HospitalInspections.org

Based on facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure the wound care policy and procedures were followed for documentation and measuring of wounds in 11 of 11 medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, and MR11).

Findings include:

Review on January 27, 2012, of the facility policy and procedure "Wound Care Policy," revised October 2011, revealed "... G. Wound Photography Sheet: Measurements and photographs of all wounds are obtained on admission, or on discovery, every Monday, and on discharge."

1) Review of MR1 on January 27, 2012, revealed the patient was admitted to the facility on December 24, 2011, and discharged on January 9, 2012. Review of the skilled nursing facility transfer documentation in MR1 revealed the patient had a "Buttock pressure ulcer, left side, pressure ulcer stage II-buttock, pressure ulcer ankle - left lateral, pressure ulcer stage III-ankle."

Review of wound photograph documentation for MR1 dated December 26, 2011, revealed a wound located on the sacral area. Review of photograph documentation for MR1 dated December 31, 2011, revealed a stage II right ankle wound. Review of photograph documentation for MR1 dated December 31, 2011, revealed a Stage II left ankle and left outer foot wound. Review of photograph documentation for MR1 dated December 31, 2011, revealed stage II [multiple] bilateral foot wounds.

There was no documentation in MR1 of wound photographs or measurements at the time of admission. There was no documentation of wound measurements at the time of the wound photographs on December 26, and 31, 2011, or at the time of discharge.

2) Review of MR2 on January 27, 2012, revealed the patient was admitted to the facility on October 26, 2011, and was discharged on October 29, 2011. Review of photograph documentation in MR2 revealed wounds with measurements located at the right hip, right groin and right stump. There was no documented evidence in MR2 of photographs or wound measurements at the time of discharge.

3) Review of MR3 on January 27, 2012, revealed the patient was admitted to the facility on December 12, 2011, and was discharged on December 24, 2011. Review of photograph documentation for MR3 dated December 22, 2011, revealed a sacral wound with measurements. There was no documentation in MR3 of a photograph or wound measurements at the time of discharge. Continued review of nursing documentation for MR3 dated December 24, 2011, revealed the patient also had a sacral slit. There was no evidence in MR3 of photograph documentation or measurements for the sacral slit on December 24, 2011, the day of discharge.

4) Review of MR4 on January 27, 2012, revealed the patient was admitted to the facility on October 26, 2011, and discharged on October 30, 2011. Review of photograph documentation for MR4 dated October 26, 2011, revealed a right buttock, right back, and two left thigh wounds without staging or measurement documentation. There was no documentation in MR4 of photograph documentation or wound measurements at the time of discharge.

5) Review of MR5 on January 27, 2012, reveled the patient was admitted to the facility on November 11, 2011, and discharged on December 1, 2011. Review of photograph documentation for MR5 revealed the patient had a right scapula wound, right knee wound and right and a left hip wounds with no documentation of measurements. There was no documentation in MR5 of photographs or measurements in MR5 for the wounds at the time of discharge.

6) Review of MR6 on January 27, 2012, revealed the patient was admitted to the facility on October 27, 2011, and discharged November 2, 2011. Review of photograph documentation for MR6 dated October 28, 2011, revealed left foot and heel wounds without measurements. Review of photograph documentation for MR6 dated Monday, October 31, 2011, revealed a photograph was taken of the left foot and heel wound without documentation of wound measurements. There was no documentation in MR6 of wound photographs or measurements for the wounds at the time of discharge.

7) Review of MR7 on January 27, 2012, revealed the patient was admitted to the facility on November 16, 2011, and discharged on November 23, 2011. Review of photograph documentation for MR7 dated November 16, 2011, revealed a sacral and left inner lateral foot wounds without measurements. Review of the photograph documentation for MR7 dated Monday, November 21, 2011, revealed no documentation of measurements for the wounds. There was no documentation in MR7 of wound photographs or wound measurements at the time of discharge.

8) Review of MR8 on January 27, 2012, revealed the patient was admitted to the facility on October 5, 2011, and discharged on October 8, 2011. Review of photograph documentation for MR8 dated October 5, 2011, revealed left buttock, left ischium and right heel wounds with measurements. There was no documentation in MR8 of photographs or wound measurements at the time of discharge.

9) Review of MR9 on January 27, 2012, revealed the patient was admitted to the facility on January 16, 2012, and discharged on January 20, 2012. Review of photograph documentation dated January 17, 2012, for MR9 revealed right ankle stage III, left buttock stage II and rash in the right groin area with no documentation of measurements. There was no documentation in MR9 of photographs or wounds measurement at the time of discharge.

10) Review of MR10 on January 27, 2012, revealed the patient was admitted to the facility on October 4, 2011, and discharged on October 13, 2011. Review of photograph documentation dated October 5, 2011, revealed a Stage II right sacrum wound and redness at the right heel without documentation of measurements. Review of photograph documentation dated Monday, October 20, 2011, revealed a right buttock wound without documentation of measurements. There was no documentation in MR10 of photographs or wound measurements at the time of discharge.

11) Review of MR11 on January 27, 2012, revealed the patient was admitted to the facility on January 6, 2012, and discharged on January 9, 2012. Review of nursing assessment documentation for MR11 dated January 6. 2012, revealed the patient had a sacral wound. Further review of MR11 revealed no documented evidence of photographs or wound measurements of the sacral wound at the time of admission.

12) Interview with EMP1 and EMP2 on January 27, 2012, at approximately 3:00 PM confirmed the nursing staff did not follow their policy and procedures for wound documentation and measurements for MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10 and MR11.

_______________

Based on review of facility policy and procedures, review of medical records (MR) and interview with staff (EMP), it was determined nursing staff failed to ensure that screening for pain was completed a minimum of twice in a 24 hour period in one of 11 medical records reviewed (MR1).

Findings include:

Review on January 27, 2012, of facility policy and procedure "Pain Management," reviewed August 2011, revealed "Procedure: A. Inpatient ... A pain screening is completed a minimum of twice in a 24-hour period or as clinically warranted and documented on the 12-hour Graphic/I and O Record."

1) Review on January 27, 2012, of MR1 revealed a "24 Hr Med/Surg Nursing Flowsheet" dated January 9, 2012. There was no documentation of a pain screening prior to the patient's discharge. Review of MR1's "24 Hr Med/Surg Nursing Flowsheet" dated December 30, 2011, revealed no documentation of a pain screening. Review of MR1's "24 Hr Med/Surg Nursing Flowsheet" dated December 28, 2011, revealed no documentation of a pain screening on the 7 AM to 7 PM shift.

2) Interview with EMP1 on January 27, 2012, confirmed there was no documentation of pain screenings on the dates listed above in MR1.