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Based on record review, interview and observation the facility failed to ensure that facility staff completed documentation according to facility policy on patient hygiene 14 out of 20, oral care 2 out of 20, range of motion (ROM) 13 out of 20, wound care dressing changes 5 out of 10 and pain reassessment 1 out of 5 patients out of a total universe of 20 medical records of inpatient and discharged patients reviewed.

The facility failed to ensure that facility staff completed documentation according to facility policy on patient hygiene, ROM and wound care. See Tag #392

The facility failed to ensure that facility staff completed and documented pain reassessments within 30-60 minutes after pain reduction interventions per facility policy. See Tag #405



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Based on record review and interview the facility failed to ensure that facility staff completed documentation according to facility policy on: patient hygiene in 14 of 20 (Patient's #1, 2, 3, 8, 9, 10, 11, 13, 14, 15, 16, 18, 19 & 20), oral care in 2 of 20 (Patient's #2 & 3), range of motion (ROM) in 13 of 20 (Patient's #2, 3, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 & 20) and wound care dressing changes as ordered in 5 of 10 patient's with wound care orders (Patient's #11, 15, 16, 19 & 20). In a total universe of 20 medical records.

Findings include:

The facility policy titled "GUIDELINES AND PROTOCOLS, CLINICAL" #S05-G last revised 1/1/2020 was reviewed. This policy revealed "Routine/Guidelines Hygiene: Patient bathed/hair combed/shaved-Minimum Frequency: Daily, If no contraindication, shower: Weekly, Washcloth and mouthwash offered: After each meal...Oral care for NPO (nothing by mouth), tube feedings: every 4 hours and every AM before breakfast, every HS (before bed)Wounds: Documentation of Dressing Changes: Dressing changes and wound site care are documented on the Wound Treatment Record or EMR (electronic medical Record)."

The facility policy "MOBILITY AND WEIGHT BEARING GUIDELINES" #M05-G last revised 7/1/2018. This document revealed "Mobility Level and SPH ( ) Level 1 Bedrest & ROM Hemodynamically instability. Expected Mobility: Active ROM 4x per day if patient can participate, otherwise passive ROM. Level 2 Lateral Transfer & ROM (Poor trunk Strength, unable to sit at Edge of Bed (EOB) or able sit at EOB with maximum assistance. Expected mobility: -Active ROM 4 x per day if patient can participate otherwise passive ROM. Level 3 Sit EOB transfer to w/c and ROM (fair trunk strength, able sit at EOB with minimum assistance). Expected Mobility: ROM-active 4x day. Level 4: Weight bearing, able to take steps and ambulate; ROM-active 4x per day."

Examples of missing hygiene documentation:

Patient #1's medical record was reviewed on 7/3/2020. Patient #1 was admitted to the facility on 2/20/20 for continued care status post anterior total hip arthroplasty (replacement) on 2/6/20 with subsequent ischemic left lower extremity, left femoral vascular injury, hemorrhagic shock, left lower extremity thrombectomy (removal of blood clot) and 4 compartment fasciotomies (a surgical procedure where the fascia is cut to relieve tension or pressure commonly to treat the resulting loss of circulation to an area of tissue or muscle) on 2/7/20. Hygiene Flowsheets were reviewed and there was no documented bath or shower completed for 1 day (2/21/2020).

Patient #2's medical record was reviewed on 7/3/2020. Patient #2 was admitted to the facility on 5/8/2020 post hospitalization for aspiration and COVID 19 pneumonia, alzheimers and vascular dementia and discharged on 6/9/2020. "Hygiene Flowsheets" were reviewed and there was no documented bath or shower completed for 8 days (5/12, 5/14, 5/16, 5/20, 5/26, 6/1, 6/6 & 6/7/2020).

Patient #3's medical record was reviewed on 7/3/2020. Patient #3 was admitted to the facility on 5/8/2020 post hospitalization for Left CVA (stroke) with Right hemiplegia (paralysis) and aphasia (unable to speak) and discharged on 5/19/2020. "Hygiene Flowsheets" were reviewed from 5/1-5/19/2020. There was no documented bath or shower completed for 10 days (5/1, 5/3, 5/5, 5/8, 5/9, 5/13, 5/14, 5/15, 5/16, & 5/18/2020).

Patient #8's medical record was reviewed on 7/6/2020. Patient #8 was admitted to the facility on 2/26/2020 post hospitalization for Necrotizing fasciitis of the right thigh and discharged on 3/19/20. "Hygiene Flowsheets were reviewed and there was no documented bath or shower completed for 16 days (2/28, 3/1, 3/3, 3/4, 3/5, 3/6, 3/7, 3/8, 3/9, 3/11, 3/12, 3/13, 3/14, 3/16, 3/17 & 3/18/2020).

