HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital failed to have an effective skin injury prevention and wound treatment program, for nine current patients (#3, #7, #8, #11, #12, #13, #33, #36 and #37), and two discharged patients (#25 and #38), of 11 patients with wounds reviewed. These failures had the potential to lead to poor outcomes for patients with wounds, and those at risk for skin breakdown.

These practices resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation: Nursing Services. The hospital census was 73.

Based on observation, interview, record review and policy review, the hospital failed to have an effective skin injury prevention and wound treatment program, for nine current patients (#3, #7, #8, #11, #12, #13, #33, #36 and #37), and two discharged patients (#25 and #38), of 11 patients with wounds reviewed. These failures had the potential to lead to poor outcomes for patients with wounds, and those at risk for skin breakdown. The hospital census was 73.

Findings included:

Review of the hospital's policy titled, "Skin Integrity," dated 08/11/22, showed the following directives for staff:
- The patient's skin integrity from head to toe will be assessed upon admission and on each shift.
- All compression stockings, dressings and other coverings or medical devices will be removed unless there is a physician's order not to remove such devices.
- Wound assessments were to include a documented description of each wound that included the location, length, width, depth in centimeters (cm, unit of measure), the wound and surrounding tissue color, presence of warmth, edema, firmness or other assessment findings, the amount, color and consistency of drainage, if there was an odor, and pain.
- Photographs should be included in the medical record to support the documentation, to determine progression of healing and effectiveness of therapy. Photos were to be posted on the wound photograph documentation form in the patient's medical record or uploaded to the electronic medical record.
- Wounds are to be photographed within 24 hours of admission, weekly, with a change in condition, upon discovery of a new wound, post-debridement (removal of dead tissue from a wound) and within 24 hours of discharge.
- Photo labels should include the Patient's initials or medical record number, location of the wound/lesion, the date and time of the photograph, the Nurses initials, measurement device, and body alignment sticker. If a photo was not obtained, document the reason in the medical record.

Review of the hospital's policy titled, "Wound Measurement," dated 06/25/22, showed the following directives for staff:
- A measurable wound is defined as one that measures greater than 0.5 cm x 0.5 cm x 1cm at the time of initial assessment. If clinically significant, smaller wounds are documented.
- Each wound will receive a number at the initial visit and when a new wound develops.
- For multiple wounds at one site, a photograph of the entire area will be taken, and numbering will be done on the photo, as well as the progress notes, for reference at subsequent visits.
- If a wound bed cannot be measured, secondary to necrosis (death of body tissue), it will be documented as unable to be determined (UTD cm).
- When the wound is healed all measurements are zero.
- Record all measurements in the designated areas in the medical record.
- Using the numbering and location of the wounds from the previous visit, measure all active wounds at each visit.
- Measurements should be taken at each assessment.

Review of the hospital's document titled, "Wound Staging/Grading," dated 05/2022, showed the following directives for staff:
- All wounds will have an appropriate assessment to include staging or grading as appropriate.
- Pressure injury's (injury to the skin and/or underlying tissue, usually over a body area) are evaluated using the Pressure Ulcer Staging System as described in the Agency for Health Care Policy and Research Guidelines.
- Diabetic (a disease that affects how the body produces or uses blood sugar, and can cause poor healing) wounds (an open wound or sore usually found on the bottom of feet in people with diabetes) of the lower extremity will be graded using the Wagner Ulcer Classification System (grading systems used for classification of ulcers to guide appropriate treatment).
- All other wounds will be staged using a "Partial Thickness" or "Full Thickness" designation, according to the loss of skin.
- If a wound is not able to be staged, then designation will be written as either "Deep Tissue Injury" (DTI, intact or non-intact skin that has red, maroon or purple discoloration that does not go away if pressure is applied. Skin in this area may feel soft, firm or mushy and underlying damage is usually present) or "Unstageable" (unstageable pressure injury, a deep opening in the skin in which the extent of the tissue damage cannot be confirmed due to the presence of dead tissue in the wound) and this will be reported to and discussed with the center Medical Director.
- The Registered Nurse (RN), Wound Care Clinician (WCC), Nurse Practitioner (NP), Physician Assistant (PA), and Medical Doctor will perform the staging/grading of wounds.
- At the time of initial wound assessment a stage/grade is determined and remains the same throughout the course of treatment unless the initial staging is found to be in error, or the level of tissue involvement increases during the course of treatment.
- If the staging is changed, it is recorded in the progress notes in the designated area. The nurse clinician, as directed by the center provider will make any adjustments to the wound description.

