HospitalInspections.org

Based on record review and staff interview it was determined the registered nurse failed to supervise and evaluate nursing care related to wound assessment and turning and repositioning for two (#1, #9) of ten sampled patients from a census of 38.

Findings include:

1. Patient #1 was admitted to the facility on 4/19/13. The Initial Wound Care Assessment dated 4/20/13 at 1:30 p.m. and signed by the Wound Care Nurse indicated Patient #1 had three pressure ulcers present at the time of his admission The wounds were located on his sacrum, right medial thigh and right heel.

Nursing documentation dated 4/23/13 indicated the patient was repositioned at 9:10 a.m. then at 1:27 p.m., approximately four hours later. The patient was turned at 5:07 p.m. then at approximately 9:15 p.m. four hours later.

The Nursing Care Plan indicated the patient was to be turned and repositioned every two hours to assist in the healing of his current pressure ulcers and to prevent the development of new pressure wounds.

An interview and record review was conducted on 6/6/13 at approximately 5:00 p.m. with the Chief Clinical Officer (CCO). She confirmed the finding the patient was not turned and repositioned every two hours on 4/23/13 in compliance with the nursing plan of care and facility policies.

2. Patient #9 was admitted to the facility on 5/17/13. The Initial Nursing Assessment dated 5/17/13 at 5:14 p.m. included documentation the patient had pressure ulcers present on admission.

The Initial Wound Care Assessment dated 5/24/13 at 4:07 p.m. and signed by the Wound Care Nurse documented pressure ulcers on the patient's sacrum, left heel and right heel.

Review of the Wound Assessments failed to reveal documentation of the wounds being reassessed by the nursing staff on 5/20/13, 5/21/13, 5/22/13, 5/29/13 and 5/30/13. There was no documentation the Wound Care Nurse had returned to reassess the pressure ulcers following her initial assessment on 5/24/13.

An interview was conducted with the Wound Care Nurse on 6/6/13 at approximately 1:40 p.m. In response to questions regarding reassessment of pressure wounds, she stated the expectation is that the staff nurses will reassess and document the wounds at least daily and the Wound Care Nurse will reassess the wounds weekly. She confirmed the finding the staff nurses had not reassessed the wounds daily and the Wound Care Nurse had not reassessed the wounds since the initial assessment on 5/24/13. She confirmed the lack of reassessments were not in compliance with facility policy for wound care.