HospitalInspections.org

The Hospital is out of compliance with the Condition of Participation for Quality Assessment and Performance Improvement (QAPI).

Findings included:

The Hospital failed, for two (Patient #6, & Patient #12) patients out of twelve sampled patients, to ensure that Hospital Quality Assessment & Performance Improvement (QAPI) Program activities provided effective corrective actions and implemented corrective actions after Patient #6's unexpected death and Patient #12's unexpected medical emergency and drug overdose.

Refer To TAG: A-0286.

The Hospital is out of compliance with the Condition of Participation for Nursing Services.

Findings included:

The Hospital failed, for seven (Patients #3, #4, #5, #6, #8, #9, & #11) out of twelve sampled patients and five non-sampled patients (NS#1, NS#2, NS#3, NS#4, & NS#5) to ensure that required ventilator checks, patient care plans, skin assessments, and wound care were completed/performed and adequate to meet the patient needs.

Refer To TAGs: A-0386 and A-0392.

Based on records reviewed and interviews, the Hospital failed to prohibit the use of p.r.n. (an abbreviation for as needed) orders for chemical restraint for one (Patient #7) patient out of 12 sampled patient records and 5 non-sampled patients records.

The Hospital's Restraints and Seclusion Policy, dated 6/2019, indicated that orders for restraints may never be written as standing orders or p.r.n. orders. Each episode of restraint must be initiated in accordance with an order by a physician or other licensed independent practitioner.

Patient #7 was readmitted to the Hospital's Neurological Rehabilitation Unit on 1/24/19 with diagnoses of traumatic brain injury, developmental delay, mood disorder and seizure disorder.

Record review indicated that Patient #7 was treated with medications under a Rogers's Guardianship (court authorized order for extraordinary treatment care for an incapacitated person, such as administering antipsychotic medications.)

Review of the Roger's Guardianship indicated that there was a treatment plan in place for Patient #7 to utilize the antipsychotic Thorazine with a dose range of 225 milligrams (mg) to 2400 mg daily. There were four alternative antipsychotic medications listed on the court approved treatment plan. They were: 1.) Trilafon with a dose range up to 32 mg per day; 2.) Abilify with a dose range up to 30 mg per day; 3.) Seroquel with a dose range up to 800 mg per day; and 4.) Zyprexa Zydis with a dose range up to 30 mg per day.

Record review indicted that, on 1/25/19, an order was written for the antipsychotic Haloperidol 5 mg/milliliter (ml) injection intramuscularly, three times a day p.r.n. for severe behavior issues and agitation.

Record review indicated that on 7/2/19, 7/3/19, 7/8/19, 7/9/19, 7/10/19, 7/11/19, 7/12/19, 7/16/19 and 7/25/19 Patient #7 received the antipsychotic medication Haloperidol 5 mg/ml by intramuscular injection for severe behavior issues and agitation.

The Surveyor interviewed Nurse #2 at 11:00 A.M. on 8/19/19. Nurse #2 said that since this is a p.r.n. order, it is not considered a restraint. She said that he/she has a Roger's Guardianship and Haloperidol is listed on it.

The Surveyor interviewed the Chief Quality Officer at 12:10 P.M. on 8/20/19. The Chief Quality Officer said that it was his understanding that the Psychiatrist would look at the Roger's Guardianship prior to ordering any antipsychotic for patient use.

Although the Survey team tried multiple times to contact the ordering Psychiatrist via telephone and in person the ordering Psychiatrist was unable to be reached for interview.

Based on records reviewed and interviews, the Hospital failed for two (Patients #6 & Patient #12) patients out of twelve sampled patients and five non-sampled patients, to appropriately analyze adverse patient events and ensure that effective corrective actions were implemented.

Findings include:

For Patient #6

1. The Hospital failed to investigate and analyze an adverse patient event and implement appropriate preventive actions when Patient #6 experienced an unexpected decline in condition and death.

The Hospital policy titled "Serious Reportable Event (SRE) Massachusetts Only" defines a Serious Reportable Event as an event that occurs on premises that results in an adverse patient outcome, is clearly identifiable and measurable, is usually or reasonably preventable and of a nature that the risk occurrence is significantly influenced by the policies and procedures of the hospital and indicates that the Chief Quality Officer will immediately initiate an investigation to determine the need to complete a Serious Incident Report to Massachusetts Department of Public Health any serious incident/accidents including death that is unanticipated.

