Rehab & Critical Care Hospital of the Black Hills

“PROVIDING ADEQUATE RESOURCES CFR(s): 482.21(e)(4) [The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following:] (4) That adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and reducing risk to patients. This Standard is not met as evidenced by: 40788 Based on South Dakota Department of Health (SD DOH) complaint, record review, interview, and policy review, the provider failed to ensure an effective, quality assurance and performance improvement (QAPI) program was implemented to track and measure performance; systematically analyze underlying causes of a systemic quality deficiency; develop and implement corrective actions or performance improvement activities; and evaluate the effectiveness of the corrective actions, and to revise those actions as needed. Findings include: 1. Review of a 3/16/26 SD DOH complaint revealed patient 1 was reported by the complainant to have a large build-up of thick secretions stuck to the roof of his mouth, tongue, and throat. The complainant was concerned that the patient was not provided oral care “for quite some time.” 2. Review of patient 1’s closed electronic medical record (EMR) revealed he was admitted to the facility on 12/24/25 for ventilator (a medical machine that pumps breathable air into and out of the lungs for patients unable to breathe when they are unable to do so for themselves) weaning and neurological (brain) recovery. His diagnoses included alcoholic cirrhosis (permanent scarring of the liver), polysubstance use (methamphetamine and marijuana), and a seizure disorder. His Glasgow Coma Scale (a tool used to measure a person’s level of consciousness and severity of acute brain injury) score was six. That was indicative of a severe traumatic brain injury and coma. Patient 1 had a tracheostomy (a surgically created opening in the neck that leads into the windpipe) placed on 12/9/25 and a percutaneious endoscopic gastrostomy (PEG) tube (a tube surgically placed through the abdomen into the stomach to administer liquid nutrition, fluids and medications) placed in November 2025. Patient 1 was discharged to an acute care hospital on 2/24/26 and was not re-admitted to the facility. 3. Interview and EMR review on 5/13/26 at 8:38 a.m. with director of quality/risk management (DOQ/RM) A regarding patient 1’s 2/19/26 through 2/24/26 oral care documentation revealed patient 1 refused to have oral care provided by the staff on 2/19/26 at 1:00 p.m. There was no other documented oral care on that day. No oral care was documented on 2/20/26, 2/21/26, 2/22/26, and 2/24/26. On 2/23/26, oral care was documented as having been provided four times, but there was no documentation to support when that care was provided. In November 2025, the facility’s leadership team identified, through EMR audits, an opportunity to improve staff’s provision and documentation of patients’ activities of daily living (ADL), including oral care. During the week of 12/1/25 through 12/5/25, the staff were educated regarding oral care expectations. Details of that education indicated, “Oral care is vital for tracheostomy patients to prevent infections, reduce the risk of pneumonia, and improve comfort and well-being. With a tracheostomy, normal oral functions are disrupted, leading to a build-up of bacteria and secretions that can be aspirated into the lungs, potentially causing serious infections.” DOQ/RM A referred to improving patients’ oral care as an “initiative.” In January 2026, chief clinical officer (CCO) B assigned infection preventionist (IP) H the task of collecting and analyzing data (audits) related to that initiative. IP H was selected for that task because of the relationship between good oral care and a lowered risk for oral infections and systemic conditions. 4. Interview on 5/13/26 at 10:45 a.m. with DOQ/RM A and review of IP H’s oral care audits revealed there were three Oral Care Audit Tool forms that were dated 3/26/26, 4/13/26, and 4/30/26. There was no oral care data documented on those audit tools. DOQ/RM A stated this was the first time she had seen those audit tools. Without audit data, no analysis or recommendations could be made to improve the provision and documentation of patients’ oral care. DOQ/RM A stated a “change in leadership oversight” was the root cause of that quality assurance (QA) process failure. 5. Interview on 5/13/26 at 2:00 p.m. with IP H revealed she had “every intention” of initiating oral care audits as soon as that task was assigned to her, but that had not happened because of a “lack of time.” Until recently, IP H was also responsible for staff education. IP H had told “several managers” that she was unable to complete the audits. 