HospitalInspections.org

Based on record review and interview, the hospital failed to ensure:

1) Wound care policy was followed for one (Pt #1) of five patients;
2) Care plan nterventions were completed for one (Pt #1) of five patients;
3) A referral was made for a wound care RN to assess a skin issue for one (Pt #3) of five patients.

Review of a policy titled "Wound Assessment and Reassessment" read in part, "If it is determined at the time of admission, that the patient is at high risk for developing a wound or if the patient is admitted with a wound.... Further assessement will be completed by a Wound Care RN and a treatment plan will be made.... assessments are timely and appropriate; and changes in condition are recognized, evlauated, reported to the patient's attending practitioner and other healthcare professionals (i.e., wound nurse) as appropriate."

Findings:

Pt #1
Review of the medical record showed the patient was inpatient 04/01/25 - 04/09/25. An admit nurses note dated 04/01/25 showed "patient reports buttock wound on L cheek". The care plan initiated 04/01/25 showed interventions for:

a) Wound Care Nurse will assess as soon as possible but within 48 hours of admission.

A review of nursing assessment notes showed the following:
04/01/25 at 1600 - no documentation of a wound.
04/01/25 at 2005 - no documentation of a wound.
04/02/25 at 1030 - no documentation of a wound.
04/02/25 at 1045 - no documentation of a wound.
04/02/25 at 2015 - no documentation of a wound.
04/03/25 at 1945 - Site: left inner buttock Stage: II Condition: open Tx.'s: Wound cleanser, pat dried, Mepilex
04/04/25 at 0730 - no documentation of a wound.
04/04/25 at 1945 - Site: left inner buttock Stage: II Condition: open Tx.'s: Wound cleanser, pat dried, Mepilex
04/05/25 at 0720 - Site: left inner buttock Condition: open Tx.'s: Wound cleanser, pat dried, Mepilex
04/05/25 at 2145 - Site: left inner buttock Stage: II Condition: open Tx.'s: Open to air, turn q 2 hours
04/06/25 at 0753 - Site: left inner buttock Stage: II Condition: open Tx.'s: Open to air, turn q 2 hours
04/06/25 at 2050 - Site: left inner buttock Stage: II Condition: open Tx.'s: Open to air, turn q 2 hours
04/07/25 at 0730 - no documentation of a wound.
04/07/25 at 2130 - Site: left inner buttock Stage: II Condition: open Tx.'s: Open to air, turn q 2 hours
04/08/25 at 0730 - no documentation of a wound.
04/08/25 at 1915 - Site: left inner buttock Stage: II Condition: open Tx.'s: Open to air, turn q 2 hours
04/09/25 at 0816 - no documentation of a wound.

Pt #3
Review of the medical record showed the patient was inpatient 02/10/25 to 03/20/25. A review of the nursing assessments for the following dates showed:

03/16/25 at 2100 Site: Perineum Conditon: Erythema/Excoriation Tx.'s: Barrier cream
03/17/25 at 0725 Site: Perineum Conditon: Erythema/Excoriation Tx.'s: Barrier cream
03/17/250at 1938 Site: Perineum Conditon: Erythema/Excoriation Tx.'s: Barrier cream
03/18/25 at 1905 Site: Perineum Conditon Erythema/Excoriation Tx.'s: Barrier cream
03/19/25 at 0900 no documentation of Perineum
03/19/25 at 2005 Site: Perineum Conditon: Erythema/Excoriation Tx.'s: Barrier cream
03/20/25 at 0730 no documentation of Perineum

Documentation provided showed no:
1) Photograph of the erythema/excoriation;
2) Diagram of area;
3) Physician notification of erythema/excoriation to the perineum;
4) Wound care nurse consult after 2-3 days of treatment.

05/20/25 at 2:30 pm Staff F stated there was no wound care nursing assessment completed for Pt #1.

On 05/21/25 at 9:35 am Staff G stated usual procedure for a wound/rash was:
1) Photograph the area;
2) Complete a diagram with the location identified;
3) Notify the physician;
4) Document area in a nurse note.

On 05/22/25 at 3:10 pm Staff H stated:
1) A consult was completed for Pt #3 for small areas on legs that were scabbed;
2) The Wound Care Nurse was not aware of the perineal rash;
3) A moisture barrier couldbe used, but after a few days and if it wasn't healing the wound care nurse should have been notified.