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Based on clinical record review, staff interview, policy review, and recommendations from the National Pressure Ulcer Advisory Panel, the hospital failed to ensure that staff were available for wound assessment and to implement physician orders. The hospital failed to ensure that nursing staff were available for wound assessments and that the frequency and components of a wound assessment was established for 5 of 6 sampled patients (#1, 2, 3, 5 & 6). There were gaps found in nursing documentation, inconsistent assessments between nurses and no discernable pattern for wound measurements. The hospital failed to ensure that nursing obtained patient weights in accordance with physician orders and dietitian recommendations for 4 of 6 sampled patients (#1, 4 & 5).

The findings include:

Wounds Patient #1:

Nursing wound assessment documentation was reviewed for patient #1. A stage 1 pressure ulcer was identified on 6/26/16 to the sacral coccyx area on patient #1. The nurses continued to document a stage 1 pressure ulcer on 6/27/16 and 6/28/16. There was no wound documentation for the next 8 days 6/29/16 through 7/6/16. Then on 7/7/16, the wound care nurse assessed the area and documented an unstageable pressure ulcer to the coccyx measuring 4cm x 8cm in size.

A review of skin assessment documentation revealed that the coccyx wound was still present during the void of wound documentation from 6/29/16 through 7/7/16. Skin assessment documentation was reviewed beginning 6/26/16. On 6/26/16 one nurse charted that "yes" patient #1 had skin breakdown, and the next nurse charted "no". From 6/27/16 - 7/2/16, unit nurses charted "yes" patient #1 had skin breakdown, but failed to document any further specifics. A review of skin breakdown documentation for the next 10 days revealed:
7/3/16: redness on bottom, Mepilex (a type of dressing) to coccyx (tail bone)
7/4/16 - 7/6/16: sacral, coccyx; erythema (redness) & tear, Mepilex
7/7/16 - 7/9/16: sacral, coccyx; erythema
7/10/16 & 7/11/16: "yes" without any further details
7/12/16: "yes, notify WOC/ET (wound nurse), photo obtained" (The wound nurse had assessed the wound 5 days previously).

On 10/11/16 at 2:30pm, an interview was conducted with the Clinical Manager of 2 West, General Surgery. The manager was asked about the missing wound documentation from 6/29/16-7/6/16. The manager stated that the oversight was most likely due to the way the electronic assessment forms operate. The nurses have to remember to hit "show all" to get all possible fields in which to document. The computer will default to the areas of the assessment form that the previous nurse utilized. If a nurse does not hit "show all", then they only get the fields that the previous nurse charted in. So if one nurse did not chart in the wound section, then the next nurse would not have that section unless they hit "show all". We have a skin assessment section and a wound assessment section. If a nurse types "yes" under the 'skin breakdown' field, the system does not ask you to document what type of breakdown or where it is located. The nurse should enter details of the skin breakdown in the wound section. The nurse can also put a description in the "skin abnormality" field of the skin assessment.

A further review of wound care documentation was conducted from the initial wound measurements of 7/8/16 until patient #1 was discharged on 9/5/16. The staging and description of the sacral coccyx wound was inconsistent between nurses, and the wound size was not documented as measured at regular intervals.

7/7/16: unstageable coccyx, non-blanching, moist, pale with brown slough, measures 4cm (centimeters) x 8cm
7/8/16 - 7/11/16: stage II
7/12/16 - 7/13/16: stage II and stage III
7/14/16 - 7/18/16: stage II
7/19/16: unstageable and stage II
7/20/16: No wound info documented
7/21/16 -7/24/16: unstageable
7/25/16 - 8/3/16: documentation fluctuated between stage IV and unstageable
8/3/16: stage III with measurements 8cm x 7cm x 2.2cm
8/4/16: unstageable & stage III with measurements 8cm x 7cm x 2.2cm
8/5/16: unstageable and stage IV
8/6/16: unstageable and stage IV with measurements 8cm x 7cm x 2cm
8/7/16 - 8/13/16: stage IV
8/14/16: unstageable & stage IV.
8/15/16: unstageable & stage IV with measurements 7cm x 7.5cm x 1cm
8/16/16 - 8/29/16: stage IV with measurements noted on 8/22/16 8cm x 8cm x 1cm
8/30/16: stage III
8/31/16-9/5/16: stage IV

