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Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by failing to document wound care for 3 (#2, #3, #4) of 3 patients reviewed for documentation of wound care from a total patient sample of 5.
Findings:

Patient #2
Review of Patient #2's medical record revealed a physician's order dated 11/16/2021 at 2:32 p.m. Calmoseptine cream to left ischium every day and PRN diaper change. Clean sacrum with wound cleanser, pat dry, apply medihoney and calcium alginate to wound every Monday, Wednesday, Friday and PRN (as needed) soiled/dislodged. Further review of Patient #2's medication administration record for 12/08/2021 - 12/20/2021 revealed the nursing staff did not document wound care as ordered on 12/10/2021 and 12/17/2021.

Patient #3
Review of Patient #3's medical record revealed a physician's order dated 03/30/2022 at 12:55 p.m. D/C wound vac to sacrum, change to clean with wound cleanser, pack with dakin's 0.25% moistened gauze every day and PRN (as needed). Further review of Patient #3's medication administration record for 03/31/2022 - 04/12/2022 revealed the nursing staff did not document wound care as ordered on 04/01/2022, 04/03/2022 - 04/12/2022.

Patient #4
Review of Patient #4's medical record revealed a physician's order dated 03/15/2022 at 1:35 p.m. D/C previous wound care orders, sacrum and left ischium- clean with wound cleanser pack and cover with dakin's 0.25% moistened gauze and cover with dry dressing every day and PRN (as needed) soiled/dislodged. Further review of Patient #4's medication administration record for 03/25/2022 - 04/12/2022 revealed the nursing staff did not document wound care as ordered on 03/25/2022, 03/29/2022, 04/01/2022, 04/06/2022, 04/07/2022, 04/08/2022, and 04/11/2022.

In an interview on 04/13/2022 at 1:20 p.m. S2DON stated the wound care is documented on the medication administration record.

In an interview on 04/13/2022 at 5:45 p.m. S2DON verified the nursing staff did not document wound care as ordered for Patient #2, Patient #3, and Patient #4.

Based on observation and interview, the hospital failed to ensure all drugs and biologicals were kept in a secure area. This deficient practice is evidenced by failing to lock the medication cart, medication refrigerator, and crash cart.

Findings:

Observation on 04/13/2022 at 9:27 a.m. of the high observation area revealed the medication refrigerator, medication cart, and the crash cart were left unlocked. The medication refrigerator, medication cart, and crash cart were in the nurse's station unsecured. Further observation of the medication cart revealed the key was left in the lock.

In an interview on 04/13/2022 at 9:35 a.m. S1Adm and S2DON confirmed the medication refrigerator, medication cart, and crash cart were left unlocked. S1Adm and S2DON verified all 3 items should have been kept locked.