HospitalInspections.org

Based on interview and record review, the hospital failed to ensure that nursing care plan interventions were provided to meet the patients' needs for 2 of 3 patients reviewed for pressure ulcers (Patient identifiers are #1 and #3).

Findings include:

Review on 4/12/23 of the hospital's policy titled "Inpatient Nursing Assessment and Documentation Standards", dated 9/29/22, revealed the following: "Nurses shall conduct assessments, observations, decision, interventions, outcomes, and evaluations of patient response to care and communicate through documentation. Documentation should always reflect the time the assessment or intervention was performed."

Review on 4/12/23 of the hospital's policy titled "Wound and Skin Assessment and Management Guidelines", dated 10/19/22, revealed the following: "4.1.5 Transfer/Discharge of Patients... Prior to discharge, patients with documented skin problems will have their skin assessed and a plan for treatment developed."

Review on 4/12/23 of the wound care nurse notes for Patient #1, dated 3/17/23, revealed that Patient #1 had a penile and buttock pressure wound. Further review revealed that the plan was to leave the buttock wound open to air and place dry gauze between buttocks in the coccyx area to manage moisture. Bacitracin was recommended for the penile wound.

Review on 4/12/23 of nursing care plan intervention documentation for Patient #1 revealed the above interventions for Patient #1 were not documented as completed from 3/17/23 to 3/23/23 and on 3/27/23.

Review on 4/12/23 the wound care notes for Patient #3, dated 2/15/23, revealed wounds on the sacral/buttock and left leg.

Review on 4/12/23 of nursing care plan intervention documentation for Patient #3 on 2/21/23 revealed Resident #3 still had a coccyx wound and a left leg wound.

Review on 4/12/23 of Patient #3's discharge summary, dated 2/21/23, revealed no plan for treatment of a the coccyx/buttock and left leg wounds.

Interview on 4/13/23 at approximately 9:30 a.m. with Staff A (Quality Nursing) and Staff B (Vice President of Nursing Operations) confirmed the above findings.