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Based on observations, staff interviews, document reviews, and in the course of a complaint investigation, it was determined the facility staff failed to consistently address multiple patients' skin/pressure ulcer conditions for 5 of 6 sampled patients reviewed for wound care (Patient #1, Patient #2, Patient #4, Patient #5, and Patient #6).

Due to a pattern of serious deficient practices identified with addressing patients' skin issues, the facility has failed to substantially comply with this Condition of Participation.

The findings include:

Patient #1 had a delay in obtaining physician orders to treat a wound.

Patient #2's decubitus ulcer was not assessed and monitored by the facility's Wound Care Nurse as directed by the facility's policy.

Patient #4's clinical record failed to provide evidence that wound care was provided as ordered and failed to provide evidence of notification of the wound care physician (Staff Member (SM) #6) or the wound care coordinator (SM # 4) of a change in the condition of the wound.

Patient #5's clinical record failed to show that wound care was provided as ordered to one or more wounds.

Patient #6 had a delay in having skin assessment completed by wound care staff; Patient #6 failed to have new wounds reported to a physician for orders.

Please see A0392 for additional information.

Based on observations, interviews, document review, and in the course of a complaint investigation, it was determined the facility staff failed to ensure patients' wounds were assessed and treated according to facility policies and procedures and physician orders for 5 of 6 sampled patients with wounds (Patient #1, Patient #2, Patient #4, Patient #5, and Patient #6).

The findings include:

1. Facility staff members failed to ensure Patient #6's right buttock wound and changes to Patient #6's left buttock wound were reported to a physician to obtain treatment orders; both buttock wounds progressed to being unstageable due to eschar.

The following skin assessment information was documented in nursing shift assessment flowsheets:
- 4/13/17 at 12:54AM - skin not intact "open area near trach, peg, trach- [sic] otherwise intact".
- The shift assessment consistently documented 'skin not-intact' until 4/15/17 at 10:00PM when the skin was documented as 'intact'.
- 4/16/17 at 11:018PM - skin was documented as 'Not intact' but no details of location or size of the break in skin were documented.
- 4/19/17 at 8:00AM - skin was documented as 'Not intact' detailed as 'skin tear at trach site'.
- 4/29/17 at 11:17AM - skin was documented as 'Not intact' detailed as 'abrasion on buttock'.
- 5/2/17 at 7:55PM - skin was documented as 'Not intact' detailed as 'PEG Trach PIV Scaral [sic] abrasion'. (PIV - peripheral intravascular access site)
- 5/3/17 at 8:06AM - skin was documented as 'Not intact' detailed as 'eschar noted to sacrum covered with mepilex fluid collection noted to posterior right neck'. No evidence of physician notification of wound change was provided to or found by the surveyor.

The above information was extracted from Patient #6's nursing shift assessment flowsheets to identify when changes were documented in the patients skin assessment. The first documentation of 'eschar' was found on 5/3/17. On 5/17/17 at 3:50PM, SM #4 (Wound Care Coordinator) was asked if he/she had received a consult related to the aforementioned change in Patient #6's skin; SM #4 reported he/she could not remember having received a consult related to Patient #6's skin changes.

Patient #6 was admitted to the facility on 4/12/17. Review of Patient #6's clinical documentation on 5/17/17 indicated the patient had been assessed twice by the wound team since his/her admission. The wound team assessments were documented on 4/28/17 and 5/2/17. On 4/28/17 Staff Member (SM) #4 documented one wound, in a wound team visit note, a Stage III Pressure Ulcer to Patient #6's left buttock; this wound was measured 6x4x0.3cm with serosanguineous thin, water, pale red exudate and no visible necrotic tissue; this wound was photographed on 4/28/17. On 5/2/17 a different employee documented one wound, in a wound team visit note, a Stage III Pressure Ulcer to the patients left buttock; this wound was measured 4x5x0.2cm with serosanguineous thin, water, pale red exudate and no visible necrotic tissue; this wound was not photographed on 5/2/17. SM #4 was interviewed on 5/17/17 at 3:50PM about Patient #6 having not been assessed by the wound care team until 4/28/17 when he/she had been admitted on 4/12/17; SM #4 acknowledged the wound care team assessment was late.

