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Based on record review and interview, the facility failed to ensure Registered Nurses (RN) evaluated wounds, notified physicians of changes and provided wound care for 4 of 10 patients (#'s 10, 8, 9, and 1) reviewed for wound care.

-Patient #10 had an order dated 3/18/15 for Betadine treatment to the left heel daily. From 3/18/15 to discharge on 4/28/15 (40 days) the treatment was documented as being done 7 times on the Wound Documentation sheet.

-Patient #10's right hip wound was being treated with Tegraderm. There was no Physician's Order to treat the wound. The wound went from a Stage II to being Unstageable. There was no documentation the Physician was notified, an assessment was performed by the physician or a treatment was ordered.

-Patient #10 had an order on admission on 3/17/15 for a Wound Consultation. There was a second order for Wound Consultation on 3/25/15. The Wound Consultation was performed on 3/26/15, a delay of 9 days.

-Patient #8 had an order to perform daily dressing changes to the right middle finger. There was no documentation the dressing was changed on 6/26/15, 6/27/15, or 6/28/15. It took three days and two orders to get a Culture & Sensitivity done for the patient.

-Patient #9 had an order to provide wet to dry dressing to sacral and abdominal wounds until 6/7/15. The dressings were not documented as done on 6/4, 6/5 and 6/6/15.

- Patient #1 had documented excoriation on 5/9/15. No treatment was sought until 5/12/15, a delay of 3 days. There was an order for topical Nystatin cream which was not documented as being applied. The CNO (Chief Nursing Officer) #51 said treatments should be on the Wound Documentation sheet, but the Policy and Procedure noted the documentation would be on the TAR (Treatment Administration Record) which the facility did not use.

Findings include:

Patient #10

Record review of Patient #10's closed medical record revealed she was a 92 year old female admitted on 3/17/15 with ulceration of sacral area and right hip with sepsis.

Record review of Patient #10's History and Physical dated 3/18/15 revealed she fell on 3/7/15 and was taken to the hospital. She was found to have a Stage IV pressure ulcer to the sacrum that was foul smelling with necrotic edges. A debridment was performed at the hospital and she was put on a wound vac (vacuum) for healing. She was sent to the facility for IV antibiotic therapy and wound care.

Record review of the Patient's Discharge Summary revealed she was discharged on 4/28/15

Record review of the patient's Physician's Orders revealed an order on 3/18/15 to 1) Apply a wound vac to the sacral ulcer, 2) Apply Betadine to the left heel daily, 3) Apply Allevyn foam to the left ankle and change weekly.

Record review of the Patient's Wound Documentation sheet for the Left Heel revealed she received treatment with Betadine as ordered on the following dates:
March 18, 26
April 1, 8, 15, 22, and 28

Record review of the Patient's Medication Administration Record (MAR) dated 3/18/15 revealed a hand written treatment to apply Betadine to the left heel. The treatment was initialed as done on the 18th. The treatment was not listed on any MAR from 3/18/15 to discharge on 4/28/15 (40 days). There was no documentation in nurses' notes that the treatment was done. In 40 days the treatment was performed 7 times.

There was a Wound Documentation sheet for right hip redness. The treatment was to apply Tegraderm absorbent weekly. The treatment was performed on the following dates:
March 18, 26
April 1, 8, 15, 22, and 28

Further review of the Physician's Orders revealed no order for treating the right hip.

Record review of the pictures taken of the right hip wound revealed on 3/18/15 there was a quarter sized circular wound on the right hip that was dark red. The wound was noted to be a blister.

Interview on 7/29/15 at 12:00 p.m. with Wound Care RN #55, she said the wound started out as a red spot. When she was asked if it was a Stage II pressure ulcer, she said no it was a blister. She said the skin was not open so it was not a Stage II pressure ulcer. Review of the picture taken on 3/25/15 of the right hip wound revealed it now had a black, leather like covering that is called eschar. The base of the wound could not be seen. On 4/1/15 the wound had 75% yellow slough and 25 % eschar. On 4/8/15 it was all yellow slough and on 4/15/15 the wound had a yellowish leather like covering. The stage was listed as a 6. The base of the wound could not be seen in the pictures.

Further interview at this time with Wound Care RN #55, she was asked what Stage 6 was. She said it was what the wounds looked like. She said a level 7 was a deep tissue injury. She was asked if she notified the Physician about the wound changes and she said she did not. She said she kept treating the wound with the Tegraderm as originally ordered. She said Tegraderm did not have any chemical properties; it was a clear dressing that covered the wound to protect it. Wound Care RN #55 verified there was no order to treat the right hip.

Record review of the facility's Policy and Procedure for Wound Assessment dated 6/10/08 and revised on 4/14/ revealed under Pressure Ulcer Stages the following:

"-Suspected Deep Tissue Injury:
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of the underlying soft tissue from pressure and/or shear....

-Stage I:
Intact skin with non-blanchable redness of a localized area usually over a bony prominence...

-Stage II:
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister....

-Stage III:
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss....

-Stage IV:
Full thickness tissue loss with exposed bone, tendon or muscle. slough or eschar may be present on some parts of the wound bed....

-Unstageable:
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Further description:
Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined...


Record review of Patient #10's Admission Orders dated 3/17/15 revealed an order for Wound Care Consult. On 3/25/15 there was a second order for Wound Care Consult.

Record review of Patient #10's Consults revealed the first Wound Care Consult was on 3/26/15 by Dr. #57, a delay of 9 days.