Review of Patient #6's medical record indicated that Patient #6 was admitted in 3/2006 with a past medical history of bipolar disorder, hyperlipidemia, and traumatic brain injury. Nursing notes written on 8/8/19 indicated that Patient #6 was found unresponsive in his/her bed. A medical emergency (Code Blue) was activated and Patient #6 was transferred by Emergency Medical Services to an outside hospital at 10:34 A.M. on 8/8/19. Patient #6 was pronounced dead at the outside hospital 50 minutes after arrival in the Emergency Department.

The Surveyors interviewed the Chief Quality Officer on 8/14/19, at 8:30 A.M. The Chief Quality Officer said that he was aware of Patient #6's unexpected death on 8/8/19. The Chief Quality Officer said that Patient #6 was 50 years old and that the Hospital did not know the cause of death and did not perform an investigation of the incident. The Chief Quality Officer acknowledged that there was no ongoing quality assessment or performance improvement as a result of this incident and that there was no investigation which focused on quality indicators and reported to the Governing Body.

For Patient #12

2. The Hospital failed to investigate and analyze an adverse patient event and implement appropriate preventive actions when Patient #12 experienced an unexpected decline in condition resulting in a Code Blue and emergent transfer to an outside facility.

Review of Patient #12's medical record indicated that Patient #12 was a 37 year old who was admitted on 6/13/19, with a past medical history of substance abuse, sepsis, and septic arthritis of the the right shoulder.

Patient #12 was found unresponsive, face down on the floor next to the bathroom in Patient #12's room on 7/4/19 at 12:00 A.M. A Code Blue was activated and Patient #12 received two doses of 0.4 milligrams (mg) Naloxone ( an "opioid antagonist" used to counter the effects of opioid overdose) intravenously. Patient #12 awoke and was breathing spontaneously and had a pulse. Patient #12 was then emergently transferred to an outside medical facility.

The Hospital's Incident Report, signed by the Chief Medical Officer on 7/30/19 at 11:53 P.M., indicated that Patient #12 applied a Fentanyl Patch laced with heroin and that Patient #12 was acutely discharged to an outside facility. Review of Patient #12's Emergency Department Document (EDD) from the receiving facility indicated that Patient #12 arrived at the outside medical facility alert, verbal and oriented. The receiving facility's EDD indicated that Patient #12 stated to staff that he/she injected Fentanyl (an opioid pain medication) into his/her percutaneous peripherally inserted central catheter (PICC) which is inconsistent with the Hospital's Incident Report.

The Surveyors interviewed the Chief Quality Officer on 8/15/19, at 10:00 A.M. The Chief Quality Officer said that he was aware of Patient #12's overdose. The Chief Quality Officer said that Patient #12 overdosed with drugs brought from the outside and said Patient #12 used a patch to administer the drugs. The Chief Quality Officer said the Hospital did not perform an investigation of the incident or determine where Patient #12 obtained the drugs used in the overdose. The Chief Quality Officer acknowledged that there was no ongoing quality assessment or performance improvement as a result of this incident and that there was no investigation which focused on quality indicators and reported to the governing body.

Based on interviews and records reviewed the Hospital failed to 3 sampled patients (Patient #3, #5 ) out of twelve sampled patients and five non-sampled patients (NS#1, NS#2, NS#3, NS#4, & NS#5) with appropriate nursing personnel necessary to provide nursing care for patients on mechanical ventilation.

Findings include:

The Hospital policy titled Mechanical Ventilation, dated 8/2018, indicates that ventilator checks are performed and documented at a minimum of twice a 12 hour shift and with every ordered change. In the event of a ventilator alarm, an immediate response is to be initiated by the respiratory therapist. The patient will be directly observed and evaluated before resetting the alarm. In the event of a heater alarm, an immediate response is to be initiated by the respiratory therapist. The heater will be directly observed and evaluated. If the heater is malfunctioning, the heater will be replaced and tagged for service.

Review of Patient #3, #5, #11, NS#1, NS#2, NS#3, NS#4, and NS#5 medical records indicated that these patients required mechanical ventilation to provide life sustaining oxygenation.

