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Based on record review and interview, the hospital failed to ensure patients rights were promoted for the prevention of neglect for 11 (Pts #2, #3, #6, #8, #10, #11,#12, #13, #15, #16, and #17) of 18 patients to receive:

1. Initial measurement of wounds.

2. Treatment orders for incision/wound care.

3. Initial and daily documentation of wounds for 11 (Pts #2, #3, #6, #8, #10, #11, #12, #13, #15, #16, and #17) of 18 patients.

4. Two licensed nurse signatures on admission wound evaluations.

5. Daily shift documentation for incisions/wounds.


This failed practice had the likelihood to place all patients at increased risk for neglect of patients admitted with incisions and wounds (see tag A0145)

Based on record review and interview, the hospital failed to ensure nursing assessment of wounds were completed, wound care was performed as ordered, and incision care was performed for 11 (Patients's #2, #3, #6, #8, #10, #11 #12, #13, #15, #16, and #17) of 18 patients.

This failed practice had the likelihood to result in patients developing decline in wound conditions with increased risk of infection,sepsis and/or death.(see tag 0395)

Based on record review and interview, the hospital failed to ensure patients rights were promoted for the prevention of neglect for 11 (Pts #2, #3, #6, #8, #10, #11,#12, #13, #15, #16, and #17) of 18 patients to receive:

1. Initial measurement of wounds.

2. Treatment orders for incision/wound care.

3. Initial and daily documentation of wounds for 11 (Pts' #2, #3, #6, #8, #10, #11, #12, #13, #15, #16, and #17) of 18 patients.

4. Two licensed nurse signatures on admission wound evaluations.

5. Daily shift documentation for incisions/wounds.


This failed practice had the likelihood to place all patients at increased risk of neglect for patients admitted with incisions and wounds.


Findings:

Review of facility policy NS-3022 revised 03/18 titled "Incision Integrity" read in part that " patient incision assessment is performed every shift for signs and symptoms of infection and to notify physician of any adverse findings."


Review of facility policy NS-3022 revised 03/18 titled "Incision Integrity" read in part to " follow physicians's orders regarding incision care."


Review of facility policy NS-2023 revised 03/20 titled" Shift Documentation" read in part that " Every shift the licensed nurse documents employing reasoning, planning,implementation and evaluation to describe the patients medical progress/ decline during a 12 hour shift."


Review of facility policy NS-3048 revised 03/18 titled "Wound prevention, care, and documentation " read in part "Two licensed nurses will evaluate all wounds upon admission and throughout the patients stay. Daily the patients nurse will document on the nurses notes regarding the wound."


Patient#2

A review of the clinical record documented an admission date of 07/06/20. Discharge instructions from Hospital #1 documented the presence of a CAM boot and a JP drain. An initial/admission assessment, dated 07/06/20 documented no measurements or assessments for the following wounds:

1. Wound#3 "Midline Abdomen"

2. Wound #6 "Burn Right inner knee,left knee,left leg scattered "

3. Wound #7 "Traumatic BLE, scattered "

4. Wound #9 "Traumatic bilateral tops of hands"

5. Wound# 10 "Traumatic bilateral arms,scattered "

6. Wound #11 "JP drain site"


A review of the initial/admission assessment, dated 07/06/20 documented no measurements or assessments for the following incisions:

1. #2 "Incision right chest times two"

2. #4 "Incision mid lower back"

3. #5 "Incision "Right upper leg"

4. #8 "Incision right ankle "


On 07/20/20 at 11:28 AM, Staff F stated, "Not sure why the wounds were not identified or measured on the initial assessment". Staff F stated there was no daily shift documentation for 4 of 4 incisions and stated there was no documentation to show the CAM boot was removed to perform a skin or wound assessment.


A review of the clinical record, dated 07/07/20, showed a White Blood Cell count of 8.5 (reference range between 3.8 and 10.8).


