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Based on record review and interview, the facility failed to ensure a skin laceration was treated. This affected one (Patient #3) of 20 medical records reviewed.

Findings include:

Review of the medical record of Patient #3 revealed the patient and her significant other were crossing the street when they were struck by a motorcycle, sustaining injuries. Review of the ambulance run report dated 07/27/24 at 12:42 AM documented a laceration on the lateral side of her right thigh about four inches long and two inches wide. Bleeding was controlled with a few rolls of gauze. The patient arrived to the ED at 12:51 AM. The patient was triaged at 12:52 AM.

Review of the nursing notes dated 07/27/24 at 12:54 AM revealed the patient had a teeth laceration to the lateral right thigh, a laceration to the left elbow, and an abrasion to the left calf. An emergency department attending physician was assigned at 1:05 AM. The attending physician's attestation note stated he examined the patient and noted a large laceration to the patient's right thigh extending into the deep tissue oozing blood "but no significant bleeding," and a laceration to the left posterior elbow. A nurse's note at 3:29 AM stated the gauze covering the right thigh laceration was saturated with blood and the resident physician was notified. At 4:13 AM, the resident physician was at the bedside of the patient to repair the laceration to the right thigh. The resident physician's progress note at 4:51 AM stated the laceration was cleaned and sutured and covered with sterile gauze. There was no documentation any treatment was provided to the patient's laceration on the left elbow.

During an interview on 09/19/24 at 10:50 AM, Staff D stated the protocol for nursing care of lacerations that don't require stitches includes cleaning the wound to prevent infection. No physician order is required. If sutures are required, the provider cleans the wound prior to placement of stitches and after stitching has occurred, places a preferred dressing. Staff D stated although there is no written policy instructing staff nurses how to care for skin lacerations, all ED nurses are required to complete wound care education as part of orientation to the department. Staff D confirmed there was no documentation related to the patient's lacerated elbow.