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DELTA HEALTH SYSTEM - THE MEDICAL CENTER
CONTENT OF RECORD: ORDERS,NOTES,REPORTS
Tag No.: A0467
Based on staff interview, record review and policy and procedure (P&P) review, the facility failed to document wound assessments, measurements, and dressing changes on five (5) out of eight (8) days of the patient's stay as set forth by the hospital's policies and procedures.
Findings Include:
A review of the facility's "Skin Assessment, Documentation, and Treatment, NS.S.001" policy, revision date of 5/17, revealed: " ...Measurements are to include length, width, and depth in centimeters and should be done on admission, after any dressing change, and upon discharge. Skin assessment is documented in the electronic medical record and by using the following steps on admission and each shift as long as a wound remain: .....Document skin and wound assessment; includes name, location of wound/incision; wound measurement, pattern and color ....".
A review of the patient's medical record revealed that the there was no documentation of wound locations, wound measurements, dressing changes on 10/15/2020, 10/17/2020, 10/20/2020, 10/21/2020 and 10/22/2020 upon discharge.
On 1/7/2021 at 4:40 PM, an interview the Director of Quality/Intensive Care Unit (DOQ/ICU) (ICU) revealed that the patient was in the Emergency Room (ER) overflow unit until he could get a bed in ICU. The DOQ/ICU reported that she did not see any wound treatment documentation during the time the patient was being held in the ER overflow on 10/14/2020 until his transfer to the ICU on 10/16/2020. DOQ/ICU also reported that she did not see any wound care documentation after 10/19/2020.
On 1/8/2021 at 11:00 AM, an interview with DOQ/ICU, revealed that she knew they changed the dressings, but she does not see it documented. Upon further interview with DOQ/ICU, it was revealed that she knew if it was not documented then it was considered to not be done. DOQ/ICU reported that she would expect the nurses to document wound care as set forth by the policies and procedures.
On 1/8/2021 at 12:45 PM, an interview with Chief Nursing Officer (CNO), revealed that she would expect the nurses to document wound care according to the policy and procedure set forth by the hospital.