The following information was found in a facility policy entitled "Skin Integrity and Pressure Ulcer Prevention Plan" (effective date - 1/5/13; review/revise date - 1/18/17):
- "Pressure Ulcer Assessment - to be complete within 4 hours of admission and every shift."
- "Response to presence of new or worsened Pressure Ulcer: - The nurse will obtain a physician order or initiate a protocol for treatment. - A Care Plan based on intereventions [sic] for level of risk ... will be initiated. - The Wound Care Specialist and Dietition [sic] will be notified and an Occurrence Report for Hospital Aquired [sic] Pressure Ulcers (HAPU) will be completed."
- "Wound Care Specialist (WCC, WOCN,) [sic] ... Performs a complete skin and wound assessment on all new admission to the facility and supervises/ensures implementation of interventions." During an interview on 5/17/17 at 3:50PM, SM #4 reported the expectation is that the wound care nurse will see all new admissions within 72 hours.
(This policy was found in the facility's policy and procedure database on 5/18/17 at 4:45PM; the facility's CEO and Director of Quality/Risk confirmed it was the current policy.)

The following information was found in a facility policy entitled "Wound Care" (effective date - 4/2017; revision date - 1/2014):
- "All identified wounds will be assessed weekly with use of Bates-Jensen Tool to document wound healing. Identified wounds will be pictured on admission and weekly."
- "Documentation ... Weekly documentation in the medical record for pressure ulcers will be done: 1. Location of wound (i.e., left trochanter, sacrum) 2. Stage of wound 3. Size of wound (use a measuring guide) A. Length (cm) B. Width (cm) 4. Depth of wound ... 5. Undermining/Tunneling ... 6. Exudates, describe type (i.e., serous, purulent) 7. Odor, if present, describe 8. Eschar/necrotic tissue A. color B. consistency (i.e., hard black, yellow slough) C. location in wound or edges 9. Pain, presence or absence 10. Periwound skin condition ... Weekly documentation in the Medical Record for non pressure [sic] related wounds will be documented using above criteria with exclusion of staging."

The following wound order documented 4/28/17 at 1:14PM was given by SM #6 (a physician): "Left buttock: Apply bacitracin ointment to wound and cover with mepilex daily."

Review of Patient #4's 'INTERDISCIPLINARY TEAM MEETING / CARE CONFERENCE" documentation dated 5/17/17 at 2:00PM reported the patient had one (1) pressure ulcer that was "improving"; the following nursing goal was documented: "Sacral wound will (continue) to decrease in size and be free from (signs and symptoms) of infection." This documentation did not address the eschar documented for the first time on 5/3/17.

On 5/18/17 at 9:10AM, SM #4 assessed Patient #6's skin with the surveyor present. SM #4 reported the wound had changed since the last time he/she had seen it. SM #4 reported the wounds were now unstageable due to eschar and slough. SM #4 reported no necrotic tissue was present on 5/2/17. SM #4 stated he/she would notify a physician of current wound conditions.

On 5/18/17 at 9:45AM, a physician (SM #6) and SM #4 assessed Patient #6's skin with the surveyor present. SM #6 reported the current order was to address an 'abrasion' on the left buttocks. SM #6 reported he/she had not provided orders to address the unstageable area on the right buttocks. SM #6's statement about not having provided an order to address the unstageable wounds was shared with the facility's CEO on 5/18/17 at 9:55AM; (SM #4 was present when the absence of an order for the treatment of the unstable right buttock wound was shared with the facility's CEO.)

The following order was entered on 5/18/17 at 9:55AM by SM #6: "Sacral Ulcer: Apply santyl ointment to wound and pack with saline moist gauze and cover with mepilex daily."

The following information was documented in a 'Wound Team Visit' note dated 5/18/17 at 10:00AM: a unstageable left buttock pressure ulcer measured 10x7cm with depth obscured by necrosis (the necrotic tissue was described as adherent, soft, black eschar and a unstageable right buttock pressure ulcer measuring 7x8cm with depth obscured by necrosis (the necrotic tissue was described as adherent, soft, black eschar).

On 5/18/17 at 5:27PM, the survey team met with the facility's CEO, Director of Quality/Risk, and Director of Nursing. During this meeting the following findings were discussed: (a) a delay in wound care team assessment of Patient#6, (b) no wound care team assessment of Patient #6 between 5/2/17 and 5/18/17, (c) the observation of eschar to Patient #6's right and left buttocks with only a physician order for treatment to a left buttock wound, and (d) a failure to notify the physician and wound care team of changes in Patient #6's wound assessments.

2. Facility staff members failed to timely obtain orders for the treatment of Patient #1's wounds. Patient #1 was admitted to the facility on 12/16/16 at 5:39PM.

