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Based on observation, interview and record review the facility failed to ensure that wound assessments and dressing changes were consistently done, wound treatment orders were written, the physician was updated timely on wound status, and the admission assessment and staging of pressure injuries was accurate for 1 (#1) of six patients reviewed for pressure injuries out of a total sample of 10. In addition the facility failed to ensure that glove changes and hand hygiene were appropriately done during wound care for one (#3) of three wound care observations out of a total sample of 10, resulting in the potential for delayed wound healing and miscommunication. Findings include:

On 9/15/20 at approximately 1145 the facility Wound Care Nurse Staff C was observed as she did wound care and a dressing change for Patient #3. Staff cleaned the zinc paste off Patient #3's buttocks and rectal area and then applied a new dressing to Patient #3's sacral (tailbone) Stage II pressure sore (a bedsore that penetrates the first layer of skin but does not extend below the dermis). Staff C did not change gloves between cleaning the patient's buttocks and rectum and applying the new dressing. Staff repositioned the patient, touched the bed siderails, and adjusted the privacy curtains with the same dirty gloves that she used to clean the patient's buttocks and apply the dressing.

On 9/15/20 at approximately 1600 Staff C was interviewed regarding her failure to change gloves between a dirty task (cleaning the patient's buttocks and rectal area) and a clean task (applying a new dressing to an open wound) and before touching environmental surfaces. Staff reported that the Chief Nursing Officer Staff B had just talked to her about it and she realized she should have changed gloves and performed hand hygiene before touching any environmental surfaces and before putting on a clean dressing.

On 9/15/20 at approximately 1230 Patient #3's clinical record was reviewed and revealed the following information:

Patient #3 was a 62 year old male who was admitted to the facility on 8/27/20. diagnoses included Cerebral Palsy, Quadriplegia (paralysis) from a car accident in 2004, Acute on Chronic Respiratory Failure, Dysphagia with tube feedings, and Contractures (limbs bent due to ligament shortening from disuse).

On 9/16/20 at 1600 review of the facility policy entitled, "Hand Hygiene", revised 7/20 revealed the following statements, "When: after any patient contact, when moving from high contaminated patient care activities to cleaner activities/if moving from a contaminated body site to a less contaminated body site, before any patient procedure."

On 9/15/20 at approximately 1400 to 1700, Patient #1's clinical record was reviewed with the Chief Nursing Officer (CNO) Staff A and the Market CNO Staff E who were interviewed during this time. The following information was revealed:

Patient #1 was an 85 year old female who was admitted to the facility on 8/13/20. Diagnoses included Mucinous Pancreatic Cyst with Whipple Procedure Surgery (an operation to remove the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder and the bile duct), Gastrointestinal Bleeding, Acute Ischemia of the Lower Extremities (lack of blood flow to the legs), Compartment Syndrome (a painful condition that occurs when pressure within the muscles builds to dangerous levels) with Fasciotomy (a surgical procedure where the connective tissue covering the muscle is cut to relieve pressure), Bilateral Iliac Artery Stent (a tube surgically inserted into the major leg artery to improve blood flow), Acute on Chronic Renal Failure with Hemodialysis, Diabetes Mellitus II, Hypertension, Stage IV Kidney Disease (advanced kidney damage), Diabetic Neuropathy (nerve damage), Deep Vein Thrombosis (blood clot), Metabolic Encephalopathy, Dysphagia (swallowing impairment) with feeding tube, Atrial Fibrillation (irregular heart beat), Generalized Rash due to Red Man Syndrome (allergic reaction to an intravenous antibiotic) Bilateral Healthcare Acquired Pneumonia, Anemia and Protein Calorie Malnutrition.

A Physician's Admission History and Physical (H&P) for Patient #1 dated 8/13/20 at 2255 documented that the physician's plan of care for Patient #1 included the a Consultation from the Wound Care Physician. There was no physician's order written for this consultation. There was no documentation that a Wound Care Physician consultation was done for Patient #1.

A Physician Progress Note dated 8/14/20 noted that Patient #1 had an extensive rash and the physician was, "awaiting a Wound Care Consultation." There was no order written for a Wound Care consultation.

Admission Wound Care Assessments for Patient #1 by part time Wound Care Nurse Staff D dated 8/13/20 at 1553 noted that Patient #1 had multiple skin problems on admission which included a coccyx (tailbone) pressure sore measuring 10.5 centimeters (cm) by 9.5 cm (no Stage noted) with serosanguinous drainage (blood and tissue fluids). A Wound Documentation form for Patient #1 dated 8/13/20 at 1539 noted that Patient #1's sacral ( tailbone) pressure ulcer had a yellow and brown wound bed.

Staff D's admission photograph of Patient #1's sacral pressure sore appeared as an open area of unknown depth which was covered with yellow slough (dead skin) with a central area that was dark brown (eschar). Staff E noted that the wound looked deeper than a Stage II pressure injury (PI) but said that it was impossible to tell because the covering of slough made it impossible to see how deep the sore was. Staff E noted that the dark brown area in the center of the pressure sore looked like either eschar (dry dead tissue) or a Deep Tissue Injury (DTI - deep tissue damage/death due to a pressure injury). Staff E noted that a DTI may consist of skin and muscle that is already dead but has not yet opened up into an open sore. Staff E noted that the extent and depth of a DTI or a pressure injury covered with eschar is impossible to determine until the dead area dried up and comes off. Staff E noted that it was impossible to tell how deep Patient #1's pressure sore was if it was covered with slough (yellow) and had evidence of either eschar ( brown) or a DTI in the center.

A Wound Care Nurse Progress Note by Staff D dated 8/13/20 at 1539 described Patient #1's coccyx/sacral wound as a Stage II pressure sore (shallow wound that does not go through all layers of skin).

