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Based on medical record review, policy review, resident interview and staff interview, the facility failed to provide treatment and monitoring for a Stage II wound, failed to notify the physician of a change of condition to the wound, and failed to ensure patients with wounds, or at risk for wounds, were turned every two hours. This affected three (#1, #3, and #6) patients reviewed with the potential to affect all patients cared for at this facility. (A936) The cumulative effects of these systemic practices resulted in the agency's inability to ensure patient care needs would be met.

Based on medical record review, patient interview, policy review, and staff interview, the facility failed to provide treatment and monitoring for a Stage II wound, failed to notify the physician of a change of condition to the wound, and failed to ensure patients with wounds, or at risk for wounds, were turned every two hours. This affected three (#1, #3, and #6) patients reviewed with the potential to affect all patients cared for at this facility.

Findings include:

1. Review of the medical record revealed Patient #3 was admitted on 02/13/24 at 6:15 PM from an outside hospital with a diagnoses of acute hypoxic respiratory failure secondary to pneumonia and chronic obstructive pulmonary disease (COPD). The patient was ventilator dependent and discharged to a hospital on 02/22/24.

Admission nursing notes from the admitting nurse on 02/13/24 documented a skin assessment was done and dressing change completed to the coccyx wound. Nursing documentation stated this wound had yellow serosanguinous drainage, no odor, was red and pink with a foam dressing applied. The the wound measurements were recorded as length 2.4 centimeters (cm), width 3 cm and depth of 0.1 cm. Bilateral heels were boggy with blanchable redness, foam dressing in place. There were no other dressing changes or treatments documented until 02/18/24.

Review of the admission orders dated 02/13/24 at 8:30 PM lacked orders for any wound care dressing changes to be completed.

Review of internal medicine (IM) physician note dated 02/14/24 identified the patient with 3+ pitting edema on all four limbs. No documentation was found of a coccyx wound.

Review of the Interdisciplinary Plan of Care (IDP) notes dated 02/14/24 listed under wound care goal for Patient #3 to continue current wound care and maintain skin integrity with barrier cream. Frequency of dressing changes are to be three times per week and as needed.

Review of the nursing notes showed a dressing change was completed on 02/18/24 by the day shift nurse. This coccyx wound evaluation stated the appearance was yellow with scant amount of purulent drainage, with an odor noted. There was no documentation the physician was notified of the drainage with an odor. No measurements were documented. The record contained no further evidence of any dressing changes or treatments being completed.

Review of the second IDP meeting notes dated 02/21/24 listed the same information written for wound care. The nursing care plan listed under nursing diagnosis/problem an alteration in skin integrity related to decreased mobility with goal of wound showing improvement. Interventions included to complete Braden scale, turn every two hours and wound care per orders.

The medical record for Patient #3 had no documentation turning was completed from admission, throughout the first night. The day shift on 02/14/24 had initials written under the position area but did not state if the position was right, left or back.

Review of the Flowsheets revealed on 02/15/24 no evidence of any turning on the day shift from 7:00 AM to 7:00 PM, with turning beginning at 8:50 PM. The Flowsheet for 02/18/24 lacked evidence of any turning completed for the night shift 7:00 PM -7:00 AM. Initials were again listed under position for the day and night shift on 02/19/24 and initials for the day shift 02/20/24 with nothing clear about rotating positions.

Interview with the IM physician, Staff G, on 04/04/24 at 2:00 PM revealed Staff G stated he/she was not aware of Patient #3 having a wound to his coccyx. Staff G stated the standard operating procedure (SOP) was the nurse takes photo of anything that looks like a wound then they notify the wound care team to get involved. Staff G also stated he would have expected to be notified of any change in drainage to a wound.

Interview with the wound care nurse, Staff D, on 04/03/24 at 12:00 PM revealed according to the measurements of Patient #3's wound it would be a Stage II. Staff D further stated the wound nurses do not remeasure the wound, but use the measurements the nurse takes. Staff D verified the wound care nurses did not do a skin assessment prior to this patient being discharged out on 02/22/24. Staff D revealed the initial skin assessment is completed by the nurse and the wound care nurse then verifies the assessment was completed. On admission the nurse takes pictures of the wound and sends it to the wound care team. They then follow the patient and do rounds on Monday-Friday with the nurse practitioner.

