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Based on policy and procedure, medical record reviews, and interviews, the facility staff failed to measure, and document size of pressure wounds for 3 of 6 patients. (Patient #1, Patient #11 and Patient #14).

Findings included:

Review of the hospital policy titled, "Skin Care Protocol/Pressure Injury Prevention & Treatment" revised 06/2019 revealed, ..."6. Wound Care consult indicated for the following: ...b. Any patient with existing skin breakdown issues. c. Wound Care Consults should be seen within 24-48 hours based on patient's need. 7. Hospital acquired Pressure Injuries require an incident report. ...Wound Documentation Entry points: 2. Inpatients: Photographs should be taken of each wound: a. On admission to inpatient. b. At time of occurrence. c. Weekly. d. At discharge...Documentation to accompany photograph includes: 1. Wound dimensions. 2. Wound Descriptors as noted in the wound assessment...and to accompany photograph includes: 1. Wound dimensions. 2. Wound Descriptors as noted in the wound assessment...Stage II Pressure Injury: Defined a distinct break in the skin; partial thickness involving epidermis and possible penetration into, but not through the dermis...d. Measure (in centimeters [cm]) and document size and appearance.."

1. Review of the closed medical record for Patient #1 on 09/01/2020 revealed, with complaint of Chest Pain who was admitted to Intensive Care Unit (ICU) on 05/28/2020 at 1426 with Septic Shock (a widespread infection causing organ failure and low blood pressure)...Review of the History and Physical dated 05/28/2020 at 1255 by Medical Doctor M D #1 revealed a Chief Complaint of Abdominal Pain..."who presented to the ED today for Shortness of Breath over the past five days and severe abdominal pain this morning after drinking some juice. She has a past medical history of HTN (high blood pressure), HLD (hypersensitivity lung disease), TIA (transient ischemic with attack), CVA (Stroke), DM (Diabetes Mellitus)...Record review of the skin assessment dated 05/28/2020 at 19:15 by RN #1 identified 3 pressure wounds on admission: "Coccyx/Sacral 1, Activity: Assess, Abnormality type: Pressure Ulcer, Detail: Open, Color: Pink, Number of sites: 1, Pressure Ulcer Stage: 2, Pressure Ulcer Present on Admission: yes, Wound Care Consult needed: yes, Dressing type: Foam, Number of Foam pieces: 1, Dressing Assessment: Clean Dry and Intact...Wound/Skin Heel Left 1, Activity: Assess, Abnormality type: Pressure ulcer, Detail: Closed, Color: Black, Maroon, Number of sites: 1, Pressure Point: Bony Prominence, Pressure Ulcer Stage: Suspect Deep, Pressure Ulcer Present on Admission: Yes, Wound Care Consult needed: Yes, Dressing type: Open to Air...Wound/Skin Heel Left: 1, Activity: Assess, Abnormality type: Pressure Ulcer, Detail: Closed, Color: Maroon, Number of Sites: 1, Pressure Point: bony prominence, Pressure Ulcer Stage: 1, Pressure Ulcer Present on Admission: yes, Wound Care Consult needed: Yes." Record revealed the Wound/Ostomy Care Nurse (WOCN) was consulted and saw Patient #1 on 05/29/2020 at 1323. Review of the WOCN note revealed, Coccyx/Sacral 1: Activity: Assess, Abnormality Type: Pressure Ulcer, Detail: open, Pattern: Flat, Color: Pink,...Pressure Point: Bony Prominence, Pressure Ulcer Stage: 2, Pressure Ulcer present on admission: yes, Dressing type: Foam, Number of Foam pieces:1...Wound/Skin Heel Left 1, Activity: Assess, Abnormality type: Pressure Ulcer, Detail: Closed, Pattern: Flat, Color: Maroon... Pressure Ulcer Stage: Suspect Deep Tissue Injury, Pressure Ulcer on Admission: Yes." Review of WOCN documentation 05/29/2020 at 1323 revealed there was no documentation of wound measurements or size of the Coccyx or Left Heel pressure injuries for Patient #1. Patient #1 left the hospital against medical advice with daughter on 06/02/2020 at 1236.