There were no wound measurements after the initial measurements documented on 7/7/16 until nearly a month later on 8/3/16. Wound measurements were documented again on 8/4/16, 8/6/16, 8/15/16 and 8/22/16. There were no further wound measurements documented in the record. Patient #1 was discharged to another hospital on 9/5/16.

A continued review of wound documentation revealed tunneling and/or undermining noted beginning on 7/12/16 and documented several times weekly through 9/1/16 without any further description as to a specific location or measurements of size/length.

On 10/11/16 beginning at 1:00pm, an interview regarding wound assessment was conducted with the Critical Care Director. The Director stated that a full assessment is completed upon admission and each shift. If a wound is found, nurses notify the physician, take photographs, measure the wound, initiate the wound care protocol, initiate the pre-printed order set for wounds as stated in the protocol and notify the wound care nurse per protocol.

On 10/11/16 at about 1:42pm, an interview was conducted with the certified wound ostomy nurse. The wound nurse stated that the floor & unit nurses can refer any type of wound to me. When notified, I go and assess the patient and render treatment based on what I see. I will call the PA (physician assistant) or doctor and make recommendations for treatment. A Mepilex dressing can be used for either treatment or prevention. Sometimes I just provide a one-time consult, and sometimes I reassess. I try to measure wounds that I am following at least weekly, but floor nurses can also measure. I get daily communication from the grand rounds with physicians. The wound nurse confirmed she was the only wound care nurse in the hospital. She does not have a relief wound care nurse, nor does she have an assistant. Her duties include receiving consults from floor nurses, performing wound care, assessing wounds, wound teaching, making recommendations for wound care, attending skin condition meetings and participating in wound rounds.

Wounds Patient #2

A closed record review was conducted for Patient #2 who was admitted in September 2016. A review of wound care documentation was conducted. Beginning on 9/5/16, unit nurses began documenting a "blister on buttocks." The unit nurses continued to document a blister through discharge on 9/12/16.

The wound care nurse evaluated patient #2 on 9/7/16. The wound care nurse documented a wound between the buttocks, partial thickness, denuded skin and a shallow open area. The wound care nurse did not document a blister. On 10/11/16 at about 1:42pm, an interview was conducted with the wound care nurse. The nurse reviewed her note and stated it was not a blister, it was already open. The wound nurse stated that typically a wound does not go back to being a blister once open, unless there are new areas being affected by shear.

Wounds Patient #3

A closed record review was conducted for Patient #3 who was admitted in September 2016. A review of wound care documentation was conducted. Upon admission on 9/4/16 at 4:23am, nursing documented a decubitus (pressure ulcer) to coccyx which was red, edematous, appeared as a "tear/shear" and measured 3cm x 2cm. A photograph of the wound was taken at that time. Unit nurses continued to document "tear/shear" daily through 9/11/16. On 9/11/16, nursing staff described the wound as a "vascular ulcer". On 9/12/16, the hospitalist documented the wound as a stage 2 decubitus.

On 9/8/16, the wound care nurse assessed the wound and documented a wound care goal to decrease wound size. The only wound measurements documented in the medical record were obtained on 9/4/16 upon admission. Patient #3 was discharged to a skilled nursing facility on 9/12/16 without further measurements being done.

Wounds Patient #5:

An open record review was conducted for Patient #5 who was admitted in September 2016. A review of wound care documentation in both the electronic and paper medical record was conducted. Upon admission on 9/7/16, nursing documented a sacral wound with erythema (redness) and excoriated (abraded) perineal area. The unit nurses continued documenting a wound daily. On 9/11/16 nursing described the wound as sacral coccyx (by tail bone) with erythema and blister.