Patient #9's medical record was reviewed on 7/6/2020. Patient #9 was admitted to the facility on 4/1/2020 post hospitalization for respiratory failure secondary to influenza and discharged 4/21/20. "Hygiene Flowsheets were reviewed and there was no documented bath or shower completed for 10 days (4/2, 4/3, 4/7, 4/9, 4/10, 4/11, 4/12, 4/13, 4/16 & 4/2020).

Patient #10's medical record was reviewed on 7/6/2020. Patient #10 was admitted to the facility on 6/4/20 post hospitalization for CVA (stroke) with Right hemiplegia and discharged on 6/30/20. "Hygiene Flowsheets were reviewed and there was no documented bath or shower completed for 7 days (6/6, 6/8, 6/15, 6/16, 6/18, 6/26 & 6/27/2020).

The above lacking documentation of daily hygiene cares was verified in interview at the time of record reviews on 7/3/2020 with Registered Nurse K and 7/6/2020 with Registered Nurse R.

Patient #11 had physician orders for: "Routine, Everyshift, First occurrence on Wed 4/22/2020 at 2000 (8:00 PM) provide wound care directly upon shower completion...Routine, 2 times weekly (Once per day Mon and Thurs) First occurrence on Wed 4/22/2020 at 11:53 AM, until specified coordinate with wound care to be done directly upon completion of shower. Please offer patient shower 2 times weekly, as per [Complainants name] POA (Power of Attorney) request."

Patient #11's medical record was reviewed on 7/2/2020. Patient #11 was admitted on 3/17/2020 quadriplegic, requiring dialysis and had a tracheostomy. There was no documented hygiene completed for 12 days (6/30, 6/26, 6/25, 6/24, 6/21, 6/20, 6/19, 6/10, 6/8, 6/7, 6/1 & 5/23/2020) the patient was documented as "refused" either bed bath or shower by nursing staff. On 18 of the days (6/18, 6/15, 6/4, 6/2, 5/27, 5/25, 5/23, 5/19, 5/18, 5/17, 5/16, 5/15, 5/12, 5/11, 5/9, 5/8, 5/5 & 5/2/2020) there was no documented bed bath or shower given. The only documented hygiene was incontinence care. Patient #11 was documented as given a shower on 6/1/2020 (Monday) & 5/31/2020 (Sunday). There was no documented giving of a shower on Monday's and Thursday's as requested by POA for the weeks of 5/4, 5/11, 5/18, 5/25, 6/8, 6/15, 6/22 & 6/29/2020. Patient #11 was documented as "refused" a shower or bath on 6/7, 6/8, 6/10, 6/19, 6/20, 6/21, 6/26 & 6/26/2020 and no documented teaching to patient of nursing of outcomes of wound care refusal.

Patient #13's medical record was reviewed on 7/6/2020. Patient #13 was admitted to the facility on 6/24/2020 after a hospitalization for a mitral valve replacement and was still a patient at time of survey. There was no documented bath or shower completed for 7 days (7/6, 7/4, 7/2, 7/1, 6/29, 6/28 & 6/23/2020).

Patient #14's medical record was reviewed on 7/6/2020. Patient #14 was admitted to the facility on 6/4/2020 after hospitalization for esophageal cancer and was still a patient at time of survey. There was no documented bath or shower completed for 4 days (7/1, 6/25, 6/12 & 6/7/2020).

Patient #15's medical record was reviewed on 7/6/2020. Patient #15 was admitted to the facility on 5/20/20 for continued wound care (4 areas being treated), recent below the knee amputations of both legs and was on a ventilator with a tracheostomy was discharged on 6/17/2020. There was no documented bath or shower for 4 days (6/15, 6/12, 6/10 & 6/4/2020).

Patient #16's medical record was reviewed on 7/3/2020. Patient #16 was admitted on 6/5/2020 post hospitalization for sepsis and was discharged on 6/26/2020. There was no documented bath or shower completed for 4 days (6/22, 6/12, 6/10 & 6/8/2020).

Patient #18's medical record was reviewed on 7/6/2020. Patient #18 was admitted to the facility on 5/29/2020 post stroke with a tracheostomy, tube feedings and required dialysis and was discharged on 6/26/2020. There was no documented bath or shower completed for 5 days (6/24, 6/15, 6/12, 6/1 & 5/31/2020).

