HospitalInspections.org

Based on medical record review, staff interview, and review of the facility's policy and procedures the facility failed to ensure a registered nurse supervised and evaluated the nursing care of weekly wound care assessments for one (#2) of four patients sampled. This practice does not ensure patient goals are met.

Findings include:

Review of the medical record revealed the patient was admitted to an acute care facility on
6/04/10 for a history of bladder cancer and underwent a cystectomy with placement of an
ileal conduit and bilateral ureteral stents. The hospital course was complicated by respiratory
failure and required intubation and mechanical ventilation and eventually the patient underwent
a tracheostomy. The patient also underwent ureteral stent exchange on 7/19/10. The
patient ' s course was further complicated by the development of retroperitoneal fluid
collection which required drainage and interventional radiology on 7/13/10. The patient was
admitted to the current facility for long term acute care on 7/21/10. Review of the
admitting nursing assessment revealed the patient had a stage I to the sacrum, right buttock,
and left buttock and an intentionally open surgical wound. Review of the medical record
revealed pictures of the abdominal surgical wound and the sacrum and buttocks. Review of
the facility ' s policy, " Wound Assessment and Classification " , H-WC 02-001, last revised
5/2010, states wounds will be reassessed weekly with each dressing change and with any
significant change. Weekly assessments will be conducted by the wound care
coordinator/designee. Review of the wound care nurse weekly assessment on 8/04/10
revealed an assessment of the sacrum/buttocks as a stage I, 5 x 4 cm (centimeters). On
8/18/10 the weekly wound care assessment revealed the abdominal surgical wound
assessment only. There was no documentation of the sacrum/buttocks wound. The next
weekly wound care assessment was completed on 8/24/10 which revealed the
sacrum/buttocks as a stage I, 3 x 4 cm. There was no weekly assessment by the wound care
coordinator/designee for the sacrum/buttocks wound from 8/04/10 until 8/24/10. Interview
with the Director of Quality on 10/14/10 at 3:40 p.m. confirmed no documentation was
present and according to the facility's policy the patient's wound should be assessed weekly
by the wound care nurse. The facility failed to follow their policy and procedure for wound
care assessment and documentation.