Review of Patient #3's medical record showed the following:
- She was a 74-year-old female who was admitted on 02/06/23 through the Emergency Department (ED) with abdominal pain which progressed through her right side. The patient's ED provider note identified an open wound of the skin on her tailbone.
- She was evaluated by Staff JJ, NP, on 02/07/23 at 2:24 PM, and the wound was described as lumbar spine (lower back)/upper sacral (above the tailbone) location, partial thickness ulceration with scant drainage, with redness and the presence of satellite lesions. There were no wound measurements included in the documentation.
- The wound was photographed once on 02/06/23, without the time or the nurse's initials.
- Physical examination on 02/18/22 showed the wound was not open and skin breakdown was not involved. The patient was assessed by the wound care team eight times prior to 02/18/22 and eight times after 02/18/22 with the physical examination documented as "partial thickness ulceration" with either scant drainage or no drainage. No wound measurements or additional photographs were documented.
- Wound assessments did not include presence or lack of warmth, firmness or odor.
- Although requested the hospital did not provide documentation for dressing changes or measurements of wounds performed by nursing staff.

Review of Patient #7's medical record showed the following:
- He was a 69-year-old male who presented to the ED on 02/24/23 with hip pain. He was a paraplegic (paralysis of the legs and lower body, typically caused by spinal injury or disease) who reported swelling to the left hip and leg for two days prior to the ED visit. The ED provider note documented that the patient's left hip was swollen, warm to touch, and showed mild redness. He had a chronic wound on his left buttock with a dry, intact dressing. No wound measurements or photographs were documented.
- The admission history and physical documented Stage 4 pressure injuries (injury to the skin that extends to the bone and muscle) to the sacrum and tailbone.
- The wound care team was consulted and assessed the patient on 02/25/23. The patient was assessed and diagnosed with cellulitis (an infection of the skin) and swelling of the left leg, and chronic Stage 4 pressure injuries to the left ischial tuberosity (bone of the pelvis that forms the lower and back part of the hip bone). The wounds were not assigned a designated number. No wound measurements or detailed description of the wounds were documented.
- The patient was assessed by the wound care team on 02/27/23 and 02/28/23. No wound measurements or detailed description of the wounds were documented.
- Two wound photographs were included in the medical record. None of the photographs contained patient identification, date, time, or initials.
- Although requested, the hospital did not provide documentation for dressing changes or measurements of wounds performed by nursing staff.

Observation on 02/28/23 at 9:45 AM, showed Patient #8, had two wounds on his left lower leg. Staff S, RN, Wound Coordinator, and Staff T, RN, performed the dressing change, but did not measure or photograph the wounds. Staff C, Assistant Chief Nursing Officer (ACNO), assisted with the dressing change. No other staff members were present during the dressing change.

