HospitalInspections.org

Based on facility policy review, medical record review, and interview, the facility failed to document a complete assessment of a wound in the medical record for 1 patient (#1) of 4 medical records reviewed.

The findings include:

Review of the facility policy "Medical Record Content" dated 5/23/2016 showed "...the medical record shall contain sufficient information to identify the patient, support the diagnosis, to justify the treatment, and document the results accurately...Clinical observations are electronically documented daily in the progress notes by the physician...Other persons making observations will be electronically documented in the progress notes...These progress notes give a pertinent chronological report of the patient's course in the hospital and reflect any change in condition, the results of treatment, and plan of care revisions when indicated...The discharge summary or final summary shall include...Final diagnosis and any associated diagnosis...History...Pertinent physical findings..."

Review of the facility Policy "Wound Care" dated 10/10/2016 showed "... Accurate wound assessment, documentation and product selection is key to promoting wound healing...Wound assessment should have the following descriptions...wound size...shape...depth...tissue type in wound...undermining...odor...heat...exudate volume..."

Medical record review showed Patient #1 was admitted to the facility on 8/26/2020 for a Left Below the Knee Amputation (BKA), Right BKA, Gangrene of Left Foot, Pneumonia, Type 1 Diabetes Mellitus, Peripheral Artery Disease, and Dementia.

Review of Patient #1's admitting History and Physical dated 8/26/2020 showed no documentation of a sacral wound

Review of a Nurse's Progress Note for Patient #1 dated 9/6/2020 showed "...blue purple area the size of silver dollar..." was noted on the patient's sacrum.

Review of a Nurse's Progress Note for Patient #1 dated 9/7/2020 showed a broken blood blister was noted on sacrum "...about the size of a silver dollar..." The area was covered with a foam dressing.

Review of the Nurses' Progress Notes dated 9/6/2020 through 9/9/2020 showed no sacral wound measurements. Continued review showed no documentation the physician was notified of Patient #1's sacral wound.

Review of a Wound Care Physician's Progress Notes dated 9/6/2020 through 9/9/2020 showed no documentation of Patient #1's sacral wound.

Review of a Physician's Discharge Summary dated 9/9/2020 showed no documentation of the sacral wound.

During a telephone interview on 10/14/2020 at 1:36 PM, Registered Nurse (RN) #1 stated the Wound Care Physician completes the wound care on his patients. RN #1 stated if nursing observes a patient with a wound, they would measure the wound, do a wound assessment, and "...would document it [in the medical record]..."

During a telephone interview on 10/14/2020 at 2:10 PM, the Director of Nursing (DON) stated nursing was required to assess the patient's skin on admission and daily and "...if a wound was found they [nursing] should document it [in the medical record] and report it to the physician..."

During a telephone interview on 10/14/2020 at 4:20 PM, the DON confirmed Patient #1's medical record was incomplete and lacked complete documentation of Patient #1's sacral wound.

During a telephone interview on 10/15/2020 at 1:35 PM, the Wound Care Physician stated he was made aware of Patient #1's skin breakdown and he ordered vitamins and protein supplements to aid/prevent further breakdown. The Wound Care Physician stated he was made aware of the patient's declining sacral wound either the day before or day of discharge, but he failed to document the wound in Patient #1's Discharge Summary.