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Based on record review and staff interview, it has been determined that the hospital continued to fail to have a registered nurse evaluate the care of each patient related to the lack of weekly wound measurements in accordance with hospital policy for 1 of 2 patients reviewed for pressure ulcers (ID#2).

Findings are as Follows:

Review of the "Wound Assessment and Reassessment" policy, last revised in March 2018, states in part,

"II. POLICY
1. All wounds will be assessed and documented within 24 hours of admission, with any significant change in the wound, at least every 7 days for chronic and stable wounds, and within 24 hours of discharge...."

"III. PROCEDURE
1. Assessment.
a. Document wound characteristics including features such as ...Size-length x width x depth in centimeters (cm), undermining, tunneling.

Record review revealed patient ID #2 was admitted to the hospital on 8/26/2020 for rehabilitation services. Upon admission nursing documentation reflects Patient ID #2 was noted to have a Stage 1 ( reddened, non-blanchable area) and stage 2 pressure ulcer (a shallow open area with slight loss of skin; may look like a fluid filled blister) on his/her coccyx area (area at the bottom of the spine) which was treated with nursing interventions.

Review of the nursing progress notes, dated 8/28/2020 revealed the wound measurements had been assessed. Further review of the nursing documentation from 8/28/2020 to 9/9/2020 revealed the ongoing nursing interventions for wound care, however, did not reflect that wound measurements had been assessed since 8/28/2020.

During a surveyor interview on 9/9/2020 at approximately 1:40 PM, with the Nurse Educator and the Director of Accreditation and Regulatory Readiness, they could not provide evidence that the wound had been measured weekly according to hospital policy.


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