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Based on record review and interview, the hospital failed to ensure a Registered Nurse supervised, evaluate, assessed, and monitored the consistency in charting wound location and treatment of the LPN - Wound Care Coordinator, per facility requirements for six of twelve patients (Records #1,3,4,5,6, and 11).

A review of "Appendix A" stated in part "a RN must evaluate the care for each patient upon admission and when appropriate and when appropriate on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy...Evaluation would include assessing the patient's care needs, patient's health status/conditioning, as well as the patient's response to interventions."

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 "Nursing - Wound Care Program" documented requirements for the Wound Care Coordinator to assess wounds as part of the comprehensive initial assessment and will document all clinical findings as per agency policy. The wound care nurse will document a description of the wound(s) and provide the dressing change. She will document a description of the wound bed, drainage, signs and symptoms of infection, healing, and wound skin condition. At least weekly the wound care coordinator will perform and document wound measurements.

On 03/04/24 at 2:25 PM, Staff A reviewed the medical record for patient #1 and stated when nurses change dressings, they were expected to describe the wound to identify if wound was worsening and that did not occur on 02/28/2024.

On 03/04/2024 at 2:40 PM, Staff B stated as the Wound Care Coordinator, wound care is performed per physician orders. Staff B states patient wound care is performed and documented on the Wound Care Coordinator flow sheet for tracking. Staff B states there is not a designated time frame used to document description of the wound bed, drainage, signs and symptoms of infection, healing, and wound skin condition.


On 03/04/2024 at 2:45 PM, Staff C stated the wound care protocol has been approved by the Medical Executive committee and will be utilized as a guide for the Wound Care Coordinator and other members of the multidisciplinary team to treat and manage wounds. All wound care activity is to be documented in the patient Electronic Medical records according to the Wound Care Program policy and procedures.