HospitalInspections.org

47413


Based on record review and interview, facility staff failed to document complete wound assessments including descriptions and measurements of the wounds resulting in the inability to determine if the wounds were improving or worsening in 5 of 6 patients who had a documented wound (Patient #'s 1, 3, 4, 9, 10) in a total sample of 10 medical records reviewed.

Findings Include:

A review of the facility's policy #MPC.100 titled, "Clinical Documentation" last revised 04/02/2021 revealed, "All caregivers on units are responsible and accountable for documentation of their care and the patient's response to such care at the point of care/bedside. The multidisciplinary team will evaluate, re-evaluate and alter or maintain care, based upon the documentation of patient outcomes... Each staff member is accountable for the quality and content of documentation in compliance with established policies, procedures, and regulatory agencies..."

A review of the facility's document titled, "Job Description Wound Care Specialist" last revised 07/2019 revealed, "... Essential Duties and Responsibilities: ... Documents complete wound care assessments and treatments..."

A review of Patient #1's medical record revealed Patient #1 was admitted on 04/21/2023 for cellulitis (bacterial skin infection), rhabdomylosis (muscle injury where the muscle breaks down), and bacteremia (bacteria in the blood). Patient #1 was discharged on 05/02/2023.

A review of Patient #1's wound assessment flowsheets revealed Patient #1 presented with redness (no wound) on his/her buttock upon admission which progressed to a Stage 2 pressure injury wound on 04/27/2023. Wound assessment flowsheets revealed:

04/22/2023 2:33 PM: No wound measurements or wound description present.
04/22/2023 11:47 PM: No wound measurements or wound description present.
04/23/2023 3:55 AM: No wound measurements or wound description present.
04/23/2023 7:26 AM: No wound measurements or wound description present.
04/23/2023 11:19 AM: No wound measurements or wound description present.
04/23/2023 2:05 PM: No wound measurements or wound description present.
04/23/2023 8:19 PM: No wound measurements or wound description present.
04/24/2023 2:18 AM: No wound measurements or wound description present.
04/24/2023 7:32 AM: No wound measurements or wound description present.
04/24/2023 11:30 AM: No wound measurements or wound description present.
04/24/2023 3:56 PM: No wound measurements or wound description present.
04/24/2023 8:31 PM: No wound measurements or wound description present.
04/25/2023 12:40 AM: No wound measurements or wound description present.
04/25/2023 3:32 AM: No wound measurements or wound description present.
04/25/2023 8:50 PM: No wound measurements present.
04/26/2023: Nothing charted on Patient #1's wound.
04/27/2023 10:00 AM: No wound measurements present.
04/27/2023 3:21 PM: No wound measurements present.
04/28/2023 8:01 AM: No wound measurements present.
04/28/2023 3:29 PM: No wound measurements present.
04/29/2023 9:00 AM: No wound measurements present.
04/30/2023 9:00 AM: No wound measurements present.
04/30/2023 8:00 PM: No wound measurements present.
05/01/2023 12:00 AM: No wound measurements present.
05/01/2023 3:00 AM: No wound measurements present.
05/01/2023 3:00 PM: No wound measurements present.
05/02/2023 3:43 PM: No wound measurements or wound description present.

These findings were reviewed and confirmed on 06/13/2023 at 9:45 AM with Wound Coordinator H and Nursing Director C.

A review of Patient #3's medical record revealed Patient #3 was a current inpatient admitted on 06/06/2023 for an abscess on his/her right buttock, present on admission.

A review of Patient #3's wound assessment flowsheets revealed:

06/08/2023 4:00 PM: No wound measurements present.
06/09/2023 1:57 AM: No wound measurements or wound description present.
06/09/2023 7:17 PM: No wound measurements or wound description present.
06/10/2023 1:54 AM: No wound measurements or wound description present.
06/10/2023 9:00 AM: No wound measurements present.
06/10/2023 7:07 PM: No wound measurements or wound description present.
06/11/2023 2:02 AM: No wound measurements or wound description present.
06/11/2023 9:00 AM: No wound measurements present.
06/11/2023 7:50 PM: No wound measurements or wound description present.
06/12/2023 2:29 AM: No wound measurements or wound description present.
06/12/2023 9:20 AM: No wound measurements present.

These findings were reviewed and confirmed on 06/12/2023 starting at 1:30 PM with RN Stroke Educator Q.

A review of Patient #4's medical record Patient #4 was a current inpatient admitted on 05/20/2023 for acute respiratory distress. S/he presented on admission with a left gluteal cellulitis that progressed to a Stage 2 pressure injury.