Review of Patient #8's medical record showed the following:
- He was a 93-year-old male who was admitted to the hospital on 02/17/23 with a urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra), and wounds on his right and left lower extremities, a wound care evaluation was ordered. Past medical history included diabetes mellitus (DM, a disease that affects how the body produces or uses blood sugar, and can cause poor healing).
- The medical record contained six photographs of wounds with no date on the label, other than the admission date, no time, no numbers to designate the wounds, and no nurse initials.
- On 02/17/23 at 11:18 AM, Staff DD, NP, documented that Patient #8 had peripheral vascular disease (PVD, blood circulation disorder that causes blood vessels to narrow, block or spasm that typically causes pain and tiredness in the legs) of his lower leg with an ulceration, a skin tear to his left elbow, an abrasion on his right knee, a vascular ulcer with cellulitis on the front and back side of his left lower leg, and on his left toes.
- On 02/17/23 at 3:44 PM, Staff S, RN, Wound Coordinator, documented that he assessed wounds to the patient's left forearm, toes, and his left lower leg. There were no measurements documented, and no assessment of the surrounding tissue, drainage, odor or pain for any of the wounds. There was no assignment of numbers for wounds.
- A physician's order placed by Staff DD, NP, on 02/17/23, showed orders for dressing changes to be performed for wounds on Patient #8's left lower leg, right knee and left toes and identified them as peripheral arterial disease (PAD, blood circulation disorder) ulcerations.
- A physician's order placed by Staff DD, NP, on 02/21/23, showed orders for a dressing change for a skin tear to Patient #8's left elbow. There were no photographs or measurements for the wound.
- On 02/28/23 at 11:20 AM, Staff JJ, NP, documented that he assessed Patient #8 and his wounds and the skin tear to the left elbow and right knee were resolved, Patient #8 continued to have PVD ulcerations with cellulitis on his left lower leg and left toes.
- There were no additional photographs in the medical record and wounds were never assigned a designated number.
- There were no measurements recorded for any identified wounds in Patient #8's medical record, and lower extremity wounds were not assigned a Wagner Ulcer Classification grade.

During an interview on 03/01/23 at 1:30 PM, Staff JJ, NP, stated that on 02/28/23, Staff S, RN, Wound Coordinator, showed him photographs of Patient #8's wounds that he obtained during the dressing change that morning.

During an interview on 03/01/23 at 2:00 PM, Staff S, RN, Wound Coordinator, stated that he did not take photographs or measure Patient #8's wounds on 02/28/23.

Observation and subsequent interview on 03/01/23 at 9:05 AM, showed Staff S, RN, Wound Coordinator, applied a wound vacuum assisted closure (wound VAC, a device that decreases air pressure on a wound to help it heal more quickly) to Patient #11's right arm pit and flank wound. Staff S did not measure or photograph the wound before applying the sealed dressing and activating the wound VAC. Staff S stated that wounds were to be measured and photographed on the patient's admission and every Wednesday, but he did not take a photograph or measure Patient #11's wound before he applied the wound VAC. The patient had topical dressing applications since his admission and he did not feel measurements of the wound were necessary.

Review of Patient #11's medical record showed the following:
- He was a 53-year-old male who presented to the ED on 02/26/23 with a fever. His past medical history included hidradenitis suppurativa (a painful, long-term skin condition that causes abscesses and scarring on the skin), scleroderma (an autoimmune connective tissue and rheumatic disease that causes inflammation in the skin and other areas of the body) and multiple wounds. He had previous admissions for debridement of a wound in his right arm pit and flank area on 02/09/23 and was discharged home with a wound VAC. The wound VAC stopped draining, his home health nurse removed the wound VAC and placed a topical dressing on the wound. He developed a fever with an increased heart rate and went to the ED.
- A physical examination on admission showed an incision which extended from under his right breast to his right side with redness and drainage. No wound measurements or photographs were documented.
- The patient was evaluated by Staff JJ, NP, on 02/27/23 at 9:36 AM. The progress note showed that the patient reported that his wound VAC was removed by his home health nurse on 02/24/23. The right lateral chest wall wound was documented as pink/red friable (tissue that tears and bleeds easily when touched), moderate drainage and without odor. A second wound in the perineal area was documented as reddened, dry, with flaky skin and multiple small lesions surrounding it. The wounds were not assigned a designated number and no wound measurements or photographs were documented in the note.
- A wound care note on 02/27/23 at 10:19 AM by Staff S, RN, Wound Coordinator, showed that the patient's wound VAC had been actively on the wound since the patient's last admission until his admission on 02/26/23. Wound measurements were documented as approximately 25 cm x 10 cm x 4 cm. Staff S documented that he cleansed and packed the patient's wound. No documentation of an assessment of the perineal wound was entered. No detailed description of the wounds or photos were documented.
- The patient was assessed by Staff JJ, NP, on 02/28/23 and by Staff II, NP on 03/01/23. No wound measurements or photographs were documented in either note.
- A nursing note documented on 02/28/23 at 9:00 AM, described the wound to the right breast area was cleansed and dressed by the primary nurse. No wound measurements or photographs were documented.
- A wound care note entered by Staff S, RN, Wound Coordinator, on 03/01/23 at 10:11 AM, showed an application of the wound VAC and no perceivable change in the measurements of 25 cm x 10 cm x 4 cm, but the wound was not measured.

