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Based on review of medical records, facility policies and interview it was determined the facility failed to investigate allegations made by a family member related to care provided in the emergency room and the facility. This had the potential to affect all patients in this facility and did affect Medical Record # 1.

Findings include:

Policy and Procedures:
Complaints/ Grievances revised 10/12

Policy: It is the policy and expectation of East Alabama Medical Center (EAMC), including any entity using the EAMC medicare provider number, that every complaint and grievance be addressed effectively, timely and in a professional manner.

I. Negative Comment/ Concern:
A negative comment or concern, for this purpose, is an expression negative in nature expressed by a patient or their representative.
i. These can be verbally shared with an EAMC employee.

Response to Negative Comment/Concern:
Negative comments or concerns expressed during the hospital visit or post-hospital visit should be addressed at the discretion of the recipient. However, follow-up is highly encouraged and use of EAMC's service recovery program should be considered when appropriate.

II. Complaint:
i. A concern regarding patient care or service expressed by the patient or patient's representative that can be resolved at the point of service by the staff present. ("Staff present" includes any hospital staff present at the time of the complaint or any involved in resolving the issue that moment or that day.)


Response to Complaints:
i. Complaints should be resolved as soon as possible, but resolution should not exceed 24 hours. (24 hours from notification of complaint by the Risk Management Department)

III. Grievance:
A patient grievance is a written or verbal complaint by a patient or the patient's representative, regarding the patient's care (when the complaint has not been resolved at the time by staff present) abuse or neglect, or the hospital's compliance with the CMS (Centers for Medicare and Medicaid) Hospital Conditions of Participation.

Patient Representative- A patient representative is the patient's legal representative pursuant to a valid Advance Directive or court order, or any determination that the patient representative is a surrogate decision maker under current Alabama Law.

Complaints which are considered grievances include:
i. Patient care issues which are not promptly resolved by staff present. Examples include when the complaint is:
1. Postponed for later resolution;
2. Referred to other staff for later resolution;
3. Required investigation; or
4. Require further action for resolution.

Response to Grievance- All grievances require a written response.
i. Grievances should be resolved as soon as possible.

Medical Record (MR) findings:

1. MR # 1 was seen in the Emergency Department 8/10/13 for multiple complaints. The husband states that she has multiple problems for which she needs to be in the hospital for three or four days.

The emergency room physician documented in the Plan for care: " We are going to do laboratory work and chest x-ray and then I will talk with whoever is on call for ... concerning her disposition. At this point, the husband is expressing very strong frustration with the system as a whole regarding her not being by his opinion, not adequately taken care of, not having adequate follow up, and he simply thinks and believes that if she is admitted then things will be taken care of."

The emergency room Registered Nurse (RN) documented 8/10/13 at 11:11 AM, " Generalized pain; UTI (Urinary Tract Infection), hospice patient brought in from home. Spouse wants her transferred to Montgomery. Presents with Foley catheter, urine purulent. With regard to hospice, spouse states ' they're going to kill her'. He appears angry and frustrated and at this time is unwilling or unable to accept grave, terminal status his spouse is in..."

There was no documented investigation into the spouse's allegations and concerns regarding the care of the patient.

MR # 1 was admitted to the facility 9/12/13 with a primary diagnoses of Sepsis, Osteomyelitis and Stage 4 pressure ulcers.

The 9/19/13 Nursing Narrative Note documented at 8:45 PM, " At BSD (bedside) pt (patient) spouse wants her to 'have a tube run down her throat' attempted to instruct Mr... about procedure risks and he is adamant that she have it. Continues to voice concern over her care and lack of care. Complains about staff physicians. he continues to remove medications from the room..."

There was no documentation of any investigation into the complaints and allegations made by the spouse.

In an interview with Employee Identifier (EI) # 1, Director of Patient Flow 11/21/13 at 9:00 AM, confirmed no investigation was documented. EI # 1 stated that daily rounds made by floor leadership addressed the spouse's concerns and issues daily. There is no documentation of this.