A review of Patient #4's wound assessment flowsheets revealed the Stage 2 pressure injury was first documented in the medical record on 06/09/2023 at 8:00 AM and revealed the following:

06/09/2023 8:55 AM: No wound measurements present.
06/10/2023 9:57 AM: No wound measurements present.
06/10/2023 3:26 PM: No wound measurements present.
06/10/2023 7:00 PM: No wound measurements present.
06/11/2023 7:47 AM: No wound measurements present.
06/11/2023 3:50 PM: No wound measurements present.
06/11/2023 8:00 PM: No wound measurements or wound description present.
06/11/2023 4:00 AM: No wound measurements or wound description present.
06/12/2023 10:00 AM: No wound measurements present.

These findings were reviewed and confirmed on 06/12/2023 starting at 1:30 PM with RN Stroke Educator Q.

Review of Patient #9's medical record revealed Patient #9 was admitted to the facility's ICU (Intensive Care Unit) on 05/17/2023 for cardiac arrest and was transferred to a different facility on 06/08/2023.

A review of Patient #9's wound assessment flowsheets revealed Patient #9 developed a left coccyx (tailbone) Stage 2 pressure injury on 05/20/2023.

Review of the medical record revealed no documented wound assessments until 06/04/2023 (14 days later). Further review of the wound assessment flowsheets revealed:

06/04/2023 12:00 PM: No wound measurements present.
06/04/2023 4:00 PM: No wound measurements present.
06/04/2023 11:00 PM: No wound measurements present.
06/05/2023 4:47 AM: No wound measurements present.
06/05/2023 7:00 AM: No wound measurements present.
06/05/2023 11:00 AM: No wound measurements present.
06/05/2023 3:00 PM: No wound measurements present.
06/05/2023 8:00 PM: No wound measurements present.
06/06/2023 8:00 PM: No wound measurements present.
06/07/2023 12:00 AM: No wound measurements or wound description present.
06/07/2023 4:00 AM: No wound measurements or wound description present.
06/07/2023 11:00 AM: No wound measurements present.
06/07/2023 3:00 PM: No wound measurements or wound description present.
06/07/2023 7:00 PM: No wound measurements or wound description present.
06/07/2023 11:00 PM: No wound measurements or wound description present.
06/08/2023 3:00 AM: No wound measurements or wound description present.
06/08/2023 7:15 AM: No wound measurements or wound description present.
06/08/2023 11:40 AM: No wound measurements or wound description present.

These findings were reviewed and confirmed on 06/13/2023 at 9:30 AM with RN Stroke Educator Q.

A review of Patient #10's medical record revealed Patient #10 was a current ICU inpatient admitted on 05/05/2023 for a STEMI (ST Elevation Myocardial Infarction- heart attack).

A review of Patient #10's wound assessment flowsheets revealed Patient #10 developed a left ischeal tuberosity (bone at the bottom of one's pelvis or sitting bone) Stage 2 pressure injury on 05/28/2023. Wound assessment flowsheets revealed:

