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Base on medical record review and interview, the facility failed to follow physician orders for wound care for 1 of 5 (Patient #5) patient records reviewed.

The findings included:

Medical record review for Patient #5 revealed an admit date of 2/7/17 for medical management of Multiple Decubiti. The admitting diagnosis: Stage 4 Pressure Ulcer of Sacral Region, Left hip ulcer, right heel deep tissue injury. Past medical history includes End Stage Renal Disease (receives dialysis 3 days a week), Type 2 Diabetes, Hypertension and Chronic Pain.

The Wound Care Status Report upon admission revealed the wound care nurse documented the following wounds and measurements:

On 2/8/17: Wound #1 - Right Heel Wound 1.5 centimeter (cm) by 1cm, #2 -Anterior Right foot 4.5 cm by 1 cm, Wound #3 - Left Trochanter 4 cm by 0.5 cm, and Wound #4 - sacral 15 cm by 16 cm by 5.5 cm.

Wound Care orders dated 2/8/17 revealed: Rights heel, Right anterior foot and Left hip skin prep daily, Sacrum- cleanse with wound cleanser and pat dry. Loosely pack with ¼ strength Dakins solution, moistened Kerlix, cover with ABD (dressing pad), secure with tape, dressing change BID (two times a day) or PRN (as needed) soilage.

Wound Care orders dated 5/4/17 revealed, "... Sacral- cleanse with wound cleanser and pat dry. Apply skin prep to peri wound area and allow to dry. Apply hydrocolloid to wound perimeter. Apply VAC (Vacuum Assisted Closure) Vera Flo dressing to sacral wound. Bridge to either trochanter. Vac vera flow settings solution normal saline, instill volume 40 cc, soak time 10 minutes, VAC therapy time 3.5 hours ...change Monday , Wednesday and Friday ..."

Wound Care orders dated 5/25/17 revealed, "...Sacral wound: cleanse with wound cleaner and pat dry. Apply skin prep to peri wound area and allow to dry. Loosely pack with Dankins wet to dry. Cover with ABD and secure with tape. Change BID and PRN..."

Wound Care orders dated 7/25/17 revealed, "...Sacrum- cleanse with wound cleanser and pat dry. Apply skin prep to peri wound area and allow to dry. Loosely pack with ¼ strength Dakins solution, moistened Kerlix, cove with ABD and secure with tape, change PRN incontinence or daily .."

Wound Care orders dated 8/3/17 revealed, "...Sacral wound: cleanse with wound cleaner and pat dry. Apply skin prep to peri wound area and allow to dry. Apply hydrocolloid to peri wound. Vera Flo Cleanse Choice foam to wound bed, followed by black foam. NPWT (negative pressure wound therapy)at 125 mmHg (millimeters of pressure)continuous, Vac changes Tuesday, Thursday, Saturday. If WCT (wound care team) is unavailable and nurse is unable to maintain VAC seal please clean sacral wound with wound cleanser and pat dry. Apply skin prep to peri wound area and allow to dry. Loosely pack with ¼ strength Dakins solution, moistened Kerlix, cove with ABD and secure with tape, change every shift and PRN incontinence until WCT can replace wound vac ..."

Wound Care orders dated 8/8/17 revealed,"...d/c (discontinue) wound vac to sacrum. Cleanse with wound cleaner and pat dry. Apply skin prep to peri wound area and allow to dry. Loosely pack with ¼ strength Dakins moistened gauze, cover with ABD and secure with tape, change daily or PRN bowel movement ..."

Wound Care orders dated 8/11/17 revealed, "... Sacrum: Cleanse with wound cleaner and pat dry. Apply skin prep to peri wound area and allow to dry. Loosely pack with ¼ strength Dakins moistened gauze, cover with ABD and secure with tape, change daily or prn bowel movement ..."

Wound Care orders dated 8/25/17 revealed,"... Sacrum: Cleanse with wound cleaner and pat dry. Apply skin prep to peri wound area and allow to dry. Apply Therahoney to areas of slough. Loosely pack with ¼ strength Dakins moistened gauze, cover with ABD and secure with tape, change daily or prn incontinence. Right heel: Betadine daily ..."