Based on review of medical records, policy and procedures, Standards of Practice and interview it was determined the nursing staff failed to:

1. Document wound measurements

2. Document specific wound care provided

3. Document wound assessments to include appearance of the wound/ wound bed, exudates, drainage, odor signs and symptoms of infection

4. Document the skin surrounding the wound

5. Document education to caregiver or patient related to wound care after discharge

6. Have orders for wound care provided.

This had the potential to affect all patients served by this hospital and did affect Medical Record (MR) # 1.

Alabama Board of Nursing Chapter 610-X-6
Standards of Nursing Practice

610-x-6-.13 Standards for Wound Assessment and Care

(1)" It is within the scope of a registered nurse or licensed practical nurse practice to perform wound assessments including, but not limited to, staging of a wound and making determinations as to whether wounds are present on admission to a healthcare facility pursuant to an approved standardized procedure..."

(2) " The minimum training for the registered nurse or licensed practical nurse that performs selected tasks associated with wound assessment and care shall include:
(a) Anatomy, physiology and pathophysiology.
(c) Equipment and procedures used in wound assessment and care.
(d) Chronic wound differentiation.
(e) Risk identification.
(f) Measurement of wound.
(g) Stage of wound.
(h) Condition of the wound bed including:
(i) Tissues
(ii) Exudates
(iii) Edges
(iv) Infection
(i) Skin surrounding the wound."

610-X-6-.06 Documentation Standards

(1)" The standards of documentation of nursing care provided to patients by registered nurses or licensed practical nurses are based on principles of documentation regardless of the documentation format.

(2) Documentation of nursing care shall be:
(a) Legible
(b) Accurate
(c) Complete. Complete documentation includes reporting and documenting on appropriate records a patient's status, including signs and symptoms, response, treatments, medications, other nursing care rendered, communication of pertinent information to other health team members, and unusual occurrences involving the patient."

Policies and Procedures

8.9 a Subject: Skin Risk Assessment

Policy:
The Skin Risk Assessment is to be completed at time of admission of the patient to the hospital as an inpatient, each week there after preferably on Thursdays and at time of patient transfer from one nursing unit to another.

Procedure:
Guidelines to assist with the development of the plan of care for pressure ulcer prevention should include the physician's specific orders as well as those outlined in the Perry & Potter Manual for Nursing, the Policy and Procedure for Pressure Ulcer Prevention as well as the Skin Integrity Manual.

8.6 c Subject: Pressure Ulcer Staging Procedure

Purpose: The staging system provides a means of identifying and labeling the extent of tissue damage in pressure wounds.

Policy:
Staging should be performed by a certified wound nurse or the physician. Nurses other than certified wound care nurses should describe the wound versus staging the wound.

ET (Enterostomal Therapist) Nurse Skin Care Management Protocol

Wound care:
Wound care goals:
" Care directed toward removal of impediments to wound healing.
...Reduce or eliminate preventable complications related to wounds.
Educate patient/caregiver on wound care and wound healing.

Physician order:
Skin care management/ ET nurse evaluation and treatment. (orders effective through hospitalization or until resolved."

Medical Record Findings:

1. MR # 1 was admitted in an Observation status 7/9/13 from the Emergency room with diagnoses of Urinary Tract Infection, Left Hip Dislocation, Left Hip Pain, Decubitus Skin Wounds and Cutaneous Candidiasis. The patient was under the care of Hospice when brought into the Emergency Room (ER) by ambulance.

The staff was unable to provide Intravenous (IV) fluids " because of inability to obtain IV access".

Nursing Narrative Note dated 7/9/13 at 10:23 AM had documentation, " Pt (patient) IV was attempted 10-12 times. Rapid response was called and they attempted as well. IV Access was unsuccessful."

The plan for the patient 7/9/13 was documented by the ER physician, " Antibiotic dosing Rocephin Intramuscularly and provide analgesia with Roxanol by mouth. The Foley catheter will be changed and provide Diflucan for three days."

The History and Physical dated 7/9/13 documented, " Skin: Poor skin turgor and has multiple pressure sores noted on in the left lower ankle and the buttock areas as per the ET nurse description."

The nursing assessment on admission 7/9/13 documented at 11:25 AM, " Brusing, left leg wound, buttocks ulceration, groin rash."

