HospitalInspections.org

Based on medical record (MR) review, facility policy and interview, it was determined the facility failed to ensure the Skilled Nurse (SN) provided wound care as ordered by the physician.

This deficient practice affected three of four MR's reviewed with wounds, including Patient Identifier (PI) # 3, PI # 6, and PI # 2, and had the potential to affect all patients served by this facility.

Findings include:

Facility Policy: Wound Assessment and Documentation
Policy Number: 2
Last Reviewed Date: 08/28/2024

Policy:

...V. Responsibilities:

...5. Nursing and therapy staff provide wound care as ordered via protocol or physician order.

1. PI # 3 was admitted to the facility for rehabilitation services on 3/4/25 following a Large Acute Left Parietal Intraparenchymal Hemorrhage (a stroke due to bleeding on the brain).

Review of the MR revealed PI # 3 had a pressure injury to the coccyx at the time of his/her admission that was evaluated by the facility Wound Care Program Director (WCPD) on 3/5/25 at 3:14 PM. The WCPD documented the wound was an unstageable Deep Tissue Injury (DTI) measuring six centimeters (cm) in length, 2.5 cm in width, and 0.2 cm in depth.

A physician order was written on 3/5/25 at 3:44 PM to clean the wound to the coccyx with soap and water, apply orange cap barrier cream, (identified as zinc oxide during an interview with the WCPD), and place a foam dressing over the sacrum every other day and when soiled.

Review of the SN wound care documentation revealed the following:

3/7/25 - no zinc oxide ointment was applied.
3/10/25 - no wound care was provided after last being provided 3/8/25.
3/11/25 - no zinc oxide ointment was applied.
3/13/25 - not cleaned with soap and water, no foam dressing applied.

The SN failed to provide wound care as currently ordered.

Further review of the MR revealed a new physician order for wound care dated 3/18/25 at 11:14 AM to cleanse the coccyx with soap and water, apply Triad Ointment and cover with sacral foam every other day and when soiled.

Review of the SN wound care documentation revealed the following:

3/20/25 - no wound care was provided after last being provided 3/18/25.
3/21/25 - no wound care was provided after last being provided 3/18/25.
3/22/25 - no wound care was provided after last being provided 3/18/25.

The SN failed to provide wound care as currently ordered.

Further review of the MR revealed a new physician order for wound care dated 3/23/25 at 5:58 PM to cleanse the coccyx with soap and water, apply Santyl Ointment and cover with wet to damp dressing twice daily.

Review of the SN wound care documentation revealed the following:

3/23/25 PM - no wet to damp dressing was applied.
3/24/25 AM - no Santyl Ointment was applied.
3/25/25 AM - no wound care was provided.
3/25/25 PM - no Santyl Ointment was applied.

The SN failed to provide wound care as currently ordered.

An interview was conducted on 4/10/25 at 5:11 PM with Employee Identifier (EI) # 1, Regional Associate Chief Nursing Officer, who confirmed the SN failed to provide wound care as ordered by the physician.

2. PI # 6 was admitted to the facility for rehabilitation services on 2/6/25 following Thoracentesis and Pneumonia.

Review of the MR revealed PI # 6 had a pressure injury to the sacrum, present on admission, that was evaluated by the facility WCPD on 2/7/25 at 10:01 AM. The WCPD documented the wound was a stage three sacral area pressure injury (SAPI) measuring 3 cm in length, 2.5 cm in width, and 0.8 cm in depth.

A physician order was written on 2/7/25 at 11:37 AM to clean the SAPI with soap and water, apply Santyl Ointment to the wound bed, and cover with wet to damp dressing BID (twice daily).

Review of the SN wound care documentation revealed the following:

2/7/25 PM - no wound care was provided after last being provided 2/7/25 AM.
2/8/25 AM - no wet to damp dressing applied.
2/10/25 AM - no wound care was provided after last being provided 2/9/25 PM.
2/10/25 PM - no Santyl Ointment was applied to the wound bed.
2/11/25 PM - no wound care was provided after last being provided 2/11/25 AM. The SN documented the SAPI was open to air.
2/13/25 PM - no wound care was provided after last being provided 2/13/25 AM.
2/14/25 AM - no wound care was provided after last being provided 2/13/25 AM.
2/15/25 PM - no documentation what specific wound care the SN provided.
2/16/25 AM - no Santyl Ointment was applied to the wound bed. The SN documented Plurogel was utilized. There was no order for Plurogel.
2/16/25 PM - no wound care was provided after last being provided 2/16/25 AM.
2/17/25 PM - no wound care was provided after last being provided 2/17/25 AM.

The SN failed to provide wound care per the physician order.

An interview was conducted on 4/10/25 at 5:35 PM with EI #1, who confirmed the SN failed to provide wound care as ordered by the physician.


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3. PI # 2 was admitted to the facility on 4/3/25 with diagnoses including Critical Illness Myopathy and Polyneuropathy, Recent Right Above Knee Amputee and Left Below Knee Amputee.

Review of the MR revealed PI # 2 had a SAPI present at the time of his/her admission and was evaluated by the facility WCPD on 4/4/25 at 2:56 PM. The WCPD documented the wound was an unstageable DTI measuring five cm in length, and 10 cm in width.

Further review of the MR revealed a physician order dated 4/4/25 to clean the SAPI with sterile saline and dry, BID.

Review of the SN wound care documentation of the SAPI revealed the following:

4/4/25 PM - No wound care was documented.
4/5/25 AM - Ointment was documented. There was no order for ointment.
4/5/25 PM - No wound care was documented.
4/6/25 AM - "Changed ointment (Santyl), ABD (abdomen) pad." There was no order for Santyl or ABD pad.
4/6/25 PM - "Changed gauze dressing, Santyl ointment ABD pad." There was no order for gauze dressing, Santyl or ABD pad.
4/7/25 AM - "Changed gauze dressing, Santyl, ABD pad." There was no order for gauze dressing, Santyl or ABD pad.

The SN failed to provide wound care as ordered.

An interview was conducted on 4/10/25 at 5:42 PM with EI # 1, who confirmed the staff failed to follow the physician wound care orders.