Review of the staffing schedules for the LTAC unit dated 8/9/19 & 8/10/19, indicted that there were two nurses (Nurse #3 & Nurse #4) working from 7:00 P.M. until 7:00 A.M. A respiratory therapist was scheduled until 11:00 P.M. There was no respiratory therapist scheduled to work from 11:00 P.M. 8/9/19 until 7:00 A.M. 8/10/19.

Review of Nurse #3 and Nurse #4's personnel files indicated that there was no ventilator training or ventilator competencies completed by either nurse.

The Surveyors interviewed Nurse #3 on 8/20/19, at 11:55 A.M. Nurse #3 said that he/she had never received ventilator training. Nurse #3 said that if there is a problem with a ventilator he/she would calls a respiratory therapist because he/she does not know how to use the ventilator. Nurse #3 acknowledged that no required ventilator checks were performed during the overnight shift 8/9/19-8/10/19. Nurse #3 said I'll never forget that shift it was a nightmare, there was no respiratory therapist working on 8/9/19 overnight and he/she was praying there wasn't a problem.

Surveyors interviewed Nurse #4 on 8/21/19, at 10:40 A.M. Nurse #4 said that he/she had never received ventilator training. Nurse #4 said that when there is a problem with a ventilator, I ask for a respiratory therapist to help. Nurse #4 said that he/she remembers that on 8/9/19 overnight shift that there was no respiratory therapist scheduled. Nurse #4 acknowledged that no required ventilator checks were performed during the overnight shift 8/9/19-8/10/19. Nurse #4 said that he/she was uncomfortable not knowing what to do and he/she felt that it was unsafe staffing. Nurse #4 said that one of his/her patients was status post two days from a new tracheostomy placement and if you don't know how to tweak the ventilator settings, the patient can get into trouble quickly.

Based on observation, record review and interviews, the Hospital failed, for six (Patients #4, #6, #8, #9, #10 & #11) patients out of twelve sampled patients and five non-sampled patients, to provide wound care, skin assessments, and complete/implement patient care plans.

Findings include:

The Hospital policy titled Nursing Patient Care Plan, dated 05/2018, indicates that the patient care plan starts as soon as the patient is admitted to the hospital and is continually updated throughout the patient's stay, in response to the changes in the patient's condition and responses to the nursing interventions rendered. It documents all problem areas identified and is personalized for each individual patient. The plan of care will be initiated by a registered nurse (RN) after completion of the Admission Assessment. The Plan of Care will be reviewed each shift and updated with changes as necessary. Goals are stated for search patient.

The Hospital Policy titled Assessment-Reassessment Interdisciplinary Patient, dated 04/2018, indicated that a licensed qualified staff member assesses each patient's care needs throughout the patient's hospital stay and provides patient specific care at the time based on assessment data. The Nursing Department performs an admission assessment and records this in the patient medical record within 24 hours of admission. This assessment is based upon actual observation, patient/family interview, and patient medical records accompanying the patient from the referral facility. The RN admission assessment will include: Biophysical, Psychological, Cognitive Environment, Self-Care Needs Assessment, Wound Risk Assessment, Pain Fall Risk, and an Educational Needs Assessment.

The Hospital Policy titled Wound Assessment, dated 10/2018, indicated that an RN conducts a skin assessment on all patients upon admission, weekly, and with any significant changes. The skin assessment includes identification of major wounds present on admission (documentation must include location, etiology and worse tissue type of each wound). Major wounds include: Pressure, Arterial, Venous, Neuropathic/Diabetic, Surgical, Major Trauma, Lacerations, Malignant, Mixed Vascular, Burns, Atypical wounds. Wound Care RN completes an initial assessment of major wounds within the Admission Reference Date (admission + 2 calendar days).

For Patient #4

1. The Hospital failed to perform an initial wound assessment for five calendar days, failed to perform daily assessments including skin/wound assessments for two consecutive days, and failed to develop a Nursing Care Plan for Patient #4. Patient #4 was admitted on 8/13/19, with multiple diagnosis including cardiomyopathy (disease of the heart muscle) and a large abdominal wound with necrotizing fasciitis (a rare bacterial infection).

The document titled Nursing Admission Assessment indicated that the Integumentary Assessment (Skin/Wound Assessment) noted the skin was normal and the patient had a surgical bruise with serosanguinous drainage. The Nursing Admission Assessment failed to document tissue type, size, or Braden scale (predicts the risk of developing a hospital acquired pressure injury). Patient #4's chart did not contain a nursing care plan and there were no indications that a care plan was started or updated. There were no Daily Wound Treatment Flow Sheets in Patient #4's chart.

