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Based on policy review, medical record review and interview, the hospital failed to ensure measures to provide nursing services to assess and treat pressure wounds.

The findings included:

1. The hospital failed to ensure pressure wounds were routinely assessed for 5 of 5 sampled patients.
Refer to A-395

2. The hospital failed to follow the plan of care for wound care treatment for 3 of 5 sampled patients.
Refer to A-396

Based on policy review, medical record review and interview, the hospital failed to ensure the family of a patient was notified of a change of condition for 1 of 5 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital's "PATIENT RIGHTS AND RESPONSIBILITIES" policy revealed, "...The patient has the right to full information in layman's terms, concerning his diagnosis, treatment, and prognosis, including information about alternative treatments and possible complications. When it is not medically advisable to give such information to the patient, the information shall be given on his/her behalf to the patient's next of kin or other appropriate person..."

Review of the facility's "Wound Assessment" policy revealed, "...Assess for and Document changes in skin/wound status, signs and symptoms of infection: pain, tenderness, redness, swelling...Notify MD [medical doctor]/Provider, patient/family..."

2. Medical record review for Patient #1 revealed an admission date of 11/17/17 with diagnoses of Acute Hypoxic Respiratory Failure, Septic Shock Related to Staphylococcal Bacteremia and Morganella Morganii Wound Infection, Seizure Disorder, Cerebrovascular Accident with Right-sided Hemiplegia and Aphasia, Acute Kidney Injury, End-stage Dementia, Encephalopathy, Oropharyngeal Dysphagia, Decubitus Ulcers and Chronic Obstructive Pulmonary Disease.

The "INFECTIOUS DISEASE CONSULTATION NOTE" dated 12/12/17 documented, "...During the night of 12/11/2017, patient spiked temperature to 102 degrees Fahrenheit and the morning of 12/12/2017, she remained febrile with temperature up to 101.7 degrees Fahrenheit. The patient's mental status was noted to be progressively worsening...blood pressure was trending down towards the hypotension and she required intravenous fluid boluses and transfusion of packed RBC [red blood cells]...Her oxygen requirements, mechanical ventilation were noted to increase...apparent significant change in status consistent with severe sepsis and septic shock..." There was no documentation the family was notified of the patient's change in condition.

The "WOUND CARE STATUS REPORT" and "WOUND PHOTOGRAPHIC DOCUMENTATION" dated 12/13/17 documented Patient #1 had seven new wounds. There was no documentation the family was notified of the new wounds.

3. During an interview in the conference room on 3/5/18 at 9:37 AM, the Chief Clinical Officer confirmed there was no documentation in the medical record the family was notified of Patient #1's change in condition on 12/11/17 or new wounds on 12/13/17.

Based on policy review, medical record review and interview, the hospital failed to ensure pressure wounds were routinely assessed for 5 of 5 (Patient #1, 2, 3, 4 and 5) sampled patients.

The findings included:

1. Review of the facility's "Wound Assessment" policy revealed, "...Pressure Ulcers-all wounds with an etiology of pressure/shear must be assessed and documented individually...Reassess & [and] document (major and minor) wound characteristics with each scheduled or prn [as needed] dressing change for initial, weekly follow-up, new wound, change in wound status & discharge..."

Review of the facility's "Photography of Wounds Guidelines" policy revealed, "...Wound photos will be obtained with the admission process: all pressure ulcers stages to include unstageable and sDTI [suspected deep tissue injury], diabetic wounds, venous ulcers, arterial wounds, surgical wounds or other complex/atypical wounds...Photographs should be redone at a minimum as the wound(s) change(s), monthly and with discharge reference period (discharge plus 2 days prior) prior to discharge...Newly identified and worsening wounds are photographed as part of the reassessment process..."

2. Medical record review for Patient #1 revealed an admission date of 11/17/17 with diagnoses of Acute Hypoxic Respiratory Failure, Septic Shock Related to Staphylococcal Bacteremia and Morganella Morganii Wound Infection, Seizure Disorder, Cerebrovascular Accident with Right-sided Hemiplegia and Aphasia, Acute Kidney Injury, End-stage Dementia, Encephalopathy, Oropharyngeal Dysphagia, Decubitus Ulcers and Chronic Obstructive Pulmonary Disease. Patient #1 was discharged from the hospital to a skilled nursing facility on 12/20/17.

The "WOUND CARE STATUS REPORT" dated 11/20/17 documented Wound #1, 2, 3 and 5 were assessed on 11/20/17 and 12/13/17. There was no other documentation of assessments for these wounds. There was no documentation for Wound #4 was assessed. The "WOUND PHOTOGRAPHIC DOCUMENTATION" revealed Wound #1 and 2 were photographed on 11/20/17 and 12/13/17. Wound #3 and 5 were photographed on 11/20/17. There were no other photographs for these wounds.