Patient #19's medical record was reviewed on 7/6/2020. Patient #19 was admitted to the facility on 5/22/2020 with arteriosclerosis (hardening) of native arteries of extremities with gangrene and resulting bilateral below the knee amputations and was currently a patient. "Hygiene Flowsheets" were reviewed from 5/22-7/6/2020. There was no documented bath or shower completed for 9 days (6/29, 6/28, 6/27, 6/12, 6/10, 6/1, 5/31, 5/30 & 5/23/2020).

Patient #20's medical record was reviewed on 7/6/2020. Patient #20 was admitted to the facility on 4/21/2020 post hospitalization for sepsis and discharged on 6/18/2020. "hygiene Flowsheets" were reviewed from 4/21-6/18/2020. There was no documented bath or shower completed for 7 days (6/14, 6/10, 6/5, 5/28, 5/24, 5/19 & 5/18/2020).

The above lacking documentation of daily hygiene cares was verified at the time of discovery on 7/2/2020 with Registered Nurse J.

Examples of missing range of motion (ROM) documentation:

Patient #2's medical record was reviewed on7/3/2020. Patient #2 was admitted to the facility
on 5/8/2020 post hospitalization for aspiration and COVID 19 pneumonia, alzheimers and vascular dementia and discharged on 6/9/2020. On "Mobility Flowsheets" were reviewed Patient #2 was documented as a "Level 2" for mobility which, per facility policy, is four times a day range of motion. Mobility flowsheets were reviewed from 5/8/20-6/9/20. Of the dates reviewed on 3 days (5/8, 5/18 & 5/28/20) there was no documented ROM completed. On 11 days (5/10, 5/11, 5/14, 5/15, 5/19, 5/26, 5/27, 6/1, 6/2, 6/3 & 6/7/20) ROM was documented as completed once a day. On 9 days (5/9, 5/12, 5/13, 5/15, 5/20, 5/24, 5/25, 5/29 & 6/6/20) ROM was documented as completed twice a day. On 3 days (5/17, 6/4 & 6/5/2020) ROM was documented as completed three times a day.

Patient #3's medical record was reviewed on 7/3/2020. Patient #3 was admitted to the facility
on 5/8/2020 post hospitalization for Left CVA (stroke) with Right hemiplegia (paralysis) and
aphasia (unable to speak) and discharged on 5/19/2020. On "Mobility Flowsheets" were
reviewed Patient #3 was documented as a "Level 2" for mobility which, per facility policy, is four times a day range of motion. Mobility flowsheets were reviewed from 5/1-5/19/20. Of the dates reviewed on 3 days (5/2, 5/13 & 5/17/20) there was no documented ROM completed. On 7 days (5/1, 5/3, 5/4, 5/5, 5/10, 5/11 & 5/12/20) ROM was documented as completed once a day. On 7 days (5/6, 5/7, 5/19, 5/14, 5/15, 5/16 & 5/18/20) ROM was documented as completed twice a day. On 1 day (5/8/2020) ROM was documented as completed three times a day.

Patient #10's medical record was reviewed on 7/6/2020. Patient #10 was admitted to the facility on 6/4/20 post hospitalization for CVA (stroke) with Right hemiplegia and discharged on 6/30/20. On "Mobility Flowsheets" were reviewed Patient #10 was documented as a "Level 2" for mobility which, per facility policy, is four times a day range of motion. Mobility flowsheets were reviewed from 6/4/-6/30/20. Of the dates reviewed on 6 days (6/8, 6/10, 6/11, 6/13, 6/14 & 6/28/20) there was no documented ROM completed. On 11 days (6/4, 6/9, 6/12, 6/15, 6/16, 6/17, 6/23, 6/24, 6/26, 6/27 and 6/29/20) ROM was documented as completed once a day. On 4 days (6/18, 6/21, 6/22 & 6/25/20) ROM was documented as completed twice a day.

The above lacking documentation of daily ROM was verified in an interview at the time of discovery on 7/3/2020 with Registered Nurse K and 7/6/2020 with Registered Nurse R.