Review of Patient #12's medical record showed the following:
- He was a 54-year-old male initially admitted to the hospital on 09/04/22 in diabetic ketoacidosis (DKA, life-threatening condition affecting people with diabetes; occurs when the body breaks down fat too fast causing the blood to become acidic), had an amputation (removal of an injured or diseased body part) below the knee on his right leg, several wound debridements, a percutaneous endoscopic gastrostomy (PEG, a tube inserted through a person's abdomen directly into the stomach to provide a means of feeding when oral intake is not possible), colostomy (a piece of the colon is passed through a surgically-created opening in the abdominal wall so as to bypass a damaged part of the colon) and an incision and drainage (I&D, incision and drainage of a wound) of his left knee. He was discharged from the hospital on 10/31/22, admitted to the inpatient Rehabilitation Unit (an inpatient area staffed and medically supervised in the care and treatment of the physical restorative needs of patients) and continued to be followed by the wound care team. While in the rehabilitation unit, he was diagnosed with osteomyelitis (infection of the bone) of his left knee and was readmitted to the hospital for an above the knee amputation of his left leg on 11/07/22. Patient #12 remained an inpatient due to the inability to find long-term care placement.
- Physicians and NPs documented from 10/26/22 through 11/01/22 an unstageable pressure injury to the left heel and left ankle and DTIat the base of the left fifth toe and mid-foot; and from 11/01/22 to 11/07/22 documented an unstageable pressure injury to the left heel, left ankle, base of the left 5th toe, left mid-foot and back of left calf region. There were no detailed wound descriptions or Wagner Ulcer Classification grade documented.
- No existing wounds or new wounds were assigned a designated number.
- Wounds were identified as resolved or documented as "healed" without a measurement of zero.
- Wounds were not described on each assessment to include measurements, surrounding tissue color; presence of warmth; edema; firmness; or amount, color or consistency of drainage.
- The medical record contained 24 photographs of wounds on 13 dates with no time and no wound number to identify the wound photographed. The last wound photograph in the medical record was taken on 02/09/23. Photographs were not obtained or documented but they were not obtained for each wound on a weekly basis.
- Although requested, documentation was not provided for dressing changes or measurements of wounds performed by nursing staff other than Staff S, RN.