A review of a skilled nurse assessment, dated 07/07/20, documented no measurements or assessments for the following wounds:
1. Wound#3 "Midline Abdomen"

2. Wound #6 "Burn Right inner knee,left knee,left leg scattered"

3. Wound #7 "Traumatic BLE, scattered"

4. Wound #9 "Traumatic bilateral tops of hands"

5. Wound# 10 "Traumatic bilateral arms,scattered"

6. Wound #11 "JP drain site"


A review of a skilled nurse assessment, dated 07/07/20 documented no measurements or assessments for the following incisions:

1. #2 "Incision right chest times two"

2. #4 "Incision mid lower back"

3. #5 "Incision "Right upper leg"

4. #8 "Incision right ankle "


On 07/20/20 at 10:30 AM, Staff F stated there were no wound care measurements taken for this assessment. Staff F stated there were no orders for incision care for 4 of 4 incisions for this assessment and stated there was no documentation to show the CAM boot was removed to perform a skin or wound assessment.


A review of a skilled nurse assessment during the morning shift, dated 07/08/20, documented no measurements or assessments for the following wounds:

1. Wound#3 "Midline Abdomen"

2. Wound #6 "Burn Right inner knee,left knee,left leg scattered"

3. Wound #7 "Traumatic BLE, scattered"

4. Wound #9 "Traumatic bilateral tops of hands"

5. Wound# 10 "Traumatic bilateral arms,scattered"

6. Wound #11 "JP drain site"


A review of a skilled nurse assessment, dated 07/08/20 documented no measurements or assessments for the following incisions:

1. #2 "Incision right chest times two"

2. #4 "Incision mid lower back"

3. #5 "Incision "Right upper leg"

4. #8 "Incision right ankle"


On 07/20/20 at 10:39 AM, Staff F stated there were no wound care measurements taken for this assessment. Staff F stated there were no orders for incision care for 4 of 4 incisions for this assessment and stated there was no documentation to show the CAM boot was removed to perform a skin or wound assessment.


A review of a skilled discharge summary, dated 07/08/20 documented a new wound located on the right posterior calf beneath the CAM boot, described in part: Size: large, Drainage amount: purulent, Drainage color: yellow, tan, pink, Drainage odor: moderate.


On 07/20/20 at 11:20 AM Staff K stated she was not sure how the wound was not initially assessed upon admission.


A physician's progress note, dated 07/08/20 at 2:58 PM, documented a "work up" was being performed for the underlying cause of a 101.9 degree temperature.


A Medicine Progress Note, dated 07/08/20 at 6:30 PM, documented, wound consults including right lower leg surgical site under CAM boot. Documentation included, "Upon removal of the right low [sic] leg dressing, a copious amount of pus drained from the wound. Right leg was warm to touch, erythematous and edematous. Labs revealed of White Blood Cells 20K (thousand) and patient febrile today." Patient to be sent to Hospital #2.


A physician discharge summary, dated 07/20/20 at 10:28 AM, documented the patient was having significant evidence of infection of this right distal lower extremity which was causing elevated temperatures and tachycardia from a previous surgical site and required further surgical intervention.


A document titled, Final Ancillary Orders, printed 07/20/20 showed wound care orders to begin 07/07/20 at 9:00 AM and to stop at 07/08/20 PM for wet to dry dressing changes to RLE under CAM boot daily. Final Ancillary Orders documented, send out to Hospital #2 for RLE wound infection, fever, White Blood Count 20.4, and possible sepsis.


A review of the clinical record showed no wet to dry dressing changes performed to wound on right lower extremity, beneath CAM boot as ordered on 07/07/20 or 07/08/20.

On 07/20/20 at 11:15 AM staff F stated "there is no wet to dry dressing change documented".


Patient #3

A review of the clinical record showed no daily shift documentation for 3 incisions:

1. "Incision right chest"

2. "Incision right nephrostomy insertion site."