On 12/16/16 at 6:31PM, the following was documented by a registered nurse (RN): " ... Scral [sic] wound with moderate bloody output noted, redness to right and left buttok [sic] noted. ..."

On 12/19/16 at 4:21PM, a facility wound care nurse (Staff Member (SM) #4) documented a right buttock Stage II pressure ulcer with "Serous thin, watery, clear" exudate measuring less than 4 square centimeters and a left Stage II pressure ulcer with "Serous thin, water, clear" exudate measuring 5x2x0.2cm.

Patient #1's first wound care order for the aforementioned areas was dated 12/21/16 at 4:28PM; the order read as "(right) and (left) buttocks wound-apply Calmazine cream after peri care".

The following information was found in a facility policy entitled "Skin Integrity and Pressure Ulcer Prevention Plan" (effective date - 1/5/13; review/revise date - 1/18/17):
- "Pressure Ulcer Assessment - to be complete within 4 hours of admission and every shift."
- "Response to presence of new or worsened Pressure Ulcer: - The nurse will obtain a physician order or initiate a protocol for treatment. - A Care Plan based on intereventions [sic] for level of risk ... will be initiated. - The Wound Care Specialist and Dietition [sic] will be notified and an Occurrence Report for Hospital Aquired [sic] Pressure Ulcers (HAPU) will be completed." (This policy was found in the facility's policy and procedure database on 5/18/17 at 4:45PM; the facility's CEO and Director of Quality/Risk confirmed it was the current policy.)

On 5/16/17 at 1:30PM, SM #4 was asked about the discrepancies between a sacral wound on 12/16/16 and bilateral buttocks wounds on 12/19/16. SM #4 stated the different individuals completing the assessments might be identifying the same wound as being in different locations.

The delay of facility staff members to obtain orders to treat Patient #1's wounds documented on admission on 12/16/16 (the order was obtained on 12/21/16) was discussed with the facility's CEO, Director of Quality/Risk, and Director of Nursing on 5/17/17 at 9:10AM.

Patient #1's clinical documentation was reviewed for a final time with the facility's Director of Nursing (SM #3) on 5/18/17 at 3:40PM. SM #3 confirmed there were no orders to address Patient #1's pressure wound until 12/21/16.

3. Patient #2's medical record was reviewed on 05/16/17 through 05/19/17. Patient #2 was admitted to the facility on 02/02/17. A Registered Nurse (RN) completed an admission assessment and at that time documented "skin intact". On 02/03/17 at 2:19pm the Wound Care Nurse (WCN) completed a wound assessment. The WCN documented "skin intact". On 02/03/17 at 2:19pm a RN documented in the nurses notes, "Pt has loose stool everytime . . . is turned. Q2H, always on L or R side. Dime sized wound on sacral area noted earlier. Cleansed with ns and mepilex applied. Msg left for wound care RN and Dr. . . . also updated. POA of pt @ bedside and also updated. All Q&A answered and extensive time spent in this room with pt, POA and other family members. +coping noted. Pt cont. to c/o headache. Meds given as ordered. Dr. . . . . neurologist in earlier to see pt. Headache discussed." According to the medical records the next time the WCN saw the patient was 02/14/17 at 4:40pm. The WCN documented the following information;

On 02/14/17 at 4:40pm:
Skin Assessment: "Skin Not Intact". Type of Wound: "Pressure Ulcer". Wound Dimensions-Length: "4x2x0.2cm". Staging: "Pressure Ulcer-Stage II". Pressure Ulcer present on admission: "No".

On 02/21/17 at 12:51pm:
Skin Assessment: "Skin Not Intact". Type of Wound: "Pressure Ulcer". Wound Dimensions-Length: "5x5x0.2cm". Staging: "Pressure Ulcer-Stage II". Pressure Ulcer present on admission: "No".

On 02/28/17 at 4:49pm:
Skin Assessment: "Skin Not Intact". Type of Wound: "Pressure Ulcer". Wound Dimensions-Length: "5x6.5x0.2cm". Staging: "Pressure Ulcer-Stage II". Pressure Ulcer present on admission: "No".

On 03/07/17 at 11:48am:
Skin Assessment: "Skin Not Intact". Type of Wound: "Pressure Ulcer". Wound Dimensions-Length: "5x6.5x0.2cm". Staging: "Pressure Ulcer-Stage II". Pressure Ulcer present on admission: "No".

On 03/15/17 at 11:48am:
Skin Assessment: "Skin Not Intact". Location photos were taken for this visit: "Sacrum". Type of Wound: "Pressure Ulcer". Wound Dimensions-Length: "5x6.5x0.2cm". Staging: Pressure Ulcer-"Unstageable slough and eschar". Pressure Ulcer present on admission: "No".

