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Based on record review, interview and hospital policy the nursing staff failed to assess and document wounds, document specific wound care that was provided and follow physician orders for wound care. This affected Patient Identifiers (PI) # 2, # 1, # 9, # 4 and # 12, five of ten sampled patients with wounds, and had the potential to affect all patients served.

Nursing staff also failed to provide baths for PI # 12. This affected one of ten sampled patients and had the potential to affect all patients served.


Findings include:

1. Patient Identifier (PI) # 2 was admitted to the hospital on 1/31/16 with diagnoses of Pneumonia, Encephalopathy, and Transverse Process Fracture times four. PI # 2 was a current patient at the hospital during the survey.

Physician wound care orders.

On 2/01/16 a physician verbal order was written to obtain Hydrofera blue dressing, cut piece to place in left great toe wound after moistening dressing with saline. Cover with a dry gauze. Change dressing daily.

On 2/02/16 a physician order was written for Hydrofera blue wound dressing, 4 X 4 gauze and tape.

On 2/03/16 a physician order was written for wound care to be performed Monday, Wednesday and Friday to the left great toe. The order was for Hydrofera Blue damp with saline, cover with 4 X 4 gauze and tape.

On 2/10/16 a physician verbal order was written for wound care as follows: Clean right upper extremity, right knee skin tears with saline daily. Apply Xeroform gauze, cover with 4 X 4 and Kerlix. Apply Allevyn adhesive to right perirectal area and change every 3 days.

Nursing Notes

A review of the nursing notes for PI # 2 dated 1/31/16 at 4:30 PM documented under integument assessment the patient was covered with bruises across lower back, hips, both legs and both arms. It was also documented the patient had skin tears to the right wrist, scaly red discolorations of the right shin, and the left great toe had a small deep vascular diabetic wound that had a small bright blue wound packing.

There was no description of the bruises or skin tears. The left great toe wound was not measured and staff did not document the physician was notified of the wound dressing that was in place when the patient was admitted. There were no orders obtained to provide wound care or treat the skin tears that were identified by nursing staff.

A review of the nursing notes dated 1/31/16 at 5:55 PM, by a different nurse, documented under the integument assessment: "Tunneling wound on left great toe. Packing and dressing intact from home. Multiple bruises on bilateral arms, sides, back, bilateral legs. Some skin tears present as well on all extremities."

There was no description of the bruises or skin tears, how the staff knew the left great toe was tunneling nor measurements of the wounds and skin tears. There was no documentation the physician was aware of the tunneling wound or orders for providing wound care and protecting the patient's skin.

A review of the nursing notes for PI # 2 was completed by the surveyor. The only documented days wound care was provided to PI # 2 was on 2/09/16 at 6:40 PM. The nurse documented under the integument assessment: "Changed dressing to left great toe, no drainage noted. Cleansed with saline. Applied Hydrofera Blue, damp with saline, 4 X 4, and wrap with conform...Wound to right leg, no drainage noted...cleanse with saline. Applied Xeroform, Telfa, and conform. Change dressing to right forearm, cleanse with saline, small amount of bloody drainage and muco-purulent drainage noted, applied Xeroform, Telfa, and kerlix..."

There was no physician order for the use of a Telfa dressing and this was the first mentioning of PI # 2 having a wound to the right leg and right forearm. No wound measurements were taken and no description of the bruising or wound to the right perirectal area was documented.

The nursing notes from 1/31/16 to 2/18/16, were reviewed. The 2/09/16 wound care is the only documented wound care provided to PI # 2. All other nursing assessments document in the integument assessment the dressing is dry and intact. There is no documented description of the wounds, dates or times when dressing changes are provided, locations of which dressings are dry and intact, notification to the physician of new wounds or changes in the integumentary system, new wound care orders or if the wounds were improving or deteriorating.

During a review of the electronic medical record with Employee Identifier (EI) # 1, Informatics Nurse, on 2/18/16 at 10:10 AM, it was confirmed this was the only documentation in the medical record and staff failed to document wound assessments, descriptions, wound care and wound care orders.

2. PI # 1 was admitted to the hospital on 2/07/16 with a diagnoses of Altered Mental Status, Dehydration, Recent Rib Fractures, Encephalopathy and Hypothermia.

Physician wound care orders

On 2/09/16 a physician verbal order was written to apply vaseline gauze to bilateral lower extremities open skin tears daily, cover with an abdominal pad and kerlix. For the right buttock wound the order was to apply Allevyn adhesive and change every 3 days. Staff were to apply calmoseptine to irritated skin on buttocks and thighs as needed for incontinence.