3. "Incision left nephrostomy insertion site."

for each of the following dates: 06/19/20, 06/20/20, 06/21/20, 06/22/20, 06/23/20, 06/24/20, 06/25/20, 06/26/20, 06/27/20, 06/28/20, 06/29/20, and 06/30/20.


On 07/20/20 at 10:41 AM staff L stated there was no daily shift documentation or physician care orders for 3 of 3 incisions:

1. "Incision right chest"

2. "Incision right nephrostomy insertion site."

3. "Incision left nephrostomy insertion site."

for the following dates: 06/19/20, 06/20/20, 06/21/20, 06/22/20, 06/23/20, 06/24/20, 06/25/20, 06/26/20, 06/27/20, 06/28/20, 06/29/20, and 06/30/20.


Patient #6

A review of the clinical record showed no daily shift documentation for 5 incisions:

1. Incision #1 Scrapes right arm

2. Incision #2 Incision abdomen

3. Incision #3 Incision left hip

4. Incision #4 Incision left thigh

5. Incision #5 Incision mid back

for the following dates: 05/25/20, 05/26/20, 05/27/20, 05/28/20, 05/29/20, and 05/30/20.


On 07/20/20 at 10:51 AM staff F stated there was no daily shift documentation or physician care orders for five of five incisions:

1. Incision #1 Scrapes right arm

2. Incision #2 Abdomen

3. Incision #3 Left hip

4. Incision #4 Left thigh

5. Incision #5 Left mid back

for the following dates: 05/25/20, 05/26/20, 05/27/20, 05/28/20, 05/29/20, and 05/30/20.


Patient #8

A review of the clinical record showed no initial wound measurement and no daily wound documentation for:

1. Unstageable wound on coccyx for the following dates: 05/04/20, 05/05/20, 05/06/20, 05/07/20, 05/08/20, 05/09/20, 05/10/20, 05/11/20, 05/12/20, and 05/13/20.


On 07/20/20 at 11:07 AM, staff L stated there was no initial wound measurement or daily wound documentation for the unstageable wound for the following dates: 05/04/20, 05/05/20, 05/06/20, 05/07/20, 05/08/20, 05/09/20, 05/10/20, 05/11/20, 05/12/20, and 05/13/20.


Patient #10

A review of the clinical record showed no initial assessment and no daily shift documentation for:

1. Wound #1 Incision midline abdominal for the following dates: 07/16/20, 07/17/20, 07/18/20, 07/19/20, 07/20/20, 07/21/20, 07/22/20, 07/23/20, 07/24/20, 07/25/20, 07/26/20, 07/27/20, 07/28/20, and 07/29/20.


On 07/20/20 at 10:42 AM staff M stated there was no daily shift documentation or physician incision care orders for:

1. Incision midline abdominal for the following dates: 07/16/20, 07/17/20 ,07/18/20, 07/19/20, 07/20/20, 07/21/20, 07/22/20, 07/23/20, 07/24/20, 07/25/20, 07/26/20, 07/27/20, 07/28/20, and 07/29/20.


Patient #11

A review of the clinical record showed no initial assessment and no wound measurement for:

1. Wound #1 Ulcer right great toe for the following dates: 07/16/20 and 07/17/20.


On 07/20/20 at 11:00 AM staff C stated there was no initial wound assessment and no wound measurement for:

1. Wound #1 Ulcer right great toe for the following dates 07/16/20 and 07/17/20.


Patient#12

A review of the clinical record showed no initial assessment and no wound measurement for:

1. Wound #1 great right toe for the following dates: 07/03/20, 07/04/20, 07/05/20, 07/06/20, 07/07/20, 07/08/20, 07/09/20, 07/10/20 and 07/21/20.

On 07/20/20 at 11:10 AM staff C stated there was no initial assessment and no wound measurement for:

1. Wound #1 great right toe for the following dates: 07/03/20, 07/04/20, 07/05/20, 07/06/20, 07/07/20, 07/08/20, 07/09/20, 07/10/20, and 07/21/20.


