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Based on record review, and interview the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to have a policy in place for wound care that described and provided instructions on how to assess, evaluate, and implement care for the different types of wounds.

Findings:

Review of the Policy and Procedure given to surveyor by S2NM titled Fundamentals of Nursing, PC-1403, revised September 2019 revealed in part: Fundamentals of Nursing Concepts, Process, and Practice will be utilized as a reference for any nursing procedure, but not limited to, procedures: #8) Wound Care.

Interview on 09/22/2020 at 10:45 a.m. with S2NM confirmed the hospital did not have a specific wound care policy that provided instructions on how to assess, evaluate, and implement care for the different types of wounds. The hospital used the Fundamentals of Nursing, which she confirmed did not provide any procedure references to wound care.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure of the nursing staff to accurately document wound assessments for 1 (#1) of 4 (#1, #2, #4, #5) patients sampled for wound care.

Findings:


Review of the Wound Flowsheet for patient #1 dated 03/31/2020 revealed last documented description of wound measurements listed as follows: left buttock 3cm X 2.5cm, and right buttock 9cm X 4cm bruised areas, no drainage, no odor, and dry.

Review of patient #1's Hospital transfer record to hospital (a) revealed Patient Care Note dated 04/06/2020 patient was a direct admit from behavioral unit, patient lethargic upon arrival with NRB mask on 8L. Patient had foul smell noted and SN found horrible unstageable wound to coccyx/sacral region measuring 10cm X 10cm with wound edges macerated. Wound was just covered with dry 4 x 4 and paper tape. The smell from the wound was very foul.

Interview on 09/22/2020 at 10:45 a.m. with S2NM confirmed that the wounds are assessed each shift and entered into the electronic record, but it only provided staff with a check off box and no place to document in detail.

Based on record review, interview, and observation, the hospital failed to ensure the nursing staff developed and kept current individualized and comprehensive nursing care plans. This deficient practice was evidenced by failure of the nursing staff to include nursing interventions for wound care for 2 (#1, #4) of 4 (#1, #2, #4, #5) sampled patients reviewed for wound care of a total sample of 5.

Findings:

Review of the hospital policy titled Treatment Plans, PC-501, revised September 2019 revealed in part: Each patient will have an individualized inter-disciplinary treatment plan developed under the direction of the psychiatrist. This comprehensive plan is initiated upon admission following assessments by the various disciplines and will reflect the individuals clinical needs, condition, functional strengths, and limitations. b) Problems are added to the Problem list as they occur.

Patient #1
Review of the medical record for patient #1 revealed she was admitted to the facility on 03/02/2020 from a NF for increased agitation, assaultive behavior towards staff at NF, confused, and non-compliant with care.

Review of the History and Physical for patient #1 revealed medical diagnosis of GERD, HTN, CAD, DM, and chronic UTI.

Review of the Weekly Skin Assessment form dated 03/31/2020 for patient #1revealed area to left buttock suspected deep tissue injury purplish, dark maroon in color 3cm X 2.5 cm. Area to right buttock suspected deep tissue injury, 5 little abrasions, breaks in skin, entire buttocks and perineal area red and excoriated.

Review of the Treatment Plan for patient #1 revealed problems listed as Alteration in Health Maintenance, and High Risk For Falls. There was no documentation to include wound care in the Treatment Plan.

Patient #4
Review of the medical record for patient #4 revealed he was admitted on 02/06/2020 from an acute care hospital due to combativeness and refusing to take medications and non-compliant with care. Admitting diagnosis included Depression, Agitation, Cognitive Impairment, and Delusions.

Further review of Multi-Disciplinary Note dated 02/06/2020 for patient #4 revealed skin breakdown to coccyx area covered with duoderm.

Weekly skin assessment dated 02/06/2020 for patient #4 documented duoderm in place to coccyx area.

Review of the Treatment Plan for patient #4 revealed problems listed as Health Maintenance Alteration, and Risk For Falls. There was no documentation to include wound care to the coccyx area.

Interview on 09/23/2020 at 10:30 a.m. with S2NM confirmed The Treatment Plans for patient #1, patient #4 did not include wound care, and the Treatment Plans should include all aspects of the patients care.