Nursing Notes

On 2/18/16 at 8:25 AM, the surveyor reviewed the electronic medical record for PI # 1 with EI # 1. The initial nursing assessment dated 2/07/16 at 1:32 AM, by the Intensive Care Unit nursing staff, documented PI # 1's skin as fragile, thin, not intact with skin tears to the left and right elbows and left and right knees.

There was no description of the skin tears during this assessment, only the dressing was dry and intact.

On 2/07/16 at 8:00 AM, nursing staff documented a hydrocolloid dressing was applied to the right gluteal region. This is the first mentioning of a wound to the gluteal region. There were no specific wound measurements or wound description documented. In addition, there was no order for the hydrocolloid dressing applied by staff and no documentation the physician was aware of the skin breakdown.

On 2/08/16 at 8:55 AM, nursing staff documented excoriation to the buttocks, peri area and scrotum with small spot on scrotum "oozing blood" from meatus. Staff documented two hydrocolloid dressings were on the buttock.

There was no documentation the physician was aware of the skin changes, oozing blood from the meatus and there was no documented interventions put in place to address these findings.

On 2/09/16 at 1:26 PM, nursing staff documented a wound photo was taken of the left great toe and second digit. This is the first documentation of a wound to the left great toe and second digit. Staff also documented PI # 1 now had a stage 2 decubitus ulcer on the right buttock.

There was no documentation the physician was aware of the skin changes, what interventions were put in place to prevent further skin breakdown, measurements or descriptions of the wounds that had been identified by staff, or wound care provided.

On 2/10/16 at 11:36 AM and again at 3:02 PM, nursing staff documented a dressing change to the left and right arm skin tears. Staff documented a vaseline gauze and abdominal pad were placed of the skin tears and secured with kerlix.

There was no documentation about PI # 1's other identified wounds.

On 2/11/16 at 1:37 PM, nursing staff documented a vaseline gauze was applied and wrapped with kerlix. There was no documentation of which wound this dressing was applied to nor a description of the wound.

On 2/12/16 at 9:34 AM, nursing staff documented PI # 1 had multiple skin tears on both arms, knees and toes with multiple bruises. Staff also documented PI # 1's "bottom, groin area is red and raw." Staff documented wound drainage was "bloody" but failed to document which wound had bloody drainage and what intervention was provided, if any. During this same assessment, staff documented a vaseline dressing was applied, but no documentation of where this dressing was applied.

On 2/13/16 at 3:32 PM, nursing staff documented a dressing change to PI # 1's arms by cleaning with normal saline, applying a vaseline gauze and covering with a 4 X 4 and tape.

The order was to cover with an abdominal pad and kerlix.

On 2/14/16 at 3:45 PM, nursing staff documented a dressing change, location of wound not documented, as cleaned with normal saline, vaseline gauze applied, abdominal pad and kerlix.

On 2/14/16 at 8:50 PM, nursing staff documented buttock was excoriated and open to air. At 10:30 PM, PI # 1 was transferred back to the Intensive Care Unit (ICU). At 10:33 PM, ICU staff documented all four extremities had multiple lacerations that were scabbed and healing and the groin and buttock were excoriated with skin tears noted.

There was no other documentation about PI # 1's wounds documented for this assessment.

On 2/15/16 at 7:31 AM, nursing staff documented redness to sacrum, skin tears to bilateral arms and multiple scabs noted to upper and lower extremities. Then, at 9:45 AM, nursing staff documented the top layer of skin "removed from sacrum x 2 spots." Staff documented Allevyn dressing was placed over the site. Staff also documented skin tears to both arms with a minimal amount of serous drainage noted - cleaned with normal saline, vaseline gauze and abdominal pad placed over the site and secured with kerlix and tape. At 7:29 PM, nursing staff documented top skin layers removed from sacrum, unable to assess due to Allevyn dressing in place.

On 2/16/16 at 7:00 AM, nursing staff documented skin tears to the left and right elbow and forearm and that the dressings were changed with vaseline gauze and secured with blue tape.

The order was to cover with an abdominal pad and kerlix. There was no documented description of the wounds, if the wounds were cleaned and how the patient tolerated the dressing change.

On 2/16/16 at 7:37 PM, nursing staff documented top layers of skin removed from buttocks, Allevyn dressing removed and cream (no documentation of what type of cream) applied.

