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Based on staff interview and document review, it was determined the hospital failed to maintain a well-organized nursing service to provide quality care to patients. Specifically, the hospital's nursing staff failed to appropriately document skin assessment findings, failed to ensure nursing assessment findings were communicated to the physician, and failed to obtain physician orders for wound care in one (1) of eight (8) clinical records reviewed in the survey sample. Clinical record # 2.

Findings:

Eight (8) clinical records were reviewed in the hospital on 04/27-28/21 with the Assistant Director of Advanced Clinicals and the Director of Informatics assisting in the navigation of the electronic record.

The clinical record for patient #2 contained documentation that the patient was admitted to the hospital following a surgical procedure on 10/06/20. Nursing documentation from 10/06-10/19/20 indicated the patient had no skin breakdown other than the patient's surgical incision site. Nursing documentation on 10/20/20, 10/21/20, 10/22/20, 10/23/20, and 10/24/20 indicated the patient had developed a "pressure injury related to moisture and friction" on the patient's posterior sacrum. The nursing documentation indicated nurses were dressing the wound with mepilex (a foam dressing). The clinical record contained no documentation of the wound's characteristics to include stage of pressure ulcer, measurements of the wound, appearance of the wound bed, edges and surrounding, presence or absence of drainage, pain, and/or response to treatment. The clinical record contained no documentation of a wound care consult, that the physician was notified of the hospital acquired pressure ulcer, or orders for wound care.

An interview was conducted with a nurse on 04/28/21 at 10:30 AM who had cared for patient #2. The nurse could not recall patient #2 or the condition of the patient's skin. The nurse stated that the expectation for any newly acquired wound would be for the nurse to place a wound care consult. The nurse stated this could be done anytime at the nurses discretion without physician notification. The nurse acknowledged there should be a physician's order in the chart for all wound care performed.

Interviews were conducted with the Quality Director throughout the morning of 04/28/21. The Quality Director confirmed a wound care consult should be initiated with a new hospital acquired wound. The Director of Quality confirmed the clinical record for patient #2 failed to contain wound care orders or a wound care consult.

The surveyors requested a policy related to wound documentation, the Director of Quality stated the hospital did not have a policy other than the policy, Skin Care Policy/Protocol. The surveyors were provided a copy of this policy that did not address wound documentation. The policy did, however state the following, "Placement of 0.9% normal saline moistened dressing to open areas is appropriate. Dry gauze dressing is appropriate to areas of eschar. Any other types of dressing to be applied require a physician's order. "

The administrative staff acknowledged the above noted findings during the exit conference on 04/28/21.

Based on staff interview and document review, it was determined the hospital staff failed to ensure it discharged the patient with all necessary medical information pertaining to the patient's current course of illness and treatment to the appropriate post-acute care service providers and suppliers responsible for the patient's follow up care. Specifically, the hospital staff failed to include information about a patient's wound and wound care orders in the discharge instructions to the patient and home health agency responsible for the patient's follow up care in one (1) of eight (8) clinical records reviewed in the survey sample. Clinical record #2.

Findings:

Eight (8) clinical records were reviewed in the hospital on 04/27-28/21 with the Assistant Director of Advanced Clinicals and the Director of Informatics assisting in the navigation of the electronic record.

1The clinical record for patient #2 contained documentation that the patient was admitted to the hospital following a surgical procedure on 10/06/20. Nursing documentation from 10/06-10/19/20 indicated the patient had no skin breakdown other than the patient's surgical incision site. Nursing documentation on 10/20/20, 10/21/20, 10/22/20, 10/23/20, and 10/24/20 indicated the patient had developed a "pressure injury related to moisture and friction" on the patient's posterior sacrum. The nursing documentation indicated nurses were dressing the wound with mepilex (a foam dressing). The clinical record contained no documentation of the wound's characteristics to include stage of pressure ulcer, measurements of the wound, appearance of the wound bed, edges and surrounding, presence or absence of drainage, pain, and/or response to treatment. The clinical record contained no documentation of a wound care consult, that the physician was notified of the hospital acquired pressure ulcer, or orders for wound care.

The patient's discharge summary and discharge instructions were reviewed and contained no evidence of documentation of the patient's wound or orders for wound care. The case management notes for the patient indicated that the patient was to receive home health services after discharge from the hospital. The case management documentation failed to include any information about the patient having a wound or wound care orders to treat the patient's wound. The clinical record failed to contain documentation that the patient or caregiver was informed of how to treat the wound upon discharge from the hospital.

An interview was conducted with a nurse on 04/28/21 at 10:30 AM who had cared for patient #2. The nurse could not recall patient #2 or the condition of the patient's skin. The nurse stated that all orders for wound care should be on the discharge instructions and the nurse discharging the patient should review them with the patient or caregiver at the time of discharge.

The administrative staff acknowledged the above noted findings during the exit conference on 04/28/21.