HospitalInspections.org

Based on record review, and interview, the facility failed to provide organized nursing services when patients with wounds were not being assessed for signs of infection. This failure places patients at risk of increased pain, a possible delay in treatment, and infection.

Findings include:

Review of Patient #1's Physician's Orders dated, 7/18/23 reflected, "Please perform wound care dressing change on patient every morning (7-3 shift) and evening (3-l1 shift). In additional, provide wound care/dressing change as needed AND when patient requests it."

Review of Patient #1's Inpatient Wound Care Notes WOCN Consult/Progress Note Entered On: 5/1/2023
stated, "Visit Type WOCN: Initial assessment/Evaluation Treatments Planned-WOCN: Pressure injury prevention, Skin care management, Wound care
New Treatment Plan Details-WOCN : Wound care to f/u MWF, next Wednesday 5/3
Progress Note WOCN: Wound care to evaluate patient for a fungating tumor on the R breast
Wound measures approximately 12x72 cm, with three small, ulcerated areas. Visible wound beds are pale pink. Overall, skin on the breast appears to be thick, purple/grey scarring/fibrosis likely from healing and reopening frequently. Very malodorous, slightly painful to touch. Took wound cultures at bedside. Slightly friable. Unable to assess the amount of daily drainage.
Patient does not believe that she has cancer and gets very agitated if you say that the wound is from cancer."

Review of Patient #1's nursing assessments did not include a daily assessment of the wound.

Review of Patient #2's physician order dated 7/6/2023 reflected, "wound care orders: 1) right heel allograft: clean with normal saline, 4x4 gauze, kerlix, tape, change 3 times per week. 2) left calf wound care orders: 1) right heel allograft: clean with normal saline, 4x4 gauze, kerlix, tape, change 3 times per week. 2) left calf: medihoney, Hydrofera blue, 4x4 gauze, tape, change 3 times per week. 3) float right heel at all times. Non weight bearing, right heel
1 EA Other-Scheduled wound care orders: 1) right heel: allograft, 4x4 gauze, kerlix, tape, change 3 times per week. 2) left calf: medihoney, Hydrofera blue, 4x4 gauze, tape, change 3 times per week. 3) float right heel at all times. Non weight bearing, right heel: medihoney, Hydrofera blue, 4x4 gauze, tape, change 3 times per week. 3) float right heel at all times. Non weight bearing, right heel 1 EA Other-Scheduled wound care orders: 1) right heel: allograft, 4x4 gauze, kerlix, tape, change 3 times per week. 2) left calf: medihoney, Hydrofera blue, 4x4 gauze, tape, change 3 times per week. 3) float right heel at all times. Non weight bearing, right heel."

Review of Patient #2's nursing assessments did not include a daily assessment of the wound.

During an interview on, 07/26/23 at 3:00 pm in the admin conference room, Staff #1, CNE (Chief Nursing Executive) confirmed the nursing notes did not reflect a description or details of the wound and that the facility did not have a procedure in place for the tracking of wounds. Staff #1, stated, "We don't have a lot of medical care. (patients requiring extensive medical treatments) We talked about it (the lack of documentation), we are putting a process in place."