On 2/17/16 at 7:15 AM, nursing staff documented a pressure ulcer to the buttock with loss of dermis, but no other information about this wound. At 7:53 AM, nursing staff documented top layers of skin removed from buttock, cream applied (no documentation of what type of cream) and abrasions to both arms had a vaseline gauze applied.

On 2/18/16 at 7:30 AM, nursing staff documented arms dark, "several" decubitus on buttocks - edges not approximated, "good granulation."

The hospital staff failed to have wound care orders for the care that was documented as provided, failed to provide wound care as ordered by the physician, failed to follow the hospital policy for wound care documentation and notify the physician of changes in the skin status of PI # 1.

3. PI # 9 was admitted to the hospital on 12/25/15 with a diagnosis of Respiratory Distress due to Pulmonary Edema. PI # 9 was transferred from the nursing home where he resided. On the nursing home face sheet under additional current diagnosis, pressure ulcer of sacral region, unstageable, was listed.

Physician orders for wound care:

The only orders for wound care found in the medical record for PI # 9 were dated 12/25/15 and only signed by a Registered Nurse. The document titled "Physician Orders" Stage 1 Pressure Ulcer Decision Tree noted wound care was to be provided to the left foot. The section of the order for the type of dressing (Apply Hydrocolloid dressing) had been lined through and hand written in was Allevyn dressing. The section of the order for the frequency of dressing changes (Change every 3 - 5 days and as needed) had been lined through and the number 3 (indicating every 3 days) was circled. There were no initials, dates or times of when these changes to the Physician Orders had been made by staff. A computer print out of the wound care orders was provided to the surveyor. A review of the computer printed wound orders only documented the date, 12/25/15 and wound care after hours, left foot, change dressing every 3 days and as needed. There was location of the wound, no type of dressing listed or what the wound was to be cleaned with prior to applying the new dressing. The hospital record had no orders to provide wound care to the pressure ulcer on PI # 9's sacral area that was listed on the nursing home current diagnosis list.

Nursing Notes

A review of the electronic medical record was conducted with EI # 1 on 2/17/16 at 3:30 PM. A review of the nursing documentation revealed the following information related to PI # 9's skin and wounds:

On 12/26/15 at 2:55 PM, nursing staff documented two healing wounds to the left lateral foot and an Allevyn dressing was placed on the wound site.

There was no physician approved order for the placement of the Allevyn dressing, no wound description, no wound measurements and no documentation if the wound site was cleaned prior to the placement of the dressing or how the patient tolerated the procedure. There was no documentation of a sacral wound for this assessment.

On 12/26/15 at 9:06 PM, 12/27/15 at 8:52 PM and 12/28/15 at 7:40 AM, nursing staff documented the left lateral foot had two wounds that were open to air with no drainage or odor noted.

On 12/28/15 at 7:20 PM, nursing staff documented "scabbed area" to left lateral heel.

On 12/29/15 at 9:23 AM, nursing staff documented left lateral heel area scabbed, dry and intact.

On 12/30/15 at 10:00 AM, nursing staff documented pressure ulcer heel and buttock area, "came from NH (Nursing Home) with these."

There was no documentation of a wound description or wound measurement, no documentation of which heel had the pressure ulcer, the pressure ulcers were not staged or measured and there was no documentation of what intervention was in place for these two pressure ulcer wounds. This is the first time nursing staff document a wound to the buttock area since admission on 12/25/15.

On 12/30/15 at 4:17 PM, PI # 9 was discharged from the hospital and transferred back to the nursing home.

On 2/18/16 at 8:14 AM, EI # 1 was asked if there was an order for the changes made to the standing Physician Orders for the type of dressing and dressing change frequency for PI # 9 and EI # 1 confirmed there was no order clarification for the changes made. EI # 1 also confirmed the wounds were not measured during PI # 9's hospital stay and staff failed to follow the physician's orders for wound care.


4. PI # 4 was admitted to the hospital on 2/8/16 with diagnoses to include Acute on Chronic Congestive Heart Failure with Edema, Coronary Artery Disease, Hypertension and Blisters on feet bilaterally. PI #4 was a patient in the hospital at the time of the survey.

A review of a wound care consultation dated 2/8/16 revealed, "Present a few weeks. Significant edema bilateral lower extremities. Pt. (patient) reports some weeping to wounds LLL (Left Lower Leg). Significant edema to bilateral lower extremities and erythema LLE (Left Lower Extremity). Post (posterior) tib (tibia) pulse diminished. Full thickness ulcer noted to posterior aspect of left heel with fat layer exposed. No purulent drainage. Mild serous exudate. 3.5 x 3.5. No tunneling. Small amount weeping of ulcer to LLE just above ankle..."