Staff D's Treatment Plan for Patient #1's sacrum pressure sore dated 8/13/20 at 1539 was, "Triad Paste (a zinc paste that absorbs moisture and breaks down dead tissue) and to cover the wound with a 4 x 4 (cloth dressing) and abdominal dressing pad (abd) twice daily (bid) and as needed (PRN)."

A Wound Care Nurse Progress note dated 8/19/20 at 0936 by Wound Care Nurse Staff C described the pressure injury on Patient #1's sacrum as a "Stage II - III pressure sore.

Staff C's treatment plan dated 8/19/20 at 0936 for Patient #1's sacrum pressure sore was to wash the wound with normal saline, apply Medihoney (a medical grade product that assists in the removal of dead {necrotic} tissue), and cover with a gauze dressing (4 x 4) and an abdominal pad or a clear foam dressing daily in the morning and as needed (PRN).

Patient #1's wound documentation form dated 8/19/20 at 1000 noted that Staff C described Patient #1's sacrum pressure sore on that date as having a wound bed that was yellow, red and black. Staff E noted that described a pressure sore that was Unstageable because the slough (yellow) and eschar (black dead dried skin) covering areas of the wound bed would make it impossible to see how deep the wound actually was. Staff E said that in her experience an area with eschar (black) usually meant that the wound was deep, usually a Stage III (through all layers of the skin) or Stage IV (down to the muscle, fascia or bone). Staff E noted that both Staff C and Staff D's initial assessments of Patient #1's sacrum pressure severity (stage) were probably incorrect.

Review of daily wound assessments and dressing changes for Patient #1 's sacral pressure sore from 8/13/20 to 9/15/20 (Wound Documentation Forms) revealed gaps in documentation of dressing changes and wound assessments. There was no documentation of wound assessments or dressing changes for Patient #1's sacrum pressure sore on the following dates:

8/15/20, 8/16/20, 8/24/20, 8/25/20, 8/28/20, 9/3/20, 9/5/20, 9/8/20, 9/7/20, 9/9/20, 9/10/20, 9/11/20, and 9/13/20.

Review of Physician's Progress notes revealed that Patient #1's physician did not document that he was aware that Patient #1 had a pressure sore on her sacrum until 8/19/20. On 8/19/20 at 0923 the physician documented that, "per Wound Care", Patient #1 had a Stage II sacral pressure sore. On 8/20/20 at 0923 Patient #1's physician documented that Patient #1 had a Stage III pressure sore measuring 8 cm by 14 cm. There were no physician signatures on the admission or the weekly Wound Care Nurse Assessment forms acknowledging that he had noted them or discussed the findings with the Wound Care Nurse.

There were no physician orders for wound care or dressing changes. On 9/15/20 at approximately 1600 Staff C reported that the Wound Care Nurse decided on the wound care and dressing changes for each patient based on her assessments and no physician orders were necessary for wound treatments or dressing changes.

On 9/15/20 at approximately 1630 Staff C was interviewed regarding Patient #1. Staff C said that she was on vacation when Patient #1 was admitted and Staff D did Patient #1's admission skin assessment and wound photographs. Staff C said that she did not agree with Staff D's assessment and Staging of Patient #1's sacral pressure sore so she revised it and changed the treatment plan when she saw the patient on 8/19/20.

On 9/16/20 at approximately 0900 Personnel files for Staff C and Staff D were reviewed for training and competency. The facility was unable to provide documentation of competency evaluations for wound assessment or pressure injury staging for either nurse.

On 9/16/20 at approximately 1015 a facility Incident Report for Patient #1 dated 9/8/20 was reviewed and revealed the facility noted that Patient #1's clinical record had missing documentation of wound assessments, wound care treatments and dressing changes. The identified corrective measures noted that the Registered Nurse responsible for the omissions would be counseled and reeducated. The facility was unable to provide any documentation to indicate that this was done.

On 9/16/20 at approximately 1330, Staff A stated that she would require the Wound Care Nurse to undergo additional training towards Wound Care certification to ensure that she was able to correctly assess and stage a pressure sore. Staff A did not provide a clear answer when she was asked who would do admission wound assessments when Staff A was not scheduled to work.

Review of the facility policy entitled, "Wound Assessment" revised 01/01/19 revealed the following notations,

"All Patients admitted will have a skin assessment within 8 hours of admission and skin will be assessed every shift."
" Pressure injuries will be staged by the Wound Nurse/Charge Nurse who have completed education an competency requirements for staging."
"Wound Bed Tissue Type/Color: Slough (necrotic) indicates the presence of necrotic tissue which is often necrotic fat and fascia adhering to the layer beneath it. Eschar (necrotic) may appear black or brown, devitalized tissue"
"Stage II: the wound bed is viable, pink or red. Granulation tissue, slough and eschar are not present."
"Stage III: Slough or eschar may be visible."
" If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury".

On 9/16/20 at approximately 1630 review of the Facility Policy entitled, "Wound Documentation", dated 12/1/18 revealed the following statements,

"A Wound Progress note is completed at least every seven days by the wound team. This document provides the physician an update on the wound status based on the wound nurse' assessment. The physician shall sign this form to acknowledge that they are updated on the wound status for their patient."
" Wound recommendations may be listed by the Wound Nurse, but they are not treatment orders until the physician initiates an order in the medical record or wound care per protocol/algorithm."
"Dressing changes and wound site care are documented in the medical record."

On 9/16/20 at approximately 1645 review of the facility algorithm included in the facility "Wound Care I-1 Appendices" (no date indicated) revealed no instructions or algorithm regarding wound care or treatments.