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Based on policy review, medical record review, and staff interview, hospital staff failed to provide a wound care consult to 1 of 3 patients (Patient #3) that had wounds.

Review of hospital policy titled "Skin Wound Care" date approved: 05, 2018, revealed, "...Consult Wound Ostomy Care Team for Patients with a Braden Score 16 or less ... presence of pressure injury ..."

Findings include:

Closed medical record review revealed Patient #3 was a 62-year-old male, who was admitted to the hospital's Intensive Care Unit (ICU) on 12/08/2018, with a diagnosis of Septic Shock and Acute Respiratory Failure. Review of an admission assessment written on 12/08/2018 at 1751 by Registered Nurse (RN) #1 revealed, " ...Integumentary ... Braden Scale Score 11 ..." Review of a Wound Assessment written by RN #2 on 12/09/2018 at 1031 revealed, "...Location Sacrum ...Staging (Initial) Stage II ... Pre-existing Yes ..." Review revealed no evidence the Wound Ostomy Care Team was consulted during the hospital admission. Patient #3 was discharged from the hospital on 12/19/2018 at 2140.

Interview conducted with RN #1 on 01/17/2019 at 1103 revealed she was aware of the hospital policy stating patients with Braden scores of less than 16 should be evaluated by the Wound Ostomy Care Team, and that was not performed for Patient #3.

RN #2 was not available for interview.

Interview conducted with the ICU Manager on 01/16/2019 at 1018 revealed that based on Patient #3's Braden Score upon admission, the Wound Ostomy Care Team should have been consulted.

Based on policy review, medical record review, and staff interview, hospital staff failed to provide a discharge plan regarding wound care for 1 of 3 patients (Patient #3) that had wounds.

Review of hospital policy titled "Skin Wound Care" date approved: 05, 2018, revealed, " ...Consult Wound Ostomy Care Team for Patients with a Braden Score 16 or less ... presence of pressure injury ..."

Findings include:

Closed medical record review revealed Patient #3 was a 62-year-old male, who was admitted to the hospital's Intensive Care Unit (ICU) on 12/08/2018, with a diagnosis of Septic Shock and Acute Respiratory Failure. Review of an admission assessment written on 12/08/2018 at 1751 by Registered Nurse (RN) #1 revealed, "...Integumentary ... Braden Scale Score 11 ..." Review of a Wound Assessment written by RN #2 on 12/09/2018 at 1031 revealed, "...Location Sacrum ...Staging (Initial) Stage II ... Pre-existing Yes ..." Review revealed no evidence the Wound Ostomy Care Team was consulted during the hospital admission. Patient #3 was discharged from the hospital on 12/19/2018 at 2140. Review of case management notes, and discharge instructions revealed no mention of Patient #3's wound, or post discharge care instructions.

Interview conducted with RN #1 on 01/17/2019 at 1103 revealed she was aware of the hospital policy stating patients with Braden scores of less than 16 should be evaluated by the Wound Ostomy Care Team, and that was not performed for Patient #3.

Interview conducted with CWON (Certified Wound Ostomy Nurse) #1 on 01/17/2019 at 0926 revealed had the Wound Ostomy Care Team been consulted for Patient #3, they would have contributed to the discharge planning process regarding wound care. Interview revealed the team normally ensured arrangements were made regarding treatment of wounds post discharge, and in the event a patient is going to be discharged home under home health care services, the caregivers had enough supplies to care for the wound until the initial home health care evaluation.

NC00146708