Review of Patient #13's medical record showed the following:
- He was a 61-year-old male with a history of lung cancer who presented to the ED from a long-term care facility on 02/16/23 with abnormal lab values.
- An ED provider note on 02/16/23 at 5:46 PM, showed diagnoses that included sepsis (life threatening condition when the body's response to infection injures its own tissues and organs), pneumonia and respiratory failure. The note showed the patient had a large sacral wound on the right buttock with no redness or warmth noted. No wound measurements, detailed description of the wounds or photographs were documented.
- A history and physical on 02/16/23 at 9:29 PM, showed a known sacral wound which was not physically assessed. A wound care consult was requested.
- Staff II, NP, assessed the patient on 02/17/23 at 11:05 AM, and documented an unstageable pressure injury of the sacral region with 100-percent slough (layer of dead tissue separated from surrounding living tissue, as in a wound, sore, or inflammation). No wound measurements or detailed description of the wound were documented.
- A photograph of a wound was documented in the medical record. The photograph did not contain the date and time of the photograph or initials of the nurse who obtained the photo.
- The wound care team assessed the patient six times between 02/20/23 and 02/28/23. Each wound assessment was documented as unstageable sacral pressure injury with 100-percent slough. No wound measurements, detailed description of the wound or photographs were documented, and there was no documentation to show why measurements and photos were not obtained.
- Staff JJ, NP, documented a wound care note on 02/28/23 at 9:00 AM, the patient's family had decided to proceed with palliative (a medical approach that focuses on quality of life and mitigating suffering among people with serious, complex illnesses) care and wound care consultations were ended at that time.
- Nursing notes did not contain any wound measurements.

Review of discharged Patient #25's medical record dated 01/05/23 through 01/24/23, showed the following:
- She was an 88-year-old female who was transferred to the behavioral health unit (BHU), from a nearby hospital after presenting to their ED from her long term care facility with combative behaviors.
- On 01/07/23 at 6:37 PM, photographs labeled left and right arms were obtained. At 6:31 PM a photo labeled buttock was obtained. There were no measurements for any of the wounds photographed.
- On 01/10/23 at 8:34 PM, there were photographs labeled, left and right arm skin tears from hitting and scratching obtained. There were no measurements for wounds on the patient's arms and no assignment of numbers to designate the wounds.
- On 01/12/23 at 6:32 AM, a photograph of a wound labeled buttocks was obtained. There were no measurements documented.
- A wound consultation note dated 01/13/23 at 11:50 AM, showed the wound care team was consulted for wounds to Patient #25's left forearm and Stage 3 pressure injury's (a deep opening in the skin that varies in depth based on location, fatty tissue may be visible, but no bone or muscle are exposed) to her sacral and bilateral gluteal areas. There were no photos or measurements documented.
- A Wound Progress Note dated 01/20/23 at 12:19 PM, showed Patient #25 was evaluated by wound care for a skin tear to her left forearm and a Stage 3 pressure injury to her sacrococcygeal region. There were no measurements documented for either wound, and no photographs obtained.
- There were no measurements documented in the medical record for any of the wounds, and no numbers assigned to designate the wounds throughout her hospitalization, and no documentation to show why measurements were not obtained. There was no documentation in the medical record indicating progress or deterioration for any of the wounds.

Observation on 03/01/23 at 2:00 PM, showed Patient #33 had wrapped dressings on both feet dated 02/28/23. Staff KK, RN, performed dressing changes on both feet, but did not measure or photograph the wounds.

Review of Patient #33's medical record showed the following:
- She was a 55-year-old female who presented to the ED on 02/22/23, reporting chest pain and shortness of breath for three days. She had a history of DM, congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues), previous toe amputations and chronic wounds. Her most recent wound debridement was performed on 02/15/23. The ED provider's physical examination showed ulcerations and redness on both feet without drainage; the wounds did not feel warm to touch and sutures from her recent debridement were present. No wound measurements or Wagner Ulcer Classification grade were documented.
- A history and physical documented on 02/23/23, showed the patient's skin examination as dry and extremities as "moves all". No wound measurements, detailed description of the wounds or Wagner Ulcer Classification grade were documented.
- Three wound photographs dated 02/24/23, did not include the time they were taken.
- Staff JJ, NP, assessed the patient on 02/24/23 and described surgical wounds to both feet after toe amputations. The wounds were documented as lateral left site with dry, stable eschar (dead skin tissue); lateral right site with moderate pus drainage; sutures in place and no redness. No wound measurements; description of warmth, odor or pain associated with the wounds or Wagner Ulcer Classification grade were documented.
- Staff JJ, NP, assessed the patient on 02/27/23, and documented that additional debridement was performed by a foot surgeon on 02/26/23. No wound measurements, detailed description of the wounds or Wagner Ulcer Classification grade were documented on any additional wound care progress notes.
- Five wound photographs were included of bilateral feet which did not include a date, time, or nurse initials.
- The infectious disease physician documented on 02/24/23, a physical exam for extremities with bilateral foot dressings. The note showed the patient had recent debridement following amputations on both feet and still had pressure wounds following the procedure. No wound measurements or Wagner Ulcer Classification grade were documented during any infectious disease assessments.
- Nursing flow sheets documented the bilateral foot dressings were changed on 02/27/23 and 03/01/23. All other dressing documentation by nursing showed the foot dressings were clean, dry and intact. Nursing documented photographs were taken of the wounds on 02/24/23 and 03/01/23. There were no wound measurements in any nursing documentation.