The wound care nurse first assessed the wound on 9/13/16 and described it as a deep tissue pressure injury with purple base on sacral/coccyx. The wound care nurse again assessed the wound on 9/19/16, documenting a partial thickness stage 2 pressure injury on the buttocks. The wound care nurse documented again on 9/21/16 and 10/5/16. On 10/5/16 the wound was described as Coccyx wound stage 2/3, moist, yellow slough (dead tissue), erythema, surrounding area red and serous drainage.

The only wound measurements in the electronic medical record to date were documented on 10/10/16. At that time, the coccyx wound measured 11cm x 9cm, and was described as unstageable.

On 10/11/16 at 5:06 pm the paper medical record was reviewed with a unit nurse, Registered Nurse F. Nurse F confirmed that the only wound measurements in the record were from the 10/10/16 assessment.

Wounds Patient #6

On 10/11/16 beginning at 10:00am, a wound care observation was conducted. The certified wound ostomy nurse completed a dressing change and wound assessment of a sacral wound on patient #6. A unit nurse, registered nurse H, assisted the wound care nurse by holding the patient on his side. There were 3 separate issues identified. Patient #6 had 1 wound on his left buttocks, a 2nd wound on his right buttocks, and a rash to his upper thighs and left hip. The wound care nurse measured each wound, but had no assistant to call the numbers to for recording. The nurse was unable to write the measurements down herself and maintain wound cleanliness. After measuring the wounds, the wounds were cleaned, a dressing was applied, the patient was repositioned for comfort, and the used dressing was discarded. By the time the wound nurse was able to document her measurements, about 20 minutes had passed.

On 10/11/16 at about 1:42pm, an interview was conducted with the certified wound ostomy nurse. The nurse was asked about documenting wound measurements. The wound nurse stated that she cannot write down measurements while performing wound care, so she just remembers the measurements.

A review of skin assessments and wound care documentation was conducted for patient #6. Skin breakdown was first noted as "yes" on 10/4/16, but no further assessment was documented. On 10/7/16 at 12:00pm, nursing documented a coccyx wound that was purple & maroon in color. At 8:00pm that same day, another nurse wrote that it was a stage II to the right and left sacral. On 10/8/16, nursing again noted a stage II. On 10/11/16, after the observed dressing change, the wound care nurse documented: suspected deep tissue injury. Right buttock wound was dark based. Left 50% red based & 50% dark tissue covered. Right buttock measured 9x7cm and left 7x5cm.


Hospital Policy:

The skin assessment and wound care policies were requested for review. The hospital provided:

CM-4194, 'Discharge and Wound Care Referral, dated 02/2014.

PCS-2859.001, 'Skin Assessment/Wound Care/Support Surfaces/Referrals,' dated 05/2014 which described the stages of pressure ulcers and recommended treatments.

PCS-2859.000, 'Skin Assessment/Wound Care/Support Surfaces/Referrals', dated 05/2014. the purpose of the policy was to "delineate the responsibilities of the staff caring for a patient with wounds." The policy stated: Initiate pre-printed wound care orders (form PO-150). Skin, bony prominences and wounds will be assessed on admission, daily, and with each dressing change. When necessary, initiate the skin care procedure and consult the wound care nurse for the following ...

The policy did not specify the components of assessment, measurements or the obtaining of photographs, nor did it address the responsibilities of the wound care nurse.

The 'Wound Care Physician Orders from (form PO-150), dated 10/2014, was reviewed. The form gives treatment options based on wound assessment. Under the section for prevention, the form states, "See Skin Assessment/Wound Care/Support Surface Policy - NUR 3073". Per the clinical risk Manager policy NUR 3073 was rescinded and replaced with PCS-2859.000 (noted above).