Patient #13

A review of the clinical record showed no initial assessment and no daily shift assessment for:

1. Incision right posterior scalp for the following dates 07/12/20, 07/13/20, 07/14/20, 07/15/20, 07/16/20, 07/17/20, 07/18/20, 07/19/20, and 07/20/20.


On 07/20/20 at 10:44 AM staff M stated there is no pintail assessment, daily shift assessment or physician orders for incision care for:

1. Incision right posterior scalp. Review of record dated 07/13/20 showed no physician's orders for incision care.


Patient #15

A review of the clinical record showed no initial assessment and no daily shift documentation for:

1. Wound #1 Surgical left hip for the following dates: 07/12/20, 07/13, 07/14/20, 07/15/20, 07/16/20, 07/17/20, 07/18/20, 07/19/20, and 07/20/20.

On 07/20/20 at 11:10 AM staff M stated there was no daily shift documentation for:

1. Wound #1 Surgical left hip for the following dates: 07/12/20, 07/13, 07/14/20, 07/15/20, 07/16/20, 07/17/20, 07/18/20, 07/19/20, and 07/20/20.


Patient #16

A review of the clinical record dated showed no daily shift documentation for:

1.#1 Incision right hip for the following dates: 07/13/20, 07/14/20, 07/15/20, 07/16/20, 07/17/20, 07/18/20, 07/19/20, and 07/20/20.

On 07/20/20 at 11:10 AM staff L stated there was no daily shift documentation or physician incision care order for:

1.#1 Incision right hip for the following dates 07/13/20, 07/14/20, 07/15/20, 07/16/20, 07/17/20, 07/18/20, 07/19/20, and 07/20/20.


Patient#17

A review of the clinical record dated showed no daily shift documentation for:

1. Incision midline lower abdomen

2. Incision Left hip staples

3. Incision Left upper groin/ Lower abdomen staples

for the following dates: 01/09/20, 01/10/20, 01/11/20, 01/12/20, 01/13/20, 01/14/20, 01/15/20, 01/16/20, 01/17/20, 01/18/20, 01/19/20, and 01/20/20.


On 07/21/20 at 10:53 AM staff C stated there was no daily shift documentation or physician orders for incision care for:

1. Incision midline lower abdomen

2. Incision Left hip staples

3. Incision Left upper groin/ Lower abdomen staples

for the following dates: 01/09/20, 01/10/20, 01/11/20, 01/12/20, 01/13/20, 01/14/20, 01/15/20, 01/16/20, 01/17/20, 01/18/20, 01/19/20, and 01/20/20.

Based on record review and interview, the hospital failed to ensure patients rights were promoted for the prevention of neglect for 11 (Pts #2, #3, #6, #8, #10, #11,#12, #13, #15, #16, and #17) of 18 patients to receive:

1. Initial measurement of wounds.

2. Treatment orders for incision/wound care.

3. Initial and daily documentation of wounds for 11 (Pts' #2, #3, #6, #8, #10, #11, #12, #13, #15, #16, and #17) of 18 patients.

4. Two licensed nurse signatures on admission wound evaluations.

5. Daily shift documentation for incisions/wounds.


This failed practice had the likelihood to place all patients at increased risk of neglect for patients admitted with incisions and wounds.


Findings:


Review of facility policy NS-3022 revised 03/18 titled "Incision Integrity" read in part that "patient incision assessment is performed every shift for signs and symptoms of infection and to notify physician of any adverse findings."


Review of facility policy NS-3022 revised 03/18 titled "Incision Integrity" read in part to "follow physicians' orders regarding incision care."


Review of facility policy NS-2023 revised 03/20 titled" Shift Documentation" read in part that "Every shift the licensed nurse documents employing reasoning, planning,implementation and evaluation to describe the patients medical progress/ decline during a 12 hour shift."


Review of facility policy NS-3048 revised 03/18 titled "Wound prevention, care, and documentation" read in part, "Two licensed nurses will evaluate all wounds upon admission and throughout the patients stay. Daily the patients nurse will document on the nurses notes regarding the wound."