Wound Care orders dated 11/15/17 revealed, "... Sacrum: Cleanse with wound cleaner and pat dry. Apply skin prep to peri wound area and allow to dry. Loosely pack with ¼ strength Dakins moistened Kerlix, cover with ABD and secure with tape, change daily or prn bowel movement. Lateral right lower extremity: Betadine daily, cover with abd and secure with Kerlix and tape change daily ..."

Review of the facility's wound care treatment record revealed documentation that wound care was not performed on the right heel, right anterior foot and left hip daily from 2/8/17 through 4/30/17 as ordered by the physician on 2/8/17. There was no documentation wound care was provided on the weekends (Saturday and Sunday) starting 2/11/17 through 3/12/17 and no documentation of wound care being provided on 3/17/17 through 3/27/17, 3/30/17 through 4/7/17 and 4/19/17 through 4/30/17. The right heel, right anterior foot and left hip was documented as being healed on 4/30/17.

Review of the facility's wound care treatment record revealed documentation that wound care was not performed on the sacral wound 2 times a day as per physician orders from 2/8/17. There was no documentation of sacral wound care on 2/11/17, 2/12/17, 2/18/17, 2/19/17, 2/25/17, 2/26/17, 3/4/17, 3/5/17, 3/11/17, 3/12/17, 3/17 through 3/27/17, 3/30/17 through 4/17/17, 4/19/17 through 4/25/17, 4/27/17 through 5/3/17, 5/5/17 through 5/25/17 through 12/6/17. The facility was unable to provide wound care treatment sheets for 9/7/17 through discharge on 12/6/17.

In an interview in the conference room on 1/4/18 at 2:40 PM, when asked about gaps in the documentation and incorrect documentation of wound care for Patient #5, the Chief Clinical Officer stated the Wound Care Nurse (WCN) was asked to resign on 12/20/17 due to gaps in documentation found during an audit. When asked what the responsibilities of the wound care nurse entailed the CCO stated, "...the WCN writes the wound care orders after assessing the wound and the physician signs the orders. The orders are then sent to pharmacy for any medication needed. The WCN fills out the treatment sheets which are left in the books at the nurse station. It is the WCN responsibility to ensure wound care is completed and to communicated with the physician related to the wounds. We have a new Director of Quality who started in November 2017. When auditing charts it was noted that there were gaps and incorrect documentation in the chart by the WCN. I was informed that day by the DOQ of the audit and reviewed the charts that day. I called the WCN in that day and after speaking with her it was decided that she could resign or be terminated. She chose to resign and her last day was 12/20/17. When asked who was responsible for providing and charting wound care when the WCN was not available, the CCO stated the floor nurses have been trained how to assess, change wound dressings and document wound care. The CCO verified wound care was not documented as being done by the floor nurses. When asked who was ultimately responsible for ensuring documentation was complete and accurate the CCO stated, " ...I am ..."

When this surveyor attempted to contact the former WCN on 1/5/18, the telephone number provided by the facility was out of service.

Based on policy review, medical record review and interview, the facility failed to ensure the plan of care was accurate, kept current by ongoing assessments and updated as needed for changes in the wound care for 1 of 5 (Patient #5) patient records reviewed.

The findings included:

Medical record review for Patient #5 revealed an admit date of 2/7/17 for medical management of Multiple Decubiti. The admitting diagnosis: Stage 4 Pressure Ulcer of Sacral Region, Left hip ulcer, right heel deep tissue injury. Past medical history includes End Stage Renal Disease (receives dialysis 3 days a week), Type 2 Diabetes, Hypertension and Chronic Pain. Patient #5 was transferred to another facility on 12/6/17.

Review of the facility's "Standard of Care" policy revealed, "...8.a. A collaborative assessment and Individualized Patient Care Treatment Plan is discussed by the interdisciplinary team (IDT) during the Patient Care Conference. The recommended IDT review of each patient will occur within at least seven days of admission and no less than weekly thereafter during the Interdisciplinary Patient Care Conference ..."

The Wound Care Status Report revealed upon admission the wound care nurse documented the following wounds and measurements:

On 2/8/17: Wound #1 - Right Heel Wound 1.5 centimeter (cm) by 1 cm, #2 -Anterior Right foot 4.5 cm by 1 cm, Wound #3 - Left Trochanter 4 cm by 0.5 cm, and Wound #4 - sacral 15 cm by 16 cm by 5.5 cm Review of the Weekly Care Plans revealed the care plans dated 2/8/17 through 12/6/17 were not updated to reflect wound management.

