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Based on medical record review and interview, the facility failed to ensure nursing services administered and documented treatments for pressure injuries as ordered by the physician.

The findings included:

The facility failed to ensure the nurses administered and documented pressure injury treatments per the physician's orders. The patient's pressure injury deteriorated during the hospital stay. The lack of documentation that treatments were performed as ordered could not rule out the possibility that the deterioration was a result of the lack of treatments provided.

Refer to A392

Based on medical record review and interview, the nursing staff failed to provide documentation the patient's pressure injury treatments were performed as ordered by the physician for 1 of 3 (Patient #1) patients reviewed with pressure injuries.

Due to the failure of the staff to provide evidence they performed pressure injury treatments as ordered could not rule out the possibility that the deterioration of the pressure injury was caused by the lack of treatments provided to Patient #1.

The findings included:

Medical record review revealed Patient #1 was admitted to the hospital on 8/7/18 with diagnoses to include Acute and Chronic Respiratory Failure, Ventilator Support via Tracheostomy, Pressure Injuries to the Right and Left Buttocks.

The physician's order dated 8/7/18 documented, "...Apply Calmoseptine Cream [skin barrier ointment] to buttock BID [two times daily] and PRN [as needed]..."

The "Braden Scale for Predicting Pressure Sore Risk" form revealed Patient #1 was classified as below:
"Severe Risk" on 8/7/18.
"High Risk" on 8/14/18, 8/28/18, 9/4/18, 9/11/18, 9/18/18, and 9/25/18.
"Moderate Risk" on 8/21/18, 10/2/18, and 10/9/18.
"Mild Risk" on 10/16/18.

All pressure injury measurements were documented in centimeters (cm) as Length times (x) Width x Depth.
The pressure injury measurements and staging documented by the wound care nurse were as follows:
On 8/7/18 (admission date) and 8/14/18:
Right (R) buttock - 0.5 cm x 1.0 cm, unstageable (wound base not visible).
Left (L) buttock - 0.5 cm x 0.5 cm, unstageable.

On 8/21/18:
R buttock - 0.5 cm x 1.0 cm, unstageable.
L buttock - 0.8 cm x 1.0 cm, unstageable.
No new orders.

On 8/28/18:
R buttock - 3.0 cm x 3.0 cm, unstageable.
L buttock - 3.0 cm x 3.0 cm, unstageable.

A new physician's order dated 8/28/18 documented, "...[Named Fluid Immersion Simulation Therapy Surface]...Low aire loss...change position Q [every] 2 hours without exception...Calmoseptine sacral wound twice daily...No diapers..."

On 9/4/18:
Now appearing as 1 [one] pressure injury.
Buttock - 7.0 cm x 7.5 cm, unstageable.

A physician's progress note dated 9/4/18 documented, "plastic: wound is getting worse...supposed to change position Q 2 hr [hours] no change in tx [treatment] now."

No new orders were written until 9/10/18.
A physician's telephone order dated 9/10/18 documented, "D/C [discontinue] Calmoseptine to Buttock wound. Cleanse Buttock wound c [with] saline, pat dry, apply Medihoney [natural product that provides a moist wound environment] and cover c dry dressing. Change daily & [and] PRN [as needed].

On 9/11/18:
Buttock - 7.0 cm x 10.0 cm, unstageable.
No new orders.

On 9/17/18:
Buttock - 7.0 cm x 13.0 cm, unstageable.

A physician's telephone order dated 9/17/18 documented, "D/C Medihoney. Cleanse Buttock Wound c saline, pat dry, apply Iodoform gauze [a fabric that uses antimicrobial properties and absorbs drainage]. Cover c ABD [abdominal] pads [absorbs drainage] and secure c tape. Change daily & PRN..."

On 9/17/18:
Buttock - Debrided (Necrotic (black) tissue surgically removed.) Depth now 2.5 cm.

On 9/18/18:
Buttock - 7.0 cm x 13.0 cm x 2.5 cm, unstageable.
Undermining is 2.5 cm at 1p. (undermining is an injury that extends into the tissue under the skin) (looking at a clock, the undermining is at the 1 o'clock area on the pressure injury).