Patient #11's medical record was reviewed on 7/2/2020. There was no documented order for ROM from physician. Occupational Therapy Evaluation dated on admission 3/17/2020 recommended daily passive ROM. "Mobility Flowsheets" were reviewed from 6/1/2020-7/2/2020 of the dates reviewed there were 5 days (6/8, 6/10, 6/15, 6/19 & 6/23/2020) with no documentation of ROM being completed at all. On 2 days (6/9 & 6/10/2020) there was an Occupational Therapy Note that ROM was completed by them. On 4 days (7/2, 6/28, 6/27, & 6/5/2020) ROM was completed by nursing staff three times a day. On 12 days (7/1, 6/29, 6/26, 6/24, 6/21, 6/19, 6/18, 6/17, 6/13, 6/12, 6/3 & 6/2/2020) ROM was documented as completed by nursing staff twice a day. On 9 days (6/30, 6/25, 6/22, 6/14, 6/11, 6/9, 6/7, 6/6 & 6/1/2020) ROM was documented as completed by nursing staff daily. On 3 days (6/9, 6/16, 6/19/2020) Patient #1 was documented as refusing ROM atleast once per day by nursing staff.

Patient #12's medical record was reviewed on 7/6/2020. Patient #12 was admitted to the facility on 6/24/2020 after a hospitalization for COVID-19 and acute respiratory failure and was still a patient at time of survey. On "Mobility Flowsheets" Patient #12 was documented as a "Level 2" for mobility which, per facility policy, is four times a day range of motion. Mobility flowsheets were reviewed from 6/24-7/6/2020. Of the dates reviewed there were 4 days (7/5, 6/30, 2/26 & 6/25/2020) there was no documented ROM completed. On 5 days (7/4, 7/1, 6/28, 6/27 & 6/24/2020) ROM was documented as completed once a day. On 3 days (7/6, 7/2 & 6/29/2020) ROM was documented as completed twice a day.

Patient #13's medical record was reviewed on 7/6/2020. Patient #13 was admitted to the facility on 6/24/2020 after a hospitalization for a mitral valve replacement and was still a patient at time of survey. On "Mobility Flowsheets" Patient #13 was documented as a "Level 2" for mobility which, per facility policy, is four times a day range of motion. Mobility Flowsheets were reviewed from 6/24-7/6/2020. Of the dates reviewed there were 5 days (7/3, 6/30, 6/29, 6/28 & 6/26/2010) there was no documented range of motion completed. On 3 days (7/5, 7/2 & 7/1/2020) ROM was documented as completed once a day. On 4 days (7/4, 6/27, 6/25 & 6/24/2020) ROM was documented as completed twice a day.

Patient #14's medical record was reviewed on 7/6/2020. Patient #14 was admitted to the facility on 6/4/2020 after hospitalization for esophageal cancer and was still a patient at time of survey. On "Mobility Flowsheets" Patient #14 was documented as a "Level 4" for mobility which, per facility policy, is active ROM four times a day. Mobility flowsheets were reviewed from 6/4-7/6/2020. Of the dates reviewed there were 2 days (6/13 & 6/5/2020) there was no documented range of motion completed. On 14 days (7/4, 7/3, 6/29, 6/25, 6/24, 6/23, 6/21, 6/18, 6/16, 6/15, 6/11, 6/9, 6/7 & 6/6/2020) ROM was documented as completed once a day. On 9 days (7/1, 6/28, 6/26, 6/22, 6/20, 6/19, 6/14, 6/12 & 6/8/2020) ROM was documented as completed twice a day. On 4 days (7/2, 6/30, 6/17 & 6/10/2020) ROM was documented as completed three times a day.

Patient #15 medical record was reviewed on 7/6/2020 was admitted to the facility on 5/20/20 for continued wound care (4 areas being treated), recent below the knee amputations of both legs and was on a ventilator with a tracheostomy was discharged on 6/17/2020. Under mobility Patient #15 was documented as a "Level 2" for mobility which, per facility policy, is four times a day range of motion. "Mobility Flowsheets" were reviewed from 5/20-6/17/2020. Of the dates reviewed there were 10 days (6/17, 6/12, 6/11, 6/9, 6/8, 6/6, 5/31, 5/30, 5/29 & 5/26/2020) there was no documented range of motion completed. On 10 days (6/14, 6/13, 6/10, 6/7, 6/3, 6/2, 5/28, 5/27, 5/24 & 5/20/2020) ROM was documented as completed once a day. On 2 days (6/16 & 5/25/2020) ROM was documented as completed three times in a day.

