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Based on observation, interview, and record review, the facility failed to document information necessary to monitor the patient's condition in 6 (#1, #2, #6, #7, #8, and #10) out of 10 sampled patients (SP) as evidenced by lack of wound assessment data on various shifts throughout the continuum of each patient length of stay at the facility.

The standard is NOT met. The findings include:

Observation on 5/31/2011 at 2:53pm of sample patient #2 revealed that she was scheduled for wound care during this shift. The primary nurse was to provide wound care, however since the patient had multiple wounds and was complete care, another nurse was to accompany and assist in wound care. Appropriate personnel protective equipment was also at the door for personnel and visitors entering the room. Further observation revealed that SP #2 was on a specialty bed with an air mattress, which is used for patients with pressure ulcers. An intravenous fluid was infusing into her right forearm. There was a peg tube observed, a flexi seal pouch and a foley bag observed with dark yellow urine in bag. This patient is ventilator dependent with a tracheostomy. Patient is arousable but is not able to communicate verbally or respond appropriately.
A total of 8 wounds were being treated which included: Sacrum - unstageable; Right buttocks - Stage III with Unstageable areas; Left Lateral Leg - Unstageable; Left Heel - Unstageable; Right Hip - Stage I; Right Knee - Stage II; Right Medial Leg - Stage III; Right Heel - Unstageable. Aseptic technique was observed during wound care treatments.

Interview of SE#3 confirmed that she was the primary nurse for SP#2 and that staff nurses provide wound care treatments every shift. This was confirmed upon review of physician orders. . SE#3 reports that she provides wound care treatments per doctor ' s orders and then documents those treatments in her nurse ' s notes in the facility ' s electronic record system. Review of the treatments observed today did not include an assessment of wound size for any of the wound in the electronic medical record.

Clinical Record review of SP#1, #6, #7, #8, and #10 also revealed that, throughout each of the patient's length of stays at the facility, there are inconsistencies in charting the assessment of sizes and other characteristics of various pressure ulcers. Record review of documentation from nursing, wound care nurse, and medical staff do not address assessment of wound size and other characteristics. Although there are various pictures on each of these charts, there are no rulers/mearsurements on the pictures. Documentation on the facility paper forms and electronic medical records lack this data as well, for each of the above patients.

On 5/31/2011 at 1:27pm, interview with the director of the progressive care unit regarding wound care assessment documentation. She confirms that all areas of the wound care assessment paper forms should be filled in by the nursing staff. She also confirms that all areas of the skin care documentation in the medical record should be filled out by the nursing staff. She confirmed the inconsistencies found on the charts on her unit related to wound care on the above mentioned patients.

Review of the facility policy and procedure titled: Wound Care Policy reveals at Step 2: [to]measure wound with measuring guide.