On 9/25/18 and 10/2/18:
Buttock - 7.0 cm x 13.0 cm x 2.5 cm, unstageable. Undermining is 2.0 cm. at 1p.

A physician's telephone order dated 9/26/18 documented, "D/C current tx [treatment] to Buttock. Cleanse buttock unstageable with saline, pat dry, apply Medihoney & moist Chlorpactin [a solution to clean and disinfect the skin, infected wounds, or burns] soaked gauze, then dry dressing. Change daily and PRN..."

On 10/9/18 and 10/16/18:
Buttock - 7.0 cm x 13.0 cm x 2.5 cm, unstageable. Undermining is 3.0 cm. at 11p.
A physician's order dated 10/17/18 documented, "Place Medihoney on necrotic areas on sacrum, apply V.A.C. [negative pressure wound therapy] 3 times a week..."

A telephone physician's order dated 10/18/18 documented, "Wound care orders for discharge: 1 Cleanse sacral/buttock wound c saline, pat dry, apply Medihoney to wound bed then place wound vac. Change q [every] M [Monday], W [Wednesday], F [Friday]...may cover with a dry dressing until Wound VAC is available..."

On 10/19/18 (day of discharge):
Buttock - 7.0 cm x 13.0 cm x 2.5 cm, unstageable. Undermining is 3.0 cm. at 11p.

The wound documentation record [treatment administration record] revealed Patient #1 did not receive pressure injury treatments as ordered by the physician. There was no documentation Patient #1 received pressure injury treatments on the following dates:
8/8/18, 8/10/18, 8/12/18 through 8/21/18.
8/23/18, 8/24/18, 8/26/18, 8/28/18, 8/29/18, 9/1/18, 9/4/18 through 9/7/18.
9/10/18, 9/12/18 through 9/14/18, 9/24/18, 9/25/18, 9/27/18, 10/3/18 through 10/5/18.
10/8/18, 10/9/18, 10/15/18, and 10/18/18.
On 10/19/18 the patient was transferred to a LTC facility.

Telephone interview with Patient #1's family member (Complainant) on 10/29/18 at 10:32 AM, the Complainant stated that Patient #1 was neglected during his admission at this facility. The Complainant stated that he did not have a pressure injury upon admission but during his stay he got a pressure injury as big as "a basketball."

Interview with RN #1 (Wound Care Nurse) on 10/29/18 beginning at 11:00 AM, she was asked about Named Patient #1's wounds beginning with his admission. RN #1 stated that he came in with 2 unstageable wounds on each buttock and they deteriorated and the treatment changed as the wound deteriorated. He was on a low air loss mattress from the beginning."

RN #1 was asked if family visited. RN #1 stated, "She was here a lot of the time and would watch wound care. She always would think the wound was worse. RN #1 was asked if the physician would see the wounds. RN #1 stated, "[Named Physician], a plastic surgeon comes in 2-3 times a week. He sees the majority of wounds and makes treatment order changes...Between 8/28/18 and 9/4/18, the wound deteriorated."
RN #1 was asked who does the wound care on the patients. RN #1 stated, "The nurses did the treatments, the nurses did not notify me of the wound deterioration. On 9/4/18, it was larger and eschar [black hard dead tissue] was present...On 9/4/18 [Named Plastic Surgeon] was still using barrier cream. He wrote no changes for now. On the 10th of September, I wrote to d/c the Calmoseptine and start Medihoney with a dry dressing. [Named Plastic Surgeon] did not sign the order as of 10/29/18, but he will." RN #1 was asked if she had any concerns using Medihoney on an unstageable wound with eschar. She stated, "No, Medihoney is an autodebridement."

Interview with the Chief Nursing Officer (CNO) on 10/29/18 at 1:15 PM, the CNO was asked what she expected the nursing staff to do after they provide wound treatments. The CNO stated, "I would expect the nurses to document per the wound care orders..."