HospitalInspections.org

Based on document review and interview, the facility failed to ensure wound assessments were completed and accurate for 1 of 10 medical records reviewed (Patient #1); and failed to notify Physician of wounds for 1 of 10 medical records reviewed. (Patient #1).

Findings include;

1. Facility policy titled "Wound Care and Treatment", PolicyStat ID: 12385988, last revised on 9/2022 indicated the following: "PURPOSE: To ensure consistent, accurate identification and assessment of all wounds, and to ensure appropriate treatment is implemented timely in accordance with professional standards of practice for wound treatment. POLICY: A. Wounds will be measured on admission (length, height, width). B. The medical provider will be notified upon identification of a wound or skin related issue. PROCEDURE: ADMISSION WOUND ASSESSMENT: 3. Measurements will be obtained and documented in centimeters by length, width, and then depth.
4. The wound bed will be described. 5. If wound exudate is present, the type and amount of drainage will be described. 6. If wound odor is present, the description of odor will be documented. 7. The peri wound tissue will be assessed and documented. 8. All of the above will be documented on the Nursing Admission assessment.

2. Facility policy titled "Assessment/Reassessment", PolicyStat ID: 12386392, last revised on 9/2022 indicated the following: "PURPOSE: To ensure that all patients receive the appropriate screening, assessment, and reassessment by qualified individuals within the organization. The assessment process will be continuous, collaborative effort with all of the health care members functioning as a team. Communication among the health care team is an essential element of the assessment process. POLICY: 2. Nursing staff completes the Nursing Admission Assessment upon admission. 5. Assessment is ongoing as appropriate throughout the hospital stay. 7. Nursing will re-assess each patient every shift and as warranted by the patient's medical condition and document findings.

3. Review of Patient #1's medical record indicated the following:
(A) The patient was admitted on 10/1/24 at 3:50 a.m. and was discharged to home on 10/8/24 at 10:20 a.m.

(B) The patient's nursing admission assessment dated 10/1/24 indicated the patient had a left heel pressure ulcer upon admission to the facility.

(C) The patient's nursing skin assessments indicated the following:
(a.) On 10/2/24 and 10/6/24, dayshift nursing staff noted that Patient #1 had no abnormal finding related to (his/her) skin assessments. Patient #1's medical record lacked documentation of a skin reassessment on night shift by nursing staff on 10/2/24 and 10/6/24 and/or patient refusal of a skin assessment.

(b.) On 10/3/24 and 10/4/24, dayshift and night shift nursing staff noted that Patient #1 had no abnormal finding related to (his/her) skin assessments.

(c.) On 10/5/24 and 10/7/24, Patient #1's medical record lacked documentation of a skin reassessment on dayshift and/or night shift by nursing staff and/or patient refusal of a skin assessment.

(D) The patient's nursing skin assessment on discharge dated 10/8/24, indicated that the patient had a foot blister.

(E) The patient's medical record lacked documentation of a description of the left heel pressure ulcer and foot blister, including wound measurements, wound bed description, whether exudate was present, type and amount of drainage, any wound odor present, description of the odor, and the peri wound tissue. The patient's medical record also lacked documentation of provider notification of the wounds.

4. During an interview with A1 (Market Director of Quality/Risk) on 12/11/24 at 3:00 p.m., A1 verified the lack of documentation in Patient #1's medical record related to skin/wound assessments and provider notification of any wounds/skin issues.

5. During an interview on 12/12/24 beginning at 10:35 a.m. with MD1 (Doctor of Medicine/Psychiatrist) and NP2 (Nurse Practitioner/Adult Gerontology) indicated that they were not notified of any wounds/skin issues on Patient #1's feet.