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Based on review of hospital policy and procedures, medical records, and staff interview, the hospital failed to ensure a registered nurse supervised and evaluated the quality of nursing care for each patient on an ongoing basis to include: following physician orders, monitoring and treating wounds, and intake and output, as well as assessing patient needs related to these orders, and notifying the physician of the progress or lack thereof in accordance with hospital policy for 1 of 5 sampled patients (#4).

Findings:

A review of the policy entitled "Skin/Wound Care: Assessment, Prevention, Treatment and Wound Culture" Procedure Number CP 3.02.06 PRO, reviewed/revised date 07/01/2022, read, "A. The health care provider will: . . . 2. Provide complete and accurate skin assessment/reassessment . . . 4. Assess wound characteristics 5. Provide skin/wound care and early treatment and initiate prevention interventions . . . G. Wound Measurements will be documented on admission, upon discover, and weekly . . . Assessment/Reassessment . . . C. If a new area of altered skin integrity is identified during assessment/reassessment . . . Note: Upon discovery of a hospital acquired pressure injury or other alteration in skin integrity, the nurse is to notify risk management and place consult to the wound/ostomy department . . . E. Assess and document the following on impaired skin integrity, pressure injury(ies) and/or wound(s), if present: 1. Location; 2. Etiology/Type . . . 3. Wound measurements . . . 4. Appearance of wound base/tissue . . . 5. Appearance of peri-wound skin . . . 6. Presence of tunneling, undermining, fistula or sinus tracts (if present), 7. Drainage amount, color, and odor (if present), 8. interventions /treatments/
dressings provided . . ."

Patient #4's medical record noted a WOC (Wound Ostomy Care) Nurse Progress Summary written on 02/08/2023 at 3:56 p.m. The progress summary included documentation of "Gluteal Cleft with very moist, linear break in the skin consistent with fissure and MASD (Moisture Associated Skin Disorder)". Recommendations in the progress summary included to applying Venelex 4 times daily by peeling back sacral border dressing then reapply. The physician orders on 02/08/2023 at 4:16 PM reflected orders to apply Venelex 4 times a day by peeling back the sacral border dressing then reapply to the gluteal cleft and bilateral lower gluteal. However, medical record had inconsistent documentation of following the physician orders and WOC recommendations for treatment of the gluteal cleft fissure and MASD, and there were no further wound reassessments to accurately describe the healing progression including measurements, appearance, and drainage (if any).

Interviews with Risk Manager L, Nurse Manager J, and Assistant Nurse Manager M were conducted on 03/22/2023 at approximately 4:02 PM, 03/23/2023 at approximately 12:50 PM, and 03/24/2023 at approximately 9:45 AM. A "parameter" was opened on 02/01/2023 initially identifying a skin concern on patient #4's gluteal area and WOC Nurses were consulted on 02/08/2023 for treatment recommendations. There was no documentation presented between 02/01/2023 and 02/08/2023 when the WOC progress note was noted for any treatment of the 02/01/2023 identified wound. Risk Manager L indicated that risk management was not notified of the "new wound" upon identification as is required in Policy CP 3.02.06 PRO - "Skin/Wound Care: Assessment, Prevention, Treatment and Wound Culture", reviewed/revised 07/01/2022.

Review of patient #4's physician's orders, dated 12/25/2022 and not discontinued until 02/27/2023, also noted orders for strict intake and output (I&O) every 2 hours for 24 hours and then every 8 hours. Review of the I&O flow sheets for this time period, 12/25/2022-02/27/2023, noted that nurses did not document consistent I&O data as ordered. This was confirmed with Risk Manager A on 03/23/2023 at approximately 12:50 PM.