The nurse documented on the assessment and treatment note 7/9/13 at 7:38 PM, " Surgical Incision left hip skin surrounding tissue, edematous, drainage yellow and odor free small amount, dressing- 4 x 4's, changed, other: medipore tape. Ulcer LLE (Left Lower Extremity) open, edematous, cleaned with sterile saline, 4 x 4's, other: Kerlix and medipore tape."

There was no order for the wound care provided 7/9/13 in the medical record.

The Skin Team Assessment was completed 7/10/13 at 2:44 PM. The Skin Care Team observed, " This pt (patient) well known to this department from multiple recent admissions, presents with red, raised rash with satellite lesions at perineal area, groin and buttock area... increased moisture dermatitis. Appears Foley is leaking. Left hip surgical incision with minimal yellow drainage. 1 cm (centimeter) diameter wound on left posterior leg small amount yellow drainage... Albumin 2.0." Other: " Dry dressing to left hip incision, Qday (every day). Clean wounds on LLE (left lower extremity) with NS (normal saline), apply Neosporin ointment and cover with Mepilex Lite Qday."

The only measurement refers to the 1 cm diameter area on LLE and their is no depth to the wound. It is unclear from the documentation if the patient only has 1 wound and 1 incision line plus the rash to the buttocks to provide wound care.

The nurse documented on the assessment and treatment note 7/10/13 at 7:20 PM, " Left hip incision serosanguineous drainage small amount, dressing changed other: Steri-Strips intact. Ulcer LLE tender, erythema dry, intact, 4x4's gauze dressing."

This was not the wound care ordered by the physician or ET nurse.

The Nursing Narrative Note form documented 7/10/13 at 9:30 PM, " Pt's spouse at bedside is removing pt dressing from left hip. Instructed not to do. Pt c/o (complain of) pain to left hip left leg. Pt spouse also continues to raise pt bed to high. Bed locked to keep Mr... from adjusting bed. He is HOH (hard of hearing) and interfering with her care. Is wanting to be at her bedside but is instructed not to remove dressing or apply any medication."

The Nursing Narrative Note form documented 7/10/13 at 11:20 PM, " Pt's dressing supplies placed in bedpan at bedside... redressed pt left hip where dressing was pulled off."

There was no documentation of what type of dressing was used on the left hip.

The facility nurses failed to document measurement of the areas wound care was provided to and a description of the wound. Wound care documented in the nurse assessment and treatments was not the wound care ordered 7/10/13 by the ET nurse.

There was no documentation of education to the caregiver of wound care to be provided after discharge.

The patient was discharged home with home health care 7/11/13.

In an interview 11/21/13 at 9:00 AM with Employee Identifier (EI) # 1, Director of Flow the above information was confirmed.

MR # 1 returned to the Emergency Room 7/25/13. The diagnoses from this visit was Constipation, Dehydration and Hypotension.

MR # 1 returned to the Emergency Room 8/10/13, diagnosed with a Urinary Tract Infection and sent back home on Cipro 500 mg (milligrams) 1 by mouth BID (twice a day) for 7 days. The spouse decided to take patient back to their home instead of the son's home on 8/10/13. Home health to continue to follow.

MR # 1 was readmitted to the hospital 8/14/13 with diagnoses of Advanced Dementia, Recurrent Urinary Tract Infection and Multiple Pressure Ulcerations.

The Skin Team Assessment was completed 8/14/13 at 11:24 AM. The Skin Care Team observed, " This pt (patient) well known to this department has multiple skin issues. Areas of possible DTI (Deep Tissue Injury) on each buttock and left heel, superficial skin impairments on back. Pt is bedbound elderly pt, admitted with skin problems... See comprehensive skin and wound assessment sheet...Albumin 1.9. Vasolex to her wounds, cover with Mepilex Lite, BID."

The Comprehensive Wound Assessment form dated 8/14/13 documented, " 1. Wound location-Back, Mid, Medial, stage 2, measured- length 3 cm x width 2 cm x depth 0.2 cm, slough, beefy red, wound edges uneven, no odor, clear exudate minimal amount.

" 2. Wound- mid back distal, stage 2, measured- length 1 cm x width 1 cm x depth 0.2 cm, beefy red, wound edges uneven, erythematous, no odor, clear exudate minimal amount .

