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Based on policy review, medical record review, and interview, the hospital failed to ensure Nursing Services provided care and services to meet patients' needs when they failed to assess a patient's surgical incision site and/or surgical dressing for signs and symptoms of infection and failed to perform wound care per physician's orders for 1 of 1 (Patient #1) sampled patients admitted with a surgical incision.

Nursing Service's failure to perform wound assessments and failure to provide wound care as ordered, resulted in a wound infection for Patient #1, a 77-year-old male admitted with a surgically closed gunshot wound.

The findings included:

1. Review of the hospital's "Nursing Standards of Care" policy revised 12/2023 revealed, "...Assessment...the nurse will assess the patient in a timely, comprehensive, accurate and systemic manner...The nurse continuously and systematically collects records, and analyzes data that are comprehensive and accurate..."

Review of the hospital's "Skin Integrity, Maintenance of" policy revised 3/2021 revealed, "...The nursing staff will...Monitor for clinical signs of wound infection..."

Review of the hospital's "Wound Care and Irrigation" policy revised 3/2016 revealed, "...When dressings are removed, inspect the wound for any signs of infection...and document the condition of the wound in the nurses' notes..."

2. Review of the Discharge Summary obtained from Hospital #2 dated 11/23/2023 revealed Patient #1 was admitted to Hospital #2 on 11/21/2023 with a self-inflicted gunshot wound to the left chest/torso region. The patient's wound was surgically debrided and closed with sutures. The patient was referred to Hospital #1 and was discharged from Hospital #2 with discharge instructions to monitor his incision site for signs and symptoms of infection and to follow up with the surgeon for suture removal in two weeks. The patient had a clean, dry dressing in place upon his hospital discharge.

3. Medical record review revealed Patient #1 was admitted to Hospital #1 on 11/23/2023 with diagnoses of Major Depression. Review of the Nursing Admission Assessment dated 11/23/2023 at 8:30 AM, revealed the patient had a dressing in place on the left chest region.

A physician's order dated 11/24/2023 with an anticipated start date of 11/25/2023 revealed wound care with the application mupirocin (antibiotic) ointment and sterile dressings changes was to be completed two times daily.
There was no documentation the wound care was completed from 11/25/2023 through 11/28/2023 and no documentation the patient's incision site and/or dressing was assessed by nursing staff.

A physician's order dated 11/25/2023 revealed cephalexin, an oral antibiotic, to be administered for 7 days.

A physician's order dated 11/29/2023 revealed mupirocin ointment was ordered to be applied twice daily to the patient's wound.

Although the wound care was documented as completed 11/19/2023 through 12/2/2023, there was no documentation of the condition of the patient's wound.

A physician's order dated 12/1/2023 revealed ceftrioxone, an injectable antibiotic, was to be given for "...infection..."

In an interview on 1/30/2024 at 12:30 PM, the Assistant Chief Nursing Officer verified there was no documentation wound care was completed 11/25/2023 through 11/28/2023 and no documentation of a nursing assessement or description of the patient's wound.

Refer to A-0395

Based on policy review, medical record review, and interview, nursing services failed to assess and document a surgical incision site and/or surgical dressing and failed to follow physician's orders for wound care for 1 of 1 (Patient #1) sampled patients admitted with a surgical incision.

The findings included:

1. Review of the hospital's "Nursing Standards of Care" policy revised 12/2023 revealed, "...Assessment...the nurse will assess the patient in a timely, comprehensive, accurate and systemic manner...The nurse continuously and systematically collects records, and analyzes data that are comprehensive and accurate..."

Review of the hospital's "Skin Integrity, Maintenance of" policy revised 3/2021 revealed, " Purpose: To maintain and promote healthy skin integrity...The nursing staff will...Monitor for clinical signs of wound infection..."

Review of the hospital's "Wound Care and Irrigation" policy revised 3/2016 revealed, "...Wound care and irrigation shall be performed by a licensed nurse as ordered by the physician to clean the wound and prevent infection...When dressings are removed, inspect the wound for any signs of infection...and document the condition of the wound in the nurses' notes..."

2. Review of the Discharge Summary obtained from Hospital #2 dated 11/23/2023 revealed Patient #1 "...was admitted after a suicide attempt...he had intended to shoot himself, but the shotgun slipped at the last second. He had a very small pneumothorax...He went to the OR [operating room] with me the day of admission for wound washout and closure. He was ready for discharge shortly after surgery, I contacted the psychiatry team and we coordinated having him admitted inpatient at [named Hospital #1]. At the time of discharge, he was doing very well...plan follow up in about two weeks for suture removal...Hospital Course...Superficial skin injury, small pneumothorax Procedures and Treatment Provided Washout and closure of skin wound, observation...Physical Exam...Integumentary: left lateral chest wound edges well approximated, peri-wound bruising noted, no drainage...Discharge Diagnosis and Plan...Monitor for s/s [signs and symptoms] infection: increased pain, redness, purulent drainage from wound...Gunshot wound of chest..."

