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Based on records reviewed and interviews, the facility failed to ensure nursing staff met patients wound care needs in accordance with physician orders and facility policies and procedures by completely assessing, documenting, and communicating changes in patient's needs to the physician and family to ensure interventions are reviewed, appropriate, or if adjustments are needed in the patient's plan of care affecting 1 of 2 patient's reviewed (Patient #1) with wound care needs.

Findings Included:

Review of Complaint Intake, TX00550380 received on 7/23/25 indicated the following in part:
Patient #1's wound progressed throughout October 2024, with no proper treatment for the state of the wound or notification to family of wound progression resulting in infection and hospitalization post discharge. Wound care documentation and assessments were incomplete or absent. The photographic evidence showed multiple wounds with necrotic tissue, eschar, and slough. The photographic evidence of wounds lacked detailed descriptions, treatment plans, or escalation of care. Recommendation on 10/24/24 for sharp debridement was not completed before discharge on 10/25/24 or coordinated after discharge.

Subsequently, on 11/1/24, Patient #1 was admitted to another Acute Care Hospital Intensive Care Unit for "severe decubitus ulceration with gas infection" started on broad spectrum antibiotics including IV Zosyn, Vancomycin, Clindamycin with surgery consultation. On 11/2/24, Patient #1 underwent extensive surgical debridement of "sacral decubitus ulcer including skin, subcutaneous tissue, muscle, fascia, extension to bilateral gluteus area, perineal area, extension of the necrotic tissue to the pelvis with thick purulence, which goes right to the anal canal and rectum wall. The final size of wound was 20 cm [centimeters] x 17 cm."

Record review of facility policy title, Wound Assessment and Documentation Policy #2 Rev. 9/25/2024 states in part, "PURPOSE: To ensure standard documentation related to the assessment of skin and wounds.
I. Assessment. An RN will inspect each patient's skin daily and as often as indicated.
2. A. A full skin assessment is completed within 8 hours of admission ...to include descriptions, measurements, and physician notification.
2. D. Pressure injuries/ulcers will be staged, measured and photographed in accordance with the wound treatment plan, but no less than weekly.
II. Photographs and measurements should be used to document wounds covered in necrotic tissue or to more accurately describe a wound in any category.
III. 2. Daily documentation of skin and wound inspection completed by an RN will include the following, If present: A. skin condition B. dressing integrity C. description of wound drainage, odor, pain, signs of inflammation or infection, if present.

Record review of facility policy titled, Pressure Injury Prevention/Basic Treatment Policy #4 Rev. 8/27/2025 states in part, "PURPOSE: To prevent the development or worsening of pressure injuries/and skin alterations."
4. Manage excessive moisture/incontinence of patient.
B. Evaluate and treat fecal incontinence
5. Promote patient involvement in prevention of skin breakdown
C. consider sharing photos with patient/family explaining progress and treatment approach.
7. Maintain clean wound healing environment.
B. Clean all wounds at each dressing change in compliance with hospital policy, protocol, plan of care or physician order.
C. Protect wound from contamination.

Record review of Patient #1's medical record revealed the following:

Patient was admitted 10/3/2024 at 3:34pm and discharged home with home health 10/25/2024 at 2:52pm.

Physician Orders by Medical Director on 10/3/24 at 4:18 pm indicated "Consult to Wound Team- Evaluate and Treat." Decubitus Precautions. Wound Care, Wound Photo

Review of the photographic images of Patient #1's coccyx wound in his record revealed dated pictures taken on; 10/3/2024, 10/6/2024, 10/18/2024, 10/20/2024, and 10/24/2024 included a paper ruler with the patient's last name, first name and the date. There was no evidence of location/reference, no evidence of written measurements, or wound description(s).

Review of Patient #1's History and Physical dated 10/4/24 at 11:18 am completed by the Medical Director, documented Skin: "Surgical wound, bandaged. No overt signs of infection or discharge." There was not any specific assessment documentation completed by the Medical Director related to the coccyx wound. The plan for Wound Care, 18. "Initiate digital recording of wounds, including after suture/staple removal. Initiate Pressure Injury Protocol."

Review of the nurse's wound assessments and/or treatments for Patient #1 with the Wound Care Registered Nurse (Staff #2) and the Chief Nursing Officer (CNO) present, revealed the following:

-on 10/3/2024 at 7:13pm Barrier protection applied, skin prep applied, edema. Photos taken of coccyx wound with observed loose brown stool on blue pad underneath buttocks. RN failed to assess coccyx wound for length, width, depth, base tissue, wound edges, surrounding skin, surrounding tissue.

