HospitalInspections.org

Based on 2 of 5 (#1 and #2) records reviewed (of patients with pressure sores), interview with staff and review of facility policy the hospital failed to ensure patient care was evaluated.

Findings include:

Hospital policy entitled "Skin Care/Wound Management" specifies that: Wound assessments shall be completed upon initial discovery and with each dressing change until healed. The wound assessment is documented on the wound care flow sheet.
According to the policy wound assessment shall include the characteristics delineated on the wound care flow sheet.

Per interview with Wound Care RN B on 11/05/2012 at 1:00 PM wounds should be assessed on admission and every shift. Additionally wounds should be measured weekly or as needed with a change in condition.

Patient #1 was hospitalized for rehabilitation following a prosthesis removal from the left knee which was replaced with a spacer allowing healing and use of joint. Pt. #1 received occupational and physical therapy services throughout this hospitalization and was discharged to a skilled nursing facility on 01/27/12.

During pt. #1's hospitalization a pressure sore developed on the left heel. It was first documented on 01/06/12 when nursing notes indicated; "Pressure sore noted to left heel 2.5 cm X 3 cm. A wound care flow sheet was partially filled out on 01/06/12 indicating only the location and size of this pressure sore. This initial wound assessment was lacking; staging of the pressure sore, color of the wound bed, margins, condition of surrounding skin, type of drainage and pain associated with the wound. Nursing notes on 01/07/12 at 1630 indicate; "Heel area has approx 3 cm. round light brown area, heel protector in place." This assessment remains the same on 01/08, 01/09, 01/10 and 01/11 describing a darkened area on the left heel 2.5 to 3 cm. in diameter. The next mention of the wound on the left heel is on 01/16/12 when nursing notes at 1945 indicate "scab noted to left heel". On 01/17/12 at 2000 the RN notes: "Left heel has black nickel-sized spot." On 01/19 and 01/20/12 the area on the left heel is described as "quarter-sized" in nursing notes. On 01/26 and 01/27/12 the wound on the heel is described as black and 50 cent sized.

Throughout the time that a wound was developing and progressing on pt. #1's left heel, approximately 3 weeks, a complete assessment was not done.

Patient #2 was admitted to the hospital on 09/15/2012 with a pressure ulcer between the buttocks. Between the dates of 09/29/12 until discharge on 10/13/12 there were no wound assessments done. Dressing changes were being documented but nothing about the condition of the wound.

These findings were confirmed per interview with COO A on 11/06/12 at 1:30 PM.