Patient #16's medical record was reviewed on 7/3/2020. Patient #16 was admitted on 6/5/2020 post hospitalization for sepsis from chronic lower extremity venous stasis with recurrent lower extremity ulcers/cellulitis and was discharged on 6/26/2020. Patient #16 was documented as a "Level 4" for mobility which, per facility policy is four times a day active range of motion. "Mobility Flowsheets" were reviewed from 6/5-6/26/2020. Of the dates reviewed there was 1 day (6/11/2020) with no ROM documented as completed. On 4 days (6/21, 6/20, 6/12 & 6/7/2020) ROM was documented as completed once a day. On 5 days (6/25, 6/22, 6/17, 6/16 & 6/8/2020) ROM was documented as completed twice a day. On 5 days (6/26, 6/19, 6/14, & 6/6/2020) ROM was documented as completed three times a day.

Patient #17's medical record was reviewed on 7/6/2020. Patient #17 was admitted on 6/8/2020 after hospitalization for a subarachnoid hemorrhage, was on ventilator and tube feedings on admit and was still a patient at the facility at the time of record review. Patient # 17 was documented as a "Level 2" for mobility which, per facility policy is four times a day passive range of motion. "Mobility Flowsheets" were reviewed from 6/8-7/6/2020. Of the dates reviewed there was 2 days (6/28 & 6/23/2020) with no documented ROM. On 16 days (7/5, 7/2, 7/1, 6/29, 6/25, 6/24, 6/22, 6/20, 6/18, 6/16, 6/15, 6/14, 6/13, 6/9 & 6/8/2020) there was documented ROM once a day. On 10 days (7/4, 7/3, 6/30, 6/26, 6/21, 6/19, 6/17, 6/12, 6/11 & 6/10/2020) there was documented ROM twice a day.

Patient #18's medical record was reviewed on 7/6/2020. Patient #18 was admitted to the facility on 5/29/2020 post stroke with a tracheostomy after acute respiratory failure, tube feedings and required dialysis and was discharged on 6/26/2020. Patient #18 was documented as a "Level 2" for mobility until 6/23/2020 when was documented as "Level 4". "Mobility flowsheets" were reviewed from 5/29-6/23/2020 of the dates reviewed 16 days (6/22, 6/21, 6/20, 6/19, 6/14, 6/11, 6/9, 6/7, 6/6, 6/5, 6/3, 6/2, 6/1, 5/31, 5/30 & 5/29) there was documented ROM once a day. On 6 days (6/18, 6/15, 6/13, 6/12, 6/10, & 6/4/2020) there was documented ROM twice a day. On 6/16/2020 there was documented ROM three times a day.

Patient #19's medical record was reviewed on 7/6/2020. Patient #19 was admitted to the facility on 5/22/2020 with arteriosclerosis (hardening) of native arties of extremities with gangrene and resulting bilateral below the knee amputations. Patient #19 was documented as a "Level 2" for mobility which, per facility policy, is four times a day range of motion. "Mobility Flowsheets" were reviewed from 5/1-7/6/2020. Of the dates reviewed there were 6 days (7/2, 6/29, 6/27, 6/20, 6/2, 5/31 & 5/30/2020) there was no documented range of motion completed. On 11 days (7/3, 7/1, 6/30, 6/28, 6/26, 6/21, 6/12, 6/11, 6/1, 5/29 & 5/22/2020) ROM was documented as completed once a day. On 12 days (7/5, 7/4, 6/25, 6/19, 6/17, 6/16, 6/8, 6/7, 6/6, 6/5, 6/4, 6/3 & 5/26/2020) ROM was documented as completed twice a day. On 7 days (6/24, 6/23, 5/28, 5/27, 5/25, 5/24 & 5/23/2020) ROM was documented as completed three times a day.

Patient #20's medical record was reviewed on 7/6/2020. Patient #20 was admitted to the facility on 4/21/2020 after hospitalization for sepsis (infection in the blood stream) from a perirectal abscess and necrotizing soft tissue infection and was discharged on 6/18/2020. Patient #20 was documented a "Level 3" for mobility which, per facility policy, is four times a day active ROM. "Mobility Flowsheets" were reviewed from 4/21-6/8/2020. Of the dates reviewed there were 7 days (6/2, 6/15, 6/8, 6/7, 6/4, 6/2 & 5/30/2020) there was no documented range of motion completed. On 14 days (6/8, 6/3, 6/1, 5/30, 5/27, 5/26, 5/23, 5/14, 5/9, 5/6, 4/29, 4/28 & 4/22/2020) ROM was documented as completed once a day. On 11 days (5/24, 5/22, 5/21, 5/19, 5/18, 5/16, 5/13, 5/10, 5/5, 5/3 & 4/27/2020) ROM was documented as completed twice a day. On 8 days (6/6, 6/5, 6/4, 5/31, 5/29, 5/17, 5/11 & 4/26/2020) ROM was documented as completed three times a day.