-on 10/4/2024 at 10:21am, 5:37pm, and 8:00pm Barrier protection applied, skin prep applied, edema. Failed to assess coccyx wound for length, width, depth, draining, exudate, base tissue, wound edges, surrounding skin, surrounding tissue.

-on 10/11/2024 at 11:32am and 5:26pm Barrier protection applied, skin prep applied, edema. Failed to assess coccyx wound for length, width, depth, draining, exudate, base tissue, wound edges, surrounding skin, surrounding tissue.

-on 10/13/2024 at 07:00am Barrier protection applied, skin prep applied, edema. Failed to assess coccyx wound for length, width, depth, draining, exudate, base tissue, wound edges, surrounding skin, surrounding tissue.

-on 10/14/2024 at 07:36am Barrier protection applied, skin prep applied, edema. Failed to assess coccyx wound for length, width, depth, draining, exudate, base tissue, wound edges, surrounding skin, surrounding tissue.

-on 10/15/2024 measurements of the coccyx wound were taken by Staff #2. No pictures were provided at that time.

-on 10/16/2024 at 11:25am Barrier protection applied, skin prep applied, edema. Failed to assess coccyx wound for length, width, depth, draining, exudate, base tissue, wound edges, surrounding skin, surrounding tissue.

-on 10/21/2024 at 07:00am Barrier protection applied, skin prep applied, edema. MD orders for Imodium x1 dose for diarrhea. RN notes state "wound contamination with stool 4-5 times/day." Failed to assess coccyx wound for length, width, depth, draining, exudate, base tissue, wound edges, surrounding skin, surrounding tissue.

-on 10/24/2024 Wound Care Registered Nurse/Staff #2 documented in part, "Coccyx wound necrotic, frequent contamination, patient would benefit from sharp debridement." There was no further MD notification of patient status change. Patient discharged the following day, 10/25/2024 without further coordination or follow up referral for the sharp debridement recommendation.

Record review of the Discharge Summary dated 10/25/24 signed at 15:30 indicated the following, in part:
Discharge Orders- Wound Care, Coccyx, Daily, cleanse with Vasche, pat dry, apply pleurogel to necrotic tissue, cover with hydrofera blue then foam dressing. Secure bottom of foam with pink tape.
Follow up Appointments: Patient to follow up with PCP within 2-5 days.

Interview with the Medical Director on 11/5/2025 at 2:15pm after review of Patient #1's H&P that he completed on 10/4/24, stated that he could not validate if he had seen this patient's coccyx wound during his physical examinations stating, "I trust staff, or report to me," and was unaware of its worsening condition. The Medical Director stated that the nursing staff will "take a picture, and review" but that he was "not sure" if he actually looked at the admission wound pictures taken. The Medical Director stated there was not a Wound Care Physician on staff or as a consultant when Patient #1 was admitted inpatient in October 2024. The Medical Director was referred to the documented recommendation made by Staff #2 on 10/24/24 prior to Patient #1's discharge where sharp debridement was recommended and he stated if the Wound Care Nurse makes that recommendation, the patient should be "sent out to have it done; unless it is "simple" then the patient can be referred to "specialized wound care" within the facility which a "specialty wound care" provider can treat.

Interview with Staff #2 on 11/5/2025 at 3:50pm stated that she could not explain why the coccyx wound was not staged per MD orders or policy and that it was overlooked. Staff #2 indicated there was usually a wound specialist nurse practitioner (NP) available for consultation in house, but she was on emergent medical leave during the time Patient #1 was inpatient. This case would have been referred to the NP for further evaluation and possible debridement if there was a provider at that time. Staff #2 stated that she did not remember if she told the physician that Patient #1 would benefit from debridement. Staff #2 stated Patient #1 was challenging because he was "bedridden and continued to have diarrhea; large amounts, and the wound was contaminated with stool requiring multiple changing." The physician was called for treatment with Imodium. Staff #2 confirmed the measurements were missed along with the nursing assessments not fully completed to include the descriptions of the wound(s); drainage, odor, color, signs of inflammation or infection, if present, etc., which are stated in the policy and within the nursing assessment flowsheet under wound care.

Interview with Chief Executive Officer (CEO) on 11/5/2025 at 5:30pm confirmed there was not a wound care specialist provider at the time of Patient #1's inpatient and that the facility had an MD specializing in wound care going through credentialing at the time of the NP leave but was not fully processed through credentialing. During that time period the wound care assessments and further recommendations would have been the responsibility of Staff #2. The CEO further indicated corrections have been put into place with ensuring availability of providers that are credentialed, training, and monitoring of RN wound assessments/treatments by Staff #2.