Review of the Weekly Care Plans revealed there were no weekly IDT review done for 23 weeks of 44 weeks that Patient #5 was hospitalized. Patient #5's skin/wound assessment was incomplete and /or not documented as part of the plan of care for 24 of 44 weeks.

Review of the Interdisciplinary Patient Care Conference Record revealed there was no Patient Care Conference record of wounds for 22 weeks of 44 weeks that Patient #5 was hospitalized. There were no goals and/or interventions, and incomplete wound assessment for 16 weeks of 21 weeks of Patient Care Conference.

In an interview in the conference room on 1/4/18 at 2:40 PM, when asked about the Care plan related to Patient #5's wounds, the Chief Clinical Officer stated the Wound Care Nurse (WCN) was responsible for updating the wound care portion of the Interdisciplinary Patient Care Conference Record weekly. The report is brought to the weekly Care Plan meetings and discussed with the IDT members.

Based on policy review, medical record review and interview the facility failed to ensure medical record entries were legible, complete and documented accurately for 2 of 5 (Patient #1 and 5) patient records reviewed.

The findings included:

1. Review of the facility's "Safe medication administration practices, general" policy revealed, "...Documentation must include the medication strength, dose, route of administration and date and time of administration. If a medication was not administered, document the reason why, any interventions taken, practitioner notification and patient's response to interventions..."

2. Review of the facility's "Pain Management" policy revealed, "...H. Assessments and Reassessments of pain and the efficacy of the treatment plan should be ongoing, and the detail of the assessments should be appropriately documented in the patient's medical record by all appropriate disciplines. Pain intensity will be assessed within 30 to 90 minutes after a pain relief intervention ...I ...Pain management efforts proven ineffective will be reported to the ordering or covering provider...L.Pain management interventions will be documented in the medical record. Reassessment will be performed and documented in the medical record..."

3. Record review for Patient #1 revealed an admission date of 11/2/17 with diagnoses of Management of Acute Diverticulitis with Sepsis, Ileus and Perforated Bowel requiring need for nasogastric (NG) tube suctioning, Intravenous (IV) antibiotics and Total Parenteral Nutrition (TPN) support.

Review of the physician orders dated 11/2/17 revealed Dilaudid 0.5 milligrams (mg) intravenous (IV) every 4 hours as needed (PRN) for pain. On 11/4/17 orders were written for Fentanyl Patch 12 (microgram) mcg per hour. Change every 72 hours.

Review of the Daily Nursing Assessment sheet revealed the facility's pain scale as 1-2 mild pain, 3-6 moderate pain, 7-8 severe pain and 9-10 worst pain.

Review of the Nursing Notes revealed the following:

On 11/3/17, pain was documented as 8 at 7:15 AM and 12:00 PM in the abdomen (abd). At 3:00 PM, the location of the pain was documented as all over. There was no documentation of the name, dosage, or route of pain medication administration or reassessments completed by the nurse.

On 11/4/17, pain was documented as 6 at 9:45 AM with location as generalized. There was no documentation of a pain reassessment. The pain scale was documented as 8 at 7:30 PM with location as generalized. The nurse documented Dilaudid was given at 7:30 PM. There was no documentation of the dosage or route of pain medication administration.

On 11/5/17, pain was documented as 8 at 8:00 AM, 12:00 PM; pain was documented as 7 at 6:00 PM and pain was documented as 8 at 12:30 AM in abd and generalized. There was no documentation of the name, dosage, or route of pain medication administration or reassessments completed by the nurse for 8:00 AM, 12:00 PM, 6:00 PM. There was no documentation of the dosage or route of pain medication administration at 12:30 AM.

On 11/6/17, pain was documented as 8 at 8:00 AM in the abd and as 7 at 10:00 AM and 6:20 PM in the abd. There was no documentation of the name, dosage, or route of pain medication administration or reassessments completed by the nurse.

On 11/7/17, pain was documented as 8 at 3:45 PM in the back. There was no documentation of the route of pain medication administration or that a pain scale reassessment was completed by the nurse.