Patient#2

A review of the clinical record documented an admission date of 07/06/20. Discharge instructions from Hospital #1 documented the presence of a CAM boot and a JP drain. An initial/admission assessment, dated 07/06/20 documented no measurements or assessments for the following wounds:

1. Wound#3 "Midline Abdomen"

2. Wound #6 "Burn Right inner knee,left knee,left leg scattered"

3. Wound #7 "Traumatic BLE, scattered"

4. Wound #9 "Traumatic bilateral tops of hands"

5. Wound# 10 "Traumatic bilateral arms,scattered"

6. Wound #11 "JP drain site"


A review of the initial/admission assessment, dated 07/06/20 documented no measurements or assessments for the following incisions:

1. #2 "Incision right chest times two"

2. #4 "Incision mid lower back"

3. #5 "Incision "Right upper leg"

4. #8 "Incision right ankle "


On 07/20/20 at 11:28 AM, Staff F stated, "Not sure why the wounds were not identified or measured on the initial assessment". Staff F stated there was no daily shift documentation for 4 of 4 incisions and stated there was no documentation to show the CAM boot was removed to perform a skin or wound assessment.


A review of the clinical record, dated 07/07/20, showed a White Blood Cell count of 8.5 (reference range between 3.8 and 10.8).

A review of a skilled nurse assessment, dated 07/07/20, documented no measurements or assessments for the following wounds:

1. Wound#3 "Midline Abdomen"

2. Wound #6 "Burn Right inner knee,left knee,left leg scattered"

3. Wound #7 "Traumatic BLE, scattered"

4. Wound #9 "Traumatic bilateral tops of hands"

5. Wound# 10 "Traumatic bilateral arms,scattered"

6. Wound #11 "JP drain site"


A review of a skilled nurse assessment, dated 07/07/20 documented no measurements or assessments for the following incisions:

1. #2 "Incision right chest times two"

2. #4 "Incision mid lower back"

3. #5 "Incision "Right upper leg"

4. #8 "Incision right ankle"


On 07/20/20 at 10:30 AM, Staff F stated there were no wound care measurements taken for this assessment. Staff F stated there were no orders for incision care for 4 of 4 incisions for this assessment and stated there was no documentation to show the CAM boot was removed to perform a skin or wound assessment.


A review of a skilled nurse assessment during the morning shift, dated 07/08/20, documented no measurements or assessments for the following wounds:

1. Wound#3 "Midline Abdomen"

2. Wound #6 "Burn Right inner knee,left knee,left leg scattered"


3. Wound #7 "Traumatic BLE, scattered"

4. Wound #9 "Traumatic bilateral tops of hands"

5. Wound# 10 "Traumatic bilateral arms,scattered"

6. Wound #11 "JP drain site"


A review of a skilled nurse assessment, dated 07/08/20 documented no measurements or assessments for the following incisions:

1. #2 "Incision right chest times two"

2. #4 "Incision mid lower back"

3. #5 "Incision "Right upper leg"

4. #8 "Incision right ankle "


On 07/20/20 at 10:39 AM, Staff F stated there were no wound care measurements taken for this assessment. Staff F stated there were no orders for incision care for 4 of 4 incisions for this assessment and stated there was no documentation to show the CAM boot was removed to perform a skin or wound assessment.


A review of a skilled discharge summary, dated 07/08/20 documented a new wound located on the right posterior calf beneath the CAM boot, described in part: Size: large, Drainage amount: purulent, Drainage color: yellow, tan, pink, Drainage odor: moderate.


On 07/20/20 at 11:20 AM Staff K stated she was not sure how the wound was not initially assessed upon admission.


A physician's progress note, dated 07/08/20 at 2:58 PM, documented a "work up" was being performed for the underlying cause of a 101.9 degree temperature.


