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Tag No.: C0296
Based on document and medical record review and staff interviews it was revealed the facility failed to document the appearance, location, stage and preventive measures used for skin breakdown on 1 of 20 patients (patient #1). This failure has the potential to adversely affect all patients with skin breakdown.
Findings include:
1. A review of the policy titled Policy for Wound Care Protocol and attachment E-Z Graph Wound Assessment Worksheet, last approved 12/18, revealed in part: "Indicate wound site on appropriate figure with X" and displayed body figures for documentation. The attachment also revealed in part: "Stage 1 intact skin with non-blanchable redness of a localized area usually over a bony prominence ..."
2. A review of the policy titled Proper Care of Patients, last approved 12/18, revealed in part: "Information regarding the patient's progress or regress is documented electronically in the record and verbal or telephone communication regarding the patient is ongoing involving the entire health care team ..."
3. A review of the policy titled Nursing Intervention/Treatments/Medications Protocol, last approved 12/18, revealed in part: "These interventions may be implemented by the Registered Nurse prior to communications with the attending. These items are to be entered into the medical record as a V.O.R.B. (verbal order read back) to be countersigned by the attending on his next visit to the hospital ...Application of appropriate dressing for skin breakdown ..."
4. A review of the medical record revealed there was no documentation of skin breakdown or pressure sores until 6/12/19 at 7:55 p.m. when the wound assessment documentation by Registered Nurse (RN) #1 showed "Pressure Ulcer Condition: Dressing dry and intact. Pressure Ulcer Drainage/Dressing: Small amount." There was no documentation regarding location of a pressure ulcer. There was no documentation regarding the size or stage of the pressure ulcer or when the dressing had been applied.
5. A review of the medical record revealed there was no documentation of skin breakdown or pressure sores on 6/14/19. Wound assessment documentation on the day shift had a line through it with a notation "Amended 6/14/19 11:24" but there was no further amended documentation. Wound assessment documentation on the night shift for 6/14/19 at 10:38 p.m. revealed "Pressure Ulcer Condition: No wounds/skin breaks. Pressure ulcer drainage/dressing: None."
6. A review of the medical record for 6/15/19 (day of discharge) at 8:59 a.m. revealed the following wound assessment documentation by RN #2: "Location of Pressure Ulcer: See Unisex Body documentation. Pressure Ulcer Condition: Covaderm dressing clean, dry & intact. 3 pressure areas noted to back." A review of the Unisex Body documentation form revealed "Site A" location on left foot. There was no documentation of the appearance or stage of the pressure areas noted to the back or the foot.
7. A telephone interview conducted on 7/2/19 at approximately 11:30 a.m. with RN #1 revealed he had received information in report that the patient had dressings placed on reddened areas on his back to prevent pressure ulcers. RN #1 documented the presence of the dressings on 6/12/19 and 6/13/19.
8. A telephone interview conducted on 7/2/19 at approximately 2:55 p.m. with RN #2 revealed the patient had three (3) reddened areas on bony prominence's down his spine. She stated she put two by two (2 x 2) covaderm dressings on the red areas and the skin was not broken. She was not aware of breakdown on either foot. A review of the medical record revealed RN #2 did not document the dressings until 6/15/19 (day of discharge) at 8:59 a.m.
9. Interviews were conducted on 7/2/19 at approximately 8:35 a.m. and at approximately 3:15 p.m. with the Nurse Manager and he concurred with the above findings.