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Based on medical record review, policy review and staff interview, the facility failed to provide wound care as ordered. This affected one (Patient #1) of 10 patients reviewed.

Findings include:

Medical record review revealed Patient #1 was admitted to the facility on 07/06/23 with diagnosis of acute respiratory failure and anoxic brain injury. Patient #1 was admitted with a deep tissue injury on his sacrum/coccyx area measuring 6.5 centimeters (cm) by 7.0 cm by 0.0 cm. The wound care order for the coccyx were cleanse with normal saline, prep with skin prep, allow to dry, apply hydrogel, and apply tegaderm foam daily.

Review of the record revealed wound care was not documented as having been completed on 07/15/23 and 07/16/23. On 07/18/23 the sacrum/coccyx wound was measured as 10.0 cm by 15.0 cm by 0.1 cm. On 07/23/23 the sacrum/coccyx wound care was not documented as having been completed. On 07/25/23 the sacrum/coccyx wound was measured as 10.0 cm by 10.5 cm by 0.1 cm. On 07//25/23 the wound care orders were changed to complete the treatment twice daily. On 07/30/23 the sacrum/coccyx wound care was described with bloody serous thin drainage and wound care was only documented as being completed once on this date.

Review of the facility policy titled "Wound Documentation," dated 04/01/23, revealed the facility policy was to document wound site care/dressing changes per the physician's order. Dressing changes and wound site care were to be documented in the medical record or electronic medical record (EMR)

Interview on 07/31/23 at 10:17 AM, Staff M confirmed the wound care order was not documented on four occasions during Patient #1's admission.