6. Interview on 5/13/26 at 2:15 p.m. with CCO B revealed her hire date was 1/20/26. In March 2026, she instructed IP H to initiate oral care audits. She met with IP H weekly or bi-weekly, but she did not ask to review any of IP H’s oral care audits. Until 5/13/26, CCO B did not know that no oral care audits were initiated. CCO B stated “The ball was dropped.” She acknowledged that no progress related to the oral care initiative first identified by the facility’s leadership team in November 2025 was made. 7. Review of patient 2’s EMR revealed his medical diagnoses, physical, and cognitive limitations were similar to patient 1’s. Patient 2’s diagnoses included: a head bleed, coma, and respiratory failure. He was receiving ventilator support and cardiac monitoring. He received his nutrition through a PEG tube. 8. Interview and EMR review on 5/13/26 at 5:00 p.m. with DOQ/RM A regarding patient 2’s 5/6/26 through 5/13/26 oral care documentation revealed that on 5/6/26, 5/7/26, and 5/8/26, there was no documentation to support patient 2 was provided oral care. Oral care documentation between 5/9/26 and 5/13/26 was identified as having occurred between one and four times on those days. Oral care documentation on 5/11/26, 5/12/26, and 5/13/26 failed to include the times when the documented oral care was provided. DOQ/RM A acknowledged that based on the above oral care documentation for patient 2, the provision and documentation of patients oral care remained unchanged for successive months and was still a problem. She stated that an effective QA process had the potential to positively impact patients’ oral care if that QA process was effectively implemented, but that did not occur. 9. Review of the provider’s 2026 Performance Improvement Plan revealed the QAPI committee’s responsibilities included, “Promoting a hospital culture that values commitment to continuous improvement in safety, quality care, and services to patients, families, visitors, community, medical and hospital staff.” “Monitoring the progress of quality control activities and of designated project teams.” “Evaluating the effectiveness of action taken to improve a process.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 40788 Based on a 3/16/26 South Dakota Department of Health (SD DOH) complaint, observation, record review, interview, and policy review, the provider failed to ensure interdisciplinary communication and follow-up occurred regarding one of one closed record sampled patient’s (1) oral health status, and that one of one closed record sampled patient’s (1) skin conditions were reported to and followed up by the provider’s in-house wound care consultants. Findings include: 1. Review of a 3/16/26 SD DOH complaint revealed photographs dated 2/24/26 accompanied that complaint. One photo showed patient 1’s mouth open. Inside of it, there was white, tan, and black-colored exudate (accumulated mucous secretions) located on the upper right side of the roof of his hard palate. That exudate covered about half of his palate. The second photo showed four to five pieces of that same exudate that were removed from his oral cavity. 2. Review patient 1’s closed EMR revealed he was admitted to the facility on 12/24/25 for ventilator (a medical machine that pumps breathable air into and out of the lungs for patients unable to breathe when they are unable to do so for themselves) weaning and neurological (brain) recovery. His diagnoses included alcoholic cirrhosis (permanent scarring of the liver), polysubstance use (methamphetamine and marijuana), and a seizure disorder. His Glasgow Coma Scale (a tool used to measure a person’s level of consciousness and severity of acute brain injury) score was six. That was indicative of a severe traumatic brain injury and coma. Patient 1 had a tracheostomy (a surgically created opening in the neck that leads into the windpipe) placed on 12/9/25 and a percutaneous endoscopic gastrostomy (PEG) tube (a tube surgically placed through the abdomen into the stomach to administer liquid nutrition, fluids and medications) placed in November 2025. Patient 1 was transferred to a local acute care hospital on 2/24/26 for treatment of a peri-rectal abscess (a pus-filled cavity located around the rectum and anal canal) and pneumonia. Patient 1 did not return to the facility after that acute care hospital stay. 3. Review of respiratory therapist (RT) N’s 2/1/26 RT Treatment Record note regarding patient 1’s RT treatment revealed, “Pt [patient] tolerated oral care moderately well. Discovered extensive oral/dental issues in pt mouth, alerted RN [O]. Worked with RN [O] and RT supervisor [RT manager D] to help clean pt mouth.” Interview and EMR review on 5/12/26 at 11:00 a.m., 2:00 p.m., and 3:45 p.m. with RT C and RT manager D revealed that along with the nursing staff, they provided patient 1’s oral care while he was a patient at the facility. A foam-tipped Q-tip and moisturizer were used to provide that care. Oral care also included suctioning of the patient’s oral cavity as needed. RT C and RT manager D stated that patient 1 had rotting and missing teeth. His remaining teeth looked like “shards.” At times, touching patient 1’s gums with the foam swab caused his gums to bleed. He could