HospitalInspections.org

Based on review of medical records (MR), facility policy and interviews with the staff it was determined the facility failed to ensure:

a) All physicians orders were written for wound care and documented in the MR.

b) All wounds were measured and documented in the MR according to facility policy.

c) All wound care provided was documented within the MR.

This affected 3 of 14 inpatient records reviewed and did affect MR # 12, MR # 14, MR # 13 and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Pressure Ulcer Prevention and Wound Care
Policy Number: SKI-04
Date Reviewed: 2017

Policy:
Upon admission, daily and per policy, every patient will be assessed for pressure ulcer risk by an assigned RN (Registered Nurse) / LPN (Licensed Practical Nurse).

Dressing Changes and Assessment

During dressing changes, the RN/LPN shall assess and document the following:
a. Location of the pressure ulcer
b. Size (length and width at largest area).
c. Color, temperature, edema, odor, moisture and appearance of skin around the ulcer.
d. Stage of the wound.
e. Exudate and drainage

Policy: Skin Care and Wound Treatment Options
Policy Number: SKI-02
Date Reviewed: 04/2017

Purpose:
To provide treatment guidelines for skin care and wounds
To establish procedure for RNs/LPNs to initiate skin care and wound treatment

Policy:
Skin issues found with assessments, Braden Scale Risk Assessment (BSRA) tool, and daily ADL (activity of daily living) and interactions will be documented in the Wound Care Flowsheet and with photos.

Only an RN who has received training and demonstrated competency on wound assessment and staging will stage wounds.

Orders and interventions will be initiated per protocol, unless otherwise ordered by a physician, and documented on the MAR (medication administration record)/MedAct and Wound Care Flowsheet...

1. MR # 12 was admitted to the facility on 5/11/17 with admitting diagnoses of Stage 2 Decubitus, Weakness and COPD (Chronic Obstructive Pulmonary Disease).

Review of the RN initial assessment dated 5/11/17 revealed the nurse documented at 7:27 PM the following order: Consult Wound Care for evaluation and treatment recommendations.

Review of the physician order dated 5/12/17 revealed the following order: Clean with NS (normal saline) wash and apply collagen, after collagen apply skin protective barrier, wipe to surrounding skin and cover with hydrocolloid dressing and change twice a week.

Review of the nursing documentation dated 5/12/17 revealed the RN documented under Metabolic/Integument Assessment Skin condition "Location: Lesion to left knee".

Review of the Wound Care Flowchart revealed the RN documented the following:
Location of wound: "See Unisex Body documentation". Wound Type/Age: "Pressure sore". Wound Drainage: "none", Wound Odor: "none" and Dressing: "dressing clean, dry and intact".

Review of the Wound Care Flowchart revealed no documentation of staging of the wound, appearance of the wound, wound measurements or dressing change to the wound.

Review of the 5/14/17 nurse note revealed the nurse documented under the wound care flowchart Type/age: Ulcer, Wound Dimensions (cm) (centimeters): Moist and dry, Wound edges/surrounding tissue: smooth, Wound Closure: well approximated, Wound Cleaned: Wound cleanser, Dressing: Endoform and thin hydrocolloid dressing, Wound Interventions: Dressing changed, as ordered.

Review of all the physician orders within the MR revealed no documentation of an order for the above mentioned dressing change which contains Endoform.

An interview was conducted on 6/8/17 at 8:10 AM with EI # 1, Director of Nursing, who confirmed the above mentioned findings and also stated "the nurse did not write an order for the new wound care and dressing change".



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2. MR # 14 was admitted to the facility on 6/5/17 with diagnoses including Weakness, Debility, Cerebral Vascular Accident with Left Hemiparesis, Coronary Artery disease with recent Myocardial Infarction.

Review of the Patient Progress Note dated 6/5/17 at 5:39 PM and amended at 5:40 PM revealed the nurse documented, "... g-tube (gastrostomy tube) dressing changed. area cleaned. purulent drainage noted at site. tx (treatment) in place..."

There was no documentation of the solution used to clean the g-tube site, treatment that was in place or that the physician was notified of the purulent drainage at the g-tube site.

A list of questions was given to Employee Identifier (EI) # 1, Director of Nursing on 6/7/17 to include the above findings.

An interview was conducted on 6/8/17 at 8:05 AM with EI # 1, who presented "clarification" documentation to the Patient Progress Note dated 6/5/17. A review of this "clarification" documentation revealed the nurse documented on 6/7/17 at 5:19 PM, "... clarafication (clarification) of notes on wound care. wound cleansed with ns (normal saline), pat dry. covered with split sponge..." EI # 1 verified the nurse documented the above after it was identified by the surveyor and the list of questions was given to EI # 1. EI # 1 stated there was no documentation the nurse notified the physician of the above findings.



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3. MR # 13 was admitted to the facility on 12/26/16 with admitting diagnoses of S/P (Status Post) Surgical Repair of Obstructed Abdominal Wall Hernia, wound to sacrum/coccyx stage 2, wound to left lower leg stage 2, and weakness.

Review of the RN initial assessment dated 12/26/16 revealed the nurse documented the patient's skin condition as: "... stage 2 to coccyx. Also a stage 2 to left lower leg..." at 5:26 PM.

Review of the physician's order dated 12/29/16 revealed the following order: "Late entry for 12/26/16. Clean wound to sacrum/coccyx w (with) / NS (normal saline) - apply mepilex and change PRN (as needed)."

Review of the Wound Care Flowchart revealed the RN documented the following:
"Location of wound: See Unisex Body documentation. Wound Type/Age: Pressure sore. Wound Drainage: none." Further review of the Unisex Body documentation dated 12/26/16 revealed the nurse failed to document the measurements, appearance, and staging of the wound per policy.

Review of the RN Patient Progress Notes dated 12/27/16, 12/29/16, and 1/4/17 revealed documentation of wound care. The nurse failed to document wound care and measurements per policy during every dressing change.

An interview was conducted on 6/8/17 at 8:25 AM with EI # 1, Director of Nursing, who confirmed the above mentioned findings.