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Based on document review and interview, the facility nursing staff failed to supervise, follow-up and to evaluate for needed care for each patient, in 1 of 10 Medical Records (MRs) reviewed.

Findings included:

1. Review of facility Policies and Procedures indicated:

A. Nursing Policy #NU.11, Nutritional Screening, issued 4/1/19, indicated: When the need to consult the contracted Registered Dietician arises, he/she will be contacted by phone and logged on the nutritional log. The contracted dietician will perform an assessment within 72 hours or as the patient's need warrants.

B. Psychiatric Rights, Policy #RE.16, issued 4/1/19, indicated: Purpose; Every person who enters this hospital has rights and responsibilities. Procedure: Along with rights and responsibilities, The Hospital will ensure that patient and family education is an interdisciplinary and coordinated process, as appropriate plan, and documented in the MR.

C. Nursing Policy #NU.83, Skin/Wound Assessments/Reports 4/1/19, indicated: photographs of wounds are to be taken on admission, on occurrence, weekly and at discharge if wound remains open. Completion of wound reports are to be to aid in the monitoring of wound status and progression of healing.

2. Review of MR of patient #10 indicated:

A. Admission skin assessment, on 6/22/20 written by staff #13, RN, indicated that nail bed on left foot, great toe, has dried blood on admission and coccyx/sacrum is clear of redness or lesions. On 7/2/20, nursing documentation written by staff #16, RN, indicated the discovery of a stage 2 coccyx wound on patient #10. MR lacks documentation that family was notified.

B. Nursing documentation of Admission Nutrition Risk, on 6/22/20 at 1655 hours, written by staff #13, RN, indicated: no weight change. Risk level was recorded as zero. Most recent weight at OSF #1 was 166 pounds on 6/3/20. Admission weight on 6/22/20 was 154 pounds: approximately 12 pound weight loss in last 19 days. MR documentation indicated that no dietary consult was initiated, even when patient's weight had continued to drop to 152 pounds, reported 7/3/20, (a drop of 14 pounds in 1 month). No further nutritional screening was done, after initial nursing screening, on patient's admission on 6/22/20.

C. On 6/22/20, great toe on left foot was discovered to have wound. On 7/2/20, nursing documentation indicated the discovery of a coccyx wound on patient #10. Nursing documentation written by staff #19 on 7/5/20, indicated: patient's foot; it looks worse and has purulent drainage. Wound cleaned and left open. Throughout patient #10's admission, nutrition status remained poor. Review of MR lacks documentation that these issues were discussed with family

D. The MR of patient #10, 1 wound photograph could be located; of coccyx, on 7/3/20. Nursing documentation by Registered Nurses (RN) lacked documentation that skin/coccyx had been properly assessed for 10 days, even though the patient was admitted knowing that barrier cream to coccyx was indicated to prevent skin breakdown. No other photographs were in MR of coccyx or toe wound. Throughout patient #10's inpatient stay, daily Certified Nursing Assistant (CNA) Shower Sheets and Monitoring Round documentation was inconsistent. After coccyx wound was discovered on 7/2/20, on 7/5, 7/8, /7/9 and 7/10/20, shower sheets were checked no wounds.
Nursing Daily Assessment sheets, which indicate the patient's skin is to be checked daily, on 6/23, 6/24, 6/25, 6/26, 6/27, 6/28, 6/29, 6/30, 7/1, 7/2, and morning of 7/3/20, Nursing Daily Assessment Sheets indicate patient's skin is pink and normal, and no mention is made of previously known toe wound. After the discovery of the coccyx wound on 7/2/20, Nursing Daily Assessment sheets, indicate coccyx wound by checking a box on the assessment sheets, but there is no documentation of characteristics of the wound (which is called for on the assessment sheets) until 7/8/20. There is no documentation of toe wound through out patient's inpatient stay from 6/22/20 through discharge on 7/10/20.


3. Interview:

A. On 8/10/20 at 1700 hours, staff member #2, Administration, indicated agreement with the above findings.