not manage his secretions by swallowing, so it was not uncommon to find a moderate to heavy amount of mucous accumulation in his mouth. Patient 1’s mouth was “always open” and his oral cavity was dry. Humidity was added to the patient’s oxygen to mitigate that dryness. He was a “clencher” (closed his mouth) during oral cares. A “bite block” (device attached to the teeth to prevent the upper and lower teeth from fully touching) was not able to be used with patient 1 due to his poor dentition. Regarding the above RT Treatment Record note, RT manager D said that in February 2026 while she was training RT N to perform patient 1’s oral care, an accumulation of dried blood and mucous was noticed on the patient’s back molars. When that area was swabbed to clean it, heavy bleeding from that area occurred. Due to a concern for the patient aspirating that blood (inhaling the blood into his lungs), the swabbing was stopped. Registered nurse (RN) O was made aware of the RTs’ findings. RN O stated she would notify patient 1’s physician of their concern regarding patient 1’s oral care status. 4. Review of RN O’s 2/2/26 nurse progress note regarding patient 1 revealed, “Upon completion of oral cares, a large mass of black substance was noted stuck to the roof of the patient’s [1] mouth. Some of his teeth were noted to be cracked, and some with scabs that when trying to complete oral care started bleeding. RT [RT manager D] was able to get the bleeding to stop by holding pressure. RN [O] will pass this off to dayshift in report who can notify attending MD [contracted travel physician M].” There were no nurse progress notes after RN O’s 2/2/26 progress note that indicated contracted travel physician M was notified about patient 1’s oral care concern. Review of contracted travel physician M’s 2/2/26 progress note revealed no mention of patient 1’s oral condition. Contracted travel physician M was no longer on staff at the facility. 5. Interview and EMR review on 5/13/26 at 11:57 a.m. with director of quality/risk management (DOQ/RM) A revealed she acknowledged there was no documentation to support communication between RN O and the unidentified day shift nurse or communication between the unidentified day shift nurse and contracted travel physician M regarding patient 1’s oral condition on 2/1/26, but there should have been. 6. Review of speech language pathologist (SLP) E’s 2/17/26 progress note regarding patient 1 revealed, “First part of session spent completing oral cares. Attempted oral cares; given severity and pt cooperation (i.e. intermittently closing mouth), unable to dislodge a significant amount of secretions. Did not trial PO [oral] intake due to this. Recommend oral cares at least once an hour to dislodge secretions.” 7. Interview on 5/12/26 at 3:00 p.m. with SLP E and director of rehab services (DRS) F regarding the above progress note revealed SLP E identified a “good amount” of build-up that covered “half of patient 1’s palate” during that treatment session. She could not remove the build-up using water, toothettes, and suction. She notified a nurse about her treatment session findings. SLP E could not remember the name of the nurse she reported her findings to. 8. Interview, EMR review, and policy review on 5/13/26 at 12:00 p.m. with DOQ/RM A revealed there was no documentation to support a nurse acknowledged SLP E’s reported concern regarding patient 1’s oral condition or that contracted travel physician M was made aware of that SLP’s concern either. Observed changes or concerns related to a patients’ condition that were reported to the nursing staff were expected to be acknowledged in their progress notes and a notification of those findings were to be reported to the patient’s physician. The physician’s response to that notification was expected to be documented by the nursing staff in the patient’s EMR. DOQ/RM A indicated that an accumulation of build-up inside a patient’s oral cavity that was unable to easily be removed was also applicable to the expectation outlined in the provider’s revised March 2022 Oral Care policy, “Report suspicious appearing lesions to the care team and document.” 42558 9. Review of patient 1’s EMR revealed his 2/24/26 Braden skin risk assessment scale was a 10, which indicated he was at a high risk for skin breaking down. His nursing skin assessments and wound care consultation documentation from 1/7/26 through 2/24/26 indicated there was an initial admission nursing skin assessment completed by contracted travel RN J, dated 1/7/26 at 4:50 p.m., that there was a skin tear to patient 1’s back and to his coccyx (tailbone). Patient 1 had a left shoulder skin shearing (occurs when the outer layers of skin stick to a surface while the body’s underlying bones and deeper tissues shift in the opposite direction, frequently leading to deep tissue injuries or skin tears), a small slit to his coccyx, a gastrostomy tube opening, and a tracheostomy opening. On 1/8/26 at 8:00 a.m., there