The National Pressure Ulcer Advisory Panel (standard of practice authority)

The National Pressure Ulcer Advisory Panel (NPUAP) recommendations for pressure ulcer assessments, dated 2014, was reviewed. The international NPUAP Pressure Ulcer Classification System defines:

-Stage I: Intact skin with non-blanchable redness (erythema) of a localized area usually over a bony prominence

-Stage II: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous).

-Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.

-Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead necrotic tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling.

-Unstageable: Depth Unknown. Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.

-Suspected Deep Tissue Injury: Depth Unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

Pressure Ulcer Assessment:

- Assess the pressure ulcer initially and re-assess it at least weekly.

- With each dressing change, observe the pressure ulcer for signs that indicate a change in treatment is required (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications).

- Assess and document physical characteristics including:
· location,
· Category/Stage,
· size,
· tissue type(s),
· color,
· periwound condition,
· wound edges,
· sinus tracts,
· undermining,
· tunneling,
· exudate, and
· odor.

- Select a uniform, consistent method for measuring wound length and width or wound area to facilitate meaningful comparisons of wound measurements across time.

- Select a consistent, uniform method for measuring depth. Caution: Care should be taken to avoid causing injury when probing the depth of a wound bed or determining the extent of undermining or tunneling.


Weights Patient #4

An electronic and paper medical record review was conducted for current patient #4 with the assistance of the Clinical Risk Manager and the floor nurse, RN E. Patient #4 had a physician order for daily weights written on 9/27/16. A review of the vital sign flow sheet and dialysis treatment sheets revealed only 1 documented weight. On 9/27/16, Patient #4 weighed 63.5 kg (kilograms).

An observation was conducted of Patient #4 was on a specialty air mattress bed on 10/10/16 at about 3:10pm, 10/11/16 at about 10:15am, 3:00pm and 5:00pm. The bed had a built in scale.

On 10/11/16 at about 5:00pm, an interview was conducted with Registered Nurse E (RN E) who worked on 1 West, Renal Care. RN E stated that Patient #4 used to be on 3 West, but transferred to her unit yesterday. She confirmed the current order for daily weights written on 9/27/16. RN E stated that specialty beds do not have a built in scale. An observation of Patient #4's bed was conducted with RN E. RN E confirmed that this specialty bed did have a built in scale and that the scale was functional.

Weights Patient #5

An electronic and paper medical record review was conducted for current patient #5 with the assistance of the Clinical Risk Manager and the unit nurse, Registered Nurse F (RN F). Patient #5 had a physician order for daily weights written on 9/11/16. A review of the vital sign flow sheet and dialysis treatment sheets revealed 7 weights were obtained after this order on: 9/21/16, 9/24/16, 9/28/16, 9/30/16, 10/5/16, 10/7/16, and 10/8/16.

On 10/11/16 at 5:06pm, an interview was conducted with the Unit nurse, RN F. RN F stated that Patient #5 has an order for daily weights at 4:00am. Patient #5 is in a bed with a built in scale. The daily weights were ordered by the physician on 9/11/16. RN F was unable to locate any further weights.

Weights Patient #1:

Patient #1 was admitted to the hospital on 6/3/16 and discharged on 9/5/16. The first documented weight in the medical record was on 6/5/16 showing 56.7 kg (125 pounds).

The discharge summary report dated 9/24/16 revealed nutritional compromise. The physician documented, "The patient remained deconditioned with severe malnutrition, was referred for PEG (Percutaneous endoscopic gastrostomy) tube placement (a feeding tube inserted into the stomach).""Remainder of the patient's hospital stay was extensive with patient not tolerating tube feedings, requiring TPN (Total Parenteral Nutrition) therapy." (TPN is a way of supplying all the nutritional needs of the body by bypassing the digestive system and dripping nutrient solution directly into a vein). "Small bowel series was ordered and abnormal. Patient was treated for gastroparesis (a condition in which the spontaneous movement of the muscles in your stomach does not function normally) and ongoing ileus (a disruption of the normal propulsive ability of the gastrointestinal tract) with a gastrostomy tube (PEG tube) to suctioning." "Nutrition consult was requested to restart gastrojejunostomy (feeding tube inserted into the jejunum, a part of the intestines) tube feedings."