The "WOUND CARE STATUS REPORT" dated 12/13/17 documented Wound #6 and 7 were assessed and photographed on 12/13/17. There was no other documentation of assessments or photographs of Wound #6 or 7. The "WOUND PHOTOGRAPHIC DOCUMENTATION" dated 12/13/17 revealed the following: 1 centimeter (cm) X (by) 1.5 cm on the right fifth toe, 1 cm X 2.5 cm on the right ischial tuberosity, 1.1 cm X 1.2 cm on the right fourth toe, 0.8 cm X 0.8 cm on the right lateral ankle and 0.9 cm X 1.2 cm on the right fifth toe. There was no documentation of an assessment or further photographs of these wounds on the "WOUND CARE STATUS REPORT" or "WOUND PHOTOGRAPHIC DOCUMENTATION."

3. Medical record review for Patient #2 revealed an admission date of 12/5/17 with diagnoses of Acute Hypoxemic Respiratory Failure Related to Pneumonia, Resolving Sepsis Secondary to Pneumonia, Right Lower Extremity Cellulitis and Severe Debility. Patient #2 was discharged to a skilled nursing facility on 12/28/17.

The "WOUND CARE STATUS REPORT" dated 12/6/17 documented Wound #1 and 2 were assessed on 12/6/17 and 12/14/17. There was no other documentation of assessments for these wounds. The "WOUND PHOTOGRAPHIC DOCUMENTATION" revealed Wound #1 was photographed on 12/6/17 and 12/14/17. There were no other photographs for Wound #1.

The "WOUND PHOTOGRAPHIC DOCUMENTATION" dated 12/6/17 revealed a 15.2 cm X 17.4 cm wound to the left lower extremity with no depth, tunneling or undermining. The "WOUND PHOTOGRAPHIC DOCUMENTATION" dated 12/14/17 revealed a wound to the left lower extremity and right lower extremity. There was no documentation of an assessment on the "WOUND CARE STATUS REPORT" for these wounds.

The "WOUND PHOTOGRAPHIC DOCUMENTATION" dated 12/28/17 revealed the following: 1 cm X 0.6 cm wound to the right proximal shin, 0.7 cm X 0.8 cm wound to the right distal shin, 0.6 cm X 1 cm to the right medial shin, and a 2 cm X 2.7 cm wound to the left medial leg. There was no documentation of an assessment of these wounds on the "WOUND CARE STATUS REPORT."

4. Medical record review for Patient #3 revealed an admission date of 10/9/17 with diagnoses of Hepatitis C with Liver Cirrhosis, Diabetes Mellitus, Hypothyroidism, Anemia, Coagulopathy, Cognitive Communication Deficient, Delusional Disorder, Difficulty Walking, Hypertension, Obesity and Diabetic Neuropathy. Patient #3 was discharged to a skilled nursing facility on 1/9/18.

The "WOUND CARE STATUS REPORT" dated 10/9/17 documented Wound #1 was assessed on 10/11/17, 10/17/17, 10/24/17 and 11/2/17. There was no other documentation of assessments for this wound. The "WOUND PHOTOGRAPHIC DOCUMENTATION" revealed Wound #1 was photographed on 10/11/17, 10/24/17, 11/2/17, 11/13/17, 11/21/17, 12/11/17 and 12/26/17. There were no other photographs for Wound #1.

The "WOUND CARE STATUS REPORT" dated 11/21/17 documented Wound #2 was assessed on 11/21/17. There was no other documentation of assessments for this wound. The "WOUND PHOTOGRAPHIC DOCUMENTATION" revealed Wound #2 was photographed on 11/21/17. There were no other photographs for Wound #2.

The "WOUND CARE STATUS REPORT" dated 11/21/17 documented Wound #3 was assessed on 11/21/17, 12/11/17 and 12/26/17. There was no other documentation of assessments for this wound. The "WOUND PHOTOGRAPHIC DOCUMENTATION" revealed Wound #3 was photographed on 11/21/17, 12/11/17 and 12/26/17. There were no other photographs for Wound #3.

The "WOUND CARE STATUS REPORT" dated 11/20/17 documented Wound #4 was assessed on 11/20/17 (assessment was dated 11/4/17 but date first observed was dated 11/20/17). There was no other documentation of assessments for this wound. The "WOUND PHOTOGRAPHIC DOCUMENTATION" revealed Wound #2 was photographed on 11/21/17. There were no other photographs for Wound #2.

