HospitalInspections.org

Based on interviews, review of the facility policy and procedures, and the review of medical record (MR) # 1, the agency failed to assure a deterioration of a wound was reported to the Wound Care Nurse or the attending physician in a timely manner. This delayed a change in the plan of care for MR#1. This affected 1 of 5 medical records reviewed with wounds.

The findings include:

Policy and Procedure #C41-N "Change in Patient Condition" revised on 10/2/07 documented, "Purpose: ... Define documentation guidelines - Define responsibility for physician notification ... Assessment: ... It is the responsibility of the charge nurse to ensure that the process to assess the patient occurs in a timely fashion, and to gather other relevant data. ... Notification: ... It is the Charge Nurse's responsibility to ensure that the attending physician is notified in a timely manner. ... Documentation: The complete assessment should appear on the nursing flow sheet. ... Form will be used to document communication about the patient to the MD and will be placed in the progress notes section of the medical record.

Medical Record (MR) # 1 was admitted on 6/7/10 with diagnoses to include Cerebral Hematoma and Persistent Vegetative State.

A review of MR #1's chart revealed on 6/30/10 the sacrum wound bed was pink with slough and measured 6 x 7 x 0.2 centimeters (cm). The surrounding tissue was dark red and purple with scant amount of serosanguineous drainage. On 7/9/10 the sacrum wound was unstageable and measured 7.4 x 8 x 0.2. The wound bed was covered with Eschar. The surrounding skin color was documented as black, dark purple and bright red edges.

The nurse wound documentation forms dated 6/30/10 documented wound bed purple. On 7/1/10 the wound bed was blue. On 7/2/10 the wound bed was documented as black and brown. These changes were not documented as reported to the wound nurse or the attending physician.

During an interview with Employee Identifier (EI) #1, Wound Care Nurse, on 9/1/10 at 1:45 PM, she verified the charge nurse had not notified her of any changes to the wound from 6/30/10 until 7/9/10.

During an interview with EI# 4, the Attending Physician, on 9/1/10 at 3 PM, he verified the staff had not notified him of any changes to the wound from 6/30/10 to 7/9/10.

During an interview with EI # 2, the Chief Nursing Officer (CNO) and EI# 3 the Divisional Director of Clinical Services, on 9/1/10 at 3:45 PM, they verified there was no documentation in the medical record of communication by the staff to alert the Attending Physician or the Wound Care Nurse of the changes to the wound from 6/30/10 to 7/9/10.