Review of Patient #36's medical record showed the following:
- He was a 61-year-old male who presented to the hospital on 02/13/23, with a rash on his back, dizziness and frequent falls. It was determined that Patient #36 had an abscess (collection or pocket of thick fluid caused by an infection) on his back which resulted in him becoming septic (infected with harmful bacteria).
- There was one photograph of a wound labeled 02/13/22, elbow, one photograph of a wound labeled 02/19/23, scrotum (part of the male's genitals) and one photograph of a wound labeled 02/19/23, sacrum, there were no measurements or any other information documented for any of the wounds throughout Patient #36's hospitalization.
- A physician's order dated 02/22/23, showed there was an order placed for wound care to the patient's buttocks/sacral/coccyx/scrotum for a pressure injury/suspected DTI, to be performed twice daily and as needed.
- An operative note dated 02/20/23, showed an I&D of the back abscess was performed and measured 25 cm in length and 15 cm in width, there was no depth documented.
- On 02/22/23 at 3:12 PM, Staff S, RN, Wound Coordinator, documented that the surgical wound to Patient #36's back measured 16 cm x 2 cm x 3cm, and there was undermining (a pocket of dead space occurring under the skin originating from the edges of the wound and spreading outwards) present all the way around the wound that measured 14 cm. There was one photograph of the wound labeled 02/22/23, back.
- A physician's order was placed on 02/22/23 for Patient #36 to have dressing changes to his back every Monday, Wednesday and Friday.
- There was only one wound care note in the medical record for a dressing change to Patient #36's back on 02/24/23. There were no measurements or photographs taken of the wound, and no documentation to indicate why they were not obtained.

Review of Patient #37's medical record showed the following:
- He was a 60-year-old male who was admitted to the hospital on 02/10/23, was unresponsive from encephalitis (inflammation of the brain, caused by infection or an allergic reaction) and had open wounds to the left ankle.
- Past medical history included a diagnosis of DM.
- A wound progress note dated 02/13/23, showed Patient #37 had an unstageable pressure injury to his left outer ankle with dry stable eschar, and a DTI to the tailbone region that was non-blanchable and purple in appearance. There were no measurements documented for either wound. The wound care team assessed the patient eight days from 02/14/23 through 03/01/23 and all documentation was exactly the same, with no measurements or documentation of the status of wound healing.
- On 02/13/23 at 9:14 AM, Staff S, RN, Wound Coordinator, documented he saw Patient #37 and his suspected DTI with redness was regressing and to continue using barrier cream. The left ankle wound had stable eschar and measured 1 cm x 1 cm and a "?" was documented for the depth.
- There was one photograph labeled sacral, in the medical record. There were no initials, time, or a date included on the patient label in the photo.
- There was one photograph labeled left, in the medical record. There were no initials, time, or a date included on the patient label in the photo.
- Nursing documentation on 02/24/23 at 9:30 PM, showed Patient #37 had wounds to his sacrum, ankle and elbow. There were no measurements documented for any of the wounds.
- There was no mention of an elbow wound anywhere else in the medical record and no documentation indicating progress or deterioration for any of the wounds.