Interview with the WOCN on 09/01/2020 at 1522 revealed, if there is a measuring device in the wound photograph she does not always do wound measurements and document size in the wound care notes. Interview revealed that the WOCN did not chart wound measurements for Patient #1's wounds to coccyx and left heel per policy.

Interview with Chief Nursing Officer, RN #8 on 09/03/2020 at 1105 revealed, "I have already seen that wound charting is not as it should be. I expect policy to be followed." Interview revealed that the WOCN did not follow the Skin Care Protocol/Pressure Injury Prevention & Treatment policy.

2. Closed medical record on 09/02/2020 revealed, Patient #11, an 85-year-old male patient admitted to the ICU from a Skilled Nursing Facility for Cardiac Arrest. Record review of the "Nursing Skin Assessment" on 06/3/2020 at 0000 by RN #11 revealed a wound to the coccyx, present on admission. Record review revealed a Wound Care Consult was electronically generated on 06/03/2020 at 1745. Record review of the "WOCN's Consult" dated 06/04/2020 at 1318 revealed: "Activity: Assess, Abnormality type: Pressure Ulcer, Surgical Incision Detail: Closed, Abnormality Pattern: Flat. Pressure Ulcer Stage: Suspect Deep Tissue Injury. Pressure Ulcer Present on Admission: yes." Review of the record revealed there was no documentation to accompany a photograph, or wound dimensions, no wound descriptors noted in the wound assessment by the WOCN. Record review of the "Patient Discharge Education" dated 06/10/2020 revealed no Education for family regarding assessment and wound care for Patient #11. Review of the record revealed that Patient #11 was discharged by transport services on 06/10/2020 at 1356 to home with hospice.

Interview with WOCN, RN #2 on 09/03/2020 at 1041 revealed that she charted her wound care assessment in the regular nursing wound flow sheet area. Interview revealed that she did not take or document wound dimensions for Patient #11. Interview revealed that the Skin Care Protocol/Pressure Injury Prevention & Treatment policy was not followed.

Interview on 09/03/2020 at 1105 with Chief Nursing Officer, RN #8 revealed, "I have already seen that wound charting is not as it should be. I expect policy to be followed." Interview revealed that the WOCN did not follow the Skin Care Protocol/Pressure Injury Prevention & Treatment policy.

3. Closed medical record on 09/02/2020 revealed, Patient #14, an 86-year-old female that was admitted to the hospital on 06/06/2020 from a rehabilitation facility for Weakness. Record review of the Nursing Skin Assessment dated 06/06/2020 at 2250 by RN #12 revealed a coccyx wound, stage II. Record review revealed a system generated WOCN consult dated 06/08/2020 at 0218. Record review of the WOCN documentation dated 06/08/2020 at 1212 revealed "Incision/Wound/Skin Coccyx: Activity: Assess, Pressure Point: Bony Prominence, Dressing Type: Foam." Review of the WOCN RN #2's assessment revealed no documentation of wound dimensions or size noted of the Coccyx. Review of the record revealed that Patient #14 was discharged to the facilities in-house rehabilitation unit on 06/11/2020 at 1146.

Interview with WOCN, RN #2 on 09/03/2020 at 1041 revealed she charted her wound care assessment in the regular nursing wound flow sheet area. Interview revealed that she did not take or document wound dimensions or size for Patient #14. Interview revealed that the WOCN assessment completed on 06/08/2020 at 1212 was the only assessment documented by the WOCN. Interview revealed that the Skin Care Protocol/Pressure Injury Prevention & Treatment policy was not followed.

Interview on 09/03/2020 at 1105 with Chief Nursing Officer, RN #8 revealed, "I have already seen that wound charting is not as it should be. I expect policy to be followed." Interview revealed that the WOCN did not follow the Skin Care Protocol/Pressure Injury Prevention & Treatment policy.

NC00166347