HospitalInspections.org

Based on record review and interview, nursing staff at this facility failed to accurately assess and document wound assessments per policy for 4 out of 10 patient's (Patient #1, 3, 5, and 7) medical records reviewed. Failure to accurately assess and document wound status has the potential to affect all patients with wounds at this facility, current active census (averaged) at the time of the survey is 157.5 (unknown how many have wounds).

Findings include:

The facility's policy titled, "Assessment/Reassessment of Patients," which is not numbered, and stated to be current as of the day of printing (4/5/2016) was reviewed on 4/5/2016 at 4:30 PM. The policy states in part, "On admission, all inpatients will have a head to toe skin assessment which will include the documentation of any pressure ulcers or other non intact skin, including a description and measurement...A head to toe assessment is to be completed 2 times a day and as needed."

In an interview with Nurse Administrator B on 4/5/2016 at 4:30 PM regarding the facility's policies not having dates on them, Administrator B stated that the policies are considered current as of the day of printing.

The facility's procedure titled, "Skin Care Assessment/Monitoring and Wound Photography Guideline," which is not numbered and stated to be current as of the day of printing (4/5/2016) was reviewed on 4/5/2016 at 6:55 PM. The procedure states in part, "A thorough skin assessment will be completed and documented within 24 hours upon admission/transfer to unit and then a minimum of every 12 hours...Measurements will also be documented in the integumentary section of the patient's chart with each dressing change, or every 24 hours if there is no dressing."

The facility policy titled, "Pressure Ulcer Management," which is not numbered and stated as being current as of the day of printing (4/6/2016) was reviewed on 4/6/2016 at 12:10 PM. The policy states in part, "Pressure ulcers are assessed on admission, at initiation of treatment, with each dressing change or care intervention, upon transfer, and prior to discharge."

The facility's policy titled, "Wound Assessment," which is not numbered and stated as being current as of the day of printing (4/5/2016) was reviewed on 4/6/2016 at 12:15 PM. The policy states in part, "A wound assessment is completed upon admission, with each dressing change, and with changes in a patient condition or status of the wound." The following assessment criteria are listed as expectations of the wound assessment and documentation: location, type of wound, type of tissue in the wound base, measurements, drainage amount and type, odor, the appearance of the skin around the wound, and presence or absence of signs or symptoms of infection.

Patient #3's closed medical record for the episode of 12/6/2015-12/18/2015 was reviewed with Informatics Nurse C on 4/5/2016 at 2:12 PM. Nurse Administrator B and Manager of Regulatory Resources I were also observing. The following findings were confirmed by all at the time of the record review: The facility's electronic medical record has a built in phrase in the integumentary [skin] section that states, "Surgical incisions are considered not intact until completely healed." Patient #3 had a surgical incision site that was identified on the nursing admission integumentary assessment on 12/6/2015 at 10:34 PM as not intact. There are no measurements recorded.
On 12/7/2015 at 6:39 AM the skin is marked as intact. At 7:00 PM on 12/7/2015 the skin is marked as not intact.
On 12/8/2015 at 7:30 AM and 7:40 PM both entries indicate skin is not intact.
On 12/9/2015 at 6:40 AM the skin is marked as not intact, at 4:30 PM the skin is marked as intact, at 10:20 PM the skin is marked as not intact.
On 12/10/2015 the skin is marked as not intact at 7:42 AM and 7:57 PM.
On 12/11/2015 the skin is marked as intact at 8:45 AM, not intact at 7:00 PM.
On 12/13/2015 the skin is marked as not intact at 7:30 AM and intact at 7:04 PM.
On 12/14/2015 the skin is marked as not intact at 6:50 AM and intact at 7:40 PM.
On 12/15/2015 the skin is marked as not intact at 7:30 AM, 4:00 PM, and 10:50 PM.
On 12/16/2015 the skin is marked as intact at 7:20 AM and 3:15 PM.
On 12/17/2015 the skin is marked as not intact at 12:45 AM, 6:53 AM, intact at 3:30 PM and not intact at 10:40 PM.
On 12/18/2015 the skin is marked as not intact at 7:20 AM and 2:45 PM.

There are no communication notes in the medical record to explain the inconsistency in the documentation of the surgical incision.

Per interview with Informatics Nurse C during the medical record review, Nurse C stated that C was seeing the same inconsistencies in skin status documentation and stated, "I can't explain the discrepancy." Nurse Administrator B and Manager I also agreed that there were discrepancies with the documentation.

Per interview with Nurse Administrator B on 4/5/2016 at 3:00 PM regarding the expectation of the frequency of skin assessments by nursing staff, Administrator B stated that the expectation is minimally twice per day.


Patient #5's closed medical record from the 12/31/2015-1/9/2016 episode was reviewed with Informatics Nurse C on 4/6/2016 at 9:26 AM. Chief Nursing Officer A, Nurse Administrator B and Manager of Regulatory Resources I were also observing. The following findings were confirmed by all at the time of the record review: Patient #5 was admitted this episode with chronic heart problems and is Diabetic. The nursing admission assessment on 12/31/2015 indicated a toe nail deformity and the skin was intact. A subsequent assessment on 1/2/2016 no longer shows a toe nail deformity and there is no documentation to support why this deformity is no longer is present. On 1/9/2016, the day of discharge, a skin assessment is not documented. The wound graph identifies the right toe as a problem but there is not a description of what that problem is.