05/28/2023 9:00 PM: No wound measurements present.
05/28/2023 3:00 AM: No wound measurements present.
05/29/2023 11:00 AM: No wound measurements present.
05/29/2023 3:06 PM: No wound measurements present.
05/29/2023 7:00 PM: No wound measurements present.
05/30/2023 3:30 AM: No wound measurements present.
05/30/2023 7:20 AM: No wound measurements present.
05/30/2023 12:00 PM: No wound measurements present.
05/30/2023 2:55 PM: No wound measurements present.
05/30/2023 7:00 PM: No wound measurements or wound description present.
05/30/2023 10:00 PM: No wound measurements or wound description present.
05/31/2023 2:00 AM: No wound measurements or wound description present.
05/31/2023 4:00 AM: No wound measurements or wound description present.
05/31/2023 8:11 AM: No wound measurements or wound description present.
05/31/2023 12:09 PM: No wound measurements or wound description present.
05/31/2023 4:43 PM: No wound measurements present.
05/31/2023 7:05 PM: No wound measurements present.
05/31/2023 11:00 PM: No wound measurements or wound description present.
06/01/2023 3:00 AM: No wound measurements or wound description present.
06/01/2023 4:00 AM: No wound measurements or wound description present.
06/01/2023 7:00 AM: No wound measurements present.
06/01/2023 11:00 AM: No wound measurements or wound description present.
06/01/2023 3:00 PM: No wound measurements or wound description present.
06/01/2023 7:00 PM: No wound measurements or wound description present
06/01/2023 11:20 PM: No wound measurements or wound description present.
06/02/2023 3:09 AM: No wound measurements or wound description present.
06/02/2023 7:30 AM: No wound measurements present.
06/02/2023 11:00 AM: No wound measurements present.
06/02/2023 3:00 PM: No wound measurements present.
06/02/2023 7:00 PM: No wound measurements present.
06/02/2023 11:00 PM: No wound measurements or wound description present.
06/03/2023 3:58 AM: No wound measurements or wound description present.
06/03/2023 11:00 AM: No wound measurements present.
06/03/2023 2:30 PM: No wound measurements present.
06/03/2023 7:00 PM: No wound measurements or wound description present.
06/03/2023 11:00 PM: No wound measurements or wound description present.
06/04/2023 3:00 AM: No wound measurements present.
06/04/2023 7:15 AM: No wound measurements present.
06/04/2023 11:00 AM: No wound measurements present.
06/04/2023 2:35 PM: No wound measurements present.
06/04/2023 7:00 PM: No wound measurements present.
06/04/2023 11:00 PM: No wound measurements or wound description present.
06/05/2023 3:00 AM: No wound measurements present.
06/05/2023 7:00 AM: No wound measurements present.
06/05/2023 10:07 AM: No wound measurements present.
06/05/2023 7:00 PM: No wound measurements present.
06/06/2023 12:00 AM: No wound measurements present.
06/06/2023 3:00 AM: No wound measurements or wound description present.
06/06/2023 7:00 AM: No wound measurements or wound description present.
06/06/2023 7:00 PM: No wound measurements or wound description present.
06/06/2023 11:00 PM: No wound measurements or wound description present.
06/07/2023 3:00 AM: No wound measurements or wound description present.
06/07/2023 9:23 AM: No wound measurements or wound description present.
06/07/2023 12:38 PM: No wound measurements or wound description present.
06/07/2023 5:00 PM: No wound measurements or wound description present.
06/07/2023 7:00 PM: No wound measurements present.
06/08/2023 12:00 AM: No wound measurements present.
06/08/2023 3:00 AM: No wound measurements or wound description present.
06/08/2023 8:01 AM: No wound measurements or wound description present.
06/08/2023 11:31 AM: No wound measurements or wound description present.
06/08/2023 3:00 PM: No wound measurements present.
06/09/2023 4:00 AM: No wound measurements present.
06/09/2023 8:15 AM: No wound measurements or wound description present.
06/09/2023 12:00 PM: No wound measurements or wound description present.
06/09/2023 4:19 PM: No wound measurements present.
06/09/2023 8:00 PM: No wound measurements present.
06/10/2023 12:00 AM: No wound measurements or wound description present.
06/10/2023 3:00 AM: No wound measurements or wound description present.
06/10/2023 8:24 AM: No wound measurements or wound description present.
06/10/2023 12:00 PM: No wound measurements or wound description present.
06/10/2023 4:20 PM: No wound measurements or wound description present.
06/10/2023 8:00 PM: No wound measurements or wound description present.
06/11/2023 12:10 AM: No wound measurements or wound description present.
06/11/2023 3:00 AM: No wound measurements or wound description present.
06/11/2023 8:20 AM: No wound measurements or wound description present.
06/11/2023 12:00 PM: No wound measurements present.
06/11/2023 3:25 PM: No wound measurements or wound description present.
06/11/2023 7:30 PM: No wound measurements or wound description present.
06/11/2023 11:30 PM: No wound measurements or wound description present.
06/12/2023 3:30 PM: No wound measurements or wound description present.
06/12/2023 7:00 AM: No wound measurements or wound description present.
06/12/2023 11:00 AM: No wound measurements or wound description present.
06/12/2023 3:00 PM: No wound measurements or wound description present.

These findings were reviewed and confirmed on 06/13/2023 at 10:30 AM with RN Stroke Educator Q.

During an interview on 06/13/2023 at 9:45 AM, when asked how it could be determined if patients' wounds were healing or deteriorating if no measurements were documented, Wound Coordinator H stated, "Ideally, documentation would include measurements."

During an interview on 06/13/2023 at 11:30 AM, when asked for policies or expectations for nursing staff to document wound assessments or pressure injuries, Chief Nursing Officer D stated, "I confirmed with [Wound Coordinator H]; we do not have any policies or guidance for pressure injury or wound assessment documentation. That can be something we'll work on."