Review of the nursing assessment completed at Hospital #2 dated 11/23/2023 at 7:15 AM, revealed Patient #1 had a gunshot wound with a surgical incision to his left chest. The assessment further revealed, "...Incision, Wound Dressing Assessment Clean, Dry, Intact...4 x 4's ABD [army battle dressing, used when high absorbency is required to handle heavy draining wounds or large wounds; also know as abdominal pads] dressing pad, Island dressing [dressing with an absorbent non-adherent central pad surrounded by a breathable adhesive border]..."

3. Medical record review revealed Patient #1 was referred by Hospital #2 and admitted to Hospital #1 on 11/23/2023 following a suicide attempt by a self-inflicted gunshot wound to his chest. The patient's admitting diagnoses included Major Depression without Psychosis.

Review of the Medical Screening Examination dated 11/23/2023 at 4:10 PM, revealed Patient #1 had a "...Hx [history] of recent GSW [gunshot wound] to chest wall..." There was no documentation the dressing was lifted and the incision site was assessed.

Review of a Skin Integrity Flowsheet-Assessment or Reassessment dated 11/23/2023 at 6:51 PM, revealed the body drawing of Patient #1 with a circle drawn on the left chest/torso region and described as a "Gun shot wound x [times] 4 days."

Review of the "Nursing Admission Assessment" dated 11/23/2024 at 8:30 PM, revealed Patient #1's "...Skin Integrity...Gunshot wound covered with dressing on L [left] rib cage..." The assessment further revealed Patient #1 "... presented with a dressing in place to the L thoracic cavity..."

Review of the History and Physical Examination dated 11/24/2023 at 9:59 AM revealed Patient #1 was "...s/p [status post] GSW (L) [left] chest, c [symbol for with] pneumothorax and pulmonary contusion...Stable; orders for wound care..."

Review of the Daily Nurse Progress Note dated 11/24/2023 at 2:17 PM, revealed "...Skin WNL [within normal limits]...new admit...Dry drsg [dressing] noted to (L) torso intact..." (The skin assessment portion has a box for the nurse place to check mark beside any of the following assessment findings: 1. Alteration in integrity/wound 2. Redness 3. Bruising 4. Odor 5. Superficial Scratches/cuts 6. Diaphoretic 7. Abnormal temperature.)

Review of the Daily Nurse Progress Notes dated 11/24/2023 at 8:11 PM, revealed Patient #1's Skin was "WNL." There was no documentation the patient's dressing and/or wound to the left torso was assessed.

Review of the Nursing Orders dated 11/24/2023 at 11:42 PM electronically signed by Physician #1 revealed, "Wound Care Left chest surgical-wound-care: mupirocin [antibiotic] ointment BID [two times a day], with sterile dressing changes...Start Time 11/25/23 9:00..."

Review of a Physician's order dated 11/25/2023 at 7:29 AM revealed, "cephalexin [antibiotic] Oral 500 mg [milligrams]...x 7 days Notes: Recent GSW left chest, emergency chest surgery..."

Review of the Daily Nurse Progress Notes and the Medication Administration Record (MAR) dated 11/25/2023 through 11/28/2023 revealed no documentation wound care was completed as ordered, no documentation the wound was assessed, and no documentation the surgical dressing was assessed.

Review of a physician's order dated 11/29/2023 revealed, "mupirocin topical 2 % [percent]...Indication: Wound Care notes: 10 days - see wound care order [Nursing Order dated 11/24/2023 above]..."

Review of the MAR dated 11/29/2023 through 12/2/2023 revealed the mupirocin ointment was applied twice daily as ordered except for 11/29/2023 at 7:58 PM, when the patient refused.

Review of the Daily Nurse Progress Notes dated 11/29/2023 through 12/1/2023 revealed Patient #1's Skin was "WNL." There was no documentation Patient #1 had a wound and no documentation of the condition of the patient's wound.

Review of an Ancillary order dated 12/1/2023 at 9:03 AM revealed, "...Medical consult for Management of condition: Incision inflamed and exudate..."

Review of a Physician's order dated 12/1/2023 revealed, "ceftriaxone Injectable 1 g [gram]...Indication: wound infection...Inject IM [intramuscularly] the entire contents of vial..." (Ceftrioxine is an antibiotic used to treat bacterial infections.)

Further review of the Daily Nurse Progress Notes dated 12/1/2023 and 12/2/2023 revealed no documentation the Patient #1 had a wound and no documentation of the condition of the patient's wound.

In an interview on 12/30/2023 at 12:30 PM, the Assistant Chief Nursing Officer verified there was no documentation wound care was completed from 11/25/2023 through 11/28/2023 and no nursing documentation and/or description of the patient's wound.

In an interview on 12/30/2023 beginning at 12:35 PM, when asked what should be documented by the nurses on the Daily Nursing Progress Notes skin assessment area, the Chief Executive Officer stated, "that [skin assessment area] just refers to skin turgor, not wounds." The hospital was unable to provide any further documentation of the patient's skin/wound status.