was an order placed by contracted travel physician M for a wound care consult to “Evaluate and treat pressure injuries to left shoulder and possible sacrum.” On 1/8/26 at 1:30 p.m., licensed practical nurse (LPN)/ wound care nurse L documented, “Patient was seen by WCT [wound care team]. Lft [left] shoulder and coccyx was assessed for wounds. No open wounds at this time. Areas cleansed with NS [normal saline] and 4x4 [four-inch by four-inch gauze dressing]. Blue Barrier Cream applied. Sacrum Optifoam [adherent foam dressing] applied to coccyx and 3x3 [three-inch by three-inch] Optifoam applied to on Lft shoulder for protection. Will continue to monitor.” On 1/9/26 at 7:37 a.m., the wound care director, RN K, documented “Wound type: None” and “Patient seen by WCT nurse, [LPN/wound care nurse L]. Reported no skin break down. No trach issues, per RT.” A 1/9/26 nursing skin assessment at 5:22 p.m. indicated that patient 1 had a skin tear to his back and to his coccyx. Calmoseptine (a multipurpose moisture barrier) ointment was applied. He had serosanguineous (a thin watery fluid with a pink hue due to red blood cells mixed in the fluid) drainage from his head, and a Mepilex (adherent foam dressing) was applied. He had bloody whitish bleeding from a penile wart and pink skin irritation to his groin. There was no documentation provided to support that the wound care consultants were notified of these findings. A 2/9/26 nursing skin assessment at 12:14 a.m. indicated that patient 1 continued to have a skin tear to his back and his coccyx that was pink with no drainage. It also revealed he continued to have a skin tear on his head with serosanguineous drainage. There was no documentation provided to support that the wound care consultants were notified, or if any treatment to his head wound was provided. On 2/17/26, there was a care plan entry for patient 1 that stated, “Alteration in Skin integrity related to identified pressure injury.” It did not identify the pressure injury location or the treatment provided, other than to “prevent, assess, and treat wounds for signs or symptoms of infection per physician order.” A 2/18/26 nurse’s note written at 6:50 p.m. revealed, “...Pt [patient] up to wc [wheelchair] this afternoon. Had 2 BMs [bowel movements], buttocks unfortunately was excoriated and bleeding upon putting back to bed. Calmoseptine applied and pt placed on side. Coccyx remains pink and blanchable [skin that temporarily turns white or pale when pressure is applied, and quickly returns to its normal color when pressure is released, which shows normal blood flow]...” There was no documentation provided to support that the wound care consultants or the physicians were notified of these findings. A 2/21/26 nursing skin assessment at 7:19 a.m. indicated that patient 1 continued to have a scabbed area on his head, a red penile wart, red right and left buttocks, and a red scrotum that was attributed to moisture-associated dermatitis (MAD). At 8:29 p.m., the nurse documented that patient 1 had a coccyx wound that was pink with no drainage and blanchable redness. The 2/22/26 nursing skin assessments revealed the same findings as from 2/21/26. A 2/23/26 nursing skin assessment at 3:28 p.m. indicated that patient 1 continued to have a scabbed area on his head, a red penile wart, and a pink scrotum attributed to MAD. A 2/24/26 nursing skin assessment at 11:22 a.m. indicated that patient 1 had a Braden skin risk assessment completed with a score of 10, which indicated his skin had a high risk for breaking down. Patient 1 continued to have a pink coccyx and pink buttocks with blanchable skin, along with a red, dry, and intact scab on his head, and a penile wart that was having whitish bleeding. Patient 1 was transferred to a local hospital on 2/24/26 and was admitted for an enlarging perirectal abscess, fever, and a left lower lobe lung infiltrate. 10. Interview and EMR review on 5/13/26 at 8:00 a.m. with wound care director K, revealed the nurses perform a skin assessment on all patient admissions, which is called “4 eyes within 4 hours”. She stated, “Generally, wound care also tries to put eyes on new patients.” She was notified of all patients’ pressure or wound concerns, and if there was a wound concern, she would be notified by the nursing staff, who placed a computer order for a wound care consult. She could not recall viewing patient 1’s skin during his last patient stay. When reviewing patient 1’s EMR, she found that on his 1/7/26 admission, it was documented that he had a skin tear to his back and to his coccyx. She stated that the corporation’s IT (information technology) staff were asked to program a “freehand” area in the wound assessment for the nurses to provide a more accurate picture of the patient’s wound description. She identified that on 2/8/26, the nurse’s documentation indicated he had a “pink” area on his head, and that there were no specifics in the documentation to show the exact location. She acknowledged that in reviewing the last skin assessment the nurses performed on 2/24/26, which was provided to the transferring hospital, he had skin alterations to his buttocks, head, and penis. She stated all were marked as “without drainage.” The back of his head was marked as “red.” She stated the computer program for the wound assessment did not have an option to document what type of redness the wound was, if there was scabbing, or just skin color. The surveyors asked wound care director K to provide all their wound care consults, treatments, and communications that were conducted for patient 1 during the above time periods. She indicated she was not made aware of any open areas on patient 1. 