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CORNERSTONE SPECIALTY HOSPITALS MUSKOGEE
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on record review and interview, the hospital failed to ensure wound care was monitored, assessesed and/or documented per facility requirements for one (Patient #1) of ten patients.
This failed practice has the likelihood to result in a delay of healing and opportunity for initiation of other interventions.
A review of a policy titled "Patient Assessment, Reassessment and High Risk Screens" documented requirements for patient care to be evaluated daily by nursing and daily assessment data to be used to document patient progress toward goals.
A review of a document titled "Medication Administration Record" showed wound care to the left foot was performed on 08/22/20 at 9:00 AM and on 08/23/20 at 2:00 PM. A review of the Skin Assessment section of a document titled "Daily Nursing Notes" dated 08/22/20 and 08/23/20 showed no documentation describing the characteristics of the left foot wound.
On 08/26/20 at 12:27 PM, Staff C reviewed the medical record for Patient #1 and stated when nurses change dressings, they were expected to describe the wound in order to identify if the wound was worsening and that did not occur on 08/22/20 or 08/23/20.