On 11/8/17, pain was documented as 8 at 8:30 AM with location as generalized. There was no documentation of the name, dosage, or route of pain medication administration or a reassessment was completed by the nurse.

On 11/9/17, pain was documented as 6 at 2:00 PM in the abd. There was no documentation of the name, dosage, or route of pain medication administration.

On 11/10/17 at 5:02 PM, there was no pain scale documented, however the nurse documented the patient had pain in the legs. Dilaudid was administered. There was no legible documentation of the dosage, or route of pain medication administration or time of the reassessment by the nurse.

On 11/11/17, pain was documented as 8 at 8:00 AM and 2:00 PM, and as 7 at 6:00 PM in the abd. There was no documentation of the name, dosage, or route of pain medication administration or reassessments completed by the nurse.

On 11/12/17, pain was documented as 1 at 8:00 AM, 12:00 PM and 6:00 PM. There was no documentation of the location of the pain, no interventions, or reassessments completed by the nurse. At 10:00 PM and 2:30 AM, pain was documented as 8 for the back and the abdomen. There was no documentation of the dosage or route of pain medication administration.

On 11/13/17, pain was documented as 9 (worst pain) at 9:10 AM and as 8 at 3:06 PM. There was no documentation of the route of pain medication administration or reassessments completed by the nurse. The pain was documented as 7 at 10:00 PM with location as generalized. There was no documentation the patient received any medication or intervention for complaints of pain. There was no documentation a reassessment was completed by the nurse.

On 11/14/17, pain was documented as 8 at 10:00 PM in the abd. There was no documentation of the dosage or route of pain medication administration.

On 11/15/17, pain was documented as 8 at 8:30 AM, 7 at 5:00 PM, 8 at 9:30 PM and 3:00 AM, in the legs. There was no documentation of the dosage or route of pain medication administration at 8:30 AM, 5:00 PM and 9:30 PM. There was no documentation of the route of pain medication administration at 3:00 AM. There was no documentation reassessments were completed by the nurse at 5:00 PM and 3:00 AM.

On 11/16/17, pain was documented as 8/10 at 8:15 AM and 6/10 at 1:05 PM in the hips and stomach. There was no documentation of the dosage or route of pain medication administration or pain reassessments completed by the nurse.

On 11/17/17, pain was documented as 7 at 9:00 AM and 8 at 2:15 PM and 2:00 AM, in the hips, stomach and right flank. There was no documentation of the dosage or route of pain medication administration.

On 11/20/17, pain was documented as 7 at 8:00 AM in the abd; pain was documented as 8 at 2:00 PM with location as prn, abd and 6:00 PM with location as prn. There was no documentation of medication intervention for 8:00 AM and 6:00 PM. There was no documentation of the name, dosage, or route of pain medication administration at 2:00 PM or reassessments completed by the nurse.

On 11/22/17, pain was documented as 8 at 8:30 AM and 7 at 1:45 PM in the back. There was no documentation of the dosage or route of pain medication administration or time the reassessments were completed by the nurse.

On 11/23/17, pain was documented as 8 at 1:30 PM and 1:40 AM in the back and generalized. There was no documentation of the dosage or route of pain medication administration.

On 11/24/17, pain was documented as 8 at 11:30 AM and 6:00 AM, 9 at 7:25 PM and 11:55 PM in the back. There was no documentation of the dosage or route of pain medication administration.

On 11/25/17, pain was documented at 9:00 AM and 6:00 PM in the back and abdomen with medication intervention of Dialudid. There was no documentation of the pain scale, dosage or route of pain medication administration or time the reassessments were completed by the nurse. At 11:20 PM, pain was documented as 9 (worst pain) in the back. There was no documentation of the dosage or route of pain medication administration. The reassessment at 12:00 AM documented pain at a 7 (Severe pain) in the back. There was no documentation of an intervention or reassessment completed by the nurse.

On 11/26/17, pain was documented as 8 at 8:00 AM, 12:00 PM and 4:00 PM in the abd. There was no documentation of the name, dosage, or route of pain medication administration, no documentation of a medication intervention or reassessments completed by the nurse.

On 11/27/17, pain was documented as 8 at 2:15 PM in the legs and back. There was no documentation of the route of pain medication administration or reassessment completed by the nurse.