Review of discharged Patient #38's medical record dated 02/13/23 through 02/28/23, showed the following:
- She was a 91-year-old female who presented to the ED with abdominal pain. Two weeks prior to her ED visit she noticed a coin sized lump on the right side of her abdomen that rapidly grew over a two week period. Patient #38 reported that she had not been eating and had sores on her bottom from lying in bed for two weeks. A surgeon saw her in the ED and made a plan to drain the abdominal mass. A physical exam showed redness and an open wound over the coccyx, "perianal" area red and with sores. The plan for the sacral wounds was to consult the wound care team.
- A computed tomography (CT, a combination of x-rays and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) of the abdomen and pelvis was performed on 02/13/23, and showed a fluid collection that measured 15.3 cm x 10.7 cm x 15.0 cm in the abdomen.
- A wound consultation note dated 02/14/23, showed Patient #38 had unstageable pressure injuries to her bilateral labia region, sacral region, coccygeal region, right ischial tuberosity, a stage 3 pressure injury to her left ischial tuberosity, suspected DTI's under her breasts and on her thighs.
- On 02/18/23 at 2:00 PM, Staff S, RN, Wound Coordinator, documented that all the wounds had been changed except the abdominal wound, then documented a dressing change to the abdominal wound. There were no measurements or photos taken and no description of any of the wounds.
- The medical record contained five photographs taken on 02/19/23. The photos were labeled abdomen, sacral, right lower extremity, and two had no location. There were nurse initials on the labels, but no time, and no number to distinguish the wounds. There were no other photographs of the wounds in the medical record.
- There were no measurements for any of the wounds documented by nursing staff in the medical record, and no documentation indicating progress or deterioration of the wounds.

During an interview on 02/28/23 at 10:00 AM, Staff T, RN, stated that the floor RN's did not photograph or measure wounds and that it was the responsibility of the wound care nurses.

During an interview on 03/01/23 at 2:00 PM, Staff S, RN, Wound Coordinator, stated that the floor RN's were responsible for measuring and photographing wounds. He was part of the wound care team and their primary role was to round on patients and put in wound care orders. Wounds were to be measured upon admission, on Wednesday's, if there were any changes and prior to the patient being discharged. Wound measurements were absolutely important to perform to determine if a dressing was working and if the wound was improving. Wound photographs should include a label with the patient's name, the date, time and location of the wound and the initials of the nurse measuring and taking the photo. He did not know why he would document a "?" as a depth, it wasn't appropriate, but most likely meant the depth couldn't be determined. He did remember that Patient #36 had wounds to his sacrum and scrotum, but he did not know if they were healing and couldn't remember when he last assessed them.

During an interview on 03/01/23 at 1:30 PM, Staff JJ, NP, stated that typically the wound RN's measured and photographed wounds. Wounds should have been measured every few days. He determined if a wound was healing mainly by the appearance of the wounds at the hospital, but relied on measurements at other facilities. It was absolutely important to measure wounds to show progression and closure in wounds.

During an interview on 03/01/23 at 1:00 PM, Staff DD, NP, stated that he did not measure wounds and it was not part of his responsibilities, measuring and photographing wounds was the responsibility of the wound RN. It would have been nice to have measurements of wounds. Wound measurements were important to determine wound healing.

During an interview on 03/02/23 at 10:45 AM, Staff C, ACNO, stated that the Wound RN was to assess wounds upon admission and then determine if the wound care team should be consulted. Measurements were to be obtained on admission, on "wound Wednesdays," if there were obvious changes to the wound and upon discharge. She expected the Wound RN to measure and photograph wounds on "wound Wednesdays" and Staff RN's to measure and photograph wounds at least once a week. A wound assessment should include a location of the wound, the size, color of the wound bed, drainage, the appearance of the wound edges and a comparison to the last assessment. NP's on the wound care team should have been measuring wounds as well as the Wound RN and the Staff RN's. She expected the NP's from the wound care team to report if there were inconsistency's with measuring and photographing wounds.


44536