HospitalInspections.org

Based on policy and procedure review, medical record review, and staff interview, the nursing staff failed to provide wound care for 2 of 2 wound care patients (# 2 and #8).

The findings include:

Review on 01/24/2018 of policy titled, "Skin Assessment and Management" with revision date of August 16, 2015, revealed "....E. Patients will receive a focused re-assessment: 1. At least every shift and as warranted by the patient's clinical condition...4. To determine a patient's response to a care intervention...."

1. Open medical record review on 01/24/2018 revealed a 75 year old male admitted on 11/03/2017 for Dementia symptoms (category of long term and gradual decrease in the ability to think and remember affecting person's daily functioning). Review of a nurse practioner (NP #1) note dated 01/08/2018 at 1104 revealed "Fall during current admission, initial/skin tear right elbow...Skin tear cleaned with NS......will apply Neosporin and small Allevyn to keept intact. Daily cleaning with NS (normal saline) prior to application of Neosporin (topical antibiotic)...." Review of nurses notes dated 01/10/2018 through 01/15/2018 failed to reveal nurses documentation of the dressing change and wound condition.

Interview on 01/25/2018 at 1110 with assigned RN (RN #1) revealed documentation should be done of wound care and skin assessment. Further interview revealed "don't recall why there are no notes on the wound care."

Interview on 01/25/2018 at 0955 with Nurse Manager #1 revealed wound care should be charted and was not charted on this patient.



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2. Review of facility policies on 1/24/2018 at 0925 revealed a Skin Assessment and Management policy updated 8/15/2016 which stated, "Team members will visualize the entire integumentary (skin) system on admission." Further review revealed for the management and treatment of skin tears, nurses should initiate "Skin Breakdown Nursing Orders" to initiate nursing interventions for the treatment of skin tears until the provider can assess the patient. Review revealed that the nurse should use the following nursing interventions to manage a skin tear while awaiting provider orders: Clean area with sodium chloride 0.9%; apply vaseline guaze; cover with dry dressing; wrap/secure as needed; avoid tape to affected skin. Review revealed instructions for wound care should be given to the patient and support person at discharge.

Review of the closed medical record of Patient #7 on 01/24/2018 at 0957 revealed a 94-year-old female who was admitted to the hospital on 04/29/2017 with a diagnosis of dementia with behavior disturbance. Review revealed a nursing note dated 05/01/2017 at 0915 and signed by RN (registered nurse) #1 which stated "Skin tear left arm, Alevyn (sic) dressing applied." Further review revealed no documentation of the size or other characteristics of the wound and no documentation of nursing interventions initiated at the onset of the wound as described in the policy. Review revealed no provider notification of the wound, and no provider wound care orders. Review revealed no documentation of appropriate wound care. Review revealed no documentation that wound care education was given to the patient and family prior to discharge.

Request for interview with RN #1 revealed the nurse was no longer employed at the facility and was not available for interview.

Interview with NM (Nurse Manager) #1 revealed that when skin tears happen, the nurse should notify the provider to assess the wound and enter orders for wound care. Interview revealed that the wound should be documented in the nursing flowsheet, and that the wound should be reassessed every shift or according to the provider's orders. Interview revealed that nurses receive annual education on skincare and that there are resources available on the unit for skin and wound care, such as policies, an internal database of "tips and tricks," and medical providers on the floor. Further interview revealed that Allevyn is a type of dressing kept on the unit but that "there should have been an order" to use that particular dressing on a wound. Interview revealed that there were no wound care orders present in the medical record and no documentation of appropriate wound care in the medical record for Patient #7.

NC00134574 and NC00134644