HospitalInspections.org

Based on document review and interview, the facility failed to ensure nursing staff document wound assessments and treatments in 1 (#3) of 10 medical records (MR) reviewed:

Findings include:

1. Policy/procedure, Policy Number: NU 83, Skin/Wound Assessments/Reports, revised/reviewed 7/2019, indicated: "The skin/wound assessment will be completed for all patients on admission, discharge, post fall and if changes to condition of skin are observed. Each wound site requires a wound report".

2. Review of patient 3's MR lacked documentation of wound assessments and treatments for each wound sustained during incident that occurred on 8/11/19 at 1800 hours.

3. On 8/22/19 at approximately 1200 hours, staff N11 (Director of Quality) was interviewed and confirmed patient 3's MR lacked documentation by nursing staff of wound assessments and treatments for each wound sustained during the incident that occurred on 8/11/19 at 1800 hours.