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Based on interview and record review the facility failed to ensure the Registered Nurses assessed, documented and reported their findings to the physician, patient, and family in 1 of 6 patients who's medical record was reviewed (patient #1 of #1 through #6).


This deficient practice had the likelihood to effect all patients of the facility.


Findings included.


On 11/29/2022 at 8:30 AM in the office of the Administrator the medical record (MR) for patient (Pt/pt) #1 was reviewed. The electronic MR review was facilitated by the Quality Nurse, staff #2. The MR revealed pt #1 was admitted to the long term acute care facility on 10/19/2022 for congestive heart failure (CHF). Pt #1 was prescribed an external defibrillator vest and was wearing the vest upon admission. This was confirmed by staff #2 who assisted with the MR review.

The initial nursing assessment identified no skin wounds. Also the initial wound care assessment identified no skin wounds. Pt #1 was 5 feet 8 inches tall and weighed 340.6 pounds.

On 11/5/2022, the day of discharge, photographs were taken by wound care nurses showing bilateral wounds below pt #1's bilateral breast. The right breast wound measured 20 x 65 x 0.2 (sic), length, width, and depth. The left breast wound was pictured and measured at 2.0 x 10.0 x 0.2 (sic), length,width and depth.

A review of the MR identified no skin assessment other than admission and discharge. A nurses note read "Moisture related skin irritation dated 11/28/2022. On 11/7/2022 identified in the notes. MASD (sic) to abdominal folds and bilateral breast-placed wicking material for moisture control". No other descriptive skin assessment was identified in the MR.

A review of pt #1's MR found no nursing or wound care documentation indicating the physician had been made aware of the length, width, or depth of pt #1's bilateral breast wounds.

Staff #2, Quality Director, confirmed there was no documentation to support that the nursing staff had made the physician aware of the actual size, length, width, or depth of pt #1's bilateral lower breast wounds.

Based on document review and interview the facility failed to include the patient's bilateral wounds in the care plan for 1 of 1 patient (Patient #1 of, #1 through #6) whose medical records were reviewed.


This deficient practice had the likelihood to affect all the patients of the facility.


Findings included:


On 11/29/2022, in the office of the Administrator, the medical record (MR) for patient (Pt/pt) #1 was reviewed. After the review, the Quality Director (QD) who assisted with the electronic MR review confirmed the care plan did not included Pt #1's bilateral lower breast wounds. The QD further confirmed the nurses had obtained treatment orders of Nystatin powder to be applied to the wounds.


Neither the wounds nor the treatments were included in pt #1's care plan.