HospitalInspections.org

Based on document review and interview, the nursing executive failed to ensure that nursing staff implemented the wound care policy related to the daily skin assessment documentation and in regard to following physician wound care orders for 3 of 10 patients, patients #1, #3 and #8.

Findings Include:
1. Review of the policy: Wound Care Protocol, policy number II - D.1, reviewed 5/2015, indicated in the "Policy" section, Any abnormality to be assessed, and reported to physician immediately. All wounds must be inspected and assessed by nursing daily. Nursing to solicit a complete set of wound care orders from medical staff. These should include applications, dressings, frequency, contact...and other changes as indicated.

2. Review of medical records indicated:
Pt. #1 had no skin issues noted on 11/6/15 per the nursing admission assessment, page 6. Future documentation indicated:
A. On 1/1/16, nursing wrote at 8:30 PM: family member...noticed...left elbow appeared with some marks that looked like rashes, bruises, or reacting to something...family thought it was a burn mark, but it looks different to staff...DON (director of nursing) to be informed. The Daily Nursing Record form for the night shift, in the "skin" section, had "Bruise" marked and "L elbow" written in.
B. The 1/2/16 day shift Daily Nursing Record form, in the skin section, had "Lesions" checked with "L elbow" written in.
C. On 1/2/16, nursing wrote at 9:00 AM: left elbows skinned. Pt stated [they] skinned it on arm rest of wheelchair.
D. The 1/2/16 night shift Daily Nursing Record form had nothing checked in the "skin" section of the document (for intact, turgor, warm, cold, clammy, dry, diaphoretic, pale , cyanotic, reddened, bruise, petechiae, scaly, rash, edema, lesions, wound).
E. The 1/3/16 day shift Daily Nursing Record form lacked documentation in the "skin" section of the document (for intact, turgor, warm, cold, clammy, dry, diaphoretic, pale , cyanotic, reddened, bruise, petechiae, scaly, rash, edema, lesions, wound).
F. The 1/8/16 night shift Daily Nursing Record form lacked documentation in the "skin" section of the document (for intact, turgor, warm, cold, clammy, dry, diaphoretic, pale , cyanotic, reddened, bruise, petechiae, scaly, rash, edema, lesions, wound).
G. The 1/9/2016 day shift Daily Nursing Record form had "intact" noted and "left inside
elbow scab healing" charted by nursing.
H. The 1/15/16 night shift Daily Nursing Record form lacked documentation in the "skin" section of the document (for intact, turgor, warm, cold, clammy, dry, diaphoretic, pale , cyanotic, reddened, bruise, petechiae, scaly, rash, edema, lesions, wound).

Pt. #3 was admitted on 12/23/15 with the nursing admission assessment documenting: Back - rough with dry patches; bilateral arms - dry with rough patches; scalp - flaking; bilateral groin and abdomen fold excoriation with peeling skin; L ankle shearing; L foot - great toe sore 1 cm x 2 cm, 2nd toe sore 0.25 cm x 1 cm; R foot - great toe 2.5 cm x 4 cm sore, 5th toe ulcer 2 cm x 4 cm; foot ulcer 6 cm x 8 cm, thick scaly skin to bottom of foot, top of foot excoriation with flaking 6 cm x 8 cm.; buttocks + excoriation with shearing; L hand - bruise to top - blue/green. Other documentation in the record included:
A. Practitioner orders on 12/25/15 were: To right inner aspect of rt (right) plantar foot cleansed with normal saline pat dry pack wound with ido-form gauze strips...cover with telfa...change daily and prn (as needed), Skin prep bilateral feet, apply skin prep to heels and outer aspect of feet q (every) shift and prn (as needed).
B. Review of the medical record for patient #3 indicated that nursing failed to document the once a day wound care at 9 AM on 1/12/16 and the q shift treatment on 1/9/16 and 1/10/16 for both shifts and the second shift treatment on 1/5/16, 1/7/16, and 1/12/16.
C. The day shift for 12/24/15 had documentation on the Daily Nursing Record form, in the "skin" section, that the skin was reddened and there was a "wound", but lacked the "Wound Report" form completion that was indicated.
D. The night shift for 12/25/15, 1/6/16, 1/12/16, and 1/24/16 had documentation on the Daily Nursing Record form, in the "skin" section, that the skin was reddened and there was a "wound", but lacked the "Wound Report" form completion that was indicated.
E. The day shift for 1/8/16 had no documentation in the "skin" section of the Daily Nursing Record form.

Pt. #8 had the nursing admission assessment completed on 1/19/16 with bruises and "scratches" noted plus a stage II wound to the sacral/gluteal area. Other documentation included:
A. Practitioner orders on 1/20/16 were for "Barrier cream bid (twice daily) coccyx".
B. Review of the medical record for patient #8 indicated that nursing failed to document the application of a barrier cream at 9 AM on 1/22/16 and 9 PM on 1/27/16.
C. Physician orders written on 1/31/16 were to "Cleanse wound to right gluteal area with NS (normal saline). Pat dry, apply bacitracin ointment...2 x a day...".
D. Per review of the medical record for Pt. #8, nursing failed to document the wound treatment for both the 9 AM and 9 PM times on 2/1/16, the 9 AM treatment on 2/2/16, and the 9 AM and 9 PM treatments on 2/3/16.
E. An order was written on 2/1/16 to "Apply Calmoseptine tid (three times/day) right gluteal to open area x 10 days".
F. Per review of the medical record for Pt. #8, nursing failed to document the application of Calmoseptine two times on 2/2/16 and all three times on 2/3/16 and 2/4/16.
G. The Daily Nursing Record form for the night shift of 1/31/16 had "wound" checked in the skin section but lacked a Wound Report form.
H. The day and night shift Daily Nursing Record forms for 2/5/16 had "intact" marked in the skin section of the form.
I. On 2/6/16, the day and night shifts marked "wound" on the Daily Nursing Record form, but did not complete a Wound Report form.
J. On 2/7/16, the day shift documented "intact" skin on the Daily Nursing Record form.

3. At 11:30 AM on 2/9/16, interview with the corporate compliance officer, staff member #50, confirmed that:
A. The current wound protocol/policy does not meet the needs of patients with skin care issues.
B. Nursing did not implement wound care orders for patients #3 and #8, as evidence by the lack of documentation on the MAR.
C. Nursing was not completing the Daily Nursing Record forms, in the "skin" area, either completely or appropriately.
D. Per the Daily Nursing Record form, if the patient has a "wound", a Wound Report form is to be completed, and nursing staff is not currently completing these forms.
E. The facility has no wound nurse, but one of the physicians has a specialty in wound care.
F. There was no documentation in the medical records for patients #1, #3, or #8 that the physician noted in 3. E. above was notified of patient wounds for consultation.