" 3. Wound- mid prox (proximal), stage 2, measured- length 1 cm x width 3 cm x depth 0.2 cm, pink, wound edges uneven, erythematous, no odor, clear exudate minimal amount.

" 4. Wound- Right lower back, stage 2, measured- length 1 cm x width 1 cm x depth 0.2 cm, slough, beefy red, wound edges uneven, erythematous, no odor, clear exudate large amount.

" 5. Wound- Right hip Unstagable- DTI, measured- length 10 cm x width 5 cm x depth 0 cm, color of tissue purple, no odor and no exudate.

" 6. Wound- Right hip Unstagable- DTI, measured- length 3 cm x width .5 cm x depth 0 cm, color of tissue purple, no odor and no exudate.

" 7. Wound- Left heel Unstagable- measured- length 2 cm x width 2 cm x depth 0 cm, color of tissue purple, no odor and no exudate."

The nurse admission assessment documented, " Skin Abnormality/ location:
# 1- type bruising, location- right buttocks
# 2- type abrasion, ulceration, location- right side of upper mid back
# 3- type bruising redness, location- leg right lateral calf
# 4 type- bruising, ulceration ,wound, location- upper back, mid back
# 5 type- bruising, wound Comment: The following are a list of skin abnormalities: 1. left butt cheek-redness 2. between buttocks- redness 3. behind left knee- skin tear 4. left calf- scab 5. boggy heels.

The wound description between the nurse on the floor and the wound nurse is inconsistent. There is a difference in the number of wounds and the areas/locations.

There was no documentation of wound care being provided 8/14/13.

The assessment/ treatment notes dated 8/14/13 documented at 12:00 CDT (Central Daylight Time) incision wound dressing: Other: Mepilex.

The assessment/ treatment notes dated 8/14/13 documented at 16:00 CDT incision, wound dressing: changed, Other: Mepilex and Vasolex.

The assessment/ treatment notes dated 8/14/13 documented at 20:15 CDT incision, wound dressing: Other: dressing intact, moderate amount of serosanguineous drainage.

The assessment/ treatment notes dated 8/15/13 documented at 08:00 CDT incision, wound dressing: Other: dressing intact, moderate amount of serosanguineous drainage.

The assessment/ treatment notes dated 8/15/13 documented at 16:00 CDT incision, wound dressing: Other: dressing intact.

The assessment/ treatment notes dated 8/16/13 documented at 10:00 CDT incision,wound dressing:Pastes/Powders/Beads, changed.

The wound care documented is not specific, each wound is not documented as being assessed and it is not clear if Pastes/ Powders/ Beads are use in the wound care.

The Medication Administration Record (MAR) documents Vasolex 1 app(application) TOP (topical) applied:
8/14/13 at 15:39 CDT
8/15/13 at 03:00 CDT.

The Medication Administration Record documents Vasolex 1 app(application) TOP (topical) applied:
8/15/13 at 09:00 CDT- family states this has already been done
8/16/13 at 03:00 CDT- family refused.

The facility failed to provide wound care to the patient two times a day as ordered 8/14/13, "Vasolex to her wounds, cover with Mepilex Lite, BID."

In an interview 11/21/13 at 9:20 AM, the surveyor asked if the patient received the wound care as ordered. EI # 1, Director of Flow stated it was on the task sheet and they could only screen print the task as follows:
" 8/14/13 at 12:00 Clean all wounds with NS, apply Vasolex ointment and cover with Mepilex Lite, turn pt to side only, please use Comfort Wipes to clean sacral buttocks."
The exact same wording is on the task for 8/14/13 at 21:00, 8/15/13 at 9:00, 8/15/13 at 21:00 and 8/16/13 at 9:00.

The MAR documentation and times do not match the Task times and the nurses failed to document completing wound care in the integumentary documentation of assessments and treatments.

There was no documentation the caregiver was educated in the new wound care.

The patient was discharged home 8/16/13 with instructions to, " Return if acute emergencies only and any other non-emergent need should be managed as an outpatient visit. She was instructed to be discharged with home health per her husband's request and a Department of Human Resources home assessment was requested upon discharge."

In an interview 11/21/13 at 9:20 AM with Employee Identifier (EI) # 1, Director of Flow the above information was confirmed.