5. Medical record review for Patient #4 revealed an admission date of 12/29/17 for intravenous antibiotics and tracheostomy weaning. The "WOUND CARE STATUS REPORT" dated 12/30/17 documented Wound #1 and 2 were assessed on 12/30/17. There was no other documentation of assessments for Wound #1 until 1/19/18. There was no other documentation of assessments for Wound #2. The "WOUND PHOTOGRAPHIC DOCUMENTATION" revealed Wound #1 and 2 were photographed on 12/30/17. There were no other photographs for Wound #1 or 2.

6. Medical record review for Patient #5 revealed an admission date of 1/27/18 for intravenous antibiotics and ventilator and tracheostomy weaning. The "WOUND CARE STATUS REPORT" dated 1/29/18 documented Wound #1, 2, 3 and 4 were assessed weekly. There was no documentation Wound #1, 2, 3 and 4 were photographed.

7. During an interview in the conference room on 3/5/18 at 9:37 AM, the Chief Clinical Officer confirmed much of the documentation for wound assessments was absent from the patients' medical records.

Based on policy review, medical record review and interview, the hospital failed to follow the plan of care for wound care treatment for 3 of 5 (Patient #1, 2 and 3) sampled patients.

The findings included:

1. Review of the facility's "Wound Assessment" policy revealed, "...Wound assessments provide...The foundation for an individualized plan of care...Pressure Ulcers-all wounds with an etiology of pressure/shear must be assessed and documented individually...Reassess & [and] document (major and minor) wound characteristics with each scheduled or prn [as needed] dressing change for initial, weekly follow-up, new wound, change in wound status & discharge...Determine goals for wound healing ...Determine treatment strategies based on goals..."

2. Medical record review for Patient #1 revealed an admission date of 11/17/17 with diagnoses of Acute Hypoxic Respiratory Failure, Septic Shock Related to Staphylococcal Bacteremia and Morganella Morganii Wound Infection, Seizure Disorder, Cerebrovascular Accident with Right-sided Hemiplegia and Aphasia, Acute Kidney Injury, End-stage Dementia, Encephalopathy, Oropharyngeal Dysphagia, Decubitus Ulcers and Chronic Obstructive Pulmonary Disease. The plan of care dated 11/20/17 documented a treatment to apply skin prep, cover with Biatain (foam dressing) and change the dressing every 3 days for Wound #1, 2, 3 and 5. The plan of care dated 12/13/17 documented a treatment to apply betadine daily for Wound # 6 and 7. There was no documentation the treatments were performed.

A physician's order dated 11/24/17 revealed, "...Risamine [menthol-zinc oxide] Ointment to perineal area and bilateral buttocks prn [as needed for] incontinence checks. Please d/c [discontinue] Risamine Ointment when [Hospital name] cream is available..." There was no documentation the treatments were performed.

3. Medical record review for Patient #2 revealed an admission date of 12/5/17 with diagnoses of Acute Hypoxemic Respiratory Failure Related to Pneumonia, Resolving Sepsis Secondary to Pneumonia, Right Lower Extremity Cellulitis and Severe Debility. A physician's order dated 12/6/17 documented, "...Sacrum: cleanse c [with] wound cleanser and pat dry. Apply skin prep and allow to dry. Cover c optifoam [foam dressing]. [symbol for change] q [every] 2 days or prn incontinence. [Hospital name] cream to perineal area and bilateral buttocks prn incontinence checks...R [right] plantar: Betadine eschar, cover c ABD [abdominal], wrap c Kerlix, secure c tape. [symbol for change] daily...R calf: Apply Venelex [castor oil and balsam peru ointment] daily and leave open to air...L [left] calf: cleanse c wound cleanser and pat dry. Cut Xeroform [petrolatum] gauze to fit open area and apply a single layer to wound bed, cover c ABD and wrap c Kerlix, secure c tape, [symbol for change] daily..." There was no documentation the treatments were performed.

4. Medical record review for Patient #3 revealed an admission date of 10/9/17 with diagnoses of Hepatitis C with Liver Cirrhosis, Diabetes Mellitus, Hypothyroidism, Anemia, Coagulopathy, Cognitive Communication Deficient, Delusional Disorder, Difficulty Walking, Hypertension, Obesity and Diabetic Neuropathy. A physician's order dated 10/13/17 documented, "...R medial buttock: NPWT [negative pressure wound therapy], cleanse wound c wound cleanser and pat dry. Apply skin prep to peri-wound and allow to dry. Apply hydrocolloids around peri-wound. Loosely pack wound c black foam, NPWT @ [at] 125mm [millimeters]Hg [mercury] continuous. VAC [vacuum-assisted closure dressing] [symbol for change]'s Mondays and Thursdays..." There was no documentation the treatments were performed.

5. During an interview in the conference room on 3/5/18 at 9:37 AM, the Chief Clinical Officer confirmed there was no documentation of wound care treatments for Patient #1, 2 or 3.