Patient #7's closed medical record from the 12/29/2015-1/12/2016 episode was reviewed with Informatics Nurse C on 4/6/2016 at 10:29 AM. Chief Nursing Officer A, Nurse Administrator B and Manager of Regulatory Resources I were also observing. The following findings were confirmed by all at the time of the record review: Patient #7 was admitted on 12/29/2015 with Pneumonia and according the the physician's discharge summary for this episode is a brittle diabetic and had pressure ulcers upon admission to the heel and mid foot and a sacral/coccyx (base of spine and top of buttocks) ulcer.
The nursing admission assessment was completed on 12/29/2015 at 6:56 PM and indicates Patient #7 had open wounds/ulcers on both heels, an elbow, the buttocks and coccyx.
All wounds were measured on 12/29/2015 and 12/31/2015. There are wound care orders from the physician dated 12/30/2015 to apply a foam dressing to the heels and elbow and change the dressing every 3 days and as needed. There are no orders for wound care to the coccyx.
On 1/3/2016 at 6:30 AM the dressing was changed to the coccyx, the documentation does not include the characteristics of the wound or measurements.
On 1/4/2016 the dressings to the heels were changed and all criteria is documented.
On 1/6/2016 at 9:00 AM dressings were changed to all sites (heels, elbow, coccyx area) but there are no measurements for the heel wounds.
On 1/9/2016 at 7:47 AM the dressings were changed to all sites and there are no wound measurements for any of the wounds.
On 1/11/2016 at 6:40 AM the dressings were changed to all sites, the color of the wounds is not documented and the measurements are not documented. The heels were not measured for 8 days/3 dressing changes, including the day of discharge. The elbow and sacral/coccyx wounds were not measured for 5 days/2 dressing changes.

In an interview with Wound and Ostomy Certified Nurse G on 4/6/2016 at 11:00 AM regarding no order for the foam dressing for Patient #7's sacral/coccyx ulcer, Nurse G stated that in the critical care unit, where Patient #7 was a patient, the nurses can use their discretion to use foam dressings as a preventative measure for pressure areas, which the sacral/coccyx area is. Nurse G and Administrator B were unable to explain why there would be physician orders for wound care to Patient #7's heels and elbow and not the sacral/coccyx area if all were present on admission.

Per interview with Nursing Informatics C on 4/26/2016 at 10:45 AM regarding the expectation of where skin/wound assessments are to be documented in the electronic medical record, Nursing Informatics C stated there are 2 sections. "If it's a wound or pressure ulcer it should be documented in the wound section. If it's an abnormality like a rash or something like that it is supposed to be in the abnormality section."


Patient #1's closed medical record from the 10/28/2015-11/4/2015 and 11/10/2015-11/18/2015 episodes was reviewed with Informatics Nurse C on 4/6/2016 at 2:20 PM. Chief Nursing Officer A, Nurse Administrator B and Manager of Regulatory Resources I were also observing. The following findings were confirmed by all at the time of the record review:
Patient #1 was admitted to this facility on 10/28/2015 with a gastrointestinal bleed (bleeding somewhere in the digestive tract). Patient #1 is also Diabetic. On 11/10/2015 Patient #1 was re-admitted for Osteomyelitis to the left foot (bone infection) and required intravenous antibiotic therapy.

The admission assessment on 10/28/2015 indicates in the skin abnormality grid bruising on both lower legs. In the infliction/wound grid it indicates a dry well healed scab to the left ankle. There is no dressing and there are no measurements.

Between 10/29/2015 and 11/2/2015 the skin abnormality grid indicates bruising on the left and right lower leg. The wound grid indicates bruising on the coccyx and a small scab to the left ankle. There is no mention of wounds to any of the toes during this time period.

On 11/3/2015 at 12:04 AM there is documentation identifying an abrasion (scrape) to the left great toe that is dry with granulation tissue (new tissue growth that forms on the surface of a wound) with a pink/tan base that is .5 centimeters by .5 centimeters in size. Per interview with Nurse Informatics C on 4/5/2016 at 2:45 PM, the actual assessment time of this entry was 7:58 PM on 11/2/2015. Nurse Informatics C was able to identify the actual assessment time through internal computer monitoring. Nurse Informatics C stated that 12:04 AM on 11/3/2015 is the time the nurse entered the documentation into the electronic medical record.

Between the assessment on 11/2/2015 at 7:58 PM and There is no other mention of any other wounds or skin issues other than the bruising on the lower legs and the scab on the left ankle between 11/3/2015 at 12:04 AM until 11/4/2015 at 4:56 AM when the toe nail on the 3rd toe of the left foot was discovered to be loose and slightly bleeding for a total of 3 subsequent assessments. Nursing assessments completed after 11/4/2015 at 4:56 AM identify the loose and slightly bleeding third toe on the wound grid but there is no assessment criteria for any of the other toes through the point of discharge on 11/4/2015.

A podiatry consult (foot doctor) was completed on 11/4/2015 prior to Patient #1's discharge and identifies, "Stable-appearing healing wounds of the 1st and 2nd digits [toes] left foot, and self-avulsed [removed] nail plate left 3rd digit."

Per interview at 2:48 PM on 4/6/2016 with Chief Nursing Officer A, Nursing Administrator B, Manager of Regulatory Resources I, and Nurse Informatics C, Chief Nursing Officer A agreed there were inconsistencies in the assessments of Patient #1's wounds, agreed that if the podiatrist identified healing wounds on the first two toes of the left foot that they would have been there for awhile and not just that day, and agreed that there is inconsistency in the documentation of wounds.