HospitalInspections.org

Based on document review and interview, it was determined that for 4 of 10 clinical records (Pt #1, Pt #2, Pt #3 and Pt #8) reviewed for admission wound assessments, the Hospital failed to ensure the registered nurse supervised and evaluated the nursing care for each patient by failing to ensure wound assessments were performed on admission, as required.

Findings include:

1. On 1/18/2023, the Hospital's policy titled, "Assessment and Re-Assessment" (dated 6/2022) was reviewed and required, "...The RN admission assessment of the patient will include...wound assessment - those patients presenting with wounds have, at a minimum, the following assessed within 12 hours with appropriate corresponding documentation:
-wound type (etiology) - indicate whether the wound presents with characteristics typical of pressure ulcer, arterial ulcer, surgical wound, diabetic ulcer, etc.
-location - body region
-worst tissue type - non-blanchable erythema (discoloration of the skin that does not turn white when pressed), partial thickness, full thickness, necrotic (the death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply), eschar (a dry, dark scab or falling away of dead skin), or muscle/tendon or bone exposed..."

2. On 1/17/2023, Pt. #1's clinical record, dated 7/1/2022 at 8:15 PM thru 7/29/2022, was reviewed and indicated:
-Pt. #1 was admitted to the Hospital on 7/1/2022 at 8:15 PM with the diagnosis of respiratory failure, unspecified with hypoxia (absence of enough oxygen) and bilateral multi-focal pneumonia, as evidenced by COPD (chronic obstructive pulmonary disease) ARDS (acute respiratory distress syndrome-life threatening condition where lungs cannot provide the body's vital organs with enough oxygen).
-Pt #1's nursing admission note, dated 7/2/2022 at 2:30 AM, included, "Integumentary assessment: General skin appearance: appropriate for ethnicity, warm, dry, smooth, well hydrated, skin integrity: Skin intact."
-Pt #1's initial nursing assessment lacked documentation of a wound to coccyx.
-Pt #1's wound care nurse's note, dated 7/2/2022 at 5:31 PM, included, "Pressure Injury: coccyx; present on admission; Stage 2; wound length 1.5cm (centimeter), width 0.5cm, depth 0.1cm."

3. On 1/18/2023, Pt #2's clinical record, dated 1/12/2023 thru 1/17/2023, was reviewed and indicated:
-Pt #2 was admitted to the Hospital on 1/12/2023 with the diagnosis of respiratory failure.
-Pt #2's admission assessment, dated 1/12/2023, noted "skin not intact - wound related."
-Pt #2's clinical record lacked documentation of a complete skin/wound assessment until 1/14/2023 ( 2 days after admission).
-Pt #2's wound assessment, dated 1/14/2023, noted the following: a) right elbow deep tissue pressure injury 10 cm x 10 cm; b) left hip deep tissue pressure injury 5 cm x 5 cm; c) right lower back stage 3 -5.5 cm x 7 cm; d) right mid back deep tissue injury 10 cm x 10 cm; e) sacrum stage 3 - 2.5 cm x 1 cm; f) right hip unstageable - 8 cm x 8 cm, wound depth unable to determine; g) right ear - 4 cm x 1 cm; h) right ischial tuberosity unstageable - 3 cm x 4 cm; i) bridge of nose - deep tissue pressure injury 1.5 cm x 1.5 cm; j) right lateral ankle deep tissue pressure injury 2 cm x 2 cm; k) right 6th toe extending to lateral foot deep tissue pressure injury 3 cm x 1 cm.
Pt #2's clinical record lacked documentation of an initial assessment of the above wounds until 2 days after admission on 1/14/2023.

4. On 1/18/2023, Pt #3's clinical record, dated 1/12/2023 thru 1/17/2023, was reviewed and indicated:
-Pt #3 was admitted to the Hospital on 1/12/2023 with diagnosis of respiratory failure.
-Pt #3's admission skin assessment, dated 1/13/2023, noted, "skin not intact - wound related."
-Pt #3's wound assessment dated 1/13/2023 noted - a) anterior portion of neck 2 cm x 0.5 cm; b) left medial foot deep tissue present of admission 0.5 cm x 0.5 cm; c) left heel unstageable 1.5 cm x 2 cm; d) right heel deep tissue pressure injury 1 cm x 2 cm.
-Pt #3's clinical record lacked documentation of a complete skin/wound assessment until 1/13/2023 (1 day after admission).

5. On 1/18/2023, Pt #8's clinical record dated 1/15/2023 thru 1/17/2023 was reviewed and indicated:
-Pt #8 was admitted to the Hospital on 1/15/2023 with the diagnosis of respiratory failure.
-Pt #8's admission skin assessment dated 1/15/2023 noted "skin not intact - wound related."
-Pt #8's wound assessment, dated 1/16/2023, noted the following: a) trauma right knee 0.5 cm x 0.5 cm; b) pressure injury right lower leg unstageable 1.5 cm x 3 cm; c) right posterior lower leg - unstageable pressure injury 9 cm x 5 cm; d) pressure injury left posterior lower leg unstageable 4 cm x 3 cm; e) sacrum extending to buttocks - stage 4 -4.5 cm x 3.5 cm x 3 cm; f) left ischial tuberosity (sit bone) 3 cm x 3 cm.
-Pt #8's clinical record lacked documentation of a complete skin/wound assessment until 1/16/2023 (1 day after admission).

6. On 1/18/2023, an interview was conducted on 10:00 AM with the Registered Nurse (E #1). E #1 stated that when a patient with a wound is admitted, the admitting nurse documents the location of the wound. The wound nurse assesses the wounds and then obtains wound care orders.