A record review for weights was conducted. The Nutrition Services report, dialysis treatment summaries and flow sheets which contained vital signs were reviewed. The review revealed that weights were obtained 8 times in June, 1 time in July, and 0 times in August and September. Per Dietitian notes, TPN was initiated on 7/10/16 due to poor tube-feeding tolerance. The weight documentation in the clinical record:

6/05/16 Documented on flow sheet, 56.7 kg (125 pounds)
6/13/16 Dialysis documented a post weight of 56.5 kg
6/15/16 Dialysis documented a post weight of 57.5 kg
6/20/16 Dialysis documented a post weight of 56.5 kg
6/22/16 Dialysis documented a post weight of 60.5 kg
6/24/16 Dialysis documented a post weight of 60.0 kg
6/29/16 Dialysis documented a dry weight of 57.2 kg
6/30/16 Documented on flow sheet, 57 kg
7/06/16 Dialysis documented "unable to weigh "
7/11/16 Dialysis documented "N/A" (non-applicable) under post weight
7/12/16 Registered Dietitian A (RD A) charted "no new weight "
7/13/16 Registered Dietitian A wrote, "please weigh today or in am"
7/14/16 Registered Dietitian A charted "no new weight - weight requested"
7/18/16 Registered Dietitian B charted "no new weights to review "
7/24/16 Documented on flow sheet, 57 kg
8/04/16 Registered Dietitian A charted "no new weight "
8/06/16 Patient Care Tech D (PCT D) documented, "refused daily weight "
8/07/16 Patient Care Tech D documented, "refused daily weight "
8/09/16 Registered Dietitian B charted "patient refusing daily weights "
8/11/16 Registered Dietitian B charted "patient refusing daily weight "
8/12/16 Dialysis documented "unable to weigh "
8/14/16 Patient Care Tech D documented, "refused daily weight "
8/15/16 Dialysis documented "unable to weigh "
8/15/16 Registered Dietitian B charted "patient continues to refuse daily weight "
8/24/16 Dialysis documented "unable to weigh "
8/26/16 Dialysis documented "unable to weigh "
8/30/16 Registered Dietitian B charted "no new weights., per RN patient is in a low bed; refusing daily weights "
9/5/16 Registered Dietitian C charted, "current weight unknown "

On 10/11/16 at about 1:00pm, an interview was conducted with the Critical Care Director. The Director stated that the beds have scales on them built in. If the scale did not work, or the bed did not have one they could use a Hoyer lift or a bedside scale to obtain a weight. Weights are obtained based on physician order and nursing judgment.

On 10/11/16 at about 2:30pm, an interview was conducted with the Clinical Manager of 2 west, General Surgery. The Manager recalled Patient #1 and stated she was very thin. At first patient #1 was on a regular bed, and we could weigh her. Our regular bed has a built in weight scale. Patient #1 was moved to a specialty bed due to the development of a wound. The specialty beds don't weigh the patient. The patient would have to stand on a scale to be weighed, and patient #1 would refuse. I have standing scales on my floor, I don't have a bed scale. I believe there is a bed scale somewhere in the hospital.

On 10/11/16 at about 3:00pm, an interview was conducted with the Clinical Manager of Dialysis. The Manager stated that all beds have built in scales, even specialty beds. If the bed did not have a scale we could use a floor scale or a bed scale - or swap beds.

Based on clinical record review, staff interview, policy review, and recommendations from the National Pressure Ulcer Advisory Panel, the hospital failed to reassess wounds in accordance with established goals in the nursing care plan for 4 of 6 sampled patients, (#1, 2, 3 & 5). The patients had a wound goal to decrease wound size. The hospital failed to regularly measure wounds to evaluate the wound goal.

