HospitalInspections.org

Patient #2 was admitted on 5/9/15 and was noted to have had venous stasis wounds to both legs. Two days later, on 5/11/15, the patient's dressings were removed for wound assessment. The assessment was completed during the wound consultation by the wound care provider from the Wound Center. The provider documented the existence of the wounds and that the dressings were changed. The initial note of the skin assessment was generated forward for the next two days with one skin assessment note that revealed that the dressings were not changed.

The patient's Care Plan was reviewed by the state surveyors on 5/12/15. The existence of the venous stasis ulcers or their treatment were not identified in the plan. There were no specific orders for dressing changes.

The hospital failed to perform an initial assessment of the patient's wound on the day of admission. Reassessment documentation lacked specific observation and care rendered and revealed the same note populated forward. Neither an individualized assessment nor care of the wounds was found in the patient's care plan.