The above lacking documentation of range of motion being completed was confirmed in an interview with Registered Nurse J on 7/2/2020 who stated, when asked, if the documentation of range of motion was completed within the facility policy ordered amount of times in a day replied "No there is no documentation that it was completed."

Examples of missing wound treatment documentation:

Patient #11 had multiple open areas being treated. "NSG (nursing) Wound Assessments/Care Flowsheets" were reviewed from 5/1-7/2/2020. This document revealed "Routine, Daily, First occurrence on Thu 6/11/2020 at 10:00 AM. Wound location; left ischia and right ischia. Wound Management: Wound care per specified algorithm/order. Type: Wet. Cleanse: Normal Saline. Prep: Prep with skin prep and allow to dry. Cover: Adhesive foam. Change/PRN: Dressing no longer intact, dressing damp, moist or saturated...Routine 2 times daily, First occurrence on Thu 6/18/2020 at 3:18 PM. -Please use eakin or calmoseptine at base of wound on open skin. There was no documented right and left ischial wound care on 6/17/2020 or 6/11/2020 (day it was ordered daily). On 6/18/2020 the wound care for the right and left ischial wounds was changed to twice a day. There was no documented wound care on 6/19, 6/21 & 6/26/2020. There was documented wound care once a day on 6/22, 6/23, 6/24, 6/27 & 7/1/2020. On admission the right and left ischial wounds were ordered for dressing change to be completed on "M-W-F". There was no documented wound care on 5/1/2020 (Friday), 5/4/2020 (Monday), 5/15/2020 (Friday) & 6/1/2020 (Monday). There was physician orders for "Wound Location: Sacral. Wound Management: Wound care per specified algorithm/order. Type: Wet. Cleanse: Normal Saline. Prep: Prep with skin prep and allow to dry. Cover: ABD, Secure with tape. Change/PRN: Dressing no longer intact, dressing damp, moist or saturated. Change daily on 5/15/2020. There was no documented dressing changes on 5/16, 5/17, 5/19, 5/21, 5/23, 5/24, 5/26, 5/28, 5/30, 6/2, 6/4, 6/6, 6/7, 6/9, 6/11 & 6/18/2020. Change BID (twice a day)" starting on 6/18/2020. There was no documented dressing change to sacrum wounds on 6/19/2020 & 6/26/2020. There was documented wound care once a day on 6/22, 6/23, 6/24, 6/27, & 7/1/2020. On 6/11/2020 wound care was ordered to go to daily on sacrum. There was no documented wound care on 6/11 & 6/17/2020. There was documented refusal of wound cares on 5/11, 5/13, 6/20, 6/30 & 7/1/2020 and no documented teaching to patient of nursing of outcomes of wound care refusal.

Patient #15's medical record was reviewed on 7/6/2020. Patient #15 was admitted to the facility on 5/20/20 for continued wound care (4 areas being treated), recent below the knee amputations of both legs and was on a ventilator with a tracheostomy was discharged on 6/17/2020. "Wound Care" flowsheets were reviewed for Patient #15's entire length of stay 5/20-6/17/2020. Patient #15's wound on coccyx had physician order dated 5/20-5/27/2020 for "Wet, necrotic; Normal Saline: Prep with skin prep and allow to dry; Medical grade honey; Adhesive foam; every Mon, Wed, Fri treatment to be completed once a day." There was no documentation of wound care and dressing change as per physician order on 5/22 (Friday) & 5/27 (Wednesday).

Patient #16's medical record was reviewed on 7/6/2020. Patient #16 was admitted on 6/5/2020 post hospitalization for sepsis from chronic lower extremity venous stasis with recurrent lower extremity ulcers/cellulitis and was discharged on 6/26/2020. "Wound Care" flowsheets were reviewed for Patient #16 for entire length of stay. Left lower lateral leg wound change order on 6/6/2020 "Wet; Normal Saline; Prep with skin prep and allow to dry; 2 times a day". On 6/9, 6/18 & 6/22/2020 there was no documented dressing change completed. On 6/7, 6/8, 6/11, 6/12, 6/12, 6/13, 6/14, 6/15, 6/16, 6/17, 6/20, 6/25 & 6/26/2020 there was dressing change documented once a day. On 6/10, 6/19, 6/21 & 6/23/2020 there was documentation that the patient refused wound care and no documented teaching to patient of nursing of outcomes of wound care refusal.