MR # 1 returned to the Emergency Room (ER) 9/4/13. The diagnoses from this visit was multiple decubitus to her back and gluteal region, urinary tract infection and poor social situation.

The ER nurse documented 9/4/13 at 9:54 PM in a Nurse Narrative Note, " Dressing changed to back and buttocks..."

There was no documentation of what type of dressing was used on the multiple decubitus, no measurements, no wound assessments, no documentation of skin surrounding the wounds and there was no order for wound care.

MR # 1 was readmitted to the facility 9/12/13 post ER visit. The emergency department physician documented, " Patient had extensive dressings applied to the dorsal and lumbar vertebral area. The patient had significant wound drainage and discharge with a malodorous, greenish-type material. The patient had significant and deep decubitus and ulcerations all along the spine. Some local erythema. The patient has 2+ to 3+ peripheral edema."

The diagnoses from the ER were Hypotension, Atrial Fibrillation, Anemia, Dehydration, Decubitus infected, Dementia and Urinary Tract infection.

The Skin Team Assessment was completed 9/13/13 at 8:55 AM. The Skin Care Team observed, " This pt is well known to this department from previous admissions. She presents to EAMC with multiple necrotic wounds (pressure wounds) on back and both feet and legs...All extremities are edematous and weeping. Pt very frail with poor verbal response. Albumin 1.8... Clean all wounds with NS, apply Silvadene Cream and cover all wounds with Mepilex Lite. Clinitron bed ordered."

The wound nurse failed to document any measurements or description of the numerous wounds, exudate, odor or if wound care was provided.

The nurse assessment and treatment form documented the following skin abnormalities 9/12/13 at 21:00 CDT:
# 1- type ulceration, location- lower back
# 2- type ulceration, location- buttocks
# 3- type ulceration, location- foot left
# 4- type ulceration, location- foot right
# 5- type ulceration, location- leg, right and multiple decubitus noted to spinal area.


The nurse assessment and treatment form documented the following skin care provided 9/14/13 at 09:00 CDT:
Ulcer leg right: tender, drainage/exudate, erythema, serosanguineous drainage, wound care: clean with sterile saline, Dressing:Pastes/Powders/Beads, changed.
Tear hand left: tender, drainage/exudate, bloody drainage, wound care: clean with sterile saline, Dressing:Pastes/Powders/Beads, changed.
Tear hand right: tender, drainage/exudate, serosanguineous drainage, wound care: clean with sterile saline, Dressing:Pastes/Powders/Beads, changed.
Ulcer heel left: tender,erythema, no drainage, wound care: clean with sterile saline, Dressing:Pastes/Powders/Beads, changed.
Ulcer back right: tender, necrotic tissue, slough, drainage/exudate warm, yellow drainage, wound care: clean with sterile saline, Dressing:Pastes/Powders/Beads, changed.
Ulcer buttock right: tender, necrotic tissue, slough,necrotic tissue eschar drainage/exudate, erythema, yellow drainage, wound care: clean with sterile saline, Dressing:Pastes/Powders/Beads, changed.

This is wound care to 6 areas, only 5 were identified on the admission nurse assessment. The wound nurse did not document a number of wounds. The wound care provided is not specific to identify if pastes, powders or beads is used. The medical record documentation for the description is not specific as to the whether all of the choices are for the wound or only parts of the choices; tender, necrotic tissue, slough,necrotic tissue eschar drainage/exudate apply to the area identified.

The nurse assessment and treatment form documented the following skin care provided 9/15/13 at 11:19 CDT:
Ulcer back right: tender, necrotic tissue, slough, drainage/exudate, erythema, yellow drainage, wound care: clean with sterile saline, Dressing:Pastes/Powders/Beads, changed other Mepilex.
Ulcer buttock right: tender, necrotic tissue, slough,necrotic tissue eschar drainage/exudate, erythema, yellow drainage, wound care: clean with sterile saline, Dressing:Pastes/Powders/Beads, changed other Mepilex.
Ulcer heel left: tender,erythema, no drainage, wound care: cleaned with soap and water cleaned with sterile saline, Dressing:Pastes/Powders/Beads, changed.
Tear hand left: tender, drainage/exudate, serosanguineous drainage, wound care: gauze dressing, Petroleum gauze,changed.
Ulcer leg right: tender, necrotic tissue, slough, drainage/exudate, erythema, yellow drainage, wound care: clean with sterile saline, Dressing:Pastes/Powders/Beads, changed other Mepilex.
Tear Leg Right:tender, drainage/exudate, erythema, yellow serosanguineous drainage wound care: clean with sterile saline, Dressing:Pastes/Powders/Beads, changed other Mepilex.