On 03/21/17 at 3:01pm:
Skin Assessment: "Skin Not Intact". Location photos were taken for this visit: "Sacrum". Type of Wound: "Pressure Ulcer". Wound Dimensions-Length: "5x5x0.8cm". Staging: Pressure Ulcer-"Unstageable slough and eschar". Pressure Ulcer present on admission: "No".

On 03/29/17 at 14:33pm:
Skin Assessment: "Skin Not Intact". Location photos were taken for this visit: "Sacrum". Type of Wound: "Pressure Ulcer". Wound Dimensions-Length: "6x5x1.5cm". Staging: Pressure Ulcer-"Unstageable slough and eschar". Pressure Ulcer present on admission: "No".

On 04/07/17 at 3:00pm:
Skin Assessment: "Skin Not Intact". Type of Wound: "Pressure Ulcer". Wound Dimensions-Length: "6x5x1.5cm". Staging: Pressure Ulcer-"Stage IV. First Post-Debridement Assessment: "Yes". Type of treatments: "Mechanically debrided 04/03/17 per Dr. . . ."

The following information was documented on 02/08/2017 by SM #6 (a physician) and read in part as follows:

CHIEF COMPLAINT: "Evaluation of sacral ulcer."

HISTORY OF PRESENT ILLNESS: "The patient . . . who I was asked to evaluate for sacral ulcer. . . . has a history of gunshot wound with extensive injuries. . . . is now paraplegic with trach [A tracheostomy is a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube] and a PEG [Percutaneous endoscopic gastrostomy is an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate]."

PHYSICAL EXAMINATION: "Skin: Evaluation of the sacral area reveals a superficial stage II ulcer. It is small approximately 3x2cm. This appears to be either from pressure or from shear injury".

ASSESSMENT AND PLAN: "We will apply Mepilex protection every day. . . . is on an air mattress. . . . needs to be repositioned every 2 hours to avoid any further pressure ulcers."

The following information was documented on 02/16/2017 by SM #6 (a physician) and read in part as follows:

OBJECTIVE: "On examination, the wound is progressed. This now is a stage III ulcer with minimal slough. It is only about 2cm in diameter, but it is deeper."

ASSESSMENT AND PLAN: "The plan is to switch to TheraHoney and moist dressing changes daily."

The following information was documented on 03/02/2017 by SM #6 (a physician) and read in part as follows:

OBJECTIVE: "On exam, the wound is not improving and becoming unstageable sacral decubitus ulcer currently. It is currently with nonviable dermis."

ASSESSMENT AND PLAN: "Unstageable sacral decubitus ulcer. The plain is switch to Santyl and moist dressing changes daily. The patient will eventually need a debridement. Currently the wound is not soft enough for bedside excisional debridement."

The following information was documented on 03/16/2017 by SM #6 (a physician) and read in part as follows:

OBJECTIVE: "On exam today, the slough is definitely soft for debridement. It will become a stage IV ulcer."

ASSESSMENT AND PLAN: "Stage IV sacral decubitus ulcer with about 80% sloughy tissue. 1. We will arrange for bedside excisional sharp debridement of the ulcer. 2. Continue with Santyl and dressing changes daily."

The following information was documented on 03/24/2017 by SM #6 (a physician) and read in part as follows:

OBJECTIVE: "On exam today, there is a stage IV ulcer with lot of slough to it. We are doing Santyl and Dakin solution dressing changes daily. Today the wound is getting softer. The wound is looking to come up with sloughy tissue. There is also fecal contamination due to the fact that . . . is unable to control . . . stools."

ASSESSMENT AND PLAN: "1.We will arrange for surgical debridement of . . . sacral decubitus ulcer. 2. We have also spoken with the patient and . . . is willing to proceed with colostomy [a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon]. This is a good idea because . . . is a quadriplegic with no control of bowel function. 3. We will wait for . . . to get pacemaker place due to bradycardia [slow heart rate] before proceeding with the surgery. 4. We will also speak to the mother. 5. In the meantime, continue with Santyl and Dakin solution dressing changes daily."

The following information was documented on 04/03/2017 by SM #6 (a physician) and read in part as follows:

OPERATIVE PROCEDURE:

NAME OF PROCEDURE: "Bedside excision and sharp debridement of sacral decubitus ulcer."