Review of Patient #4's daily nursing assessments indicated that the last assessment was completed on 8/15/19. The form in Patient #4's chart titled Daily Nursing Assessments was blank on 8/16/17 & 8/17/19.

Patient #4's first initial Wound Care Status Report indicates that the Wound Nurse did not perform an initial admission wound assessment until 8/18/19 (5 days after Patient #4 was admitted). The Wound Care Nurse documented that Patient #4 had three wounds (surgical wound lower abdomen, left lateral upper abdomen superior, and the left lateral abdomen interior).

The Surveyors interviewed Nursing Supervisor #1 on 8/19/19 at 11:45 A.M. and asked where nursing assessments including wound assessments are documented. Nursing Supervisor #1 said that wound assessments, dressing changes, and overall nursing assessments are found in the nursing chart on the Daily Nursing Assessment Form or the Daily Wound Treatment Flow Sheet. Nursing Supervisor #1 said that nurses are to complete these forms by the end of their shift on a daily basis.

The Surveyors interviewed Nursing Supervisor #2 at 11:23 A.M. on 8/20/19. Nursing Supervisor #2 said that she performed Patient #4's dressing change that morning and it was a very large wound requiring more than one nurse to provide the dressing change.

For Patient #10

2. The Hospital failed to perform an initial wound assessment for five calendar days and failed to develop a Nursing Care Plan for Patient #10.

Patient #10 was admitted on 8/13/19, with multiple diagnosis including an intra-abdominal abscess requiring a percutaneous drainage tube status post resection of the bowel, and wounds located on both heels, left knee, buttocks and sacral area.

Review of Patient #10's Daily Wound Treatment Flow Sheet and the Weekly Care Plan indicated that the forms were blank.

Patient #10's first initial Wound Care Status Report indicated that the Wound Nurse did not perform an initial admission wound assessment until 8/18/19 (5 days after Patient #10 was admitted). The Wound Care Nurse documented that Patient #10 had six wounds (surgical wound lower abdomen, surgical wound upper abdomen, sacrum coccyx, left buttock, lateral upper abdomen surgical drain site, and left anterior knee).

For Patient #11

3. The Hospital failed to document dressing changes on the Daily Wound Care Treatment Flow Sheet and failed to perform Daily Nursing Assessments including skin/wound assessments for two consecutive days for Patient #11.

Patient #11 was re-admitted (after multiple admissions) on 7/28/19. Patient #11 was admitted with multiple diagnosis which included ventilator dependence and wound to the back with a vacuum dressing.

Review of Patient #11's orders indicated that Patient 11's wound vac was to be changed Monday, Wednesday, and Friday starting 7/29/19. Review of Patient #11's Daily Wound Care Treatment Flow Sheet indicated that the wound vac was changed only two times (7/29/19, and 8/7/19).

Review of Patient #11's record indicated that the Daily Nursing Assessments dated 8/09/19 & 8/10/19 were blank.


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For Patient #8

4. The Hospital failed to complete the Admission Nursing Assessment, daily wound care assessments, care plans and two daily nursing assessments for Patient #8.

Patient #8 was admitted to the Hospital on 8/9/19 with diagnoses of clostridium difficile colitis (infection of the colon), pneumonia, respiratory failure and tracheotomy.

Record review for Patient #8 indicated that the only portion of the Admission Nursing Assessment that had any documentation was the Integumentary Assessment which indicated that Patient #8's skin was dry, warm and had no skin breakdown present.

Record review of the discharge paperwork from the previous hospitalization for Patient #8 did not indicate any skin breakdown or concerns.

Record review indicated the Hospital's History and Physical, completed by the physician and dated 8/10/19, did not identify any skin breakdown or concerns.

Record review indicated that, on 8/10/19 and 8/17/19, there was no documented Daily Nursing Assessment and there were no care plans created for Patient #8.

Record review indicated that, on 8/11/19, the Wound Nurse completed the Wound Care Status Report (wound care admission assessment) for Patient #8. The Wound Care Status Report indicated that the Patient had 2 wounds:

A. A sacrum and coccyx deep tissue injury which measured 8 centimeters by 6.5 centimeters. The Wound Nurse recommended silver sulfadiazine cream (a topical antimicrobial drug) treatment to be performed every shift, an air mattress, every two hour turning and repositioning and follow-up weekly.