This is wound care to 6 areas, however the tear hand right was not identified and a wound to tear leg right was dressed.


The nurse assessment and treatment form documented the following skin care provided 9/16/13 at 9:22 CDT:
Ulcer back right: tender, necrotic tissue, slough, drainage/exudate, erythema, purulent drainage, wound care: cleaned with soap and water, drainage present changed.
Ulcer buttock right: tender, necrotic tissue, slough,necrotic tissue eschar drainage/exudate, erythema, malodorous, purulent drainage, wound care: cleaned with soap and water, changed.
Ulcer heel left: Changed.
Tear hand left: Changed.
Tear leg right: Changed.

This is wound care to 5 areas, the right leg ulcer was not identified. The wound care documented as provided 9/16/13 is incomplete and does not follow the orders for wound care. There was no Mepilex used, no Silvadene used and soap and water was used to clean areas instead of sterile saline. There was no documentation the physician or wound care team was notified of the malodorous and purulent drainage.


The nurse assessment and treatment form documented the following skin care provided 9/17/13 at 2:00 CDT:
Ulcer back right: tender, necrotic tissue, slough, drainage/exudate. Incision, wound dressing- Dry, intact, gauze dressing.
Ulcer buttock right: tender, necrotic tissue, slough,necrotic tissue eschar drainage/exudate. Incision, wound dressing- dry, intact.
Ulcer heel left: Tender. Incision, wound dressing-dry, intact.
Tear hand left: Incision, wound dressing-dry, intact.
Ulcer leg right: Incision, wound dressing-dry, intact.
Tear leg right: Incision, wound dressing-dry, intact.

There was no documentation of wound care provided and no complete assessment of the wounds. The wound assessment 9/16/13 lists 5 wounds and on 9/17/13 there was 6 wounds.

The physician's progress notes dated 9/18/13 by the Infectious Disease (ID) physician documented, " Plan: recommend PO (by mouth) antibiotics + Dakins solution wet to dry dressing. Keflex 500 mg po TID (three times a day) + Doxycycline 100 mg PO BID (twice a day)."

The 9/18/13 Assessment and Treatment section of Integumentary failed to identify the wounds and failed to document any type of care provided to the wounds.

The nurse assessment and treatment form documented the following skin care provided 9/19/13 at 10:15 CDT:
Ulcer back right: Necrotic tissue, slough, Necrotic tissue, eschar. Drainage- Yellow, serosanguineous, malodorous. Incision, wound dressing- Cleaned with sterile saline. Silvadene and mepilex applied.
Ulcer buttock right:Necrotic tissue, slough, Necrotic tissue, eschar. Drainage yellow, serosanguineous. Incision, wound dressing- Cleaned with sterile saline. Silvadene and mepilex applied.
Ulcer heel left: Necrotic tissue, eschar. Incision, wound dressing- prevalon boot.
Tear hand left: Open drainage/ exudate. Drainage: Serous. Incision, wound dressing-cleaned with sterile saline, gauze dressing, petroleum gauze, changed.
Ulcer leg right: Open drainage/ exudate. Drainage: Serous. Incision, wound dressing-cleaned with sterile saline, gauze dressing, petroleum gauze, changed.
Tear leg right: Open drainage/ exudate. Drainage: Serous. Incision, wound dressing-cleaned with sterile saline, gauze dressing, petroleum gauze, changed.

The nurse documented regarding each of the 6 wounds and a description. The wound care provided to the ulcer left heel, left hand tear, ulcer right leg and tear right leg did not have documented wound care orders for the care provided.

The physician's progress notes dated 9/19/13 by the Plastic surgeon documented, " Agree with ID physician wet to dry Dakins solution, patient not a surgical candidate."

