HospitalInspections.org

Based on record review and interview, the facility failed to assess and document wound care per facility policy in one (1) of ten (10) patients (ID#1)

Findings include:

Record review of facility policy titled " Wound Care," dated 7/11/22 showed the following information:
Stage III (DEEP), STAGE IV, OR FULL THICKNESS WOUNDS
1. Irrigate the wound with NacL using a 35 cc syringe and 18g needle or other appropriate irrigation equipment as available (i.e. wound vac.)
2. Select appropriate dressing to cover wound...
7. Clean wound and replace dressing every 2-3 days and PRN if loosened or with drainage.

Review of medical record for patient (ID#1) was admitted through the emergency department 4/25/22. Upon arrival to the inpatient unit an unstageable wound on the patient's coccyx was documented in the nurses note. Initial wound assessment was completed and documented 4/25/22 at 17:45 and showed the following information:
Location: COCCYX
Stage: Not Stageable (wound bed not visible)
Size: Total area with redness is 15cm x 11.5cm
Total Blackened area is 8cm x 5.5 cm
Center opened area is 5cm x 3 cm
Slough:Extensive
Color: Black
Color Other: Large area of redness surrounding the wound
Odor: Yes
Drainage: Bloody
Treatment: Orders received to cleanse wound with NS, pat dry, cover with Santyl, and then apply dry dressing daily
Photograph taken: Yes

Nurses note dated 4/26/22 showed the following:
Wound care completed at this time, wound cleansed with NS and patted dry, covered with Santyl, and then covered with ABD and secured with tape. Aseptic technique used. Patient tolerated well...

No other wound care documentation was found.

Interview with DON (ID# 52) on 8/31/22 at 10:00 she stated the facility is looking into revising the wound care policy. Nurses are currently completing the full assessment with measurements, pictures, and documenting on the wound flow sheet every seven days. She went on to say that nurses are looking at the wounds daily and providing dressing changes. She acknowledged that this practice is different than what the policy states.


Interview with staff nurse (ID# 60) on 8/31/22 at 10:30, she stated that upon admission a wound assessment is completed with measurements and pictures taken. This is repeated every Sunday.