On 11/28/17, pain was documented as 8 at 10:45 AM in the back. There was no documentation of the dosage, or route of pain medication administration or reassessment pain scale completed by the nurse. At 9:50 PM and 4:00 AM, pain was documented as 7. There was no documentation of the location of the pain or route of pain medication administration.

In an interview in the conference room on 1/4/18 at 2:00 PM, the CCO verified the pain medication had not been charted correctly and was unable to verify if medications had been given as ordered.

4. Review of the facility's "Wound Assessment" policy revealed, "...B. the skin assessment includes identification of major wounds present on admission (documentation must include location, etiology and worst tissue type of each wound) ...F. Reassess and document (major and minor) wound characteristics with each schedule or PRN dressing change for initial, weekly follow-up, new wound, change in wound status and discharge ...H. wound photos are obtained on admission ...photographs should be redone at a minimum as the wound(s) change)s), monthly ...I. determine goals for wound healing (documented via care planning pathway) ..."

Medical record review for Patient #5 revealed an admit date of 2/7/17 for medical management of Multiple Decubiti. The admitting diagnosis: Stage 4 Pressure Ulcer of Sacral Region, Left hip ulcer, right heel deep tissue injury. Past medical history includes End Stage Renal Disease (receives dialysis 3 days a week), Type 2 Diabetes, Hypertension and Chronic Pain.

Review of the Wound Care Status Report revealed wound measurements as:

Wound #1: measurement to Right heel 1.5 x (by) 1 on 2/8/17, 1.5 x 1.5 on 2/15/17 and was not measured again until 8/22/17 as 1.5 x 2.5 cm. The Right heel was documented as being healed on 4/30/17 on the wound care treatment record.

Wound #2: measurement to Pedal/ankle 1 x 4.5 on 2/8/17 and 1 x 5 on 2/15/17. There were no other measurements documented. The Pedal/ankle was documented as being healed on 4/30/17 on the wound care treatment record.

Wound #3: measurements to Left Trochanter 4 x 5 on 2/8/17. There was no other measurements documented. The Left hip was documented as being healed on 4/30/17 on the wound care treatment record.

Wound #4: measurements to sacral 15 x 16 on 2/8/17, there were no measurements documented for 3/2017, no date for measurements of 10.5 x 12.2, and last measurement on 11/15/17 was 11.5 x 12.

Review of the Weekly Care Plans revealed the care plans dated 2/8/17 through 12/6/17 were not updated to reflect wound management.

Record review revealed the facility failed to photograph wounds monthly and as changes occur per hospital policy. There was no documentation on the Wound Photographic Documentation for 3 photographs dated 2/8/17 of the location, size, wound number date first observed or nurse signature. The facility failed to photograph the sacral area wound in March and June 2017.

In an interview in the conference room on 1/4/18 at 2:40 PM, when asked about gaps in the documentation and incorrect documentation of wound care for Patient #5, the Chief Clinical Officer stated the Wound Care Nurse (WCN) was asked to resign on 12/20/17 due to gaps in documentation found during an audit. When asked what the responsibilities of the wound care nurse entailed the CCO stated, " ...the WCN writes the wound care orders after assessing the wound and the physician signs the orders. The orders are then sent to pharmacy for any medication needed. The WCN fills out the treatment sheets which are left in the books at the nurses station. It ids the WCN responsibility to ensure wound care is completed and to communicated with the physician related to the wounds. We have a new Director of Quality who started in November 2017. When auditing charts it was noted that there were gaps and incorrect documentation in the chart by the WCN. I was informed that day by the DOQ of the audit and reviewed the charts that day. I called the WCN in that day and after speaking with her it was decided that she could resign or be terminated. She chose to resign and her last day was 12/20/17. When asked who was responsible for providing and charting wound care when the WCN was not available, the CCO stated the floor nurses have been trained how to assess, change wound dressings and document wound care. The CCO verified wound care was not documented as being done by the floor nurses. When asked who was ultimately responsible for ensuring documentation was complete and accurate the CCO stated, " ...I am ...".

Based on policy review, record review and interview the facility failed to ensure patient medical records were legible, completed, dated and timed by the person responsible for providing or evaluating the services provided for 1 of 5 (Patient #1) records reviewed.