There was no order written for the use of wet to dry Dakins solution dressings the two physicians discussed and approved.

The Medication Administration Record documents Silvadene 1% cream 1 app TOP applied:
9/13/13 at 16:00 CDT
9/14/13 at 09:00 CDT
9/15/13 at 10:30 CDT
9/16/13 at 09:00 CDT
9/17/13 at 09:00 CDT
9/18/13 at 09:00 CDT
9/19/13 at 10:30 CDT
9/20/13 at 09:00 CDT these entries are electronically signed by the nurse as being completed.

The wound care documentation was not consistent with the orders for wound care and the wound was not measured during the 9/12/13 admission.

The patient expired 9/21/13 in the facility.

In an interview 11/21/13 at 9:00 AM, EI # 1 confirmed the above and that the nurses documentation of wound care was incomplete.

Based on review of medical records, policy and procedures, Standards of Practice and interview it was determined the nursing staff failed to:

1. Document wound measurements

2. Document specific wound care provided

3. Document wound assessments to include appearance of the wound/ wound bed, exudates, drainage, odor signs and symptoms of infection

4. Document the skin surrounding the wound

5. Document education to caregiver or patient related to wound care after discharge

6. Have orders for wound care provided.

This had the potential to affect all patients served by this hospital and did affect Medical Record (MR) # 1.

Alabama Board of Nursing Chapter 610-X-6
Standards of Nursing Practice

610-x-6-.13 Standards for Wound Assessment and Care

(1)" It is within the scope of a registered nurse or licensed practical nurse practice to perform wound assessments including, but not limited to, staging of a wound and making determinations as to whether wounds are present on admission to a healthcare facility pursuant to an approved standardized procedure..."

(2) " The minimum training for the registered nurse or licensed practical nurse that performs selected tasks associated with wound assessment and care shall include:
(a) Anatomy, physiology and pathophysiology.
(c) Equipment and procedures used in wound assessment and care.
(d) Chronic wound differentiation.
(e) Risk identification.
(f) Measurement of wound.
(g) Stage of wound.
(h) Condition of the wound bed including:
(i) Tissues
(ii) Exudates
(iii) Edges
(iv) Infection
(i) Skin surrounding the wound."

610-X-6-.06 Documentation Standards

(1)" The standards of documentation of nursing care provided to patients by registered nurses or licensed practical nurses are based on principles of documentation regardless of the documentation format.

(2) Documentation of nursing care shall be:
(a) Legible
(b) Accurate
(c) Complete. Complete documentation includes reporting and documenting on appropriate records a patient's status, including signs and symptoms, response, treatments, medications, other nursing care rendered, communication of pertinent information to other health team members, and unusual occurrences involving the patient."

Policies and Procedures

8.9 a Subject: Skin Risk Assessment

Policy:
The Skin Risk Assessment is to be completed at time of admission of the patient to the hospital as an inpatient, each week there after preferably on Thursdays and at time of patient transfer from one nursing unit to another.

Procedure:
Guidelines to assist with the development of the plan of care for pressure ulcer prevention should include the physician's specific orders as well as those outlined in the Perry & Potter Manual for Nursing, the Policy and Procedure for Pressure Ulcer Prevention as well as the Skin Integrity Manual.

8.6 c Subject: Pressure Ulcer Staging Procedure

Purpose: The staging system provides a means of identifying and labeling the extent of tissue damage in pressure wounds.

Policy:
Staging should be performed by a certified wound nurse or the physician. Nurses other than certified wound care nurses should describe the wound versus staging the wound.

ET (Enterostomal Therapist) Nurse Skin Care Management Protocol

Wound care:
Wound care goals:
" Care directed toward removal of impediments to wound healing.
...Reduce or eliminate preventable complications related to wounds.
Educate patient/caregiver on wound care and wound healing.

Physician order:
Skin care management/ ET nurse evaluation and treatment. (orders effective through hospitalization or until resolved."

Medical Record Findings:

1. MR # 1 was admitted in an Observation status 7/9/13 from the Emergency room with diagnoses of Urinary Tract Infection, Left Hip Dislocation, Left Hip Pain, Decubitus Skin Wounds and Cutaneous Candidiasis. The patient was under the care of Hospice when brought into the Emergency Room (ER) by ambulance.

