HospitalInspections.org

Based on policy review, medical record review and interview, the hospital failed to keep a current nursing care plan for 1 of 5 (Patient #3) sampled patients.

The findings included:

1. Review of the hospital's "NE1 [Wound Assessment Tool] Wound Assessment" policy revealed, "...PURPOSE...To increase documentation accuracy and consistency for skin and wound documentation. To provide guidelines for skin and wound digital image documentation for the medical record. To provide guidelines for appropriate implementation of the NE1 Wound Assessment Tool...DEFINITION...A standardized, evidence based skin and wound assessment tool used to assess patients who have been admitted with or develop skin break down...The NE1 Tool can also be used for "other" types of skin and wound problems for correct identification and assessment for level of tissue damage and healing progression or regression...POLICY...The admitting physician should be contacted for any patient with a wound to receive a wound care consult...Patient's nurse or wound care team member takes a digital image of skin breakdown that is caused by pressure...occurrence...prior to discharge (beginning with stage 1 pressure ulcers..."

2. Medical record review for Patient #3 revealed an admission date of 10/5/17 with diagnoses which included Chronic Liver Disease, Liver Cirrhosis with Hepatic Encephalopathy and Ascites, Severe Hyponatremia, Metabolic Encephalopathy, Alcohol Abuse and Withdrawal, Moderate Protein Calorie Malnutrition, Anascara and History of Bipolar Disorder.

A nurse's note dated 10/6/17 at 12:00 PM revealed, "...Excoriation Posterior Buttock bilateral...Tissue type-worst: Purple/maroon/deep red..." A nurse's note dated 10/27/17 at 4:00 AM revealed, "...Excoriation Posterior Buttock bilateral...Tissue type-worst: Pink/red/erythema/intact..." The same wound was documented in the nurses' notes at least once each shift from 10/6/17 through 10/27/17. There was no documentation of the size of the area of the wound or whether the wound progressed or regressed. There were no photographs of the wound in the medical record. There was no documentation the physician or the wound care team was notified of the wound.

A nurse's note dated 10/6/17 at 12:00 PM and 4:00 PM and 10/8/17 at 8:00 PM revealed, "...Cleansed/applied: Prot [protective] barrier crm [cream]/oint [ointment]/wip [wipes]..." A nurse's note dated 10/11/17 at 8:00 AM revealed, "...Cleansed/applied: POWDER..." There were no other treatment interventions documented for the wound.

Review of Patient #3's medical record from Hospital #2 dated 10/27/17 at 3:15 PM revealed documentation of 6 wounds: "...Admission Wound Assessment...Location (Anatomical Site): R [right] hip [box checked] Pressure Injury...DPTI [deep pressure tissue injury]...Site (cm) [centimeters] (LxW) [length by width]: 3x3... Location (Anatomical Site): R heel...Pressure Injury...DPTI...Site (cm) (LxW): 4x4...location (Anatomical Site): L [left] heel...Pressure Injury...DPTI...[LxW documented on Pressure Ulcer Data Collection Tool was 4x4]... Location (Anatomical Site): R ear...Pressure Injury...DPTI...Site (cm) (LxW): 1x0.5... Location (Anatomical Site): R back...Pressure Injury...DPTI...[LxW documented on Pressure Ulcer Data Collection Tool was 2x2]...Location (Anatomical Site): gluteals...Pressure Injury: Stg [Stage] II c [with] DPTI...Site (cm) (LxW): 2x3 (Stg II) - 10x8 (DPTI)..." There was no documentation of the wounds to the right hip, right and left heel, right ear or right back by Hospital #1. There was no documentation of an assessment of a Stage II wound to the gluteals by Hospital #1.

3. During an interview in the Senior Clinical Analysist Office on 6/26/18 at 9:47 AM, the Risk Manager confirmed the four treatments noted above were the only documented treatments in the medical record for Patient #3. The Risk Manager confirmed the only wound documented in the medical record for Patient #3 was the excoriation of the buttocks. The Risk Manager confirmed there was no documentation of the progression or regression of the wound, no documentation the physician or wound care team had been notified and no photographs of the wound.