HospitalInspections.org

Based on record review and staff interview, it has been determined that the hospital failed to follow their policy related to the documentation of a new pressure wound for 1 of 5 patient's reviewed for pressure ulcers, Patient ID #1.

Findings are as follows:

A community reported complaint was submitted to the Rhode Island Department of Health on 4/17/2024 from the patient's family member alleging that Patient ID #1 needed surgery to clean out an infected wound.

Review of the hospital policy titled, "Wound Assessment/Reassessment and Nursing Protocol Orders for Impaired Skin Integrity" last reviewed on 9/2023, states in part:
Policy ...
...3. All wounds which require ongoing assessment shall be added as a single wound LDA (Lines, Drains, Airway, Tubes and Wounds) [a section in the nursing flow sheet to document assessment/care provided by the nurse] with the wound type specified in the LDA properties in the electronic health record ...
Procedures ...
...2. Initiation of Wound LDA ... documentation should include. wound type, present on admission ...
...3. Wound Assessment ... document wound characteristics ...

Record review for Patient ID #1 revealed this patient presented to the hospital for rehabilitation on 2/24/2024, as a transfer from another hospital after sustaining an incomplete spinal cord injury while swimming.

Review of the initial nursing admission assessment on 2/24/2024 revealed that both the patient and family member are hearing impaired. Patient ID #1 is alert and oriented X 4.

On admission (2/24/2024) the patient was noted to have an open blister on his/her right upper and lateral thigh and an open blister to right inner thigh, with small intact blisters noted on the trunk related to generalized swelling.

A Review of the patient's Plan of Care revealed a nursing note dated 2/27/2024 at 2:40 PM, noting the following new wound area was identified "scattered open/dry blisters noted to peri area bilateral thighs and buttocks". Notes indicate a foam adhesive dressing was applied to the wound, but per the hospitals policy the nurse failed to initiate a Wound LDA which would identify and describe each wound separately. Records indicate the first documentation of the wound LDA (a wound description and measurement) did not occur until 3/4/2024 (7 days after being identified), as new open blister on the patient's left buttock.

During a surveyor interview on 4/23/2024, with Certified Wound Nurse Staff H, she stated that it was her expectation that on 2/27/2024 when the wound was first identified, the nurse should have initiated the wound LDA documentation of the newly identified area on the patient flow sheet. When asked if she would have recommended a different treatment, she stated she would not.

During a surveyor interview with the Risk Manager on 4/23/2024, she was not able to provide evidence that when the nurse identified the new skin wound on 2/27/2024, it was added to the patient's hospital record in the flowsheet as per hospital policy.



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