HospitalInspections.org

Based on document review and staff interview, nursing staff failed to supervise and evaluate the nursing care for each patient related to lack of documentation of the measurement of a pressure ulcer wound for 1 of 11 (#1) patient medical records reviewed.

Findings:

1. Policy #NADM 1.30 AP titled, "Documentation Standards: Inpatient", revised/reapproved 3/16, indicated on Admission Standards Appendix 2016, under Integumentary Assessment section, "Documentation standards...Wounds...Size (length, width and depth in centimeters."

2. Review of patient 1's medical record on 11/16/16 at approximately 1235 hours indicated a pressure ulcer was first documented by nursing staff on 8/12/16 at 1830 hours as a stage II pressure ulcer to the bilateral buttocks and it was not measured at this time.

3. Staff 5 (Clinical Nurse Specialist and WOCN) was interviewed on 11/16/16 at approximately 1254 hours and confirmed, nursing staff did not measure patient 1's pressure ulcer wound after it was assessed on 8/12/16 as required by facility policy and procedure.