A Medicine Progress Note, dated 07/08/20 at 6:30 PM, documented, wound consults including right lower leg surgical site under CAM boot. Documentation included, "Upon removal of the right low [sic] leg dressing, a copious amount of pus drained from the wound. Right leg was warm to touch, erythematous and edematous. Labs revealed of White Blood Cells 20K (thousand) and patient febrile today." Patient to be sent to Hospital #2.


A physician discharge summary, dated 07/20/20 at 10:28 AM, documented the patient was having significant evidence of infection of this right distal lower extremity which was causing elevated temperatures and tachycardia from a previous surgical site and required further surgical intervention.


A document titled, Final Ancillary Orders, printed 07/20/20 showed wound care orders to begin 07/07/20 at 9:00 AM and to stop at 07/08/20 PM for wet to dry dressing changes to RLE under CAM boot daily. Final Ancillary Orders documented, send out to Hospital #2 for RLE wound infection, fever, White Blood Count 20.4, and possible sepsis.


A review of the clinical record showed no wet to dry dressing changes performed to wound on right lower extremity, beneath CAM boot as ordered on 07/07/20 or 07/08/20.


On 07/20/20 at 11:15 AM, staff F stated "there is no wet to dry dressing change documented".


Patient #3

A review of the clinical record showed no daily shift documentation for 3 incisions:

1. "Incision right chest"

2. "Incision right nephrostomy insertion site."

3. "Incision left nephrostomy insertion site."

for each of the following dates: 06/19/20, 06/20/20, 06/21/20, 06/22/20, 06/23/20, 06/24/20, 06/25/20, 06/26/20, 06/27/20, 06/28/20, 06/29/20, and 06/30/20.


On 07/20/20 at 10:41 AM staff L stated there was no daily shift documentation or physician care orders for 3 of 3 incisions:

1. "Incision right chest"

2. "Incision right nephrostomy insertion site."

3. "Incision left nephrostomy insertion site."

for the following dates: 06/19/20, 06/20/20, 06/21/20, 06/22/20, 06/23/20, 06/24/20, 06/25/20 and 06/26/20, 06/27/20, 06/28/20, 06/29/20, and 06/30/20.


Patient #6

A review of the clinical record showed no daily shift documentation for 5 incisions:

1. Incision #1 Scrapes right arm

2. Incison #2 Incision abdomen

3. Incision #3 Incision left hip

4. Incision #4 Incision left thigh

5. Incison #5 Incision mid back

for the following dates: 05/25/20, 05/26/20, 05/27/20, 05/28/20, 05/29/20, and 05/30/20.


On 07/20/20 at 10:51 AM, staff F stated there was no daily shift documentation or physician care orders for five of five incisions:

1. Incision #1 Scrapes right arm

2. Incison #2 Abdomen

3. Incision #3 Left hip

4. Incision #4 Left thigh

5.Incison #5 Left mid back

for the following dates: 05/25/20, 05/26/20, 05/27/20, 05/28/20, 05/29/20, and 05/30/20.


Patient #8

A review of the clinical record showed no initial wound measurement and no daily wound documentation for:

1. Unstageable wound on coccyx for the following dates: 05/04/20, 05/05/20, 05/06/20, 05/07/20, 05/08/20, 05/09/20, 05/10/20, 05/11/20, 05/12/20, and 05/13/20.


On 07/20/20 at 11:07 AM, staff L stated there was no initial wound measurement or daily wound documentation for the unstageable wound for the following dates: 05/04/20, 05/05/20, 05/06/20, 05/07/20, 05/08/20, 05/09/20, 05/10/20, 05/11/20, 05/12/20, and 05/13/20.


Patient #10

A review of the clinical record showed no initial assessment and no daily shift documentation for:

1.Wound #1 Incision midline abdominal for the following dates: 07/16/20, 07/17/20, 07/18/20, 07/19/20, 07/20/20, 07/21/20, 07/22/20, 07/23/20, 07/24/20, 07/25/20, 07/26/20, 07/27/20, 07/28/20, and 07/29/20.