Physician Wound Care Orders:

On 2/11/16 a physician order was written for Xeroform to cracked heels. Aquacel Ag to open wounds on both legs and feet qod (every other day)- Wrap ankles, foot and legs with Kerlix or snug ace or Coban (self adhering wrap).

Nursing Notes:

A review of the electronic nurses' notes dated 2/10/16, 2/12/16, 2/13/16 and 2/16/16 revealed no documentation wound care was provided with Xeroform and Aquacel as ordered every other day to PI # 4's wounds. The lack of documentation of care was verified by the Clinical Informatics RN, EI #1, on 2/17/16 at 3:00 PM.


5. PI # 12 was admitted to the hospital on 2/13/16 with diagnoses to include Breast Cancer and Left Chest Wall Surgical Wound. PI # 4 was a patient in the hospital at the time of the survey.

Physician Wound Care Orders:
2/13/16: 4:27 PM: Wet to dry saline dressing to Left Mastectomy.

2/13/16 5:35 PM: Dakin's Solution Full strength topical (applied on or in the body) daily.

2/14/16 5:23 PM: Dakins Solution 0.125 % to wound daily for dressing changes.

Nursing Notes:
The admission nursing assessment of the wound on 2/13/16 at 7:35 PM revealed dressing to left breast chest area: clean, dry, intact. Wound type: Mastectomy wound. Dry and intact.

2/14/16 - 6:00 PM: Left chronic chest wound with slight odor. Small amount muco-purulent drainage. Dressing changed...

2/15/16 - 3:35 PM: Dressing done by MD.

2/16/16 - 10:17 AM: Surgical wound to left upper chest wall. Edges not approximated. Condition of tissue: Yellow, Full thickness loss. No odor. Small amount serosanguinous drainage. Dressing changed.

2/17/16: No measurement of the wound and no treatment and/or dressing change to PI # 12's wound was documented in the medical record on 2/17/16 at 12:47 PM during a review of the electronic record with EI # 1, Clinical Informatics RN.

The lack of documentation of PI # 12's wound measurement and wound care and/or dressing change on 2/17/16 was verified by the Clinical Informatics RN, EI #1, on 2/17/16 at 12:47 PM.

A review of the nursing notes dated 2/13/16 through 2/17/16 revealed no documentation by nursing staff regarding baths for PI # 12. The Clinical Informatics RN, EI #1, verified no baths were documented for PI # 12 on 2/17/16 at 12:47 PM.


Hospital Policies:

I. Title: Skin Care Protocol
Effective Date: January 1991
Purpose: To prevent injury and/or promote healing of all compromised patients.

Policy:
Patients will be assessed by a registered nurse on admission and once each shift for signs of skin breakdown/non-surgical wounds. If skin breakdown /non-surgical wound present, a wound care consult will be generated. The appropriate skin care protocol will be placed on the chart and appropriate intervention initiated.

Procedure:
Assessment:
3. Clinical Manifestations of wound infection:
a. Redness, excessive swelling, tenderness, warmth.
b. Red streaks in the skin near the wound.
c. Pus or other discharge from wound.
d. Foul smell from wound.
e. Generalized body chills or fever.
f. Elevated temperature and pulse.

Note: Notify physician if noted.

Document in the electronic flow chart:
1. Note the specific treatment given and detail preventive strategies performed.
2. Document the pressure ulcer's location and size (length, width, and depth), color and appearance of the wound bed, amount, odor, color, and consistency of drainage and condition of the surrounding skin.
3. Document when the doctor was notified of any pertinent abnormal observations and any orders received.
4. Update the problem list as needed.

Title: Documentation of Nursing Process
Effective date: March 1991
Purpose: To clarify the documentation of the nursing process.

Procedure:
4. Implementation

D. Interventions and their responses should be documented in the electronic flowchart. Example: States pain relieved after receiving pain medications.

II. Title: Bath, Bed
Effective Date: January 1973
Revised: 8/2015
Policy: A bed bath is a method of cleansing, providing comfort, stimulating circulation and [promoting relaxation for the bed bound patient. Bed baths will be offered daily and as needed unless otherwise contraindicated....

Documentation:
1. Document in Flow Chart that bath was given and the time...