Interview with the admitting nurse, Staff E, on 04/03/24 at 3:00 PM revealed when a patient is admitted Staff E will look at the Community Referral Form to see what type of treatments were completed for wound care, but in this case the patient did not come with this referral. Staff E would write orders for dressing changes,. but in this case it was a shift change and orders were completed by the nurse Staff E gave report to. Staff E completed an assessment of the wound and completed a dressing change with measurements, but did not do the orders.

Review of the facility policy titled "Wound Care Program Nursing," dated 09/18/23, stated every patient will receive a thorough "head to toe" assessment, within twenty-four hours of admission, to identify any wounds or areas of breakdown and to accurately document them. Wound care will be overseen by the wound care nurse and conducted at their direction. All wounds or areas of concern will be documented photographically, including measurements, and described with a narrative/flowsheet description on the Wound Documentation Form and placed in the "skin care" section of the patient's chart. If not available to assist with this at the of admission, the wound care nurse shall perform their own assessment as soon as practicable, usually within twenty-four hours or on Monday for weekend admissions. Additionally, the wound care nurse will perform "head to toe" assessments and detailed documentation of any wounds or areas of concern on all patients on a weekly basis. If the patient has wounds but is admitted without wound care orders, the patient's nurse will consult with the wound care nurse for orders. In the absence of the wound care nurse, the patient's nurse may consult with the admitting physician for appropriate orders. If any scheduled wound care is not completed, the reason should be clearly documented and the wound care nurse should be notified. Under maintenance of skin integrity if the patient is unable to effectively reposition themselves they will be turned every two hours. Positioning shall rotate between left, right sides and onto back to minimize risk of pressure injury, dependent upon presence and location of wound.

Review of the facility policy titled "Physician Notification-Change In Patient Condition" revealed it is the primary registered nurse (RN) assigned to the patient, or supervising the care of the patient, is responsible for recognizing, notifying and communicating with the medical staff regarding significant change or deterioration in the patient's condition and for assuring that the physician responds.

Interview with Staff A on 04/04/24 at 2:00 PM verified there were no orders for treatment to the Stage II wound on Patient #3's coccyx. Staff A verified the Wound Care Program was not notified within 24 hours of admission to assess and write orders. Staff A verified the patient wasn't turned every two hours.

Interview with Staff A on 04/04/24 at 4:30 PM verified the physician was not notified per policy on 02/18/24 when Patient #3's wound had purulent drainage.

2. Review of the medical record revealed Patient #1 was admitted on 03/09/24 from another hospital. Diagnoses included a history of spinal stenosis, COPD and Type 2 diabetes.

Orders were received on 03/09/24 at 3:32 PM for Cavilon Advanced cream to the buttocks. Wound care notes from admission showed a purple area on the sacral region measuring 5 cm long by 4 cm wide with a depth of 0.01 cm.

A skin care assessment documented by the wound care nurse on 03/19/24 revealed the skin was intact with wound care to assess as needed.. Notes stated to continue with protective and topical barriers for prevention as well as turn every two hours.

Review of the daily nursing flow sheet for 03/27/24 stated this patient was up in the chair at 10:15 AM. The next documentation of position was at 8:00 PM with the patient identified to be resting on their back. Positioning was completed at 10:00 PM with the next documentation at 2:30 AM. No documentation of repositioning was found for the day shift on 03/28/24 with the first notation of position at 8:00 PM. Flowsheets on 03/29/24 listed turning completed on day shift at 8:00 AM and 10:00 AM. No documentation was found of any turning for the rest of the day until 8:00 PM.

Interview during the initial tour on 04/02/24 at 10:50 AM, Patient #1 stated they had complaints of not being turned every two hours with turning occurring every four hours.

Interview with Staff A on 04/04/24 at 8:15 AM verified the findings of not turning Patient #1 every two hours.

3. Review of the medical record revealed Patient #6 was admitted on 12/28/23 from a outside hospital with a history of a hemorrhagic stroke, stage IV coccyx ulcer with osteomyelitis. Wound dressing changes were completed by the wound care team three times per week. Patient #6 was unable to turn himself and needed assistance.

The nursing flowsheet on 01/01/24 had nothing written as far as positioning. Review of the in room flowsheet listed position changes for 01/01/24 at 9:50 AM with the next documentation of turning at 7:15 PM. The Flowsheet for 01/02/24 had initials listed on the day shift under position but did not state what position this patient was in. No documentation was found the patient was turned during the 7:00 PM to 7:00 AM shift.

Interview with Staff A on 04/04/24 at 4:00 PM verified the findings of not turning Patient #6 every two hours.