11. Interview on 5/13/26 at 9:50 a.m., with wound care director K stated that LPN/wound care nurse L had seen patient 1, and she would get us documentation of all their wound care consults, treatments, and communications conducted for patient 1. She stated, “She [LPN/wound care nurse L] said he had no wounds.” 12. Interview on 5/13/26 at 10:00 a.m., with wound care director K revealed the staff were having IT issues and were unable to print their wound care consult information. She further stated, “The nurses are pretty ‘on it’ [about ordering a wound care consult] if [skin] issues are identified. I know they were trying a neck pillow and then a towel to relieve the pressure on his head.” She stated that patient 1 also had a two-hour turning schedule, a low-air-loss mattress, and his heels were elevated off the bed. She verified that all care staff, including contracted travel agency staff, were trained by her in ordering a wound care consult if patient skin concerns were identified. 13. Interview on 5/13/26 at 10:20 a.m. and at 1:10 p.m. with LPN/wound care nurse L revealed she had conducted a head-to-toe skin assessment on patient 1 on 1/8/26. Patient 1 had pressure-related redness on one of his shoulders from resting on it, and on his buttocks, and they were monitoring him for skin breakdown. She stated that patient 1 was on a two-hour turning program, and the nurses had requested an order for Calmoseptine barrier cream from the doctor. Patient 1 had no open areas when she conducted her initial wound consultation on 1/8/2026, and she did not recall seeing him at any other time during that stay. She would occasionally “take a peek” at him during cares, but she did not document those visits. She stated, “He [patient 1] had no wounds.” He had a tracheostomy and a PEG tube and stated, “He would often pull out his trach [tracheostomy]; we had to send him to the local hospital several times because he would pull it out.” She denied having any knowledge of him having any open areas up until the day he was transferred back to the hospital on 2/24/26. Her head-to-toe skin assessments were conducted by looking at a patient’s heels, back of legs, back, elbows, head, neck, and ears. “Basically, anything that touches a mattress.” The nursing staff would report to wound care if there was a patient’s skin issue identified. The wound care notification process was that the nursing staff would fill out a paper sheet and put it under the wound care director’s office door. She took those papers every morning and did her assessments and treatments based on the papers. The nursing staff would sometimes verbally tell her if a patient had a skin tear, but they were expected to fill out the paper notifications. If a Mepilex dressing was applied to a patient’s skin alteration by the nursing staff, the expectation would be that wound care, along with nursing, would look at it 2-3 times a week. She expected to be informed by the nursing staff about a Mepilex dressing application so they could follow up on it. She had visually inspected patient 1’s skin, and he had no skin issues. When shown the nurse’s documentation of his skin issues, she claimed she did not know of those issues. She stated that patient 1 had no skin issues up until the day of his discharge from the facility on 2/24/26. 14. On 5/14/26, at 8:25 a.m., a request was made to DOQ/RM A to provide a copy of any documentation related to the 2/17/26 care plan entry of a pressure injury and any wound care consultation notes on patient 1. 15. Interview on 5/14/26 at 9:45 a.m., with DOQ/RM A revealed she was unable to locate any other documentation from the wound care consultants other than the initial consultation on 1/8/26, and that was discontinued on 1/9/26. She was unable to locate any physician notifications of patient 1’s worsening skin conditions or any treatment orders. 16. Interview on 5/13/26 at 2:00 p.m. with RN I revealed that she was a travel nurse who was on her second assignment at this facility. She stated that she vaguely recalled patient 1. She remembered there was some type of skin alteration to the back of his head, and the family had asked that his head and face be shaved. She could not recall if the family or staff performed the shaving. She could not recall any time frames for the above statements. The normal process when an open skin wound was identified was to apply appropriate dressings and to notify wound care for a consultation. 