Saint Mary Home

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility documentation and policy, interviews for one (1) of three (3) residents (Resident #1) reviewed for wounds, the facility failed to ensure the clinical record was complete and accurate to include documentation of a physician order for wound care.

The findings included:Resident #1 had diagnoses which included an unspecified wound, and local infection of the skin, subcutaneous tissue.

Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition.

Review of the RCP dated 8/20/2025 identified Resident #1 had an open wound/impaired skin integrity to the left lower extremity.

Interventions directed to apply treatment: wound vac on Mondays/Wednesdays/Fridays. A physician's order dated 8/31/2025 directed to apply a wound vac at a low, continuous suction of 125 millimeters.

Review of a nurse's note dated 9/1/2025 at 12:34 AM identified Resident #1's wound vac was malfunctioning.

The Infectious Disease Nurse and Med Essentials Representative (provider for the wound vac) were notified, and that staff were advised to apply a wet to dry dressing until the morning when a new wound vac would be delivered.

Record review failed to identify a physician's order dated 8/31/2025 that directed a wet to dry dressing until the morning when a new wound vac would be delivered.

Interview with APRN #1 on 10/6/2025 at 1:08 PM identified that he/she was aware the wound vac had malfunctioned.

APRN #1 further identified that an order for wet to dry dressing changes was not provided as it was the facility protocol to perform a wet to dry dressing changes until a new wound vac was received and that he/she agreed with the protocol.

Interview with the Director of Nurses (DON #2) on 10/6/2025 at 2:25 PM identified the facility did not have a facility policy/protocol that directed staff what to do when a wound vac malfunctioned. DON #2 stated staff was trained to follow the [NAME] Nursing Procedure and Skills Guidelines, which directed wet to dry dressing changes when a wound vac malfunctioned.

Although APRN #1 was notified of the malfunctioning wound vac on 8/31/2025, and per the nursing note the APRN directed use of a wet to dry dressing, DON #2 was unable to provide documentation that a physician order was entered into the medical record. DON #2 stated she thought referring to [NAME] Guidelines was sufficient.

Review of the Physician Services policy dated 11/1/2019 directed each resident must remain under the care of a physician and that a physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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