The findings:

Patient #1:

The wound Care Goal for patient #1 was initiated on 7/7/16 and stated the goal was to decrease wound size, increase granulation tissue and remove necrotic tissue. This goal was repeated on 7/13/16 and 7/19/16. On 7/26/16 the goal was modified to include decreased drainage in addition to decrease wound size, increase granulation tissue and remove necrotic tissue. This goal was repeated on 8/3/16 and 8/5/16.

Nursing wound assessment documentation was reviewed for patient #1. A stage 1 pressure ulcer was identified on 6/26/16 to the sacral coccyx area on patient #1. The nurses continued to document a stage 1 pressure ulcer on 6/27/16 and 6/28/16. There was no wound documentation for the next 8 days 6/29/16 through 7/6/16. Then on 7/7/16, the wound care nurse assessed the area and documented an unstageable pressure ulcer to the coccyx measuring 4cm x 8cm in size. By the time of discharge on 9/6/16, the wound was being assessed as a stage IV pressure ulcer. Per the documentation, the pressure wound size was evaluated via measurements 6 times during the hospital stay. The initial measurements were documented on 7/7/16. The next set was not obtained until nearly a month later on 8/3/16. Wound measurements were documented again on 8/4/16, 8/6/16, 8/15/16 and 8/22/16. There were no further wound measurements documented in the record. Patient #1 was discharged to another hospital on 9/5/16. The wound assessments with measurements are listed below:

7/7/16: unstageable coccyx, non-blanching, moist, pale with brown slough, measures 4cm (centimeters) x 8cm

8/3/16: stage III, non-blanching, yellow slough, small amount of serous drainage, measures 8cm x7cm x 2.2cm

8/4/16: stage III, granulation and yellow slough, rolled edges, pink, small amount of serous drainage, measures 8cm x7cm x 2.2cm

8/6/16: stage IV, non-blanching, moist, undermining, moist drainage, measures 8cm x7cm x 2cm

8/15/16: stage IV, moist, granulation, tunneling, serous and serosanguinous drainage, measures 7cm x 7.5cm x 1cm

8/22/16: stage IV, moist, granulation, tunneling, pink, medium amount of serous and serosanguinous drainage, measures 8cm x 8cm x1cm

A continued review of wound documentation revealed tunneling and/or undermining noted beginning on 7/12/16 and documented several times weekly through 9/1/16 without any further description as to a specific location or measurements of size/length.

On 10/11/16 at about 1:42pm, an interview was conducted with the certified wound ostomy nurse. The wound nurse stated that the floor & unit nurses can refer any type of wound to me. When notified, I go and assess the patient and render treatment based on what I see. I will call the PA (physician assistant) or doctor and make recommendations for treatment. A Mepilex dressing can be used for either treatment or prevention. Sometimes I just provide a one-time consult, and sometimes I reassess. I try to measure wounds that I am following at least weekly, but floor nurses can also measure. I get daily communication from the grand rounds with physicians. The wound nurse confirmed she was the only wound care nurse in the hospital. She does not have a relief wound care nurse, nor does she have an assistant. Her duties include receiving consults from floor nurses, performing wound care, assessing wounds, wound teaching, making recommendations for wound care, attending skin condition meetings and participating in wound rounds.

Patient #2:
A closed record review was conducted for Patient #2 who was admitted in September 2016. A review of wound care documentation was conducted. Beginning on 9/5/16, unit nurses began documenting a "blister on buttocks." The unit nurses continued to document a blister through discharge on 9/12/16.

A wound care goal to decrease wound size was established on 9/7/16 for patient #2. There were no wound measurements in the medical record to evaluate this goal.

Patient #3:
A closed record review was conducted for Patient #3 who was admitted in September 2016. A review of wound care documentation was conducted. Upon admission on 9/4/16 at 4:23am, nursing documented a decubitus (pressure ulcer) to coccyx which was red, edematous, appeared as a "tear/shear" and measured 3cm x 2cm. A photograph of the wound was taken at that time.