Patient #19's medical record was reviewed on 07/06/2020. Patient #19 was admitted to the facility on 05/22/2020 after hospitalization of a bilateral (both legs) below the knee amputations (BKA), patient is currently inpatient status. Wound care flowsheets were reviewed for patient #19 from 05/22/20-07/01/2020. Bilateral BKA wound care orders released from ordering doctor on 05/23/2020 revealed bilateral BKA dressing changes 2 times daily, "Bilateral BKA; Wound Care per specified algorithm/order; Dry; Normal Saline; Other (NA) Other (NA); Other (Dry Telfa Curad nonadherent dressings); Roll gauze; Dressing no longer intact (i.e. lifting, leaking, damaged), Dressing." Patient refused dressing changes on 6/4 at 8:00AM, 6/15 at 3:00PM and 10:00PM, 6/16 at & 7:15AM and 8:30PM, and 6/17 at 9:00PM-with no documented teaching to patient of nursing of outcomes of wound care refusal. On 6/15, 6/16, 6/17 and 6/21 there was no documented dressing changes completed for both below the knee amputation wound sites.

Patient #20's medical record was reviewed on 7/6/2020. Patient #20 was admitted to the facility on 4/21/2020 after hospitalization for sepsis (infection in the blood stream) from a perirectal abscess and necrotizing soft tissue infection and was discharged on 6/18/2020. Patient #20 had multiple open areas."NSG (nursing) Wound Assessments/Care Flowsheets" were reviewed from 4/21-6/18/2020. This document revealed Right gluteal area dressing change was ordered on 6/12/2020 as "Wet; Normal Saline; Prep with skin prep and allow to dry; 2 times a day". There was no documented dressing change completed on 6/18/2020 (day of discharge). On 6/13 & 6/14/2020 there was dressing changed documented as completed once a day. Left lower back wound on 5/11/2020 was ordered for "Wound care per specified algorithm/order; Wet; Normal Saline; Prep with skin prep and allow to dry; 2 times a day". There was no documented dressing change on 5/15, 5/26, 5/29, 5/28, 5/29, 5/30, 5/31, 6/1, 6/2, 6/4, 6/6, 6/9, 6/11, 6/13, 6/14, & 6/16/2020. There was one time a day dressing change documented on 5/11, 5/14, 5/16, 5/17, 5/25, 5/27, 6/3, 6/5, 6/10, 6/12, 6/15 & 6/17/2020.

The above lacking documentation of dressing changes completion was verified in an interview at the time of discovery on 7/2/2020 with Registered Nurse J who, when asked, stated "Yep I don't see that it they were documented as done."



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Examples of missing Oral Care Documentation

Patient #2's medical record was reviewed on 7/3/2020. Patient #2 was admitted to the facility on 5/8/2020 post hospitalization for aspiration and COVID 19 pneumonia, alzheimers and vascular dementia and discharged on 6/9/2020. Patient #2 had orders for oral care once per shift (12 hours). "Hygiene Flowsheets" were reviewed and oral care was not documented as completed twice a day for 31 days (5/8, 5/9, 5/10, 5/11, 5/12, 5/13, 5/14, 5/16, 5/17, 5/18, 5/20, 5/22, 5/23, 5/24, 5/25, 5/26, 5/27, 5/28, 5/29, 5/30, 5/31, 6/1, 6/2, 6/3, 6/4, 6/5, 6/6, 6/7, 6/8 & 6/9/2020).

Patient #3's medical record was reviewed on 7/3/2020. Patient #3 was admitted to the facility on 5/8/2020 post hospitalization for Left CVA (stroke) with Right hemiplegia (paralysis) and aphasia (unable to speak) and discharged on 5/19/2020. Patient #2 had orders for oral care once per shift (12 hours). "Hygiene Flowsheets" were reviewed from 5/1-5/19/2020 and oral care was not documented as completed twice a day for 5 days (5/2, 5/3, 5/5, 5/8, 5/15 & 5/19/20).

The above lacking documentation of daily oral cares was verified in an interview at the time of discovery on 7/3/2020 with Registered Nurse K.

Based on record review and interview the facility failed to ensure that pain reassessments were completed and documented within 30-60 minutes after pain reduction interventions per facility policy in 1of 5 patients out of a total universe of 20 medical records of inpatient and discharged patients reviewed. (Patient #1)

Findings include:

The facility policy titled "Pain management, assessment and intervention protocol" #P01-G last revised 4/1/18 revealed "Procedure: 1. Assessment: A. Pain is assessed using the following scales: Numeric Rating Scale (NRS) 0-10 or the Critical Care Pain Observation Tool (CPOT) 0-8 [our adopted Behavior Pain Scale (BPS)]. B. All patients will be assessed for pain upon admission. i. If no pain indicated, patient will be assessed every shift (12 hours) thereafter ii: If pain indicated based on NRS or CPOT pain score, patient will be assessed about every 4 hours. E. Re-Assessment: i. Pain will be assessed prior to pain reduction interventions. iii. Pain will be reassessed 30-60 minutes following a pain reduction intervention. iv. Revise the management POC if the pain is poorly controlled or interventions are failing to achieve the patient's stated pain goal."