TISSUE DEBRIDED: "Dermis, subcutaneous tissue, and muscle."

PROCEDURE DESCRIPTION: "The patient was placed in left lateral position. Forceps with #15 blade was used to debride nonviable tissue including dermis, subcutaneous tissue, and muscle. There was still some minimal slough left at the base of the wound."

PLAN: "1.The plan is now to do Santyl and quarter-strength Dakin solution dressing changes daily. 2. [The patient] is on a specialized mattress. 3. [The patient] needs to be repositioned every 2 hours. 4. The plan is for diverting colostomy once [the patient] has been cleared from a cardiac standpoint and has pacemaker."

On 05/17/17 at 1:30pm an interview was conducted with SM #4 (WCN). The above finding was discussed with WCN. He/she acknowledged there was a delay in his/her addressing the pressure ulcer. The WCN stated the RN had left a message on the answering machine and he/she had not received the message. Because of the delay in care an in-service was provided to the staff. SM #4 provided the surveyor with a document that stated; "What do I do if I find a new wound".
"Do an Incident report, document in nurses notes, notify physician-either on call or staff doctor, notify family, notify wound care coordinator by leaving note in [his/her] box or have supervisor email me (do not leave phone message) I will inform [physician's name] our wound care Dr. or [physician's name] our podiatrist, get a treatment order from staff Dr."

The following information was found in a facility policy titled "Skin Integrity and Pressure Ulcer Prevention Plan" (effective date - 1/5/13; review/revise date - 1/18/17):
d) "Response to presence of new or worsened Pressure Ulcer:
- The nurse will obtain a physician order or initiate a protocol for treatment.
- A Care Plan based on intereventions [sic]for level of risk ... will be initiated.
- The Wound Care Specialist and Dietition [sic] will be notified and an Occurrence Report for Hospital Aquired [sic] Pressure Ulcers (HAPU) will be completed.
- Rehabilitation services notification may be made for screening for positioning or pressure reducing devices needed by the patient.
- Patient/Family/Significant other will receive education and be involved in the plan of care.
e) Documentation of finding will be entered in the medical record according to facility policy and the plan of care will be initiated or revised."

The above findings were discussed with the management team at the end of day on 05/18/17. No further information was provided to the survey team.

Review of Patient #2's "INTERDISCIPLINARY TEAM MEETING / CARE CONFERENCE" (IDT) documentation dated, 02/15/17, 02/22/17, 03/01/17, 03/08/17, 03/15/17, 03/29/17 and 04/05/17 reported the following wound care information: The patient had one (1) pressure ulcer that was "stable". Nursing goals: The patient would have "improve wound healing" and to "implement care to avoid skin breakdown." The surveyor was unable to find any documentation that the IDT addressed the pressure ulcer deteriorating.

On 05/19/17 at 9:25am an interview was conducted with SM #4. SM #4 was asked if he/she was aware of the above findings. SM #4 stated he/she was out of work the first week in March, and the replacement staff would have been responsible for changing the status of the pressure ulcer. SM #4 stated, "I'm pretty sure I made a mistake and didn't update the wound assessment." He/she stated that Patient #2's pressure ulcer was discussed during the IDT meetings. No further documentation was provided.

The following information was found in a facility policy titled "Interdisciplinary Team Care Conference/Meeting" (effective date - 1/2011; review/revise date - 1/2017) read in part as follows:

"PROCEDURE
I. An IDT (Interdisciplinary Team) meets at least once, within seven (7) calendar days of a patient's admission and then at least weekly.

IV. THE TEAM MEETING PROCESS
A. Each discipline completes their section of the IDT form to the extent possible prior to the meeting.
B. During the meeting, each discipline provides a summary of the patient's progress towards identified goals.
D. Barriers to goal attainment are identified and care-planned appropriately.
F. Care plans and care plan goals dates are updated by each discipline accordingly.
G. As each discipline reports, discussion amongst the team members is open and ongoing. If goals are to be changed, or additional documentation is to be added, the individual disciplines do so."

The above findings were discussed with the management team at the end of day on 05/18/17. No further information was provided to the survey team.


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3. Patient #4 was admitted on 3/7/17 and was discharged on 4/11/17. A consult with the wound care team because of a wound on the left upper buttock was ordered by the attending physician. On 4/8/17 Patient #4 was seen by the wound care physician (Staff Member (SM) #6) and the wound care coordinator (SM # 4). SM #6 determined the wound was an unstageable pressure ulcer. On 3/8/17, SM #6 gave orders for "Left Buttock: Apply therahoney to pwound and cover with miplex daily". (Therahoney® is a product that is used to " create a moist wound environment conducive to wound healing, promote natural (autolytic) debridement to clear away necrotic tissue, and reduce wound odor" (https://www.medline.com/product/TheraHoney-Gel/Debridement-Dressings/Z05-PF13869/#mrkMore.)

