HospitalInspections.org

Based on medical record review, policy review and staff interview, it was determined that the registered nurse (RN) failed to supervise and evaluate the nursing care for 1 of 3 patients (Patient #2) in the medical record review sample with wounds. Findings included:

The hospital policy entitled "Wound Assessment and Documentation" stated, " ...Daily documentation of skin and wound inspection completed by an RN will include the following if present: A. skin condition B. dressing integrity C. description of wound drainage, odor, pain, signs of inflammation or infection if present ...Daily documentation will be recorded by the RN ...Weekly documentation will include A. Re-assessment i. skin inspection and assessment of applicable items listed above ii. Documentation of current treatment.

Review of Patient #2's medical record revealed:
A. "Order Sheet" included order dated 8/26/20 for "Left, Cleaned with Soap and Water, Skin Prep, Daily, Cleanse leg with soap and water, pat dry, Apply sureprep to blister. Note any open areas ...Wrap with kerlix, apply splint and ACE."

B. Review of Nursing documentation on 9/7/20 revealed:
- "Specialty Wound Care": RN documented that wound care was "completed", but did not include information as to the details of the wound care, or application of sureprep (wound treament), kerlix (type of dressing), splint or ACE (bandage)- no evidence that the left lower extremity wound was assessed/inspected on 9/7/20
These findings were confirmed on 10/23/20 at 11:02 AM, by Director of Nursing A.