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Based on interview, medical record review and policy review, the facility failed to ensure a wound assessment was completed on admission, failed to notify the physician wound care orders were needed, and failed to follow physician orders for wound care (A392). The cumulative effect of these systemic practices resulted in the facility's inability to ensure patients received safe care in accordance with physician orders and facility policy.

Based on medical record review, policy review and interview, the facility failed to notify the physician that wound care orders were needed for one patient (Patient #3), failed to assess a patient's wound on admission for one patient (Patient #5), and failed to ensure wound care was performed in accordance with physician orders for one of ten medical records reviewed (Patient #7). This had the potential to all patients receiving services in the facility. The facility census was 237.

Findings include:

Review of the facility's policy titled Skin Integrity, Pressure Injury Prevention, policy Number I-13, approved on 11/15/16 revealed on admission a comprehensive skin assessment was performed to examine the patient's current skin condition.

Review of the job description of the registered nurse (RN) revealed the following was included in the Principle Accountabilities (7.) performs medical/surgical treatments accurately and (8.) implements physician's orders accurately.

1. Review of the medical record for Patient #3 revealed the patient was admitted to the facility on 12/19/16 at 2:16 PM with diagnoses including acute and chronic systolic heart failure, uncontrolled type 2 diabetes mellitus, chronic kidney disease and diabetic ulcer of the left heel. Review of the orders revealed a physician order on 12/19/16 at 6:49 PM to "notify inpatient wound care nurse to evaluate and treat". Review of the record revealed no physician orders for wound care of the left heel ulcer.

Review of the flowsheet data in Patient #3's medical record revealed an RN assessed the patient's left heel on 12/20/16 at 6:44 AM. The left heel wound measurements were three centimeters (cm) length by two cm width by 0.2 cm depth. The flowsheet revealed the RN rinsed and irrigated the patient's wound with normal saline and applied a four by four gauze dressing and kerlix (gauze in a roll for wrapping).

On 12/21/16 at 3:00 PM, Staff A confirmed there were no orders for wound care and the physician was not notified wound care orders were needed. Staff A also confirmed the wound nurse had not seen Patient #3 on 12/20/16.

2. Review of the medical record for Patient #5 revealed the patient was admitted on 12/09/16 at 1:09 PM with diagnoses including altered mental status, respiratory distress, fluid overload and congestive heart failure (CHF). The admission assessment on 12/09/16 at 2:30 PM revealed a pressure ulcer of the coccyx was present with a dressing. There was no assessment completed of the pressure ulcer. The skin assessment also revealed Patient #5 had a skin tear to the right buttocks. The wound was described as red, purple in color. The periwound (skin around the wound) was painful and pink, red and white in color. There was a mepilex dressing (foam dressing) on. There were no measurements of this wound.

On 12/10/16 at 7:51 AM, the coccyx dressing was changed. The pressure ulcer assessment described the wound as pink, red and painful with blanchable erythema (redness that turned pale when pressure was applied). The flowsheet revealed there was a scant amount of serosanguinous (slightly blood tinged) drainage. The wound was cleansed and irrigated with normal saline and a foam dressing was applied. There was no measurement of the pressure ulcer completed during this assessment.

Further review of the record revealed the first measurement of the wound to the coccyx and right buttocks was on 12/14/16 at 5:16 AM. The size of the area to the coccyx was seven cm by four cm. The wound was described as fragile with scant serosanguinous drainage. The wound to the right buttocks was two cm by four cm with no depth and was red in color with no drainage.

On 12/09/16 at 1:08 PM, the physician ordered the wound nurse to evaluate Patient #5's wounds. The wound nurse first attempted to see Patient #5 on 12/14/16 at 4:16 PM; however, the patient was in surgery for placement of a feeding tube. The wound nurse's initial assessment was on 12/19/16 at 6:04 PM. The coccyx pressure ulcer was assessed as two cm by one cm and the wound bed was described as a yellow obscured area. The right buttocks was described as three cm by two cm and the wound bed was described as yellow obscured area. The wound nurse's impression was unstageable pressure ulcers of the coccyx and right buttocks due to incontinence. The plan was to recommend calmoseptine (ointment to reduce pain, reduce infection and treat skin inflamation).

On 12/22/16 at 8:30 AM, Staff B confirmed these findings.

3. Review of the medical record of Patient #7 revealed the patient was admitted to the facility on 12/07/16 at 9:24 PM with the diagnosis including CHF and osteomyelitis of fifth toe of left foot. Patient #7 was admitted with wounds to the right inner buttock, left fifth toe, left posterior calf, left pretibial area and left outer ankle. The wound nurse assessment findings on 12/08/16 revealed the following: right inner buttocks measured 0.4 cm by 0.6 cm by 0.2 cm with red tissue; the left fifth toe measured one cm by two cm by 0.4 cm with scant purulent drainage; left leg posterior calf measured five cm by 2.8 cm by 0.2 cm with red, yellow tissue; left pretibial area was one cm by 0.4 cm by 0.1 cm with red tissue; left outer ankle measured one cm by two cm by 0.1 cm with 20 percent pink tissue and 80 percent yellow tissue; right posterior calf measured 4.2 cm by one cm by 0.2 cm with 75 percent red tissue and 25 percent yellow tissue.

A physician order on 12/08/16 was written to cleanse with normal saline, apply xeroform (petroleum dressing) and wrap daily the right calf, the left leg and the left fifth toe. On 12/09/16, Patient #7 had an amputation of the left fifth toe. The physician ordered on 12/11/16 to clean the left surgical wound with normal saline, apply betadine (antiseptic), Aquacel Ag (dressing to treat infections), four by four dressing and wrap from toes to knees daily. On 12/15/16, the order changed to apply betadine to the left foot and dressing as before, but not to apply the xeroform daily.

Review of the flowsheets for wound treatments of the left foot surgical wound for Patient #7 revealed on 12/11/16 at 6:45 PM the dressing change was documented as changed/new. There was no description of the treatment completed. On 12/12/16 at 10:36 AM, the dressing was changed by applying a silver dressing, four by four gauze dressing and an ace wrap. There was no documentation the wound was cleansed with normal saline or that betadine was applied. On 12/14/16 at 11:05 AM the wound measured two cm by two cm and the sutures were closed. The dressing change on 12/14/16 revealed a dry dressing four by four and an ace wrap was applied. There was no documentation of cleansing the wound with normal saline or the application of Aquacel Ag and betadine as ordered. On 12/16/16 at 2:01 AM, the only documentation of a dressing change was the wound was rinsed and irrigated with saline. No additional information was documented of the type of dressing applied.

Review of the flowsheets for the dressing changes of the left ankle revealed the dressing was not done on 12/17/16 and 12/19/16. On 12/18/16 at 5:46 AM, the flowsheet revealed the dressing was changed and was documented as "changed/new". There was no additional documentation of these dressing changes.

Review of the dressing change documentation of the right calf on the flowsheets revealed xeroform was not applied with the dressing change on 12/18/16 and there was no documentation the dressing was changed on 12/19/16.

There was no evidence on the flowsheets the dressings were changed on 12/20/16, but there was a progress note by the RN at 4:18 PM that stated "changed dressing as ordered at this time". There was no further documentation to identify which dressing was changed or the treatment performed.

On 12/22/16 at 8:30 AM, Staff B confirmed these findings.