B. Excoriation of the scrotum which measured 7 centimeters by 7.5 centimeters by 0.1 centimeters with scant bloody red drainage. The Wound Nurse recommended normal saline wash and silver sulfadiazine cream every shift, leave open to air and follow-up weekly.

Record review indicated that there was no further assessment of the wounds, no weekly follow up and that the Daily Wound Care Treatment Flow Sheet was never filled out. As of 8/21/19 the Wound Nurse had not done any follow-up assessments or measurements of the Patient #8's wounds.

The Surveyors interviewed Nursing Supervisor #1 at 12:20 P.M. on 8/15/19. Nursing Supervisor #1 said that the Admission Nursing Assessment should be completed on the day of the Patient's admission.

The Surveyors interviewed Nurse #1 at 1:10 P.M. on 8/19/19. Nurse #1 said that, due to staffing issues, documentation is incomplete at times. Nurse #1 said that patients need the help of multiple staff people at one time and this is very difficult when there isn't enough staff. Nurse #1 said that patients have to wait to be repositioned and cared for. Nurse #1 said that, on 8/19/19, there were six patients who required Hoyer lift transfer and not enough staff to support these needs. Nurse #1 said that nurses only did dressing changes on the patients when there is an order. Nurse #1 said that the Wound Nurse does all assessments and measurements and she comes in once a week.

For Patient #9

5. The Hospital failed to perform an initial wound assessment on Patient #9 for five calendar days, wound assessment follow-up, care plans and daily nursing notes.

Patient #9 was admitted to the Hospital on 7/31/19 with diagnoses of respiratory failure and left metatarsal amputation.

Record review indicated that the Nursing Admission Assessment was completed on the day of admission. The Integumentary Assessment indicated that there was a stage 2 coccyx wound, a tracheotomy wound, a gastric tube wound, a chest tube wound and amputated toe wounds. There were five wounds observed and documented upon Patient #9's admission. There were no measurements or a skin assessment to indicate further skin condition.

Record review indicated that, on 8/1/19, a Physician's History and Physical was completed and did not address evidence of /or treatment for the stage 2 coccyx ulcer or treatment of the left metatarsal amputation wounds.

Record review indicated that there were no Physician's Orders written in the Electronic Medication Administration Record to address treatment of the five wounds observed in the Nursing Admission Assessment on 7/31/19, 8/1/19, 8/2/19, 8/3/19 or 8/4/19.

Record review indicated that there was a Wound Care Treatment Flow Sheet created on 8/2/19 (two days after admission) for the coccyx wound that included wound care orders to wash with normal saline, followed by sliver sulfadiazine cream and Biatin to change every 12 hours and as needed. The record indicated that the treatment was only provided every 24 hours versus the order requiring every 12 hours on 8/2/19 and 8/3/19.

Record review indicated that the Treatment Administration Record, dated August 2019, had two treatments written on it. 1.) Second and third toes amputation areas normal saline wash followed by silver sulfadiazine cream followed by dry sterile dressing changed daily and as needed. 2.) Coccyx pressure wound that was now unstageable area normal saline wash followed by silver sulfadiazine cream change every 12 hours and as needed. The Treatment Administration Record indicated that dressing #1 was only done on 8/1/19 and 8/17/19. The Treatment Administration Record indicated that dressing #2 was changed on 8/1/19 during the 7:00 A.M. to 7:00 P.M. shift, 8/6/19 during the 7:00 P.M. to 7:00 A.M. shift and 8/17/19 during the 7:00 A.M. to 7:00 P.M. shift.

There were no documented treatments of any wounds identified by the nurses on 8/2/19, 8/3/19 or 8/4/19.

Record review indicated that, on 8/4/19, the Wound Nurse completed the Wound Care Status Report (wound care admission assessment) for Patient #9. The Wound Care Status Report indicated that the Patient had nine wounds.

Wound 1. Left distal foot second and third toe surgical amputation wounds which measured 3.2 centimeters by 4.3 centimeters by 0.7 centimeters with 50% yellow slough. The Wound Nurse recommended a normal saline wash, followed by Santyl cream (a sterile enzymatic debriding ointment), followed by gauze, followed by kerlix wrap daily and follow up weekly.

