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Based on record review, policy review and staff interview, it was determined that the facility failed to ensure ongoing and consistent assessment of skin status of wounds for the period of 1/29 - 2/17/2010, per patient care plan and facility protocol, for 1 (#2) of 4 sampled patients.


Findings include:

1. The facility's policy "Skin integrity, Maintenance and Restoration of" # 607 - 78 - 176 revised 2/10 requires that "any wound (s) discovered on admission or which develop after admission will be assessed and information regarding the location, size, color, drainage amount & color, odor and wound periphery will be documented." It further requires that a wound evaluation will be documented a minimum of once every day or with each dressing change." It also requires that "wound measurements will be completed on admission, upon discovery, weekly, with significant change in wound status."

2. Patient #2 was admitted to the facility on 1/29/10 as a transfer from another acute care hospital for continued neurosurgical care. The History and Physical noted that the patient had been admitted to the other facility with the diagnosis of right Thalamic stroke requiring 2 ventriculostomy procedures to relieve symptomatic hydrocephalus.

The initial skin assessment performed on 1/29/10 at 8:10 p.m. identified 2 wounds; #1 an incisional wound with a gauze dressing and #2 skin tears on the left wrist with an occlusive dressing. The size of the wounds were not documented.

Two assessments were performed on 1/30/10. At 7:45 a.m. and 8:00 p.m. wounds # 1 and #2 with the same locations documented were assessed as to dressing, color, peripheral tissue and drainage.

Two assessments were performed on 1/31/10. At 7:30 a.m., again #1 the abdominal incision was noted. The wound color was noted to be red. There was no documentation of size. A dressing was noted to be "marked, dated and timed." Wound #2 skin tear left wrist was documented with steri strip dressing, serous drainage and pink color. The size was again not noted. Wound #3 was identified as the site of the ventriculostomy on the cranium. The location on the head was not noted. The dressing was noted to be dry and intact. At 8:00 p.m. wound #1 was documented with gauze dressing, red in color, with no drainage. Wound #2 the skin tear left wrist was noted with occlusive dressing, red color and no drainage. Wound #3 the ventriculostomy was note with an occlusive dressing, no drainage.

Two assessments were performed on 2/1/10. At 7:30 a.m., there was documentation of location, dressing and wound color for #1, location, wound color dressing and drainage for wound #2 and location, condition of surrounding tissue and dressing for #3. At 8:00 p.m. wound #1, the abdominal wound was assessed regarding location, wound color and drainage. There was also documentation that open areas were packed wet to dry with dressing change. The size of the wound and open areas was not noted. The other 2 wounds were assessed with the same information as in the morning assessment.

Two assessments were performed on 2/2/10. At 8:00 a.m., only the locations of wounds #1,#2 and #3 were documented. Wound location, color, dressing and drainage were documented at 7:42 p.m.

Two assessments were performed on 2/3/10. At 7:40 a.m., the location, wound color, dressing, drainage and condition of surrounding tissue were documented for wounds #1,#2,#3. Wound #4 was noted as an abrasion on the upper lip. The color was noted to be red/black. The comment indicated "area cleaned." The surrounding tissue was noted to be dry and scaly. There was no documentation of application of moisturizer. At 8:00 p.m., location only was noted for wounds #1 and #2. Wound #3's documentation included location, condition of surrounding tissue and dressing. Documentation for wound #4 included location, surrounding tissue, drainage and dressing.

Two assessments were performed on 2/4/10. At 8:15 a.m. wounds #1,#2,#3,#4 were assessed for location only. At 8:00 p.m., wounds were assessed for location, dressing and drainage.

Two assessments were performed on 2/5/10. At 7:45 a.m. only the location of wounds #1,#2,#3,#4 was documented. At 7:00 p.m., documentation for wound #1 included location, condition of surrounding tissue, dressing and drainage. There was documentation that staples were present, but no documentation regarding the open areas noted on 2/1/10 and no documentation as to size of the wound. Documentation of wounds #2, #3, #4 included location, surrounding tissue, dressing and drainage.