On 3/16/17 the wound care order was changed to "Left Buttock: Apply santyl ointment to wound and pack with saline moist gauze and cover with meplex daily." (Santyl® ointment is an enzymatic debriding ointment per https://www.drugs.com/cdi/santyl-ointment.html)

On 4/3/17 the daily wound care order was changed to read "L buttock wound-cleanse with 1/4 strength Dakins soln, apply Santyl ointment, pack w Dakins moist gauze and cover with meplex". (Dakin's solution is a type of hypochlorite solution. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine, the active ingredient in Dakin's solution, is a strong antiseptic that kills most forms of bacteria and viruses (http://www.webmd.com/drugs/2/drug-62261-541/dakins-solution-non/details).

Review of the clinical record for Patient #4 failed to provide evidence of ordered wound care on 13 occasions during Patient #4's hospital stay. Additionally on 3 occasions (3/16/17, 3/20/17 and 3/22/17) when wound care was provided it was documented (by different nurses) "Santyl and honey" applied to the wound (no evidence was found of an order for Santyl and honey).

Review of the clinical record revealed on 3 occasions (3/20/17, 3/21/17 and 3/29/17) the nurse providing wound care documented a "foul" or "moderate" odor to the wound and on 3/29/17 it was documented as having purulent drainage. The clinical record failed to provide evidence that the physician or the wound care coordinator was informed of a change in the condition of the wound.

On 4/4/17, SM #6 the wound care physician, performed a "bedside excisional sharp debridement of the left buttock pressure ulcer". The postoperative diagnosis was "Stage IV left buttock ulcer with some significant infected purulent drainage." An infectious disease consult was ordered by the attending physician, SM #18, for fever and leukocytosis. The consult assessment and plan read in part: 'The patient has 3 potential sources for his infection....The most likely source of fever and leukocytosis is left ischial decubitus ulcer...(SM #6) noted gross purulence as well as slough tissue and has staged the wound as a stage IV raising the possibility of underlying osteomyelitis..."

In an interview with SM #6 on 5/18/17 the aforementioned issues were discussed. When asked about the use of Santyl and honey concurrently, SM #6 confirmed that Santyl and honey would not be used at the same time for a wound dressing. SM #6 was asked if he/she had been notified the wound had developed an odor by nursing staff or by the wound care coordinator, SM #6 stated that he/she did not recall being informed of a change in the wound. SM #6 stated he/she would certainly expect to have been notified of any change in a wound such as an odor and confirmed that it could have influenced decisions about treatment.

On 5/ 18/17, SM #4 was asked about what instruction staff nurses were given regarding wound care, he/she presented the survey team with a document that is given to nursing staff during orientation. Under the heading "What to report to Wound Care Coordinator" read in part... Report=Signs of infection-odor, purulent drainage, redness and warmth, etc.". SM #4 did not recall nursing staff reporting an odor to the wound. On 5/18/17, the surveyor conducted a random interview with a staff nurse (SM #16) concerning what if any extra training was given to nurses on the types of wound treatments. He/she stated the nurse gets some during orientation but feels it's not enough.

The above findings were discussed with the management team at the end of day on 5/18/17. No further information was provided to the survey team.

4. Patient #5 was admitted on 1/12/17 and discharged on 1/25/17. A wound care consult was ordered 1/13/17. Wound care orders for daily dressing changes to three areas were given on 1/13/17. Review of Patient #5's clinical record failed to provide evidence that wound care was provided as ordered to one or more areas for 10 of 13 days.

The clinical record review revealed the following orders for wound care entered on 1/13/17: Abdominal wound-pack with NS moist gauze and cover with foam border.; R buttock wound-apply therahoney and cover with foam border.; RLQ pinpoint wound--change foam border daily for weeping at site. Review of the clinical record for Patient #5 revealed the following information related to wound care: for the abdominal wound--no wound care documented for 7 of 13 days; for the buttock wound--no wound care documented for 10 of 13 days and for the pinpoint wound--no care documented for 7 of 13 days. Additionally there is no wound care documented for any wound for 5 of 13 days.

The above findings were discussed with the management team on 5/18/17 at the end of day meeting. No further information was provided to the survey team.