On 9/8/16, the wound care nurse assessed the wound and documented a wound care goal to decrease wound size. The only wound measurements documented in the medical record were obtained on 9/4/16 upon admission. Patient #3 was discharged to a skilled nursing facility on 9/12/16 without further measurements being done.

Patient #5:

An open record review was conducted for Patient #5 who was admitted in September 2016. A review of wound care documentation in both the electronic and paper medical record was conducted. Upon admission on 9/7/16, nursing documented a sacral wound with erythema (redness) and excoriated (abraded) perineal area. The unit nurses continued documenting a wound daily. On 9/11/16 nursing described the wound as sacral coccyx (by tail bone) with erythema and blister.

The wound care nurse first assessed the wound on 9/13/16 and described it as a deep tissue pressure injury with purple base on sacral/coccyx. The wound care nurse again assessed the wound on 9/19/16, documenting a partial thickness stage 2 pressure injury on the buttocks. The wound care nurse documented again on 9/21/16 and 10/5/16. On 10/5/16 the wound was described as Coccyx wound stage 2/3, moist, yellow slough (dead tissue), erythema, surrounding area red and serous drainage.

The only wound measurements in the electronic medical record to date were documented on 10/10/16. At that time, the coccyx wound measured 11cm x 9cm, and was described as unstageable.

On 10/11/16 at 5:06 pm the paper medical record was reviewed with a unit nurse, Registered Nurse F. Nurse F confirmed that the only wound measurements in the record were from the 10/10/16 assessment.

Hospital Policy:

The skin assessment and wound care policies were requested for review. The hospital provided:

CM-4194, 'Discharge and Wound Care Referral, dated 02/2014.

PCS-2859.001, 'Skin Assessment/Wound Care/Support Surfaces/Referrals,' dated 05/2014 which described the stages of pressure ulcers and recommended treatments.

PCS-2859.000, 'Skin Assessment/Wound Care/Support Surfaces/Referrals', dated 05/2014. the purpose of the policy was to "delineate the responsibilities of the staff caring for a patient with wounds." The policy stated: Initiate pre-printed wound care orders (form PO-150). Skin, bony prominences and wounds will be assessed on admission, daily, and with each dressing change. When necessary, initiate the skin care procedure and consult the wound care nurse for the following ...

The policy did not specify the components of assessment, measurements or the obtaining of photographs, nor did it address the responsibilities of the wound care nurse.

The 'Wound Care Physician Orders from (form PO-150), dated 10/2014, was reviewed. The form gives treatment options based on wound assessment. Under the section for prevention, the form states, "See Skin Assessment/Wound Care/Support Surface Policy - NUR 3073". Per the clinical risk Manager policy NUR 3073 was rescinded and replaced with PCS-2859.000 (noted above).


The National Pressure Ulcer Advisory Panel (standard of practice authority)

The National Pressure Ulcer Advisory Panel (NPUAP) recommendations for pressure ulcer assessments, dated 2014, was reviewed. The international NPUAP Pressure Ulcer Classification System defines:

-Stage I: Intact skin with non-blanchable redness (erythema) of a localized area usually over a bony prominence

-Stage II: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous).

-Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.

-Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead necrotic tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling.

-Unstageable: Depth Unknown. Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.

-Suspected Deep Tissue Injury: Depth Unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

Pressure Ulcer Assessment:

- Assess the pressure ulcer initially and re-assess it at least weekly.

- With each dressing change, observe the pressure ulcer for signs that indicate a change in treatment is required (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications).

- Assess and document physical characteristics including:
· location,
· Category/Stage,
· size,
· tissue type(s),
· color,
· periwound condition,
· wound edges,
· sinus tracts,
· undermining,
· tunneling,
· exudate, and
· odor.

- Select a uniform, consistent method for measuring wound length and width or wound area to facilitate meaningful comparisons of wound measurements across time.

- Select a consistent, uniform method for measuring depth. Caution: Care should be taken to avoid causing injury when probing the depth of a wound bed or determining the extent of undermining or tunneling.