Two assessments were performed on 2/6/10. At 7:45 a.m., documentation of wound #1 included location, surrounding tissue, wound color and dressing being marked, dated and time. No size or drainage was documented. Documentation of wound #2 include location, surrounding tissue, wound color, dressing, drainage amount and drainage type. Drainage amount was noted to be "large." It was not documented that dressing was changed nor was the size of the wound. Documentation of wound #3 noted location and dressing only. Wound #4 documentation included location, color, surrounding tissue and dressing. A new wound, #5 was identified on the right wrist and forearm. It was described as "skin tears." Documentation included wound color, surrounding tissue, dressing, drainage (large) and type of drainage. The size of the wounds was not documented. At 7:00 p.m., documentation for wounds #1,#2,#3 included location, wound color, dressing and drainage. The locations were the same as the previous assessment. Wound #4, which had been an abrasion on the upper lip, was now two skin tears of the right arm. On the previous assessment, wound #5 had been skin tears of wrist and forearm of the right wrist. Documentation included location, wound color, surrounding tissue, dressing drainage amount (large) and drainage type. Size was not documented.

Two assessments were performed on 2/7/10. At 7:30 a.m. Documentation for wounds #1.#2,#3.#4 included location and dressings only. Documentation at 7:51 p.m. included location, dressing and drainage and surrounding tissue.

Two assessments were performed on 2/8/10. At 7:30 a.m., documentation for wounds #1 and #2 included location , surrounding tissue, wound color and dressing. Documentation for #3 and #4 included location and dressing only. At 7:45 p.m. only wound #1 was addressed. Documentation included location, surrounding tissue, wound color and dressing. Size, drainage and status of the open areas identified on 2/1/10 were not addressed.

Two assessments were performed on 2/9/10. Documentation at 8:04 a.m. for wounds #1,#2,#3 included location only. Wound #4 was not addressed. At 8:04 p.m., documentation of wound #1 included location, surrounding tissue, dressing and drainage. Documentation of wounds #2, #3,#4 included location, surrounding tissue, wound color, dressing and drainage. Wound #3 was now described as an incision, rather that ventriculostomy. Size was not documented.

Two assessments were performed on 2/10/10. At 8:56 a.m., documentation for wound #1,#2 included location, wound color, surrounding tissue and dressing. It did not address size or drainage. Documentation for wound #3 included location, wound color, dressing and drainage. Documentation of wound #4 included location ( right arm X 2), surrounding tissue wound color and dressing. It did not address size or drainage. For the 1st time, wound #5 was identified. It was described as skin tears right wrist and forearm. Documentation included location, surrounding tissue, wound color and dressing. It did not include size or drainage. It appeared that # 5 was a new wound, but documentation indicated there was no new skin breakdown. Documentation at 7:45 p.m. of wound # 1 include location, surrounding tissue, dressing and drainage. Documentation indicated wet to dry packing, but did not assess the status of the open areas being packed or the incision color or size. This was the first time packing of the wound had been mentioned since 2/1/10. Documentation of wounds #2 and #3 included surrounding tissue, wound color, dressing and drainage. Wound #5 (skin tears, right forearm and wrist) was not addressed.

Two assessments were performed on 2/11/10. Documentation at 7:59 a.m. of wounds #1,#2,#3 and #4 included location, wound color, surrounding tissue and dressing. Wound #3 was also assessed for drainage. There was documentation wound #5, location right wrist and forearm, wound color, surrounding tissue and dressing. There was no assessment of drainage. At 8:00 p.m., documentation of wounds #1,#2,#3,#4,#5 include only location, surrounding tissue and dressing.

Two assessments were performed on 2/12/10. Documentation at 7:30 a.m. of wound #1 included location, surrounding tissue and dressing only. Documentation of wound #2 included only location and dressing. Documentation of #3 included location, surrounding tissue, wound color, dressing and drainage. Documentation of #4 included location and presence of edema only. Documentation of wound #5 included location and dressing. Documentation at 8:00 p.m. of wounds #1,#2,#3,#4,#5 included location only.

Two assessments were performed on 2/13/10. At 8:00 a.m., Documentation of wounds #1,#2,#3,#4,#5 included location, surrounding tissue, dressing and drainage. Documentation of wounds #2 and 3 include wound color. Documentation of wounds #1,#2,#3,#4,#5 included only location and wound color at 8:00 p.m.