The staff was unable to provide Intravenous (IV) fluids " because of inability to obtain IV access".

Nursing Narrative Note dated 7/9/13 at 10:23 AM had documentation, " Pt (patient) IV was attempted 10-12 times. Rapid response was called and they attempted as well. IV Access was unsuccessful."

The plan for the patient 7/9/13 was documented by the ER physician, " Antibiotic dosing Rocephin Intramuscularly and provide analgesia with Roxanol by mouth. The Foley catheter will be changed and provide Diflucan for three days."

The History and Physical dated 7/9/13 documented, " Skin: Poor skin turgor and has multiple pressure sores noted on in the left lower ankle and the buttock areas as per the ET nurse description."

The nursing assessment on admission 7/9/13 documented at 11:25 AM, " Brusing, left leg wound, buttocks ulceration, groin rash."

The nurse documented on the assessment and treatment note 7/9/13 at 7:38 PM, " Surgical Incision left hip skin surrounding tissue, edematous, drainage yellow and odor free small amount, dressing- 4 x 4's, changed, other: medipore tape. Ulcer LLE (Left Lower Extremity) open, edematous, cleaned with sterile saline, 4 x 4's, other: Kerlix and medipore tape."

There was no order for the wound care provided 7/9/13 in the medical record.

The Skin Team Assessment was completed 7/10/13 at 2:44 PM. The Skin Care Team observed, " This pt (patient) well known to this department from multiple recent admissions, presents with red, raised rash with satellite lesions at perineal area, groin and buttock area... increased moisture dermatitis. Appears Foley is leaking. Left hip surgical incision with minimal yellow drainage. 1 cm (centimeter) diameter wound on left posterior leg small amount yellow drainage... Albumin 2.0." Other: " Dry dressing to left hip incision, Qday (every day). Clean wounds on LLE (left lower extremity) with NS (normal saline), apply Neosporin ointment and cover with Mepilex Lite Qday."

The only measurement refers to the 1 cm diameter area on LLE and their is no depth to the wound. It is unclear from the documentation if the patient only has 1 wound and 1 incision line plus the rash to the buttocks to provide wound care.

The nurse documented on the assessment and treatment note 7/10/13 at 7:20 PM, " Left hip incision serosanguineous drainage small amount, dressing changed other: Steri-Strips intact. Ulcer LLE tender, erythema dry, intact, 4x4's gauze dressing."

This was not the wound care ordered by the physician or ET nurse.

The Nursing Narrative Note form documented 7/10/13 at 9:30 PM, " Pt's spouse at bedside is removing pt dressing from left hip. Instructed not to do. Pt c/o (complain of) pain to left hip left leg. Pt spouse also continues to raise pt bed to high. Bed locked to keep Mr... from adjusting bed. He is HOH (hard of hearing) and interfering with her care. Is wanting to be at her bedside but is instructed not to remove dressing or apply any medication."

The Nursing Narrative Note form documented 7/10/13 at 11:20 PM, " Pt's dressing supplies placed in bedpan at bedside... redressed pt left hip where dressing was pulled off."

There was no documentation of what type of dressing was used on the left hip.

The facility nurses failed to document measurement of the areas wound care was provided to and a description of the wound. Wound care documented in the nurse assessment and treatments was not the wound care ordered 7/10/13 by the ET nurse.

There was no documentation of education to the caregiver of wound care to be provided after discharge.

The patient was discharged home with home health care 7/11/13.

In an interview 11/21/13 at 9:00 AM with Employee Identifier (EI) # 1, Director of Flow the above information was confirmed.

MR # 1 returned to the Emergency Room 7/25/13. The diagnoses from this visit was Constipation, Dehydration and Hypotension.

MR # 1 returned to the Emergency Room 8/10/13, diagnosed with a Urinary Tract Infection and sent back home on Cipro 500 mg (milligrams) 1 by mouth BID (twice a day) for 7 days. The spouse decided to take patient back to their home instead of the son's home on 8/10/13. Home health to continue to follow.

MR # 1 was readmitted to the hospital 8/14/13 with diagnoses of