HospitalInspections.org

Based on staff interviews, medical record review and policy and procedure review, the facility staff failed to document practitioner's orders, wound care assessment, dressing changes and document of repositioning on a consistent basis to monitor patient's condition during the inpatient hospital stay from 03/21/2025 to 04/02/2025 for three (3) of three (3) days of survey; Patient #1.

Findings Include:

During an interview on 04/30/2025 at 10:45 a.m. the Director of Quality confirmed there was inconsistent facility staff documentation of dressing changes and repositioning Patient #1 every two hours in the medical record.

During an interview on 04/30/2025 at 11:36 a.m., the RN #2 Day Supervisor confirmed being on duty the dates of 03/29/2025-04/02/2025. The RN Day Supervisor could not recall anyone reporting to her concerning a problem or complaint regarding a patient care.
During an interview on 05/01/2025, the Director of Quality confirmed Physician #1 should initiate and identify the recommendations in the orders section of the medical record to complete the physician's orders, and it is no evidence that this process was completed in the medical record of Patient #1.

Review of documentation from Patient #1's medical record for wound assessments and wound care dressing changes revealed no wound care dressing changes were documented for dates 03/21/2025, 03/24/2025, 03/25/2025 or 03/30/2025.

Review of documentation from Patient #1's medical record revealed on 03/29/2025 Patient #1 was turned and repositioned at 10:12 p.m. and 11:55 p.m., on 03/30/2025 repositioned at 2:43 a.m. and 6:51 a.m. and on 04/01/2025 at 02:26 a.m. was repositioned at 04:41 a.m. and 2:00 p.m. No further documentation was submitted for evidence of repositioning Patient #1 every two (2) hours for Patient #1.

Review of Physician #1 progress note titled "Infectious Disease Consult Draft" dated 03/20/2025 revealed for wound care to reposition patient every two hours and cleanse wounds with normal saline and then apply dry dressing daily and when necessary. The only evidence in the "active order section" in the medical records on 03/20/2025 was consult wound care routine. No further documentation submitted regarding a complete order for wound care in the medical record.

Review of order section from the medical record revealed on 03/26/2025 Physician #2 documented ...Wound Care: Continue recommendations of Physician #1. No further specific order was submitted for review.

Review of facility policy titled "Skin Assessment, Documentation and Treatment, NS.S.001" last revision 07/2022 revealed ... "All patients will automatically be assigned a Braden Skin Risk Assessment score in the electronic health record computer system when the nurse documents the nursing assessment on admission ...All patients skin will be assessed from head to toe during the Nursing Admission Assessment and during each shift for wounds and/or reddened areas. Any wounds will be documented on the Wound Assessment Record ...Any patient scoring 12 or below on the skin integrity assessment or identified as at-risk during reassessment will have skin protocol implemented which is listed below ...Minimize potential damage resulting from mechanical forces such as friction, shear, and pressure ...Reposition every 2 hours and as needed for comfort using turn clock as a guide. Document in the electronic record ...Utilize pillows or positioning wedges to avoid pressure on bony prominences and/or heels ...".

During the exit conference on 05/01/2025 at 1:09 p.m. with Director of Quality, Infection Control Director, Informationist RN, Director of Intensive Care Unit (ICU) survey findings were discussed, and no further documentation was submitted for review.