Two assessments were performed on 2/14/10. Documentation of wounds #1,#2,#3,#4,#5 included location, surrounding tissue, wound color, dressing and drainage. There continued to be no documentation of the size or progress of the open areas on wound #1, although the wound color was assessed. At 8:00 p.m., only the locations and wound color were documented for the 5 wounds.

Two assessments were performed on 2/15/10. Documentation of wound #1 included location, and dressing only. Documentation of #2 included only location and wound color and a note "healing." Documentation of wound #3 included location, surrounding tissue, wound color and presence of sutures. Documentation of wound #4 included location, wound color and a note"healing." Documentation of wound #5 including location and a note "healing." At 8:13 p.m., documentation of wounds #1,#2,#3,#4 included location, surrounding tissue, wound color, dressing and drainage. The skin tears of the right wrist and forearm previously documented as wound #5 were not addressed. A new wound, pressure ulcer on the sacral area was identified as wound number 5. Location, surrounding tissue, wound color and dressing and drainage were noted. Size was not noted.


Two assessments were performed on 2/16/10. Documentation of wounds #1,#2,#3,#4 included location, surrounding tissue, color and dressing. Wound #5 was still the sacral ulcer. Size of the wound was not documented and wound color which had been pink on 2/15/10, was now purple. A note indicated barrier cream was applied. Documentation at 8:00 p.m. of wound #1 indicated the wound had staples and included assessment of surrounding tissue, wound color, dressing and drainage. The status of the open areas on the incision was not noted.

Documentation of #2,#3,and #4 included location, surrounding tissue, wound color, dressing and drainage. Documentation for wound #5, the sacral pressure ulcer, included location, surrounding tissue, wound color, and dressing. Drainage and wound size were not documented. Wound # 6 was documented as the trach incision. This wound was present at the time of admission, but had not been assessed in the wound assessment until this date. Location, surrounding tissue, wound color, drainage and dressing were documented.

Two assessments were performed on 2/17/10. The shift assessment, performed by the unit staff nurse was documented at 7:29 a.m. Documentation of wound #1 included location, surrounding tissue, dressing, drainage and a note that the incision was "well approximated." This was the first such note. Documentation of wound #2 included location, surrounding tissue, dressing and drainage. Documentation of wound #3 included location and surrounding tissue only. The color of the wound was not documented. There was no documentation that a dressing was in place. Drainage was not addressed. Documentation of wound #4 included surrounding tissue and dressing only. Documentation of wound #5 included location, surrounding tissue, wound color and drainage. Wound #6 included location, surrounding tissue and a note that incision is "well approximated. Drainage, size and dressing were not addressed. A second wound assessment was performed by the wound care nurse on 2/17/10 at 1:50 p.m. There were several discrepancies between the wound care nurse's assessment and that of the staff nurse performed only 6 hours prior. She noted the abdominal incision, but did not assess the wound. She noted three skin tears on the left arm. She noted the wounds were covered with eschar. Her documentation of the wound on the left posterior cranium noted the wound was 2 cm in length and 3.5 cm in width. This was the first time size of the wound had been documented. She noted the wound was covered with eschar, with slight peripheral erythema. The wound had been assessed by the staff nurses and being pink with normal surrounding tissue. She documented the presence of 2 skin tears on the right arm. she documented eschar as being present and that the wounds were "healing." She documented a "discoloration" of the left upper buttocks. She documented a wound color of deep red to deep purple. The measurements of the wound was length of 2 cm and width of 4.7. She indicated there was no drainage. She also documented the trach incision, only indicating the location. She also noted an open area on the right outer ear, which had not been identified by the nursing staff. It measured 0.9 in length and 1.9 cm in width.

The Chief Nursing Officer was interviewed on 4/27/10 at approximately 2:30 p.m. regarding the lack of consistent documentation of the required wound assessment and confusion related to the numbering of wounds. She explained that the facility's documentation does not allow the nursing staff to assign a unique number to each wound. She stated that the nurses rely on nurse to nurse report to track the progress of the wounds. She confined that there was lack of consistency in the assessments by the nursing staff, which did not always included all information required by facility policy.


5/27/10