17. Interview on 5/13/26 at 2:10 p.m. with contracted travel RN J revealed that she recalled patient 1, and his health was poor. She conducted patient 1’s admission skin assessment on 1/7/26. He had two skin tears, one to his mid-back and one to his coccyx. She could not recall the exact measurements of the skin tears or what treatment was provided. She could not recall whether she had notified wound care for a consultation, but she thought skin tears were not considered a wound. She was educated by wound care director K upon her initial shift about seeking a wound care consultation for any wound concerns. 18. Interview and EMR review on 5/13/26 at 2:30 p.m., and at 2:50 p.m., with wound care director K regarding patient 1’s skin tears revealed that the nurses have a skin care algorithm that they follow for skin tears. She stated that a wound care consultation only needs to be notified if there are issues of concern, such as infection, pressure ulcer (PU, localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence caused by prolonged pressure, friction, or shear), or worsening skin conditions. She stated they do not need to be notified of minor skin tear issues. Wound care director K found nursing documentation that there was a scab to patient 1’s back of the head initially documented by the nursing staff on 2/21/26 and that it was monitored by the nurses up until his last day at the facility. The last entry on 2/24/26 stated it was “red.” Copies of those nursing assessments were provided. She also stated that BWAT (Bates-Jensen Wound assessments/treatments) were for pressure ulcers only. A copy of patient 1’s Braden skin assessment was requested and provided. 19. Interview and EMR review on 5/13/26 at 3:20 p.m. with chief clinical officer (CCO) B, revealed that she was responsible for the direct oversight of all nursing services provided to the patients. She started her position at the end of January 2026 and spent the first few weeks focused on the clinical components and training. She started nursing oversight sometime in mid-February, into March of 2026. She could not recall patient 1. She stated that any skin wounds, including skin tears, should have had a wound care consult. However, if the nurses had not identified any skin issues on the initial admission skin assessment, a wound care consult would not have been initiated. Upon review of patient 1’s nursing skin assessments during his stay at the facility, she confirmed his skin issues had worsened and that wound care should have been following his care. She stated, “We have 34 patients and two wound care consultants. There is no reason they can’t look at all the patients.” 20. Interview on 5/13/26 at 4:15 p.m. with CCO B and DOQ/RM A. CCO B stated she had reviewed the provider’s wound care policy and verified that wound care should be consulted for all skin conditions. 21. Interview on 5/14/26 at 9:56 a.m. with the DOQ/RM A regarding patient 1, revealed that she had identified, during the surveyor’s investigations and requests for documentation, that there was a breakdown in communication and documentation of skin alterations between the nursing staff and the wound care consultants. 22. Review of the provider’s undated Skin Tear Algorithm revealed there was no direction on when to notify the wound care consultants. 23. Review of the provider’s March 2020 Wound Care Coordinator job description revealed responsibilities for “The provision of care includes direct care along with the delegation and supervision of all wound, ostomy [surgically created opening in the abdomen that allows stool or urine to exit the body when natural function is impaired], and incontinence [involuntary leakage of bowel and bladder] care.” 24. Review of the provider’s October 2025 Skin Integrity and Pressure Injury Prevention policy revealed that clinical staff were responsible for completing the new admission skin and wound assessments, monitoring ongoing skin integrity assessments, and consulting with the Medical or Clinical Director of the Wound Care Program, along with the completion of documentation requirements. Licensed nurses were responsible for notifying the Wound Care specialist if new skin/wound problems were found during their daily skin integrity checks. Nursing assistants were responsible for promptly communicating any change in skin integrity to the licensed nurse. 25. Review of the provider’s April 2026 Wound Care Assessment and Reassessment policy revealed that all care staff were to initiate a review when a wound was identified or demonstrated a change in condition. They were to notify appropriate team members, including the primary nurse, wound care nurse, and leadership, as indicated. They were to ensure documentation of date, time, and circumstances of identification.”