HospitalInspections.org

Based on review of documentation in 2 of 2 medical records (Patients 1 and 2), review of policies and procedures and interview, it was determined the hospital failed to implement policies and procedures related to skin/wound care, including an initial skin condition and head to toe assessment upon admission to the inpatient unit. A wound/skin assessment was not completed on Patient 1 during his/her hospitalization as required by the hospital's policy.

Findings Include:

1. The medical record of Patient 1 was reviewed with the APS on 08/29/2018 at 1358. The record reflected the patient presented to the ED on 06/19/2018 at 2014 with "sepsis/end of life care" and was admitted to unit 5NW on 06/16/2019 at 2350. The medical record lacked documentation that the RLE dressing was ever removed and the wound assessed per hospital policy. The charting reflected:
* RN flow sheet dated "06/20/18" at 1430 reflected "Wound-UTA, covered with drsg."
* RN flow sheet dated "06/20/18" at 2018 reflected "drsg."
* RN flow sheet dated "06/21/18" at 0739 reflected "UTA."
On 06/21/2018 at 0926 the charting reflected that the patient expired and an open wound with a "copious amount of large maggots" on his/her RLE had been discovered while the patient was being put into a body bag.

2. The medical record for Patient 2 was reviewed with the APS on 08/29/2018 at 1513. The record reflected the patient was admitted to the ICU on 05/02/2019 at 1610 with an admitting diagnosis of "SOB." The documentation reflected he/she was repositioned using the following terms: "tilting to one side or the other, up in chair, ambulating or at a test/procedure." The documentation reflected some gaps in the patients chart, for example:
* VS ADLs flow sheet dated "05/04/18" at 0033 reflected the patient was positioned onto his/her back.
* VS ADLs flow sheet dated "05/04/18" at 0129 reflected the patient refused to be re-positioned.
* VS ADLs flow sheet dated "05/04/18" at 0316 reflected he/she refused repositioning again.
* VS ADLs flow sheet dated "05/04/18" at 0418 reflected the patient was tilted to the right side after being on his/her back for over 3 hours.
* VS ADLs flow sheet dated "05/04/18" at 0546 reflected the patient requested to be on his/her back.
* VS ADLs flow sheet dated "05/04/18" at 0520 reflected the patient was turned.
* VS ADLs flow sheet dated "05/04/18" at 0900 reflected the patient was turned and skin blanchable under the "Integumentary" row after being in the same position for over 3.5 hours.
* VS ADLs flow sheet dated "05/07/18" at 0310 reflected the patient was turned.
* VS ADLs flow sheet dated "05/07/18" at 0759, nearly 5 hours later reflected the patient was turned.
* RN flow sheet dated "05/08/18" at 1730 reflected "tears between fold in buttocks preexisting per pt comment."
* RN flow sheet dated "05/08/18" at 2119 reflected "Skin tear x2."

3. Interview with APS on 08/29/2019 at the time of the record review, he/she confirmed findings 1 and 2.

4. Document titled "Salem Hospital Medical/Surgical Oncology RN Initial Skill Validation" for new employees to demonstrate that the RN was directly observed completing all skills by the end of orientation with signatures from the orientee, validator and the manager/assistant nurse manager. The skills checklist includes but not limited to:
* "Patient Assessment- Completes admission assessment for the Adult. "
* "Integumentary Assessment."
* "EPIC Risk Assessment flowsheets based on patient assessments (Fall Risk, Braden Scale, Sepsis, etc.)."
* "Performs pateint care and other duties as outlined in unit's Standard of Care."
* "Locates Policies and Procedures online."
* "Locates Lippincott's Nursing Skills online."

5. The policy and procedure "Skin/Wound Care Protocol" dated as last revised "06/29/18" contained the following references to skin/wound assessments:

* "Perform a full skin assessment once daily and on each new adult inpatient admission, or transfer per the Coordination of Care from Admission through Discharge Policy.'"
* "Remove all wound dressings, devices, braces and casts as allowed by provider on admission and transfers from ED, inspect, and replace dressing(s) ..."
* "Skin/Wound Documentation: Initiate appropriate care plan in EMR- Integumentary care plan should be initiated for patients with skin breakdown that require intervention(s), (i.e. pressure injuries, stage 1-4, DTI), moisture wounds, wound infections, etc ..."
* "Skin/Wound Photography (when to take a skin photograph)- As soon as possible on admission/transfer or pressure injury development. If a new pressure injury or new unintentional wound. For complex wounds present on admission or if developed during hospital stay to track/document progression of healing, or worsening ..."
* "Documentation needs for an admitted patient with a wound- Complete the Wound Assessment Record (electronic). Enter each wound in to the EMR under its own LDA in the wound LDA section of the Adult Assessment flow sheet and fill in the data as prompted; reassess and document each shift and PRN."
* "CWON consult for specific patient treatment plan should be made for one or more of the following patient scenarios- Multiple pressure injuries, stage 3, 4, or unstageable pressure injuries: or Deep Tissue Injury (DTI); or Open/Weeping arterial or venous ulcers ..."

6. The "Standards of Care: Medical/Surgical Oncology" dated last reviewed 03/02/2018 contained the following references to general, integumentary and wound care assessments:

* "General - Assess patients on admission, when received in transfer and upon return from surgery. Assess all patients' from head to toe at the beginning of each shift: further focused assessments according to patient's needs and condition. Assessment includes chart review for completion and initiation of appropriate care plan(s) and patient education initiation based on patient's needs/condition.
* "Integumentary - ... Assess skin condition on admission, transfer, and each shift; provide basic hygiene each shift and PRN as appropriate for the patient's condition. Evaluate patient's skin and complete the Braden Scale every shift and PRN ... Follow wound care/skin integrity - photo documentation/evidence collection policy and procedure. Pressure Injury Prevention as indicated per condition ..."
* "Wound and Incision Care - Assess wound and/or incision every 4-5 hours and PRN and document assessment. Assess color, drainage, edges of incision or wound, etc. Assess and monitor dressings. Reinforce dressing if needed ... Consider consult to CWON."