Record review of the facility's Policy and Procedure for Wound Documentation dated 10/1/13 and revised on 4/01/14 revealed the following:

"Policy...
4. All dressing changes and wound site care are documented on the wound Treatment Record...Wound treatment orders are written out in the chart per physician order or protocol/algorithm. Then they are transcribed to the Wound Treatment Form...One form for each wound and if the orders change, a new form is initiated...
5. The Wound Progress Note...is completed at least every 7 days by the wound team as they round. This form give the physician an update on the wound status based on the wound nurses' in-depth assessment. The physician shall sign this form to acknowledge that they are updated on the wound status for their patient...."

During an interview on 7/29/15 at 2:40 p.m. with CNO (Chief Nursing Officer) #51, she was asked if the Wound Care Nurse wrote progress notes to the physician to sign weekly. She verified Wound Progress Notes were not being done.

Patient #8

Record review of Patient #8's closed medical record revealed he was admitted on 6/24/15 for IV antibiotic therapy and local wound care for a right finger abcess that had be opened and drained at an outside hospital.

Record review of Patient #8's Physician's Order dated 6/25/15 revealed an order to apply Alginate to the right middle finger and cover with a foam dressing daily.

Record review of Patient #8's Physician's Progress notes revealed on 6/29/15 a family member was concerned the patient was not getting dressing changes.

Record review of the Patient's Wound Documentation sheet revealed a treatment on 6/25/15. The next treatment was documented on 6/29/15.

Record review of the Patient's Nurses' Notes and the MAR (Medication Administration Record) revealed no documentation of any dressing changes to the right middle finger. The daily dressing change was not documented as being done on 6/26/15, 6/27/15, or 6/28/15.

Further review of the Patient's Physician's Orders revealed on 6/27/15 an order for a Culture and Sensitivity (C&S) of the right middle finger wound. There was a second order on 6/29/15 to "Please culture wound in am - C&S."

Record review of Patient #8's Microbiology Reports revealed only one C&S of the right middle finger dated 6/30/15 when the culture was submitted (three days later).


Patient #9

Record review of Patient #9's closed medical record revealed he was admitted on 6/2/15 for antibiotic therapy and wound treatment with wound vacuum to sacral and abdominal wounds.

Record review of Patient #9's Physician's Orders revealed an order dated 6/3/15 at 2:20 p.m. to apply moist to dry dressing to the abdomen and sacral wounds daily until the wound vacuum was started. On Friday, 6/5/15 there was an order to continue packing the sacral wound and to start the wound vacuum on Sunday (6/7/15 or Monday (6/8/15). On 6/7/15 there was an order to start the wound vacuums. There was no order from 6/3/15 to 6/7/15 to discontinue the treatment to the abdomen.

Record review of Patient #9's Nurses' Notes, MAR, and Wound Documentation sheet revealed no documentation that the treatments to the sacrum and abdomen were performed on 6/4 and 6/5/15. On the MAR on 6/6/15 there was an initial that the sacral wound was packed with moist to dry dressing at 3:00 p.m., but there was no notation the abdominal wound was packed.

During an interview on 7/29/15 at 11:20 a.m. with CNO #51, she checked Patient #8 and 9's medical records and verified there was no documentation that the treatments had been performed as ordered.

Patient #1

Record review of Patient #1's closed medical record revealed she was admitted on 4/21/15 for antibiotic therapy and wound care. Review of the patient's Discharge Summary revealed she was discharged on 5/14/15.

Record review of Patient #1's Nurses' Notes dated 5/9/15 revealed she was assessed with excoriation to her buttocks. There was no documentation the physician was notified or a treatment order was obtained. There was no documentation in the Nurses' Notes from 5/9/15 to 5/12/15 that any treatment was given for the excoriation. There was no documentation on the Wound Documentation sheets.

Record review of Patient #1's wound care photos revealed on 5/12/15 a picture of the Patient's extensive dark, red excoriation over both buttocks and upper thighs.

Record review of Patient #1's Physician's Orders revealed on 5/12/15 an order for Difulcan 400 mg by mouth today then 200 mg by mouth daily for 10 days. Nystatin topical cream was ordered to be applied twice a day to the affected areas.

Further record review revealed no documentation that the Nystatin cream was applied daily to the affected area from 5/9/15 to 5/13/15.

Interview on 7/28/15 at 11:15 a.m. with CNO #51, she was asked why it took three days to get a treatment for Patient #1's excoriation and, when treatment was ordered, where was it documented? She said she would look through wound care notes for treatments and would get Wound Care Nurse #55 to answer the other question.

Interview at this time with Wound Care Nurse #55, she said the facility had over the counter products they could use for yeast infections. She said the staff may have been using those products to see if they would work. She said excoriation treatment was up to nursing to treat and document.

Interview on 7/29/15 at 10:30 a.m. with CNO #51, she said treatment with over the counter creams should be documented on the treatment sheet or the Wound Documentation sheet. She said the nurse who documented the excoriation on 5/12/15 was an agency nurse.

Record review of the facility's Policy and Procedure for Wound Documentation dated 10/1/13 and revised on 4/01/14 revealed the following:

"Policy...
4...The Wound Treatment form is used for wound care including trach site wounds, pressure ulcers, lower extremity ulcers, skin tears, etc. This form is not used for prevention strategies which are documented on the Kardex ..., nor is it used to documented (sic) ointments, lotions, barrier creams etc. which are documented on the Treatment Record/TAR..."

Interview on 7/19/15 at 2:40 p.m. with CNO #51, she was asked about the facility's Policy and Procedure for not documenting topical creams and ointments on the Wound Documentation sheet, but on the TAR. She was asked where use of over the counter creams and ointments for yeast would be documented if only being used with incontinent care. She said she saw the problem that the nurses may not have a place to document treatments. She said she saw how the nurses had to document some treatments on the MAR or in the nurses' notes. She was asked if the facility used TARs and she said they did not.