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Based on record review and interview, the CAH failed to ensure a registered nurses provided, or assigned other personnel, the nursing care of each patient. This was evidenced by the failure to clarify a vague physician order for 1 (Patient #1) of 2 patients with wound care orders (Patient #1, #2) in a total sample of 3 (Patient #1, 2, 3).
Findings:

Review of the medical record for Patient #1 revealed an admit date of 04/15/2025. Review of the history and physical, dated 04/15/2025, revealed diagnoses including status post left total knee replacement complicated by quadriceps tendon rupture recently repaired on 04/11/2025. The history and physical further stated that the patient was admitted to the CAH with a hinged knee brace in full extension with plans for PT/OT.

Review of physician orders dated 4/15/2025 revealed to change dressing if saturated with sterile technique and cleanse before redressing. This order did not indicate the specific type of dressing or cleansing product to use.

Review of the initial nursing assessment dated 04/15/2025 at 8:00 PM revealed the patient had a wound to the left anterior knee. The wound was not visualized due to surgical dressing. The knee was wrapped in ACE bandage with knee immobilizer in place. Dressing was clean, dry and intact.

Review of the nurses note dated 04/25/2025 at 8:15 PM revealed patient's daughter came to nurses station stating patient was itching at dressing site. Daughter discovered that inner dressings and immobilizer was wet. The note revealed that the drainage was yellow and thin. The note further stated that the nurse was unsure of what dressing was initially in place and that Hydrofera blue was placed over incision, secured with kerlix, covered with ABD pad and wrapped with ACE bandage.
There was no documented evidence that the physician was notified in order to clarify the dressing change order dated 04/15/2025. There was no order to use Hydrofera blue on the incision.

On 07/23/2025 at 10:55 AM, interview with S1DON confirmed that the nurse should have clarified the treatment order dated 04/15/2025 to determine exactly what dressing and cleaning product the physician wanted to use. S1DON further confirmed that there was no physician order to use Hydrofera blue on the patient's wound.

Based on record review and interview, the CAH failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This was evidenced by the failure to 1) routinely and accurately assess the wounds of 1 (Patient #1) of 2 patients (Patient #1, 2) with wounds and 2) notify the physician of a patient's decline in wound status (Patient #1) in a total sample of 3 (Patient #1, 2, 3).
Findings:

Review of the medical record for Patient #1 revealed an admit date of 04/15/2025. Review of the history and physical, dated 04/15/2025, revealed diagnoses including status post left total knee replacement complicated by quadriceps tendon rupture recently repaired on 04/11/2025. The history and physical further stated that the patient was admitted to the CAH with a hinged knee brace in full extension with plans for PT/OT.

Review of physician orders dated 4/15/2025 revealed to change dressing if saturated with sterile technique and cleanse before redressing.

Review of the initial nursing assessment dated 04/15/2025 at 8:00 PM revealed the patient had a wound to the left anterior knee. The wound was not visualized due to surgical dressing. The knee was wrapped in ACE bandage with knee immobilizer in place. Dressing was clean, dry and intact.

Further review of the twice daily nursing assessments revealed no documented evidence that the patient's wound dressing was assessed on 04/18/2025 (day shift) and 04/20/2025 (night shift). The assessments had indicated the dressing was clean, dry and intact until 04/25/2025 at 8:15 PM.

Review of the nurses note dated 04/25/2025 at 8:15 PM revealed patient's daughter came to nurses station stating patient was itching at dressing site. Daughter discovered that inner dressings and immobilizer was wet. The note revealed that the drainage was yellow and thin. The note further stated that the nurse was unsure of what dressing was initially in place and that Hydrofera blue was placed over incision, secured with kerlix, covered with ABD pad and wrapped with ACE bandage.
There was no documented evidence that the physician was notified of the change in condition of the wound.

Review of the nurses note dated 04/27/2025 at 7:05 AM revealed "slight drainage stain noted to dressing" on the lower knee area. Dressing intact and knee immobilizer remained in place.
There was no documented evidence that the physican was notified of the change in condition of the wound or that the dressing was changed.

Review of the next nursing assessment dated 04/27/2025 at 8:00 PM revealed left knee dressing was clean, dry and intact. However, the previous assessment (04/27/2025 at 7:05 AM) indicated there was a drainage stain to the dressing.

On 07/23/2025 at 11:15 AM, interview with S1DON revealed that the patient's wound dressing should have been assessed twice daily (once per 12 hour shift), during the routine nursing assessments. S1DON further confirmed that there was no documented evidence that the physician was notified of the change in condition in the wound on 04/25/2025 at 8:15 PM, when the patient's daughter found the dressings and immobilizer wet or on 04/27/2025 at 7:05 AM, when the nurse found drainage stains on the dressing.
The surveyor requested a policy indicating frequency and description of wound/dressing assessments per nursing staff, but S1DON stated there was no policy to be located.