On 07/20/20 at 10:42 AM staff M stated there was no daily shift documentation or physician incision care orders for:

1. Incison midline abdominal for the following dates: 07/16/20, 07/17/20 ,07/18/20, 07/19/20, 07/20/20, 07/21/20, 07/22/20, 07/23/20, 07/24/20, 07/25/20, 07/26/20, 07/27/20, 07/28/20, and 07/29/20.


Patient #11

A review of the clinical record showed no initial assessment and no wound measurement for:

1.Wound #1 Ulcer right great toe for the following dates: 07/16/20 and 07/17/20.


On 07/20/20 at 11:00 AM staff C stated there was no initial wound assessment and no wound measurement for:

1.Wound #1 Ulcer right great toe for the following dates 07/16/20 and 07/17/20.


Patient#12

A review of the clinical record showed no initial assessment and no wound measurement for:

1. Wound #1 great right toe for the following dates: 07/03/20, 07/04/20, 07/05/20, 07/06/20, 07/07/20, 07/08/20, 07/09/20, 07/10/20, and 07/21/20.

On 07/20/20 at 11:10 AM staff C stated there was no intial assessment and no wound measurement for:

1. Wound #1 great right toe.
for the following dates: : 07/03/20, 07/04/20, 07/05/20, 07/06/20, 07/07/20, 07/08/20, 07/09/20, 07/10/20 and 07/21/20.


Patient #13

A review of the clinical record showed no initial assessment and no daily shift assessment for:

1. Incision right posterior scalp for the following dates 07/12/20, 07/13/20, 07/14/20, 07/15/20, 07/16/20, 07/17/20, 07/18/20, 07/19/20, and 07/20/20.

On 07/20/20 at 10:44 AM staff M stated there is no intial assessment, daily shift assessment or physician orders for incision care for:

1. Incision right posterior scalp Review of record dated 07/13/20 showed no physician's orders for incison care.


Patient #15

A review of the clinical record showed no initial assessment and no daily shift documentation for:

1.Wound #1 Surgical left hip for the following dates: 07/12/20, 07/13, 07/14/20, 07/15/20, 07/16/20, 07/17/20, 07/18/20, 07/19/20, and 07/20/20.

On 07/20/20 at 11:10 AM staff M stated there was no daily shift documentation for:

1.Wound #1 Surgical left hip for the following dates: 07/12/20, 07/13, 07/14/20, 07/15/20, 07/16/20, 07/17/20, 07/18/20, 07/19/20, and 07/20/20.


Patient #16

A review of the clinical record dated showed no daily shift documentation for:

1.#1 Incision right hip for the following dates: 07/13/20, 07/14/20, 07/15/20, 07/16/20, 07/17/20, 07/18/20, 07/19/20, and 07/20/20.

On 07/20/20 at 11:10 AM staff L stated there was no daily shift documentation or physician incision care order for:

1.#1 Incision right hip for the following dates 07/13/20, 07/14/20, 07/15/20, 07/16/20, 07/17/20, 07/18/20, 07/19/20, and 07/20/20.


Patient#17

A review of the clinical record dated showed no daily shift documentation for:

1. Incision midline lower abdomen

2. Incision Left hip staples

3. Incision Left upper groin/ Lower abdomen staples

for the following dates: 01/09/20, 01/10/20, 01/11/20, 01/12/20, 01/13/20, 01/14/20, 01/15/20, 01/16/20, 01/17/20, 01/18/20, 01/19/20, and 01/20/20.


On 07/21/20 at 10:53 AM staff C stated there was no daily shift documentation or physician orders for incision care for:

1. Incision midline lower abdomen

2. Incision Left hip staples

3. Incision Left upper groin/ Lower abdomen staples

for the following dates: 01/09/20, 01/10/20, 01/11/20, 01/12/20, 01/13/20, 01/14/20, 01/15/20, 01/16/20, 01/17/20, 01/18/20, 01/19/20, and 01/20/20.