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Based on record review and interview, the facility staff failed to accurately assess, complete interventions and document wound assessments per policy for 1 of 10 patients (pt. #1) medical records reviewed. This deficiency has the potential to affects all 211 inpatients at this facility during this complaint survey.

Findings Include:

Per review on 3/8/2016 at 12:30 PM of policy titled, General Standards of Care, 902.10.04, dated 10/13/2010, stated in part under V. C. 1. Assess and document integumentary status every 8 hours shift and with status changes including: a. Condition and care of skin. d. Condition and care of wounds and incisions. 1. location and description 2. Presence of edema, drainage, redness, erosion. 3. Color and consistency of drainage. 5. Care of wounds/incisions per provider order or Ministry Health Skin and Wound Care Manual.

Per interview with pt. #1 on 3/3/2016 at 11:30 AM, pt. #1 stated he entered the Emergency room with a groin wound, informed the staff he was receiving home care and a nurse was coming to his home daily to change the dressing. Pt. #1 stated the nurses looked at his wound during his hospitalization but never changed the dressing. Pt. #1 stated the nurse on the fourth day looked at the wound and notified Urologist K. Urologist K came to see pt. #1 on 2/5/2016. Patient #1 stated the staff did not change the dressing through the hospital stay.

Per review of medical record for pt. #1 on 3/8/2016 at 10:00 AM, pt. #1 presented to the emergency department on 2/1/2016 at 8:39 PM and was admitted with a diagnosis of Pneumonia. There is no documentation of a wound/dressing in the History and Physical, physician progress notes, or nursing assessments through 2/4/2016.

Physician progress note dated 2/4/2016 at 11:05 AM states "patient has some bleeding from his bottom", and "perineal hematoma, status post anterior urethroplasty" (repair of an injury or defect within the walls of the urethra) "not acute".

Physician progress note dated 2/5/2016 at 10:35 AM states "Perineal hematoma, status post anterior urethroplasty (not acute) per urology patient can be discharged with continued wound care at home."

Discharge summary dated 2/5/2016 stated, "3. History of recent anterior urethroplasty complicated with perineal hemotoma. Present on admission: No change in the status. Patient will be discharged to continue wound care at home." Page 8 under Hospital course, "2. In November, patient had an anterior urethroplasty complicated with perineal hematoma. RN reported that there was some bloody spotting from the area. His hemoglobin was closely monitored and it did not change over time. The bleeding was not significant. Urology was consulted on the day of discharge to check to wound".

Nursing assessments dated 2/1/2016 through 2/4/2016 all indicate integumentary- within normal limits.

Nursing assessment on 2/4/2016 at 7:50 AM stated "Incision #1 location: scrotal; Drainage: minimal drainage, bright red; Dressing: Shadowing MD notified". Nursing assessment on 2/5/2016 at 12:41 AM stated, "integumentary- not within normal limits, scrotal dressing dry and intact". There is no documentation of a dressing change, an assessment of the wound, or measurements of the wound. Findings in medical record were confirmed with Performance Improvement Specialist A at time of record review.

Per interview on 3/8/2016 at 10:50 AM, Manager of Patient Care Services B stated "when patients are admitted it is the expectation of the nurses to complete an admission assessment which includes a head to toe skin assessment". "Full assessment are required to be completed by the nurse on every shift." Manager of Patient Care Services B stated "it would be reasonable to expect that if a patient had a ulcer, surgical wound or a dressing intact, it would be noted on the admission and the daily assessments".

Per interview with Wound Ostomy Nurse Practitioner D on 3/8/2016 at 11:05 AM, Wound Ostomy Nurse Practitioner D stated it is "the expectations of the hospital that a wound would be found in the first 24 hours". "The dressing should be removed and an assessment of the wound should be completed, initial measurements should be obtained and then weekly measurements or upon discharge should be completed".