HospitalInspections.org

Based on record review and interview, the facility failed to ensure nursing provided wound care assessments per facility policy in 1 of 3 records reviewed (Patient ID # 1).

Findings included:

Record review of HHSC intake received on 6/5/2023 via email from complainant for Patient ID # 1, stated "I was present from May 5 - May 8. During that time, the care team was not consistently repositioning her every 2 hours and the result of this care caused bed sores ..."

Record review of facility policy titled "Clinical Practice Guidelines for Skin Alterations", dated 08/2022, stated the following:
"Wound documentation and photographs will be completed per each alteration weekly and include the following: a. wound type, b. Anatomic location of the wound, c. Staging of the wound, d. Wound length and width; and e. Description of wound bed, drainage, tissue type present." If further stated, "Standard of care: 1. Comprehensive skin and tissue assessments will be performed as outlined above, and recorded in the medical record."

Review of electronic medical record for patient ID# 1 on 07/20/2023 with Wound Care Manager Staff ID # 62 showed the following information:
Patient ID # 1 was admitted to the facility on 04/28/2023 and discharged 05/23/2023.
Admission wound/skin assessment: there were no skin or pressure injuries recorded/noted.
The first assessment which identified skin integrity issues was by Staff RN ID # 66 on 5/2/2023.
Wound care pictures on 5/2/2023 at 4:08 pm entered by Staff RN # 66 included 4 wound photographs:
"Wound #1 Posterior Body, Sacrum"
"Wound #2 Posterior Body, Buttock"
"Wound #3 Posterior Body, Buttock"
"Wound #4, Posterior Body, Perineum"
There was no staging, size or depth description or description of wound bed/drainage.
There was a hospital wound care team consult placed by Physician Staff ID # 68 on 5/16/2023 at 02:07am. There was a wound care team nurse consult completed on 5/16/2023 at 4:03 pm by Wound Care Team RN Staff ID # 67. However, Wound Care Manager Staff ID # 62 confirmed there was no detailed wound assessments of the 4 wounds and no repeat photographs uploaded by the wound care team as a part of this consult.

Interview with Wound Care Manager Staff ID # 62 on 7/20/2023 at 4:30 pm, revealed he would expect weekly wound assessments and photographs per facility policy. He confirmed the policy included description of wound type, anatomic location, staging of the wound, wound length and width and descriptions of the wound. He confirmed he was unable to locate these assessments of the wounds in the medical record. He confirmed there was no documented photographs between 05/02/2023 and the day of discharge 05/23/2023.