes in the record and was also communicated to the kitchen and nurses via phone call.

On 10/11/2023 at 4:35 PM, the DON confirmed via email that Physician #7, the admitting physician for Patient #1 and the physician who oversaw all of Patient #1's medical care, was currently out of the country on vacation and not available to discuss wound treatment.

During an interview on 10/11/2023 at 4:45 PM, Physician #6, who was a current admitting physician at the facility but who had no involvement in the care of Patient #1, said the nurses would notify the physician of changes with the patient and the first line of wound treatment and defense was repositioning. Physician #6 said if a wound started to become more severe, then management changed to treatments such as antibiotics, topical medications, and even debridement (removal of damaged tissue), if necessary. Physician #6 said if the wound was too severe, the patient may be transferred for a higher level of care, as the facility did not have a surgical or wound care team. Physician #6 said he would refer to nursing or pharmacy related to the topical medication that would be used as he worked at several hospitals, which all stocked different items.

During an interview on 10/11/2023 at 5:05 PM, the DON confirmed that there were no photos of the pressure ulcers in Patient #1's record, and that Physician #7's notes did not contain an assessment or mention of the Stage 2 pressure ulcer on the patient's sacrum.