Wound 2. Sacrum/coccyx pressure ulcer which measured at 5.1 centimeters by 6.9 centimeters with no measurable depth. The wound had 100% yellow slough with surrounding deep tissue injury. The Wound Nurse recommended a normal saline wash followed by silver sulfadiazine cream, followed by foam dressing daily and follow-up weekly.

Wound 3. Right buttock pressure ulcer which measured at 3 centimeters by 2.7 centimeters with no measurable depth. The Wound Nurse recommended normal saline wash followed by silver sulfadiazine cream, followed by foam dressing daily and follow-up weekly.

Wound 4. Left lower buttock pressure ulcer which measured at 4.8 centimeters by 5.9 centimeters with no measurable depth. The Wound Nurse recommended normal saline wash followed by silver sulfadiazine cream followed by foam dressing daily.

Wound 5. Left anterior shin trauma wound which measured at 1.5 centimeters by 0.9 centimeters by 0.5 centimeters. The Wound Nurse recommended normal saline wash followed by Xerofoam daily (a type of medical dressing) and to follow-up weekly.

Wound 6. Right anterior shin trauma wound which measured 2.5 centimeters by 0.6 centimeters by 0.5 centimeters. The Wound Nurse recommended normal saline wash, followed by Xeroform, followed by foam daily.

Wound 7. Inferior/anterior trachea surgical wound with hypergranulation (an excess of granulation tissue) which measured 1 centimeter by 1.5 centimeters by 0.05 centimeters. The Wound Nurse recommended dry protective dressing daily and follow-up weekly.

Wound 8. Right upper chest and neck bruise which measured at 1.7 centimeters by 3 centimeters with no measurable depth. The Wound Nurse recommended tegaderm weekly and follow-up weekly.

Wound 9. Right flank chest tube site which measured at 0.8 centimeters by 0.4 centimeters with no measurable depth. The Wound Nurse recommended normal saline wash, followed by foam dressing daily and follow-up weekly.

As of 8/20/19 there were no nursing notes documented for measurement or follow up regarding any of the original five wounds documented on the Nursing Admission Assessment dated 7/31/19 and there was no weekly follow-up performed by the Wound Care Nurse since the Wound Care Status Report was completed on 8/4/19. There was no evidence of the origin of the additional four wounds identified by the Wound Nurse five days after Patient #9 was admitted to the Hospital.

Record review indicated that there were no care plans created for Patient #9.

Record Review indicated that on 8/9/19 and 8/10/19 there were no documented Daily Nursing Assessments performed for Patient #9 by the nursing staff.

The Surveyors interviewed Nursing Supervisor #1 at 10:35 A.M. on 8/19/19. Nursing Supervisor #1 said that the nurses do the dressing changes as ordered in the electronic medication administration record and do not perform the assessment and measurements. Nursing Supervisor #1 said that the Wound Nurse is responsible for the assessments and measurements of the wounds. Nursing supervisor #1 said that the Wound Nurse used to be in daily, but since an environmental emergency within the hospital in March of 2019, the Wound Nurse only comes in one day a week. Nursing Supervisor #1 said that daily nursing assessment documentation is very difficult to complete because of staffing concerns. Nursing Supervisor #1 said that the nursing staff does the best they can with what they have.

The Surveyors interviewed Nursing Supervisor #2 at 11:23 A.M. on 8/20/19. Nursing Supervisor #2 said that if a patient has a wound, the nurses should be documenting the wounds progress of healing on the Daily Wound Care Treatment Flow Sheets. Nursing Supervisor #2 said that documentation is very difficult because staffing is an issue.

The Surveyors interviewed the Chief Quality Officer at 12:05 P.M. on 8/20/19. The Chief Quality Officer said that the Wound Nurse only does the admission wound assessments and that it is the responsibility of the daily nursing staff to perform assessments. The Chief Quality Officer said that they need to teach the nursing staff to do the assessments.

The Surveyors interviewed the Wound Nurse at 10:20 A.M. on 8/21/19. The Wound Nurse said that she only comes in one day a week and she is there to do admission assessments. She does not have the capacity within her hours to do follow-up wound assessments and measurements. The Wound Nurse said that her position was a full time position, but in the last few months her work hours were changed to one day per week and there is no other Wound Nurse coverage in the Hospital.