Patient #1's medical record was reviewed on 7/3/2020. Patient #1 was admitted to the facility on 2/20/20 for continued care status post anterior total hip arthroplasty (replacement) on 2/6/20 with subsequent ischemic left lower extremity, left femoral vascular injury, hemorrhagic shock, left lower extremity thrombectomy (removal of blood clot) and 4 compartment fasciotomies (a surgical procedure where the fascia is cut to relieve tension or pressure commonly to treat the resulting loss of circulation to an area of tissue or muscle) on 2/7/20. Patient's stated pain goal is "no pain". On 2/20/20 at 11:00 AM pain assessment was documented as a pain score of "7" (severe pain) there was no documented analgesia given on the pain flowsheet. At 4:00 PM scheduled and prn oral pain medication were documented as given on the medication administration record (MAR). There was no documented pain reassessment. At 8:24 PM scheduled and prn oral pain medication were documented as given with no pain assessment. At 10:00 PM pain assessment was documented as a pain score of "8" there was no documented analgesia given on pain flowsheet. On 2/21/20 at 1:46 AM prn oral pain medication were documented as given with no pain assessment. At 9:51 AM scheduled and prn oral pain medication were documented as was given on the MAR. At 1:46 PM scheduled oral pain medications were documented as given on the MAR. There was no documentation of pain assessment. At 3:05 PM PRN intravenous pain medication was documented as given on the MAR prior to a dressing change with no documented assessment. At 6:54 PM PRN oral pain medication was documented as given on the MAR. At 9:27 PM scheduled oral pain medication was documented as given on the MAR. There was no documentation of pain assessment. On 2/22/20 at 1:30 AM PRN oral pain medication was documented as given on the MAR. There was no documentation of pain assessment. At 8:00 AM pain assessment was documented as a pain score of "3" and at 8:42 AM and 8:51 AM scheduled and PRN oral pain medication was documented as given on the MAR. There was no documented pain assessment. At 1:02 PM scheduled oral pain medication was documented as given on the MAR. There was no documentation of pain assessment. At 6:10 PM PRN oral pain medication was documented as given on the MAR. There was no documented pain assessment. At 9:20 PM scheduled oral pain medication was documented as given on the MAR. At 9:35 PM pain assessment was documented as a pain score of "2". At 11:53 PM PRN oral pain medication was documented as given on the MAR. There was no documented pain assessment. On 2/23/20 at 4:00 AM PRN oral pain medication was documented as given on the MAR. There was no documented pain assessment. At 8:24 AM scheduled and PRN oral pain medication was documented as given on the MAR. There was no documented pain assessment. At 9:12 AM pain assessment was documented as a pain score of "5" there was no documented interventions on the pain flowsheet. At 10:00 AM pain assessment was documented as a pain score of "5" the documented interventions on the pain flowsheet "medicated-see MAR." At 2:47 PM scheduled and PRN oral pain medication was documented as given on the MAR. There was no documented pain assessment. At 6:54 PM PRN oral pain medication was documented as given on the MAR. There was no documented pain assessment. At 9:30 PM pain assessment was documented as a pain score of "5" and scheduled oral pain medication was documented as given on the MAR. On 2/24/20 at 12:12 AM PRN oral pain medication was documented as given on the MAR. There was no documented pain assessment. At 4:56 AM PRN oral pain medication was documented as given on the MAR. There was no documented pain assessment. At 8:24 AM scheduled and PRN oral pain medication was documented as given on the MAR. There was no documented pain assessment. At 8: 45 AM pain assessment was documented as a pain score of "10". At 9:20 AM pain assessment was documented as a pain score of "--". At 11:37 AM a Fentanyl patch (pain medication) was documented as given on the MAR. At 12:43 PM pain assessment was documented as a pain score of "10" and a PRN oral pain medication was documented as given on the MAR. At 1:25 PM pt left AMA with 911 ambulance."

Patient #1's record review was completed with RN K on 7/3/20. During interview, RN K stated "I would expect to see documentation of pain reassessment."